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.

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.

https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/acr2.11503