Guidelines for the Use of Conventional and Newer Disease-Modifying Antirheumatic Drugs in Elderly Patients with Rheumatoid Arthritis

Treatment strategies in the management of rheumatoid arthritis (RA) have significantly changed in the past decade. The early use of disease-modifying antirheumatic drugs (DMARDs) is the basis of this new treatment strategy. Because these agents alter the natural disease course of RA, early aggressive intervention results in better outcomes with respect to future structural damage and disability. The arrival of the 'biologic agents' era in rheumatology has further improved the therapeutic options in patients with RA. A significant portion of individuals with this ailment are elderly, with approximately one-third of patients experiencing their first symptoms after the age of 60 years. Yet, many elderly patients with RA do not receive optimal treatment. Although the reasons for this have not been completely defined, it seems clinicians are reluctant to use DMARDs in the elderly because of uncertainty regarding their efficacy and safety in this population. The aging process is associated with important changes in drug pharmacokinetics and pharmacodynamics. It appears that the former, mainly through decreased renal clearance, is responsible for an increased incidence of adverse effects with some DMARDs. The old are also more susceptible to infection than the young, making prevention of infectious disease through vaccination of particular importance; however, healthcare professionals should be aware that some DMARDs, including biologic agents, may interfere with responses to vaccination. The available data, although limited, suggest that DMARDs, including some biologic agents, are similarly effective in the old and the young, while maintaining very good adverse effect profiles. Therefore, the elderly with RA should not be excluded from receiving optimal treatment with these medications. At the same time, clinicians must be aware of the possible increased risk of drug toxicities, recognize the need to adjust therapy to match individual patient characteristics (i.e. renal function, co-morbidities, concomitant medication use or polypharmacy), and use the lowest possible effective dosage. This review describes the special considerations to be taken into account when administering conventional (synthetic) or biologic DMARDs to elderly patients with RA.