Treatment of Rheumatic Diseases in the Elderly: Minimizing Harm, Maximizing Benefit

May 25, 2013

Mala Joneja, MD MEd FRCPC

• Identify factors that contribute to risk in the medical treatment of Rheumatic Diseases in the elderly population

• Identify risks associated with specific pharmacological interventions in the elderly

• Be aware of practice strategies to minimize risk in elderly patients

2

Learning Objectives

• Not applicable

Disclosures

Focus on RA

‘Elderly’ is in the eye of the beholder-chronological age vs. biological age-importance of comorbid disease, polypharmacy

Reflect on your personal experience

Discuss with colleagues

A couple of stories…

IntroductionsQuestion 1Reporting on question 1Summary

Question 2Reporting on question 2Summary

Question 3Reporting on question 3Summary

Closing

Workshop Format

7

Question 1

What are three challenges that you face in treating elderly patients with Rheumatoid Arthritis?

Question 1:

Treatment Issues in Elderly Patients

Question 1 Reporting – see flip chart

EORA = onset after 60 years of age

But also consider YORA who age – Patients who developed RA at an age<60, growing into older years

Frail elderly

Different paths to RA in older adults:

Rheumatoid Arthritis in Older Adults

Clinical Features of Elderly Onset Rheumatoid Arthritis

Age of onset >60 yrMale:female ~1:1Acute presentationOligoarticular (two to six joints) diseaseInvolvement of large and proximal jointsSystemic complaints, e.g., weight lossAbsence of rheumatoid nodulesSicca symptoms commonLaboratory: high erythrocyte sedimentation rate; often negative rheumatoid factor

Elderly Onset Rheumatoid Arthritis

• Elderly are a heterogeneous group• Pharmacokinetics=relationship between drug input and

concentration of drug achieved over time• Most consistent change in pharmacokinetics in older

adults=increase in interindividual variability• Reduced hepatic clearance and renal clearance• Decrease in GFR, though extent is unclear• No drugs are contraindicated because of age

Drug Treatment in the Elderly

Drug Metabolism

• Occur more frequently• Often more severe• Sometimes delayed recognition – under-recognition of ADRs

as being related to medication• Increased vulnerability due to comorbidity, altered

pharmacokinetic changes and polypharmacy (resulting in drug-drug and drug-disease interactions)

• Account for 5-10% hospitalizations• Important cause of morbidity and mortality

In the Elderly

Adverse Drug Reactions

• Also decline in physical function and high risk of death• A key feature is loss of lean muscle mass• Associate with many risk factors for adverse drug events

including: sarcopenia, less physiologic reserve, polypharmacy, compliance issues, hospital admissions

Definition – high susceptibility to disease

The Frail Elderly

• EORA itself• Disease duration• Concomitant OA, cardiac disease, lung disease, neuro

disease• If functional disability is increased in elderly patients,

should we not treat their RA as aggressively as possible?

Complex Interaction of Factors

Functional Disability

Cognitive ImpairmentDepressionFallsIncontinenceMalnutrition

What are these?

Geriatric Syndromes

• Increased risk in RA• Increased frequency of comorbidities• Multiple risk factors• Mortality risk• Interruption of treatment

Increased risk

Infections

Question 1: Summary

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Question 2

Is your approach to the use of traditional DMARDs such as MTX, LEF, SAS and HCQ different in the elderly RA patient?

Is your approach to the use of biologic treatment different for elderly RA patients?

How?

Question 2

Medications and Monitoring in the Elderly

Question 2 Reporting – See Flip Chart

• MTX clearance decreases with decline in creatinine clearance

• Dose adjustments required in patients with renal impairment, elderly included

• NSAIDs may reduce creatinine clearance, displace MTX• Age does not affect MTX efficacy• Bone marrow toxicity and CNS disturbances• Prolonged use with steroids can result in bone loss

Methotrexate – DMARD of Choice

Methotrexate

• Recommended for use in elderly patients• Lower dose recommended• Combination therapy with MTX has not been studied in the

elderly• Some authors report a higher risk of pancytopenia with LEF

and MTX combination• HTN is common adverse effect

Monotherapy and Combination Therapy

Leflunomide

• Safe alternative to MTX

Sulfasalazine

• No suggestion that efficacy declines in age• Kidneys are main route of elimination• Retinal toxicity

Hydroxychloroquine

• Anti-TNF agents• Rituximab• Access - drug reimbursement, risk of toxicity

Biologic Therapy in Elderly RA Patients

Safety of Novel Immunomodulatory Therapies: Optimizing Treatment

Stratify: Identify the patient's risk of adverse effects based on various factors, such as comorbidities (e.g., chronic obstructive pulmonary disease and diabetes mellitus), age, concomitant medication use, and a history of similar events (e.g., opportunistic infection).Assess: Evaluate the patient for important risks (e.g., exposure to tuberculosis or hepatitis B or C virus infection, vaccination status, and status of comorbid conditions).Fend off: Optimize the patient's health before treatment (e.g., wherever possible, vaccinate against infections and treat and/or control the patient's comorbidities).Evaluate: Quickly evaluate adverse events, remembering that both typical and atypical presentations may be seen.Treat: Aggressively manage adverse events to help minimize their severity.Yearly: Reevaluate the patient on a regular basis.

Adapted with permission from Hennigan S, Kavanaugh A. Optimizing the use of TNF- inhibitors. J Musculoskel Med. 2007;24:293–298.

Question 2 - Summary

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Question 3

How would you conduct a chart audit of elderly RA patients, as a quality assurance exercise, to ensure they are receiving optimal treatment?What factors would you assess?

Question 3

Maximizing Effectiveness and Minimizing Harm

Question 3 Reporting – See Flip Chart

• Patients with EORA receive biological treatment and combination DMARD treatment less frequently

• Despite identical disease duration and comparable disease activity

• Lower doses of MTX• Greater use of prednisone• Not necessarily due to age bias, but perhaps good clinical

practice

EORA vs YORA patients

Treatment of Elderly RA Patients

• Getting older, and older• Not seeing a Rheumatologist• However, database studies can’t always capture potential

contraindications and the individual patient’s personal preference

Not getting a DMARD …

Treatment of Elderly RA Patients

Question 3 Summary

Conclusion

Thank you!

Special thanks to Dr. Henry Averns, Queen’s University

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