Management of Inflammatory Rheumatic Conditions in the Elderly

Clément Lahaye; Zuzana Tatar; Jean-Jacques Dubost; Anne Tournadre; Martin Soubrier

Disclosures

Rheumatology. 2019;58(5):748-764. 

In This Article

Abstract and Introduction

Abstract

The number of elderly people with chronic inflammatory rheumatic diseases is increasing. This heterogeneous and comorbid population is at particular risk of cardiovascular, neoplastic, infectious and iatrogenic complications. The development of biotherapies has paved the way for innovative therapeutic strategies, which are associated with toxicities. In this review, we have focused on the scientific and therapeutic changes impacting the management of elderly patients affected by RA, SpA or PsA. A multidimensional health assessment resulting in an integrated therapeutic strategy was identified as a major research direction for improving the management of elderly patients.

Introduction

As a result of increasing life expectancy, risk transition and improved quality of care, the number of people living with at least one chronic disease is increasing.[1] Chronic inflammatory rheumatic diseases (IRDs) affect 2–3% of the general population, involving a non-negligible proportion of elderly subjects. Almost one-third of RA patients are >60 years of age, and elderly patients with IRDs are at particular risk for cardiovascular, neoplastic and infectious complications. Furthermore, IRD in the elderly may have a distinct clinical and biological presentation, with differing responses to treatment.

These features reflect the physiological changes (e.g. immunosenescence and alterations in pharmacokinetics) and comorbidities (diabetes, obesity, renal failure, etc.) associated with ageing, which vary widely from one individual to another.[2,3] Multimorbidity and polypharmacy, both of which are common in the elderly, are well-known risk factors for adverse drug reactions (ADRs) and interactions.[4]

In parallel with this epidemiological evolution, a new class of maintenance therapy agents known as biologics, which comprise specific antibodies with immunomodulating properties, has emerged, thereby expanding the therapeutic arsenal hitherto containing DMARDs, such as MTX, and anti-inflammatory drugs.

Paradoxically, elderly patients have mostly been left out of new therapeutic opportunities. Randomized controlled trials and prospective cohorts primarily recruit healthy or single-disease volunteers rather than elderly and comorbid patients.[5] Thus, the extrapolation of findings to real-life elderly patients may be compromised. Against this background, the novel mechanisms of action of biologics and paucity of literature specifically pertaining to the elderly have raised concerns about the safety of these new drugs, leading to more conventional therapeutic regimens in this population.

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