Management of Inflammatory Rheumatic Conditions in the Elderly

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


Rheumatology. 2019;58(5):748-764. 

In This Article

SpA and PsA

Specificities of Initial Presentation in the Elderly

Only 5% of SP patients are >50 years of age. These late-onset SP cases may present distinctive characteristics: constitutional signs, cervical involvement, predominant peripheral arthropathy of the upper and lower limbs and more frequently mixed forms, namely axial and peripheral joint disease.[91–93]

Data on elderly patients mostly concern PsA, which occurs in 6–42% of psoriasis. Although arthritis may precede the onset of psoriasis by many years, the common scenario is that the onset of psoriasis is 10 years before PsA.[94] PsA has a more severe onset and more destructive outcome in the elderly than in younger subjects.[95] Elderly-onset PsA patients are characterized by higher rates of fatigue, pain scores, comorbid diseases and acute phase reactants and less dactylitis and nail involvement than young-onset PsA.[96]

PsA is associated with increased mortality, most commonly with cardiovascular causes.[97] PsA, as well as ageing and tobacco use, is an independent risk factor of subclinical atherosclerosis (explored by intima–media thickness).[98] Patients with AS also exhibit a higher risk of myocardial infarction and stroke,[99] but no specific study has addressed elderly patients. Yet, screening for cardiovascular risk factors by physicians proves insufficient,[100] resulting in under-treatment.[101]

PsA patients exhibit a higher risk of opportunistic infections and haematological cancer[102] than matched controls, partly linked to immunosenescence.[103] In the CORRONA registry, the adjusted incidences of overall malignancy and cancer subtypes, including non-melanoma skin cancer and lymphoma, were similar in PsA and RA patients, increasing with age, without a significant difference between csDMARD and boDMARD cases.[104] PsA also potentiates the risk of osteopenia, osteoporosis and pathological fractures in the elderly.[105]

Age and Treatment Effectiveness

Therapeutic efficacy and safety data in elderly PsA patients are limited (Table 2).[106,107] The efficacy of csDMARDs could be lower than that of boDMARDs in the elderly.[108] Biologics and conventional systemic therapies appear to be as effective in the elderly as in adult patients with moderate-to-severe Pso.[109–111] In a conflicting study involving 146 consecutive PsA patients initially undergoing TNFi treatment, age inversely correlated with minimal disease activity at 3 months.[112] Most authors reported a favourable risk/benefit ratio for long-term use of TNFi therapy in elderly Pso patients.[110,113,114]

Age and Adverse Drug Reactions

Data concerning the effect of age on the occurrence of AEs, including infection rates for both biologics and conventional systemic treatments, appear to be inconsistent,[103,109,115] whereas conventional systemic treatments are more frequently discontinued in the elderly due to AEs compared with biologics. Similar to RA, TNFi exhibit an increased risk of reactivating latent tuberculosis in Pso patients, thereby requiring adequate screening and prevention strategies.[116] In AS, the risk of tuberculosis is elevated during TNFi therapy, and BMI <22 kg/m2 is a significant risk factor in this complication.[68] In a large-scale US cohort, the use of TNFi was not associated with increased mortality in patients with Pso, PsA or AS compared with non-biologic therapies, regardless of the drug used, even after 75 years.[64] In the DANBIO registry, patients on TNFi therapy for PsA or AS did not exhibit an increased incidence of cancer compared with TNFi-naïve patients, regardless of age.[65] Recently, ustekinumab has exhibited adequate efficacy and safety.[117,118] In the Psoriasis Longitudinal Assessment Registry (38% of PsA), long-term (≥12 months) treatment with a TNFi, but not MTX and ustekinumab, seemed to increase the risk of malignancy.[119] However, larger sample sizes and longer observation duration will be required to confirm the safer profile of ustekinumab compared with other TNFi in elderly Pso patients.

Despite the limited data on biologic drugs (Table 2), biologics seem to be an effective and safe alternative to conventional systemic agents in the elderly PsA population.

Place of the Elderly in the Recommendations

Three recommendation sets for PsA management have been published in the past 2 years.[120–122] Though no reference has been made to age, the impact of disease on pain, function, HR-QoL and other potentially related conditions (e.g. cardiovascular disease, malignancy, osteoporosis), as well as drug-related risks, should be considered in order to determine individualized targets. All guidelines recommend multidisciplinary and multispecialty assessment and management. In the UK guidelines of the British Association of Dermatologists concerning Pso, age, history and comorbid conditions should be considered when choosing the optimal biologic therapy, with no more details given.[123]