How to Optimize Treatment for Aging Patients with Rheumatic Conditions

The rheumatology patient population continues to age. In recognition of this fact, Jiha Lee, MD, MHS, a rheumatologist at the University of Michigan, Ann Arbor, and colleagues addressed the issue in a describing best practices for optimizing medication use in older adults—typically defined as aged 65 years or older—with rheumatic musculoskeletal disease (RMD), published in ACR Open Rheumatology, December 2022.¹ These practices incorporate an understanding of the burden of polypharmacy and encourage prescribing practices designed to improve the safe and effective medication use in this patient population.

Polypharmacy

Often, older adults with RMDs experience polypharmacy (i.e., the simultaneous use of five or more medications), which brings with it a tremendous burden for side effects. Example: The authors describe the findings from a large national rheumatoid arthritis (RA) cohort that found half of patients aged 65 years and older had been prescribed five or more medications.² Moreover, polypharmacy was associated with serious adverse effects, including hospitalization and death.

In some cases, polypharmacy is the result of a prescribing cascade in which a new medication is prescribed to treat the adverse side effects of previously prescribed medications—adverse effects that were misdiagnosed as new clinical conditions. This situation may lead to the inappropriate, unnecessary or potentially hazardous use of additional medications.³

In the review article, Lee et al. encourage an ongoing and frequent assessment of the medication benefit-to-harm ratios in older adults. Such an assessment should include accurate ascertainment of drug-related adverse effects, awareness of prescribing cascades and interruption of potentially inappropriate and/or suboptimal medications. The authors cite the American Geriatrics Society Beers Criteria for guidance regarding potentially inappropriate medications that should be avoided under most circumstances or depending on certain drug interactions. Additionally, the guidance describes a de-prescribing approach focused on improving appropriate medication use, which for older adults means optimizing the outcomes most important to the patient.⁴

Dr. Lee describes this attitude toward geriatric care as age-friendly prescribing, noting that because the treat-to-target approach remains important for older patients, rheumatologists should be careful not to undertreat at the beginning. But after disease control has been achieved, rheumatologists should initiate a discussion with patients about their goals and priorities for care. This conversation may include addressing such topics as lifestyle changes associated with retirement and travel plans.

Rheumatologists should also have frank discussions with older patients about potential functional limitations that may conflict with the storage and self-delivery of certain biologic treatments, as well as the regular blood draws required for adherence and safety monitoring.  Answers to these questions can inform whether specific medications should be de-prescribed to maintain treatment benefits while minimizing potential harm.