Lack of Older Adults Included in Rheumatoid Arthritis Clinical Trials May Be Hampering Care

Few older adults are included in rheumatoid arthritis (RA) clinical trials, and as a result, rheumatologists lack guidance on how best to manage those with elderly-onset RA, according to rheumatologist Marloes van Onna, MD, PhD, who is with Maastricht University Medical Center, Maastricht, the Netherlands. A lack of clinical evidence is one of many significant barriers when it comes to providing optimal care for elderly-onset RA. Elderly-onset RA is defined as arthritis that has its onset after age 60.

“Today’s rheumatologists already made a shift from a traditional disease-centered approach to chronic care management. However, the biggest barriers to managing older patients [with RA] is that current RA treatment strategies might not be directly translatable to elderly patients with RA and comorbidity. Elderly patients with comorbidities are often excluded from intervention studies and are less likely to participate in observational cohorts,” Dr van Onna told Rheumatology Advisor.

She said that because the number of older people with RA will increase over the next decade, investigators should take “the complex treatment reality” of these patients into consideration when designing clinical trials. Managing older patients with RA is inherently more complex because these patients often face comorbidity and biologic changes typical of aging. Dr van Onna noted that these comorbidities can precede RA or accompany RA.

“Lack of insight might result in overtreatment, but also undertreatment of patients. To fill this gap, first, outcome measures should be validated for use in the elderly. Next, future clinical trials should take the complex treatment reality of these patients into consideration by including elderly patients and correcting for the effect of aging and comorbidity on RA-specific outcome measures. This may ultimately result in the development of recommendations that can guide rheumatologists when making complex management decisions,” she indicated.

A recent review article by Dr van Onna and her colleague Annelies Boonen states that cardiovascular disease (CVD), lung disease, malignancy, bone and muscle wasting, and neuropsychiatric disease all occur more frequently in those with RA compared with the general population.¹ The authors maintain that when factoring in comorbidities, it becomes apparent that a paradigm shift from a disease-centered to a goal-oriented approach is warranted. 

“Rheumatologists should be aware of this issue because in the future, elderly patients with [RA and] comorbidity will be the rule and not the exception. The most important message is that future research should focus on the complex interdependencies between RA, aging, and comorbidity. These findings can then be integrated into daily clinical practice by developing and testing integrated and coordinated healthcare services,” said Dr van Onna.

Older-Age Onset RA May Have Unique Profile

RA is a progressive disease, and therefore those with elderly-onset RA may be affected differently from those with younger-age onset. A recently published study found that large and small joints are affected initially at the onset of RA. However, those with early elderly-onset RA may have higher scores of disease activity and higher levels of acute-phase reactants than those with early younger-onset RA.² 

The study researchers classified patients into 2 clinical subsets: elderly-onset RA and younger-onset elderly RA. They found that tumor necrosis factor (TNF) inhibitors were equally or slightly less effective in older patients than in younger patients with RA. They noted that evidence is lacking for the use of non-TNF biologic disease-modifying antirheumatic drugs (DMARDs) in those with elderly-onset RA.