RA & The Elderly – Ask Joe DiMatteo

Last week we went over the rheumatism basics. We told you the main treatment goals with rheumatoid arthritis are to control inflammation which will ease pain and ultimately reduce disability linked to RA. However, despite aggressive guidelines, one particular demographic is still undermedicated and undertreated.

The elderly.

A new study suggests that doctors are not prescribing many older adults disease-modifying medications for their inflammatory autoimmune disease.

Researchers at Michigan Medicine used the National Ambulatory Medical Care Survey to analyze all ambulatory visits from 2005 to 2016 for rheumatoid arthritis by adults 65 and older, representing 7.8 million visits. They found that only 45% of patients were prescribed disease-modifying antirheumatic drugs, like methotrexate, used to treat inflammation caused by several diseases. The results are published in A.C.R. Open Rheumatology.

Jiha Lee, M.D., M.H.S., lead author of the paper and a rheumatologist at U-M Health, commented,

“These medications have really changed the landscape of rheumatology, allowing low disease activity and remission to be achieved in people with rheumatoid arthritis, and now there needs to be a shifting consideration of how we can better target their use among older adults. The prescription rates for these disease-modifying drugs have improved over the past few decades, but there is more work to be done to ensure older adults are on optimized treatment.”

One in four patients observed in the study visited primary care physicians for their rheumatoid arthritis, while rheumatologists saw the others. The PCPs prescribed disease-modifying antirheumatic medications in 30% of visits, compared to 56% by rheumatologists.

Data from the 1990s and early 2000s estimate fewer than 30% of older adults with rheumatoid arthritis were prescribed these drugs. Researchers say the rise in prescriptions presumably reflects a shift towards early treatment and expanded Medicare coverage. Regardless of this recent increase, Dr. Lee says prescription practices of rheumatologists and primary care physicians fall below the standard set by the American College of Rheumatology, which advocates that most rheumatoid arthritis patients receive some form of disease-modifying antirheumatic drugs.

“When you look at younger adults with this condition, more than 70 to 80% are on some form of treatment. Prescribing for older adults is challenging because polypharmacy and multimorbidity are common, and this population is more prone to the negative effects of disease-modifying drugs. However, we should be cautious older adults do not experience more pain and deformities that really limit their functioning because of undertreatment,” Dr. Lee explains.

Of patients not prescribed disease-modifying antirheumatic drugs, around 20% took only steroids for their rheumatoid arthritis, which is known to cause joint pain and stiffness. Experts advise against using steroids, which can increase the possibility of gastric ulcers, poor glycemic control, osteoporosis, and subsequent fracture.

The disease-modifying antirheumatic drugs also come with potential drawbacks. They are considered immunomodulatory or immunosuppressant medications. They suppress the immune system and increase the risk of serious infections as they combat inflammation caused by the disease.

Lee says these medications’ benefits must be balanced carefully against their risks, especially in older adults.

“This study highlights the important role that rheumatologists play in providing optimal treatment for the older rheumatoid arthritis patients,” said Raymond Yung, M.B., Ch.B., co-author of the paper and chief of the Division of Geriatric and Palliative Medicine at U-M Health. “Unfortunately, the results also show that ageism continues to exist in our health systems that has impacts on the care that patients receive.”

The findings come at a time in which rheumatologists are in high demand. Yet, in many regions, access to rheumatologists is limited. For this reason, Lee says, primary care physicians also play an essential role in recognizing the symptoms for early diagnosis, making referrals to rheumatologists, and, when needed, beginning treatment for older adults with rheumatoid arthritis.

“The world population is aging, and rheumatologists must be prepared to care for older adults with rheumatic diseases while addressing additional diseases and medications they may have,” she said. “We can work more closely with primary care providers and learn from our colleagues in geriatrics and adopt age-friendly approaches to improve prescribing practices for older adults with rheumatoid arthritis.”