How to Optimize Treatment for Aging Patients with Rheumatic Conditions

Half of patients aged 65 years & older [with RA] had been prescribed five or more medications.

Other Considerations

Although rheumatologists recognize that older patients are more vulnerable to adverse side effects from treatments, the exact nature and extent of this vulnerability is still largely unexplored.

Dr. Lee notes the rheumatological recommendations in the 2021 American College of Rheumatology (ACR) Guideline for the Treatment of Rheumatoid Arthritis (RA) are based on results from clinical trials in which the average patient age was 53 years.⁵ Because the clinical trials included few older adults and excluded those with a high burden of comorbidity, they do not capture realistic assessments of risks and benefits for older adults.

“All the approaches that we currently have for rheumatoid arthritis care in [the ACR] guideline are mainly developed from data from middle-aged adults,” she says.

Additionally, Dr. Lee says a growing body of evidence suggests that as patients with RA enter remission they may not require the same maintenance dose of rheumatologic medications. Although she acknowledges these data have not yet crystallized into clinical practice guidelines, she encourages rheumatologists to recognize that because older adults are more prone to the negative effects of medications for rheumatic conditions, such as serious infections, than younger patients, it may be reasonable to taper or withdraw their RA treatment.

“As a community, we need more training in this area and [on] how to treat older adults,” says Dr. Lee. She points to the Geriatric 5Ms that specialists in geriatric medicine have put forth to guide the care of older patients: mind, mobility, medications, multi-complexity and matters most.⁶

During the pandemic, Dr. Lee helped form the ACR’s Aging Community Hub, which provided a space for rheumatologists to connect on these important issues. Although Community Hubs have been discontinued, the topics are now being incorporated into sessions during ACR Convergence 2023 focused on frailty. Also, Dr. Lee will be giving a presentation on Tuesday, Nov. 1, titled Geriatric Rheumatology: An Under-Represented Group. Her presentation will include a call to involve older adults in clinical studies to generate more age-specific evidence for their treatment.

References

1. Lee J, Singh N, Gray SL, et al. Optimizing medication use in older adults with rheumatic musculoskeletal diseases: Deprescribing as an approach when less may be more. ACR Open Rheumatol. 2022 Dec;4(12):1031–1041.
2. Bechman K, Clarke BD, Rutherford AI, et al. Polypharmacy is associated with treatment response and serious adverse events: results from the British Society for Rheumatology Biologics Register for rheumatoid arthritis. Rheumatology (Oxford). 2019 Oct;58(10):1767–1776.
3. O’Mahony D, Rochon PA. Prescribing cascades: We see only what we look for, we look for only what we know. Age Ageing. 2022 Jul;51(7):afac138.
4. By the American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2019 updated AGS beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019 Apr;67(4):674–694.
5. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2021 Jul;73(7):924–939.
6. Tinetti M, Huang A, Molner F. The geriatrics of 5M’s: A new way of communicating what we do. J Am Geriatr Soc. 2017 Sep;65(9):2115.