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Elderly Onset Rheumatoid Arthritis
Elderly onset Rheumatoid Arthritis (EORA) is the development of RA in persons older than 60 years.
It is characterized by acute onset, pronounced elevations in ESR, disabling morning stiffness and marked pain predominantly affecting the upper extremities. The physical examination is remarkable for synovitis of the shoulders, wrists, MCP and PIP joints, with marked limitation of range of motion. Some investigators have stressed the involvement of large joints as a striking feature of EORA. Also, EORA has a lower female/male ratio.
Diagnostic testing has some particularities in EORA. The diagnostic value of RF is limited among older persons, whereas anti-CCP antibody may be a more specific marker in this population. Although an elevated ESR may be useful in establishing disease activity, it may be misleading in the elderly because it is often associated with other factors, such as anemia, infection, congestive heart failure, hypercholesterolemia and malignancy.
Radiographic evaluation is seldom helpful as a diagnostic test in older patients who have recent symptoms. In early disease, soft tissue swelling and periarticular osteopenia are common. The diagnostic imaging procedure of choice is probable magnetic resonance imaging and musculoskeletal ultrasonography with power Doppler.
Significantly higher Interleukin-6 and lower TNF-alpha levels have been found in patients with EORA as compared to younger patients.
Differential diagnosis can sometimes be challenging. The differential diagnoses include Polymyalgia Rheumatica (PMR), monosodium urate, or calcium pyrophosphate dehydrate crystal-induced inflammatory arthritis, inflammatory osteoarthritis, remitting seronegative symmetrical synovitis with pitting edema (RS3PE), occult malignancy, thyroid disease, arthritis associated with infections such as septic arthritis, hepatitis B and C and immunodeficiency virus. Tuberculosis and fungal infections also can present with inflammation in many joints. Endocrine disorders such as diabetes and Cushing’s disease also may present with diagnostic challenges.
PMR may have overlapping symptoms with sero-negative EORA. The absence of pain and morning stiffness in the neck, shoulders and pelvic girdle as well as the absence of significant constitutiona symptoms (i.e. malaise and fatigue) does not support the exacerbation of PMR.
RS3PE resembles seronegative EORA but has a self-limited course and responds to a low dose of corticosteroids.
The treatment of EORA presents special challenges. First, a patient with RA past the age of 60 probably has other medical conditions. Second, they are probably on multiple medications. The diagnosis may be confounded by the fact that both ESR and rheumatoid factor can be elevated in older patients who don’t have RA. Finally, treatment with medications needs to be tempered with the knowledge that potential side effects may be increased in this population where the drug metabolism is less certain than that of younger patients.
Nonetheless, the approach to therapy for patients with EORA is not substantially different from the treatment strategies employed for younger patients.
Non-steroidal anti-inflammatory drugs (NSAIDS) are often used early or in younger patients. However, in older patients who may develop kidney and liver toxicity with these drugs, the use of NSAIDS is probably a strategy that has to be watched closely. Low dose prednisone (5-10 mgs) given as a single morning dose provides symptomatic relief and can serve as a “bridge” until the effects of second line agents begin. The potential complications of long-term prednisone therapy will be more concerning in elderly patients than in younger patients.
Second line agents consist of two groups. They are disease-modifying anti-rheumatic drugs (DMARDS) and biologic drugs. DMARDS such as methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide are all potentially useful, but potential toxicities need to be monitored for carefully.
Biologic therapies also can be helpful for patients with EORA. TNF inhibitors are all effective and well tolerated in the older population with rheumatoid arthritis. Second line biologics such as rituximab and abatacept also have been used in patients with EORA, however, experience with Actemra and IL-6 inhibitor is limited.
Advancing age should not, by itself, be a contraindication to the use of biologic therapies. The aim for older patients, as with younger patients, is to establish remission. This may be even more important in older patients since independence is cherished more. Finally, since cardiovascular events are an established complication of rheumatoid arthritis and also are more common in older adults, every effort should be instituted to establish and
Dr. Gheorghe Ignat is a board-certified rheumatologist on the Medical Staff of Southwest General. He has special medical interests in rheumatoid arthritis, connective tissue disease and osteoporosis.
MD News November/December 2011, Cleveland/Akron/Canton