If you are over the age of 65 and have rheumatoid arthritis (RA), your physician may not be treating you as aggressively as recommended by American College of Rheumatology (ACR). Updated in 2021, the guidelines endorse early treatment with DMARDs (disease-modifying antirheumatic drugs), medications that help decrease pain and prevent joint damage. However, a study published in ACR Open Rheumatology in January 2022, conducted by researchers at University of Michigan (UofM) Medicine, found that older people were receiving this treatment in far fewer numbers than younger people who had RA.
Rheumatoid arthritis is a progressive disease; early, aggressive treatment can reduce symptoms such as fatigue and prevent irreversible joint damage.
Are DMARDs Underused in Older Adults?
The research team used the National Ambulatory Medical Care survey to analyze almost eight million ambulatory visits by patients aged 65 and older from 2005 to 2016 for RA, an inflammatory autoimmune disease that affects more than one million Americans. “We discovered that while the guidelines recommend that everybody with the RA diagnosis should be on some form of treatment, less than half of older adults are on any form of treatment, which is lower than what we expect. In the younger population, that number is closer to 80 percent. There is undertreatment overall with the DMARDs. Even among those, the biologics are the newer medications that have significantly changed the outcomes with rheumatoid arthritis, and that are prescribed in fewer proportions in older adults,” says Jiha Lee, MD, MHS, a rheumatologist at UofM Health and lead author of the study.
It concluded, “DMARD use for older adults with RA remains low from both rheumatologists and PCPs [primary care physicians], including biologic DMARDs, even though American College of Rheumatology guidelines recommend earlier and more aggressive treatment of RA.”
Rheumatologists, as Well as Primary Care Doctors, May Underuse DMARDs
Also of interest is that 74 percent of the visits were with rheumatologists; the rest were with primary care physicians PCPs. The study found that “any DMARD use was recorded at 56 percent of rheumatologist and 30 percent of PCP visits. Among visits with any DMARD use, 20 percent of rheumatologist visits had two or more DMARDs compared with 6 percent of PCP visits.”
Undertreated RA Increases Likelihood of Disease Activity, Irreversible Joint Damage, Other Problems
“If the disease is less than treated, there's a slew of consequences that can happen with that. The most obvious ones are decreasing quality of life, increase in depression rate, increase in pain. I think it's really one of the things that we should pay attention to,” says Vinicius Domingues, MD, rheumatologist from Daytona Beach, Florida, and medical advisor to CreakyJoints.
What Is Behind the Discrepancy in Treatment of Older vs. Younger People?
Dr. Lee theorizes that the difference in prescribing can be due to several factors, one of which is ageism. She points to research published in Rheumatology, where rheumatologists were presented with the same clinical scenario of an RA patient, only changing the ages. When the same disease script was for an older patient, the rheumatologists were less likely to suggest aggressive treatment. “There may be hesitancy on the patient side but there also may be the same hesitancy on the physician side,” she says.
Other concerns are:
- Older people tend to be on more medications, so there is more chance of drug interaction. Some doctors and patients may be hesitant about adding more drugs to the regimen.
- Biologics tend to depress the immune system, which can be concerning for people who have other underlying disease.
- Older patients may be less inclined to make changes.
Older People With RA Need Aggressive Treatment, Too
“There are a lot of other factors that play into this that have yet to be further understood. But that doesn't mean that older patients should be receiving less aggressive treatment if there are better outcomes to be achieved,” says Lee.
Dr. Domingues agrees, “The risk of side effects increases as you get older, so physicians often want to protect these patients, but actually, you're doing a disservice to them if you don't treat the disease.”
Doctors Must Initiate Treatment Discussion, Patients Should Aim to Make Informed Decisions
“Doctors need to get patient-informed consent. Outline to the patient the benefits and possible risks. If the answer is yes, you move forward. If the answer is no, you try to find an alternative medication that has less side-effect profile. And if nothing is achieved, then again, it's the patient decision at the end of the day, but you have to include them into the conversation,” explains Domingues.
Treatment From Rheumatologist vs. Primary Care Doctor
As noted earlier, PCPs tend to underprescribe for RA significantly more than rheumatologists. Lee urges seeing a rheumatologist over a PCP, if you can. “Seeing your primary care doctor can help achieve early diagnosis but they're not the ones who should be responsible for prescribing the DMARDS. It’s always much appreciated when they do so there is early treatment, but they should be referring you to a specialist,” says Lee.
People With RA Must Self-Advocate
If you, as an older patient, feel your symptoms are not being well controlled, bring it up to your physician. If your doctor dismisses your concerns with “You’re 78, that’s what 78 feels like,” look for another doctor. Domingues says patients need to be empowered to speak for themselves. “You have to voice your concerns about trying to differentiate what is inflammatory arthritis, and what is osteoarthritis, regardless of age. You should mention to your doctor if treatment is not working, you're still complaining of joint pain, joint stiffness, and joint swelling. If your doctor continues not to listen, get a second opinion.”
Lee adds, “We see patients in the office visits but patients live with this on a day-to-day basis. The more aware and informed they are about their symptoms that they can communicate back to the physician is going to really help inform how to optimize medication use.”