A graphic of a patient visiting a physician for rheumatoid arthritis. CREDIT Jacob Dwyer, Michigan Medicine

Despite guidelines that call for early and aggressive treatment of rheumatoid arthritis, a new study suggests many older adults are not prescribed disease-modifying medications for their inflammatory autoimmune disease.

Researchers at Michigan Medicine used the National Ambulatory Medical Care Survey to analyze all ambulatory visits for rheumatoid arthritis by adults 65 years of age and older, representing 7.8 million visits from 2005 to 2016. They found that only 45% of patients were prescribed disease-modifying antirheumatic drugs, like methotrexate, which are used to treat inflammation caused by several diseases. The results are published in ACR Open Rheumatology. 

“These medications have really changed the landscape of rheumatology, allowing low disease activity and remission to be achieved in people with rheumatoid arthritis, and now there needs to be a shifting consideration of how we can better target their use among older adults,” said Jiha Lee, M.D., M.H.S., lead author of the paper and a rheumatologist at U-M Health. “The prescription rates for these disease-modifying drugs have improved over the past few decades, but there is more work to be done to ensure older adults are on optimized treatment.”

One in four patients observed in the study visited primary care physicians for their rheumatoid arthritis, while the others were seen by rheumatologists. Those physicians prescribed disease-modifying antirheumatic medications in 30% of visits, compared to 56% by rheumatologists.

Data from the 1990s and early 2000s estimate these drugs were prescribed to fewer than 30% of older adults with rheumatoid arthritis. Researchers say the rise in prescriptions likely reflects a shift towards early treatment and expanded Medicare coverage. Despite this recent increase, Lee says, prescription practices of both rheumatologists and primary care physicians fall below the standard set by the American College of Rheumatology, which advocates that most rheumatoid arthritis patients receive some form of disease-modifying antirheumatic drugs.

“When you look at younger adults with this condition, more than 70 to 80% are on some form of treatment,” said Lee, who is also an assistant professor of rheumatology at University of Michigan Medical School. “Prescribing for older adults is challenging because polypharmacy and multimorbidity are common, and this population is more prone to the negative effects of disease-modifying drugs. However, we should be cautious older adults do not experience more pain and deformities that really limit their functioning because of undertreatment.”

Around 20% of patients not prescribed disease-modifying antirheumatic drugs took only steroids for their rheumatoid arthritis, which is known to cause pain and stiffness in the joints. Experts advise against the use of steroids, which can increase the possibility of gastric ulcer, poor glycemic control, and osteoporosis and subsequent fracture. 

Disease-modifying antirheumatic drugs also come with potential drawbacks. They are considered immunomodulatory or immunosuppressant medications; as they combat inflammation caused by the disease, they stifle the immune system and increase the risk of serious infections. The benefits provided by these medications, Lee says, need to be carefully weighed against their risks, especially in older adults.

“This study highlights the important role that rheumatologists play in providing optimal treatment for the older rheumatoid arthritis patients,” said Raymond Yung, M.B., Ch.B., co-author of the paper and chief of the Division of Geriatric and Palliative Medicine at U-M Health. “Unfortunately, the results also shows that ageism continues to exist in our health systems that has impacts on the care that patients receive.”

The findings come at a time in which rheumatologists are in high demand. In many regions, access to rheumatologists is limited, as the field contends with a shortfall in the workforce. For this reason, Lee says, primary care physicians also play an important role in recognizing the symptoms for early diagnosis, making referrals to rheumatologists and, at times, initiating treatment for older adults with rheumatoid arthritis.

“The world population is aging, and rheumatologists must be prepared to care for older adults with rheumatic diseases while addressing additional diseases and medications they may have,” she said. “We can work more closely with primary care providers and learn from our colleagues in geriatrics and adopt age-friendly approaches to improve prescribing practices for older adults with rheumatoid arthritis.”

Dr Björn Svensson, Rheumatology, University of Lund, Sweden, will today present a study which shows significant differences in the remission rates between women and men diagnosed with rheumatoid arthritis (RA).

Remission means a condition with little or no evidence of ongoing disease and as there is no cure to rheumatoid arthritis, this is currently the treatment goal of the disease. Dr Svensson and his research team analyzed the frequencies and predictors of remission in a large patient group observed for five years in a structured follow-up programme. During the period September 1995 to September 1999, 689 patients were included in a multicentre follow-up programme for patients with recent onset RA (disease duration < 1 year). The frequency of remission was studied after 2 and 5 years respectively.

In patients overall, 37.9% were in remission after the 2-year follow-up, while 38.5% were in remission after 5 years. However, only 32% and 31% of the women were in remission at 2 and 5 years respectively, versus 49% and 52% of the men.

Importantly, the female group in the study did not have explicitly different disease activity at treatment start compared to the male group. The results could not be explained by different treatment approaches as DMARDs and glucocorticoids were given similarly and as early to women as to men. Nor did patients age influence since the younger women and men were in remission as often as the older.

The causes of rheumatoid arthritis are unknown, but are predicted to be rather complex. However some of the factors that might play a role in the development of the disease are infections, genetics and gender, as shown in this study.

“The study showed that the disease course of the women examined was considerably worse than for the men. The reason for this gender discrepancy found in this study are at present unclear and will need further investigations”, said Dr Svensson. “However, the data seems solid enough to call for reinforced attention in the frequency and quality of follow-up in order to achieve an optimal suppression of the inflammatory process in all patients, regardless of gender”, he added.

Arthritis, in particular rheumatoid arthritis (RA), has devastating effects on the body, causing many debilitating effects and leaving many patients immobile or able to function normally. However, there are also some additional effects associated with the disease which are less well known, but just as threatening. A number of studies presented at the Annual European Congress of Rheumatology provide new data on the risks of cardiovascular diseases for RA patients, as well as some of the risks associated with the new therapies in the area, that are just beginning to emerge.

INCREASED HEART ATTACK RISKS IN RA PATIENTS DESPITE CHANGES IN DISEASE MANAGEMENT

Today (Friday 23 June), Dr. Ulf Bergström will present the results of a study showing that, despite changes in the management of rheumatoid arthritis in the last 20 years, there is no significant impact on co-morbidity related to cardiovascular diseases, in particular, related to myocardial infarction (heart attack).

As recognized by the investigators, patients with rheumatoid arthritis (RA) have a shortened lifespan when compared to people with same gender and similar age and recent studies suggest that this is largely due to increased mortality from premature cardiovascular disease, in particular myocardial infarction. As the medical field has gained a better understanding of rheumatoid arthritis, the management of it has changed significantly in terms of medical treatments and physiotherapy.

The study evaluates the effects of the changes in management of RA on the cardiovascular morbidity and mortality in patients with established RA during 1978 to 2002, by analyzing two separate patient studies from 1978 and 1995 (with an 8 year follow-up), and compared to the corresponding background population. The study found no significant changes in the cardiovascular morbidity between the two studies (standardized mortality ratios: 158 (CI: 111-225) and 168 (CI: 118-232) for the 1978 and 1995 cohorts respectively).

“The management of the disease has changed significantly over the decades and this study gives excellent measurement into whether this has had an improvement on cardiovascular events experienced by RA patients”, said Dr. Bergström. “It shows that further action is necessary in order to reduce additional mortality in RA”.

This study also highlights the need for further data on whether newer treatment options, such as TNF inhibitors that were introduced in Europe at the beginning of the millennium and therefore did not have a significant role in this study, will have an effect on cardiovascular events for RA patients in the future.

TNF INHIBITORS REDUCES THE RISK OF SERIOUS CARDIOVASCULAR EVENTS IN RHEUMATOID ARTHRITIS PATIENTS

Dr. William Dixon presented the results of a new study today (Friday 23 June) at the Annual European Congress of Rheumatology in Amsterdam, which shows encouraging data that treatment with TNF inhibitor reduces the risk of Myocardial Infarction (MI) and Cerebrovascular Accidents (CVA) in rheumatoid arthritis (RA) patients, when compared to patients treated with traditional DMARDs.

Recent studies suggest that the excess of deaths in rheumatoid arthritis patients is largely due to increased mortality from premature cardiovascular disease. Dr. Dixon comments, “It is already known that TNF inhibitors reduce the risk of cardiovascular events in RA patients, including less serious events. But this study has suggested that they specifically reduce the risk of myocardial infarction and cerebrovascular accidents, which are two of the most serious cardiovascular events, often leading to death”. He added, “This study shows encouraging results for people with RA which could potentially reduce the mortality amongst these patients.”

TNF inhibitors are a new class of drugs available for the treatment of severe rheumatoid arthritis. The drugs work by blocking the action of TNF (tumour necrosis factor), a molecule responsible for increasing levels of inflammation in people with rheumatoid arthritis. “The reason why the TNF inhibitors have shown to reduce the risk of MI and CVA could be that the events are caused by inflammatory factors, which is reduced by the TNF inhibitors’ anti-inflammatory effects”, said Dr. Dixon.

INCREASED RISK OF SERIOUS INFECTIONS WITH TNF INHIBITOR TREATMENT

Treatment with TNF inhibitors might increase the risk of common serious infections, according to a new study, presented at the Annual European Congress of Rheumatology in Amsterdam by Dr. Johan Askling on Friday (23 June).

As recognized by the investigators of the study, it is already established that TNF inhibitors increases the risk for intracellular infections such as TB. The risk for much more common, yet still serious, infections remains less clear. Studies from clinical practice have shown mixed results, and taken together, clinical trials indicate the possibility for a risk increase of clinical significance.

The infections that were included in the study were respiratory, septicaemia, articular, gastrointestinal, cutaneous, or other infections leading to hospitalisation.

Based on 422 hospitalizations with infection, the study concluded that, if treated with TNF inhibitors, the patients experienced a 20 to 30%-increase in risk of hospitalizations related to infections.

“The reason for this drug-related increase in risk of infections is not yet clear, although our results demonstrate a lower degree of risk increase than what was recently suggested based on trial data. However, since part of the drugs’ very action is to interfere with the body’s normal defense against infections, some degree of risk increase is fully conceivable”, Dr. Askling said. “TNF inhibitors drugs have showed great effectiveness for many patients and is an excellent example that raises the discussion of whether, or when, the benefits the drugs outweighs any risks associated with them”, Dr. Askling added.