Older rheumatoid arthritis patients deprived of advanced therapies

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An estimated 1.3 million Americans suffer from rheumatoid arthritis, an inflammation of the joints that can leave patients disabled and suffering in severe pain, sometimes with terrible morning stiffness that can last for hours. But while older patients tend to have a more advanced form of the disease, it seems they are less likely to receive the latest, most effective and safer drug therapies than their younger peers, according to a study presented at the American College of Rheumatology meetings in Washington last week.

The authors, based at several medical centers in northern Sweden, studied the course of rheumatoid arthritis among 950 patients consecutively diagnosed and followed prospectively for disease activity, treatment, and co-morbidities (other illnesses), including mortality, every five years via survey. The patients median age was 58, and two-thirds were female which is the typical gender distribution of rheumatoid arthritis.

Among the patients over age 58, activity and prognosis criteria were significantly worse, or more advanced, than among the younger patients. Further, the older patients were less likely to be treated with disease-modifying agents and biological agents, such as methotrexate and immunomodulators (Enbrel and similar powerful drugs shown to suppress rheumatoid arthritis activity), and more likely to be on high doses of corticosteroids, which have a high risk of adverse effects.

The lead author, Dr. Lena Innala, said that these findings imply that doctors caring for older rheumatoid arthritis patients may be hesitant to treat such patients aggressively, despite the high risk of disability, due to fear of adverse effects including infections. She perceived this as an inequality in treatment approach, and added that relying on steroids instead of newer disease-modifying drugs runs a real risk of increasing cardiovascular effects, diabetes and osteoporosis, when active rheumatoid arthritis is already known to be a risk factor for premature death.

ACSH's Dr. Gilbert Ross, who practiced rheumatology when he was an active clinician, was distressed by these findings. Active rheumatoid arthritis is a devastating disease, with often gradual decline into severe disability and premature mortality. There is no reason clinically why older patients should be deprived of the modern, more effective and safer therapies, such as tumor-necrosis factor blockers, out of an excess of caution. Allowing them to suffer the ravages of inadequate treatment and steroid side effects is inexcusable.