Are Older People With Rheumatoid Arthritis Undertreated?

If you are over the age of 65 and have rheumatoid arthritis (RA), your physician may not be treating you as aggressively as recommended by American College of Rheumatology (ACR). Rheumatoid arthritis is a progressive disease; early, aggressive treatment can reduce symptoms such as fatigue and prevent irreversible joint damage.

Are DMARDs Underused in Older Adults?

The University of Michigan Medicine research team analyzed almost eight million ambulatory visits by patients aged 65 and older for RA. “We discovered that while the guidelines recommend that everybody with the RA diagnosis should be on some form of treatment, less than half of older adults are on any form of treatment, which is lower than what we expect,” says Jiha Lee, MD, a rheumatologist at University of Michigan Health in Ann Arbor and the lead author of the study.

“In the younger population, that number is closer to 80 percent. There is undertreatment overall with the DMARDs. Even among those, the biologics are the newer medications that have significantly changed the outcomes with rheumatoid arthritis, and that are prescribed in fewer proportions in older adults,” she says. The study concluded that “DMARD use for older adults with RA remains low from both rheumatologists and PCPs [primary care physicians], including biologic DMARDs, even though American College of Rheumatology guidelines recommend earlier and more aggressive treatment of RA.”

“If the disease is less than treated, there's a slew of consequences that can happen with that. The most obvious ones are decreasing quality of life, increase in depression rate, increase in pain. I think it's really one of the things that we should pay attention to,” says Vinicius Domingues, MD, a rheumatologist from Daytona Beach, Florida.

What Is Behind the Discrepancy in Treatment of Older vs. Younger People?

Concerns that affect the treatment of older adults include the following.

• Older people tend to be on more medications, so there is a greater chance of drug interaction. Some doctors and patients may be hesitant about adding more drugs to the regimen.
• Biologics tend to depress the immune system, which can be concerning for people who have other underlying diseases (comorbidities) and may be at greater risk of infection as they age; as we age, our immune system is not as strong and equipped to fight infection. A review of research found that older people with immune-mediated diseases who were on a biologic were three times more likely to have an infection than those not on a biologic.

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• Older patients may be less inclined to make changes to their treatment.
• Insurance coverage can be a major barrier to care as certain plans don’t cover biologic medications.

Older People With RA Need Aggressive Treatment, Too

“There are a lot of other factors that play into this that have yet to be further understood. But that doesn't mean that older patients should be receiving less aggressive treatment if there are better outcomes to be achieved,” says Lee.

Dr. Domingues agrees, “The risk of side effects increases as you get older, so physicians often want to protect these patients, but actually, you're doing a disservice to them if you don't treat the disease.”

Make Informed Decisions and Advocate for Yourself

Older people diagnosed with RA may need to advocate for themselves — and educate themselves — in order to make informed treatment decisions with their doctors. “You have to voice your concerns about trying to differentiate what is inflammatory arthritis, and what is osteoarthritis, regardless of age. You should mention to your doctor if treatment is not working, and you're still [experiencing] joint pain, joint stiffness, and joint swelling,” says Domingues.

Treatment decisions should be the result of a shared decision-making process that involves both patients and rheumatologists. Domingues says that doctors should outline the benefits and possible risks of certain treatments to the patient, who ultimately makes the decision. Your doctor should also be able to present you with alternatives if the potential side effects of a medication concern you.

Lee urges seeing a rheumatologist over a primary care practitioner, if you can. “Seeing your primary care doctor can help achieve early diagnosis, but they're not the ones who should be responsible for prescribing the DMARDS. It’s always much appreciated when they do, so there is early treatment, but they should be referring you to a specialist,” says Lee.

Lee adds, “We see patients in the office visits, but patients live with this on a day-to-day basis. [If they are] more aware and informed about their symptoms and can communicate back to the physician, that is going to really help inform how to optimize medication use.”