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5 Articles in this Series
ACR Releases Updated Draft Guidelines for Juvenile Idiopathic Arthritis (JIA)
Debate: When Methotrexate Fails – The Use of JAK or TNF Inhibitors
Pharmacotherapy & Rheumatic Disease in Older Adults
Rheumatoid Disease Therapy and Immunological Complications
When Rheumatoid Arthritis Treatment Gets Difficult: 3 Cases Offer Potential Solutions

Pharmacotherapy & Rheumatic Disease in Older Adults

An ACR Convergence 2020 Meeting Highlight with Ann Biehl, MS, PharmD, BCPS, Ananta Subedi, MD, Anna Khananian, MD, and Suraj Rajasimhan, PharmD


Older patients with rheumatic disease can pose a challenge to healthcare providers. Ideally, multidisciplinary care involving rheumatologists, primary care doctors, and other specialists can improve care and reduce adverse outcomes, according to speakers at the ACR Convergence 2020 session on "Pharmacotherapy Pearls for the Older Rheumatic Disease Patient."

With a broader range of treatment options for rheumatic diseases, clinicians must be aware of monitoring requirements and adverse reaction profiles for traditional oral disease-modifying anti-rheumatic drugs (DMARDs) as well as newer targeted DMARDs and biologic DMARDs.

In the virtual session, moderated by Ann Biehl, MD, Pharm D, an FDA epidemiologist the FDA, two speakers – Ananta Subedic, MD, of Wakemed Physician Practices, and clinical pharmacy specialist Suraj Rajasimhan, Pharm D, of the NIH Clinical Center – reviewed important terms to know, key changes that occur in older patients, and how all of this impacts safety and treatment.

Older Rheumatic Disease Patients: Physiologic Changes

Dr. Subedi started the talk by reviewing two important pharmacotherapy terms:

  • Pharmacokinetics – what the body does to a medication in terms of absorbing it, distributing it and metabolizing it and excreting it
  • Pharmacodynamics – what a medication does to the body, in terms of its biochemical and physiological effects

He also recapped the importance of paying attention to glomerular filtration rate (GFR) and creatine clearance.

As a person ages, physiological changes occur in renal function, hepatic function, and volume of distribution, he said. GFR and drug clearance are reduced ''and there is a faster decline in patients with inflammatory diseases.''

More than one-third of patients diagnosed with rheumatic disease are over age 60, according to Dr. Subedi, and it is, therefore, important to consider:

  • co-morbidities – older patients are more likely to have cardiovascular, neoplastic and infectious complications
  • polypharmacy and drug interactions
  • there may be different responses to therapy compared to younger patients.
  • there is less data from clinical trials that applies to older adults

When rheumatic disease strikes later in life, it may look different, he said. Onset may be abrupt and morning stiffness greater, for instance. A higher DAS28 is common as well as higher disability.

As for the treatment of RA in older patients, Dr. Subedi offered the following recommendations:

  • Good efficacy is found for methotrexate and leflunomide
  • TNF inhibitors offer similar efficacy but are more likely to be associated with infections
  • Abtacept has similar efficacy
  • Corticosteroids may have a higher rate of side effects including development of osteoporosis and infection
  • JAK inhibitors have good efficacy but obtaining vaccinations prior to therapy is crucial to prevent reactivation of herpes zoster (see a related ACR highlight on JAK inhibitors).

When ordering therapies, he said, the multiple comorbidities must be taken into account.

Biologic DMARDS tend to be underused in older adults, he said, while NSAIDs and corticosteroids are overused. Such practice is leading to higher adverse events in this population," he said. Don't choose a therapy based strictly on age, he added, a practice that is all too common.

Healthcare providers should also be aware of other challenges possibly facing older patients with rheumatic disease, including low income, poor social support, and cognitive impairment.

While older adults have a reputation for poor adherence to medication, Dr. Subedi said that ''busy middle-aged adults are more likely to be non-adherent. So we need to stop blaming just the age for medication noncompliance."

Pharmacotherapy Pearls for Treating Older Patients with RA

Among the special considerations in older patients to evaluate, Dr. Rajasimhan said, are decreased drug and metabolite clearance. It's important to monitor GFR and adjust doses of medication. Folate supplements may improve the tolerability of drugs. Bear in mind the older patient may be more sensitive to getting anemia. He highlighted a few pros and cons of common treatments.

  • sulfasalazine may lead to GI side effects
  • leflunomide, which has a similar safety profile in younger and in older adults, is key to monitor for hepatic toxicity; be aware of risks of hypertension and anorexia
  • JAK inhibitors generally lead to more adverse effects in older patients than in younger ones
  • As for the safety of bDMARDS, recent studies have shown that being over age 65 can be an independent risk factor for adverse events
  • Be aware of polypharmacy – about half of older adults take five or more medications daily.

Overall, "Review the medication list to see what patients are taking," he said. Be sure to ask about supplements –  the new trend is to call these '"proprietary blends” – and remind patients that the supplements have no FDA oversight, concluded Dr. Rajasimhan.

Expert Perspective

''The most important point to take from this lecture is to be aware of age bias that exists when treating [rheumatic] patients and try to avoid it as much as possible," said Anna Khananian, MD, a rheumatologist in Sonora, CA, and founder of www.MdNetWrk.com, an online community for physicians to network, collaborate and engage.

"The age bias manifests in the fact that elderly patents [with rheumatic disease] are being undertreated with DMARD, biologic and combination therapies and over treated with glucocorticoids and NSAIDS medications that actually carry a high risk of side effects in this population of patients."

The good news? "It's important to know that all DMARD and biologic medications showed efficacy in the elderly and with proper dosing, vaccination, and monitoring, one should optimize their use when treating rheumatic conditions."

More on osteoarthritis and ACR updated multimodal guidelines.



Lahaye C, Tatar Z, Dubost JJ, et al. Management of inflammatory rheumatic conditions in the elderly. Rheum. 2019;58(5):748-754.

Maher Rl, Hanlon J, Hajjar E. Clinical consequences of polypharmacy in elderly. Expert Opinion Drug Safety. 2014;13(1):57.

Curtis JR, Schulze-Koops H, Takiya L, et. al. Efficacy and safety of tofacitinib in older and younger patients with rheumatoid arthritis. Clin Exper Rheum. 2017;35(3):390-400.


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