Elderly-onset rheumatoid arthritis

Trends in treatment for patients with late-onset rheumatoid arthritis in Japan: Data from the NinJa study

OBJECTIVES

Our objective was to investigate trends in the treatment of patients with late-onset rheumatoid arthritis (LORA) using data from the National Database of Rheumatic Diseases in Japan (NinJa).

METHODS

Patients registered in the National Database of Rheumatic Diseases in Japan were classified according to the disease onset: at <65 years (young-onset rheumatoid arthritis); at 65-74 years (early LORA); and at ≥75 years (late LORA). Chronological changes in the treatment and disease activity were compared.

RESULTS

A total of 7178, 13,171, 15,295, and 15,943 patients were evaluated in 2010, 2013, 2016, and 2019, respectively. In all groups, the use of methotrexate gradually decreased, whereas that of biological/targeted synthetic disease-modifying antirheumatic drugs (DMARDs) increased; the use of tumor necrosis factor inhibitors decreased, whereas that of non-tumor necrosis factor inhibitors increased. LORA was characterized by more single DMARD use and less methotrexate and biological/targeted synthetic DMARD use. Tumor necrosis factor inhibitors and interleukin-6 inhibitors were used less frequently, whereas abatacept was utilized more frequently in late versus early LORA. Conventional synthetic DMARD (excluding methotrexate) and glucocorticoid use was higher in late versus early LORA.

CONCLUSIONS

This analysis revealed chronological changes in the treatment of LORA in Japan. Differences between early and late LORA suggest that patients are not a homogeneous population.

Association of Hydroxychloroquine Use with a Dose-Dependent Decrease in Mortality Risk in Patients with Elderly-Onset Rheumatoid Arthritis

INTRODUCTION

Elderly-onset rheumatoid arthritis (EORA) is associated with an increased mortality risk; however, the effect of conventional synthetic, biologics or targeted synthetic disease-modifying anti-rheumatic drugs (csDMARDs, bDMARDs or tsDMARDs) on the EORA-specific mortality risk is unknown. In this study, we investigated the risk factors for all-cause mortality of patients with EORA.

METHODS

Data of EORA patients diagnosed with RA at age > 60 years between January 2007 and June 2021 were extracted from the electronic health record of Taichung Veterans General Hospital, Taiwan. Multivariable Cox regression was used to calculate the hazard ratio (HR) and 95% confidence interval (CI). The survival of patients with EORA was analyzed by Kaplan-Meier method.

RESULTS

Among the 980 EORA patients who were enrolled (survivors 852 and non-survivor 128), the significant mortality-associated risk factors [HR (95% CI)] included higher age (1.10 [1.07-1.12], p < 0.001), male sex (1.92 [1.22-3.00], p = 0.004), current smoker (2.31 [1.10-4.87], p = 0.027) and underlying malignancy (1.89 [1.20-2.97], p = 0.006). Hydroxychloroquine treatment conferred protection against mortality in patients with EORA (HR 0.30, 95% CI 0.14-0.64, p = 0.002). Patients with malignancy who did not receive hydroxychloroquine treatment had the highest mortality risk compared with their counterparts. Patients with a monthly cumulative dose of hydroxychloroquine dose < 1374.5 mg had the lowest survival rate compared to patients who received hydroxychloroquine 1374.5-5778.5 and ≥ 5778.5 mg.

CONCLUSION

Hydroxychloroquine treatment is associated with survival benefits in patients with EORA, and prospective studies are needed to validate the abovementioned findings.

Elderly-onset rheumatoid arthritis vs. polymyalgia rheumatica: Differences in pathogenesis

Rheumatoid arthritis is a chronic autoimmune disease that mainly affects the facet joints. Elderly-onset rheumatoid arthritis appears to exhibit symptoms similar to those of polymyalgia rheumatica, characterized by morning stiffness and pain in the shoulder and hip joints. Both diseases develop in the elderly, and it is sometimes challenging to distinguish them. Here, we identify the differences in pathogenesis between elderly-onset rheumatoid arthritis and polymyalgia rheumatica to assist with a clear differential diagnosis and effective early intervention.

Work Ability and Quality of Life in Patients with Rheumatoid Arthritis

BACKGROUND

Reduced work participation has social implications (sickness absence, economic impact) and consequences for the individual patient (impoverishment, depression, limited social interaction). As patients with rheumatoid arthritis (RA) are more likely to experience job loss and/or at-work productivity loss and are at higher risk of sickness absence and, ultimately, permanent work productivity, consideration should be given to the association between work productivity or partial work capacity and quality of life (QoL). The aim of the study was to assess the relationship between QoL and the risk of work disability, as well as to estimate the risk of a future event and identify factors affecting the risk of work disability in RA inpatients.

MATERIAL AND METHODS

This cross-sectional study included 142 inpatients (65 male) aged 47 (38-58) years, who met the established criteria for a diagnosis of RA and treatment with biologic drugs. Only standardized tools were used to examine the patients: WHOQOL-BREF, MFIS and AS-WIS.

RESULTS

An analysis of the QoL scores on the WHOQOL-BREF demonstrated that the patients' QoL was lowest in the physical health domain and highest in the social relationships domain. The median WHOQOL-BREF total score in the group studied was 62.8, which indicates a moderate QoL. The median total score for the risk of work disability (AS-WIS) was 10.1, which indicates that the level of risk of work disability in the patients was higher than the average level reported in the literature. A multivariate analysis showed that the following were significant independent determinants of a higher risk of work disability: low QoL in the WHOQOL-BREF physical health (β = 0.961; p = 0.029) and psychological health (β = 1.752; p = 0.002) domains, being in a relationship (β = 0.043; p = 0.005) and the use of opioids for pain (β = 3.054; p = 0.012).

CONCLUSIONS

RA patients presented with moderate QoL, moderate fatigue (MFIS) and high risk of disability (AS-WIS). There is an association between a high risk of work disability and lower QoL, especially in the physical and psychological health domains. The lower the QoL in those domains, the higher the risk of work disability. The identification of factors increasing the risk of work disability will help in planning tailored interventions to improve at-work productivity loss and thus prevent work disability.

Elucidating a bidirectional association between rheumatoid arthritis and depression: A systematic review and meta-analysis

BACKGROUND

Rheumatoid arthritis (RA) and depression are conditions which commonly co-exist. Recent longitudinal studies now suggest a bidirectional association between these disorders, with inconsistent results. We conducted a systematic review and meta-analysis to examine this relationship.

METHODS

Three electronic databases (PubMed, Embase and PsycINFO) were searched from inception to September 4, 2021 for cohort studies evaluating either the risk of depression in RA patients or the risk of RA in patients with depression, as well as the secondary outcome of all-cause mortality risk in RA patients with depression. A random effects model was used to summarize the included studies.

RESULTS

Eleven cohort studies were included, comprising a total of 39,130 RA patients, 550,782 patients with depression and 7,802,230 controls. RA patients had a 47% greater risk of incident depression compared to controls, while patients with depression had a 34% greater risk of developing RA. Subgroup analysis by age was only significant in the ≥60 years old age group. RA patients with depression had an 80% increased risk of all-cause mortality compared to those without depression.

LIMITATIONS

The results may have been confounded by factors such as differing methods of depression ascertainment across studies and overlap in presentation between the two conditions.

CONCLUSION

There exists a bidirectional association between RA and depression especially in the elderly which increases mortality risk. This invites the need for clinicians to screen and be vigilant for the presence of these conditions.

Phenotype and treatment of elderly onset compared with younger onset rheumatoid arthritis patients in international daily practice

OBJECTIVE

To identify possible differences in baseline characteristics, initial treatment and treatment response between RA patient subgroups based on age at disease onset.

METHODS

Daily practice data from the worldwide METEOR registry were used. Patients (7912) were stratified into three age-groups (age at disease diagnosis <45 years, 45-65 years, >65 years). Initial treatment was compared between the different age-groups. With Cox regression analyses the effect of age-group on time-to-switch from first to second treatment was investigated, and with linear mixed models differences in response to treatment (DAS and HAQ) between the age-groups were assessed, after correction for potential confounders.

RESULTS

The >65 years age-group included more men, and more seronegative RA with somewhat higher inflammatory markers. Initial treatment choices differed only slightly between the age-groups, and the time-to-switch from initial treatment to the next was similar. DAS and HAQ improvement were dependent on the age-group, reflected by a significant interaction between age-group and outcome. The stratified analysis showed a difference of -0.02 and -0.05 DAS points and, -0.01 and 0.02 HAQ points per month in the <45 and 45-65 years age-groups as compared with the >65 year age group, a difference that did not seem clinically relevant.

CONCLUSION

In this international study on worldwide clinical practice, patients with RA onset >65 years include more men and seronegative arthritis, and were initially treated slightly differently than younger patients. We observed no clinically relevant differences in timing of a next treatment step, or response to treatment measured by DAS and HAQ.

Elevated Nesfatin-1 Level in Synovium and Synovial Fluid is Associated with Pro-Inflammatory Cytokines in Patients with Rheumatoid Arthritis

Background

Adipocytokines have been proven to be involved in the progression of autoimmune diseases, including rheumatoid arthritis (RA). Nesfatin-1, a newly discovered adipokine, has recently been reported to possess potent anti-inflammatory, antiapoptotic, and antioxidative properties. However, its role in RA has not yet been reported. Therefore, this study aimed to determine nesfatin-1 levels in the synovium and synovial fluid (SF) of patients with RA and examine their correlation with clinical manifestations and proinflammatory cytokine levels.

Methods

Synovium and SF samples were collected from patients with RA and non-RA patients during joint surgery. Immunohistochemistry was used to measure nesfatin-1 protein expression in the synovium. Enzyme-linked immunosorbent assay was used to measure nesfatin-1, interleukin-1β (IL-1β), and tumor necrosis factor-α (TNF-α) levels in the synovium and SF. Pearson correlation analysis was used to evaluate the correlations between nesfatin-1 levels, RA clinical features, and proinflammatory cytokines. The diagnostic value of synovium nesfatin-1 for RA was assessed using receiver operating characteristic (ROC) curve analysis.

Results

The results showed that nesfatin-1, IL-1β, and TNF-α levels in the synovium were significantly higher in patients with RA than in controls, with age and body mass index as covariates. Moreover, the results of Pearson correlation analysis showed that nesfatin-1 levels were positively correlated with IL-1β and TNF-α levels in the synovium of patients with RA. Furthermore, there was a positive relationship between synovium nesfatin-1 levels and rheumatoid factor in patients with RA. Additionally, the results of the ROC curve analysis revealed an area under the curve of 0.733 with 77.5% sensitivity and 60.0% specificity for synovium nesfatin-1 in discriminating patients with RA from controls.

Conclusion

These findings suggest that increased nesfatin-1 levels in the synovium may be associated with proinflammatory cytokines and RA severity.

Bone Loss and Radiographic Damage Profile in Rheumatoid Arthritis Moroccan Patients

Background

Rheumatoid arthritis (RA) is a known cause of joint destruction and systemic bone loss. In this study, we aimed to evaluate the bone damage and bone loss profiles of established RA patients.

Methods

We designed a cross-sectional study on a cohort of established RA patients. The bone evaluation was performed by obtaining standard X-ray images of hands and feet combined with bone mineral density (BMD) measurements. Radiographic joint damage was calculated by the modified total Sharp /van der Heijde score (mTSS). BMD was obtained by performing dual energy X-ray absorptiometry of the lumbar spine and femoral neck. Data on age, smoking, alcoholism, steroid prescription, body mass index (BMI), disease duration, disease activity, and functional disability were collected.

Results

A total of 93 RA patients were recruited. Their mean age was 51.59±12.38 years, with a mean disease duration of 12.07±9.19 years. A total of 36.6% of patients had osteoporosis, and the mean mTSS was 70.33±48.93. Both hip (P=0.0005) and lumbar BMD (P=0.0005) were correlated with mTSS. Backward regression analyses determined that bone damage was associated with high titers of rheumatoid factor, low lumbar BMD, and low BMI. General bone loss was associated with gender, steroid dose, steroid duration, menopause, and BMI.

Conclusions

Bone damage was associated with low BMI and axial bone loss in our RA population.

Association between Malnutrition and Quality of Life in Elderly Patients with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a progressive articular disease. In addition to damaging the joints, it may cause multiple organ complications, and considerably impair the patient’s functioning. Elderly patients with RA report pain, fatigue, mood disorders, sleep disorders and insomnia, accompanied by weakness, poor appetite, and weight loss. All these factors combined have an adverse effect on the patient’s perceived quality of life (QoL). Due to the chronic nature of RA and the high risk of malnutrition in this patient group, the present study investigated QoL, activities of daily living, and frailty syndrome severity in relation to MNA (Mini Nutritional Assessment) questionnaire scores among elderly RA patients. The study included 98 patients (aged over 60) diagnosed with RA per the ARA (American Rheumatism Association) criteria. The following standardized instruments were used: WHOQoL-BREF for QoL, the Edmonton Frail Scale for frailty syndrome severity, MNA for nutritional status assessment, and MMSE (Mini-Mental State Examination) to assess any cognitive impairment. Medical data were obtained from hospital records. Patients with a different nutritional status differed significantly in terms of limitations in activities of daily living (ADL) and instrumental activities of daily living (IADL). Higher levels of malnutrition were associated with greater limitations in activity. An adverse impact of lower body weight on cognitive function was also observed (dementia was identified in 33.33% of malnourished patients vs. 1.79% in patients with a normal body weight). Likewise, frailty was more common in malnourished patients (mild frailty syndrome in 33.3%, moderate in 16.67%, and severe in 16.67%). Malnourished patients had significantly lower QoL scores in all WHOQoL-BREF questionnaire domains than those with a normal body weight, and multiple-factor analysis for the impact of selected variables on QoL in each domain demonstrated that frailty was a significant independent determinant of poorer QoL in all domains: perceived quality of life (β = −0.069), perceived health (β = −0.172), physical domain (β = −0.425), psychological domain (β = −0.432), social domain (β = −0.415), environmental domain (β = −0.317). Malnutrition was a significant independent determinant of QoL in the “perceived health” domain (β = −0.08). In addition, regression analysis demonstrated the positive impact of male sex on QoL scores in the psychological (β = 1.414) and environmental domains (β = 1.123). Malnourished patients have a lower QoL than those with a normal body weight. Malnutrition adversely affects daily functioning, cognitive function, and the severity of frailty syndrome. Frailty syndrome is a significant independent determinant of poorer QoL in all WHOQoL BREF domains.

Pathological features of established osteoarthritis with hydrathrosis are similar to rheumatoid arthritis

OBJECTIVES

The prevalence of rheumatoid arthritis (RA) and knee osteoarthritis (OA) is increasing with our aging society. Some reports suggest that OA with effusion synovitis develops into RA and early OA patients with effusion are pathologically similar to those with RA. The purpose of this study was to examine the relationship between histological features of established knee OA with or without effusion and RA.

METHODS

Seventy-nine patients in which synovial specimens were obtained during total knee arthroplasty were included. Patients were divided into an RA group, OA with effusion (OA+) group, and OA without effusion (OA-) group. The Rooney synovitis score and serum matrix metalloproteinase (MMP)-3 levels were compared among groups. We also examined the correlation between the Rooney synovitis score and its sub-scores with MMP-3 levels.

RESULTS

The total Rooney score was significantly higher in the RA group than in the OA+ and OA- groups (25.4 vs 17.1, p < 0.01; 25.4 vs 13.5, p < 0.001, respectively). This score also was significantly higher in the OA+ group than in the OA- group (p < 0.05). The proliferating blood vessels score, perivascular infiltrates of lymphocytes score, focal aggregates of lymphocytes score, and diffuse infiltrates of lymphocytes score were significantly higher in the RA group than in the OA- group (7.05 vs 3.29, 4.95 vs 3.43, 3.29 vs 1.46, and 2.26 vs 1.18, respectively; p < 0.05), but not compared with the OA+ group. The total Rooney score demonstrated a significantly positive correlation with serum MMP-3 levels in the RA group (r = 0.61; 95% CI: 0.28 to 0.81; p < 0.01) and in the OA+ group (r = 0.57; 95% CI: 0.24 to 0.78; p < 0.01).

CONCLUSIONS

Previous reports showed the histological similarity between RA and early OA with effusion. We confirmed this histological similarity, in particular the distribution of lymphocytes, between RA and established OA with effusion. It is possible that cases diagnosed as OA with effusion might progress to overt RA.

KEY POINTS

• Histological similarity was observed between RA and established OA with effusion.

Elderly-onset rheumatoid arthritis: an outlook from a practicing rheumatologist

All current challenges and concerns associated with rheumatoid arthritis (RA) in the elderly are analyzed from the point of view of a practicing rheumatologist, including issues of terminology and diagnostics, the need to develop classification criteria for RA presenting at old age. This paper also discusses RA management in the elderly during the coronavirus disease 2019 (COVID-19) pandemic. A multicenter international study, initiated by the League of Eurasian Rheumatologists, can provide necessary insight to develop unified recommendations for RAP. 

The Impact of CRISPR-Cas9 on Age-related Disorders: From Pathology to Therapy

With advances in medical technology, the number of people over the age of 60 is on the rise, and thus, increasing the prevalence of age-related pathologies within the aging population. Neurodegenerative disorders, cancers, metabolic and inflammatory diseases are some of the most prevalent age-related pathologies affecting the growing population. It is imperative that a new treatment to combat these pathologies be developed. Although, still in its infancy, the CRISPR-Cas9 system has become a potent gene-editing tool capable of correcting gene-mediated age-related pathology, and therefore ameliorating or eliminating disease symptoms. Deleting target genes using the CRISPR-Cas9 system or correcting for gene mutations may ameliorate many different neurodegenerative disorders detected in the aging population. Cancer cells targeted by the CRISPR-Cas9 system may result in an increased sensitivity to chemotherapeutics, lower proliferation, and higher cancer cell death. Finally, reducing gene targeting inflammatory molecules production through microRNA knockout holds promise as a therapeutic strategy for both arthritis and inflammation. Here we present a review based on how the expanding world of genome editing can be applied to disorders and diseases affecting the aging population.

Favorable retention rates and safety of conventional anti-rheumatic drugs in older patients with rheumatoid arthritis

Physicians are challenged by the recognition and treatment of older patients with rheumatoid arthritis (RA). The aim of this case-control study was to evaluate the retention and safety of conventional disease-modifying anti-rheumatic drugs in older patients with RA.In this observational case-control study, we assessed older patients with RA (≥65 years) who were diagnosed in 3 different rheumatology centers from Turkey. Patients were divided as to those aged ≥65 years (elderly rheumatoid arthritis [ERA]) and those aged <65 years (young rheumatoid arthritis [YRA]) at the time of conventional DMARD treatment initiation. The Mann-Whitney U test was used for the comparison of 2 non-normally distributed groups. The Chi-square (χ) test was used for categorical variables. Survival analysis were performed using the Kaplan-Meier method.Four hundred eighteen patients with RA (296 females [71%]) were included from January 2010 to January 2018. The age of treatment onset of 190 (47%) patients was in the elderly period and they were included in the ERA group. In the analysis of drug retention rates, there was no significant difference between the ERA and YRA groups for each conventional DMARD (methotrexate 71.2% in ERA, 62.7% in YRA, P = .817; hydroxychloroquine 82.9% in ERA, 78.8% in YRA, P = .899; leflunomide 81.4% in ERA, 84.4% in YRA, P = .205; sulfasalazine 37.5% in ERA, 40.9% in YRA, P = .380). The adverse event data were also similar in both groups.The drug retention and adverse effect rates in older patients with RA using conventional DMARDS are similar to the rates in young patients with RA.

Nivolumab induced remitting seronegative symmetrical synovitis with pitting edema in a patient with melanoma: a case report

BACKGROUND

Novel immune checkpoint inhibitors have been often utilized for different types of malignancies as salvage therapy with varying success. One obstacle to immune checkpoint inhibitor use is the higher incidence of immune-mediated side effects that can prompt discontinuation of therapy. Remitting seronegative symmetrical synovitis with pitting edema has been described with immune checkpoint inhibitors only once previously. We report a case of a patient who developed remitting seronegative symmetrical synovitis with pitting edema related to immune checkpoint inhibitor therapy and stress that these symptoms can be managed without cessation of immune checkpoint inhibitor therapy.

CASE PRESENTATION

We present a 70-year-old white man who presented with 4 months of progressive inflammatory arthritis with pitting edema. He had been started on nivolumab therapy for his metastatic melanoma with excellent response prior to symptom onset. The symptoms started in his knees and subsequently involved both hands and feet. On evaluation, he was wheelchair bound and completely dependent for all activities of daily living. Evaluation revealed negative serological testing and plain film imaging. Ultrasound demonstrated diffuse flexor tenosynovitis and soft tissue swelling, and a diagnosis of remitting seronegative symmetrical synovitis with pitting edema was made. He was treated with orally administered corticosteroids (0.5 mg/kg per day) which improved his symptoms significantly and allowed him to regain prior independent functioning. His corticosteroids were tapered (0.15 mg/kg per day) but not discontinued and his nivolumab treatment was not interrupted. In follow up he continued to have stable control of his melanoma as well as his remitting seronegative symmetrical synovitis with pitting edema.

CONCLUSIONS

In conclusion we present the first case of nivolumab-induced remitting seronegative symmetrical synovitis with pitting edema that is controlled by maintenance low-dose orally administered corticosteroids allowing for continuation of nivolumab therapy. Clinicians who encounter mild-to-moderate immune checkpoint inhibitor immune-mediated adverse effects can consider maintaining immune checkpoint inhibitor therapy with concomitant low-dose corticosteroids rather than abrupt cessation of the immune checkpoint inhibitor.

Neutropenia in the Elderly: A Rheumatology Perspective

The majority of rheumatic diseases are chronic and require long-term use of disease-modifying agents to confer the best chance of controlling the disease. A significant proportion of these drugs have a risk, albeit small, of potentially serious side effects, such as neutropenia; therefore, there has been an understandable concern over the use of potentially toxic rheumatic drugs in the elderly. Factors that may contribute to this concern include age, pre-existing co-morbidities, polypharmacy, difficulty in monitoring side effects, and patient perception. The risk of using such medication needs to be balanced with their benefits in controlling chronic disease. This review discusses how rheumatic disease and anti-rheumatic medication are associated with neutropenia in an older age group. Of the rheumatic diseases, we give special focus to rheumatoid arthritis and the use of methotrexate, as well as touching on management considerations in neutropenia.

The prevalence of ACPA is lower in rheumatoid arthritis patients with an older age of onset but the composition of the ACPA response appears identical

BACKGROUND

Rheumatoid arthritis (RA) consists of two syndromes, one autoantibody-positive and one autoantibody-negative. Existing data on the relation between age of onset and prevalence of autoantibodies were conflicting. Therefore this multicohort study assessed the age of onset in relation to the presence of autoantibodies. The association with characteristics of the anti-citrullinated protein antibodies (ACPA) response was also explored.

METHODS

The 1987 criteria-positive RA patients included in the Leiden EAC, BARFOT, ESPOIR, Umeå and Lund cohorts (n = 3321) were studied at presentation for age of onset and the presence of ACPA, rheumatoid factor (RF) and anti-carbamylated protein (anti-CarP) antibodies. Logistic regression analyses were performed; effect sizes were summarized in inverse-weighted meta-analyses. Within ACPA-positive RA, ACPA level was studied in all cohorts; ACPA isotypes, ACPA fine specificity and ACPA avidity index and clinical characteristics were studied in the Leiden EAC.

RESULTS

From the age of 50 onward, the proportion of ACPA-negative RA patients increased with age in the five cohorts. Similar observations were made for RF and anti-CarP. The composition of the ACPA response did not change with increasing age of onset with respect to titer, isotype distribution, fine specificity and avidity index. With increasing age of onset, RA patients smoked less often, had higher acute phase reactants and more often had a sub(acute) symptom onset.

CONCLUSIONS

Data of five cohorts revealed that with older age of onset ACPA-negative RA is more frequent than ACPA-positive RA, while characteristics of ACPA-positive RA as judged by the composition of the ACPA response appeared not age dependent. Further biologic studies are needed to characterize the pathogenesis of ACPA-negative polyarthritis at older age and to promote personalized treatment decisions in ACPA-negative patients in daily practice.

Knee Arthritis Without Other Joint Symptoms in the Elderly With Seronegative Elderly Onset Rheumatoid Arthritis

Elderly onset Rheumatoid arthritis (EORA) has important clinical distinctions when compared with younger onset RA (YORA). In knee arthritis of elderly patients, infection, crystal-induced arthritis or EORA should be suspected if elevation of CRP in the preoperative examination and turbid joint effusion in their knee joint are found. Furthermore, if joint swelling and effusion remain after performing total knee arthroplasty (TKA), the infection after TKA, implant debris-related arthritis and EORA should be considered. However, it is difficult to diagnose patients as EORA if Rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (ACPA) are negative. The differential diagnosis is very important.

Effect of age at rheumatoid arthritis onset on clinical, radiographic, and functional outcomes: The ESPOIR cohort

OBJECTIVES

To investigate whether age at disease onset determines clinical, radiographic or functional outcomes in a cohort of early RA.

METHODS

The ESPOIR cohort is a multicenter cohort of patients with early arthritis. We selected patients fulfilling the 2010 ACR/EULAR criteria for RA during the first 3years of follow-up. Patients were pooled into 3 groups by age at RA onset: <45years (young-onset RA [YORA]), 45 to 60years (intermediate-onset RA [IORA]) and>60years (late-onset RA [LORA]). The following outcomes were compared at baseline and during the first 3years of follow-up: Simple Disease Activity Index (SDAI) remission rate, one additional erosion, Health Assessment Questionnaire Disability Index (HAQ-DI)<0.5 and first disease-modifying anti-rheumatic drug (DMARD) continuation rate.

RESULTS

We included 698 patients (median [interquartile range] age 50.3 [39.8-57.2]years), 266 YORA, 314 IORA, and 118 LORA. At 1year, SDAI remission was greater for YORA than IORA and LORA (P<0.0001). Having at least one additional erosion was greater for LORA and IORA than YORA after 1year (P=0.009) and 3years (P=0.017). The proportion of patients with HAQ score<0.5 was greater for YORA than IORA and LORA at 1 (P=0.007), 2 and 3years. First DMARD continuation rate was lower for YORA than other groups during the 3years (P=0.005).

CONCLUSIONS

In a cohort of early RA, young age at disease onset is associated with high rate of remission at 1year, no radiographic progression at 3years and low functional score during 3-year follow-up.

Connective tissue diseases, multimorbidity and the ageing lung

Connective tissue diseases encompass a wide range of heterogeneous disorders characterised by immune-mediated chronic inflammation often leading to tissue damage, collagen deposition and possible loss of function of the target organ. Lung involvement is a common complication of connective tissue diseases. Depending on the underlying disease, various thoracic compartments can be involved but interstitial lung disease is a major contributor to morbidity and mortality. Interstitial lung disease, pulmonary hypertension or both are found most commonly in systemic sclerosis. In the elderly, the prevalence of connective tissue diseases continues to rise due to both longer life expectancy and more effective and better-tolerated treatments. In the geriatric population, connective tissue diseases are almost invariably accompanied by age-related comorbidities, and disease- and treatment-related complications, which contribute to the significant morbidity and mortality associated with these conditions, and complicate treatment decision-making. Connective tissue diseases in the elderly represent a growing concern for healthcare providers and an increasing burden of global health resources worldwide. A better understanding of the mechanisms involved in the regulation of the immune functions in the elderly and evidence-based guidelines specifically designed for this patient population are instrumental to improving the management of connective tissue diseases in elderly patients.

Age at disease onset: a key factor for understanding psoriatic disease

Psoriasis and PsA are immune-mediated diseases with a strong genetic component. More than 20 new loci have been recently linked to these diseases. However, interactions between these genes and the phenotypic traits of both diseases are poorly understood at present. Stratification of psoriatic disease according to the sex of the patients, genetic factors or age at onset has allowed in the last few years a better understanding of the principles governing the onset and progression of these processes. The age of onset of psoriasis has been used for decades as an appropriate descriptor to define two subpopulations of psoriatic patients (types I and II) whose clinical and immunogenetic characteristics have been very well differentiated. Moreover, in patients with PsA this distinction between type I and II psoriasis also seems equally operative. In patients with PsA expressing the HLA-C*06 antigen, the latency between the onset of psoriasis and onset of joint symptoms is longer than in those without this marker. It is also known that PsA tends to appear earlier in patients with HLA-B*27 positivity, and that these patients also show a shorter interval of time between the onset of cutaneous lesions and the onset of joint disease. This review highlights the growing importance of age at disease onset as a key stratification factor in worldwide clinical and genetic studies of psoriatic disease.

The influence of ageing on the development and management of rheumatoid arthritis

The population of elderly individuals with rheumatoid arthritis (RA) is expanding, due mainly to increasing life expectancy. A variety of theories have been proposed to explain the ageing process, including accumulation of DNA damage and resultant changes in biological processes. Such changes can influence the development and/or course of disease. Furthermore, alterations in biological function determine the biological age-as opposed to chronological age-of an individual, which strongly influences their ability to cope with disease. Moreover, comorbidities are more frequent in elderly individuals. Together, these factors complicate treatment of disease and necessitate careful patient management. Indeed, although evidence from clinical trials suggests that DMARDs and biologic agents have good efficacy and are well tolerated in elderly patients with RA, such individuals are often undertreated and inadequately managed. Unfortunately, insufficient data are available for the development of evidence-based guidelines for this population, as elderly patients are often excluded from clinical trials owing to age restrictions or comorbidities. Thus, additional clinical studies in elderly patients are warranted, with treatment regimens tailored according to vitality or frailty parameters. This Review focuses on the pathophysiological aspects of ageing and their implications for the management of RA in elderly patients.

Discontinuation of anti-TNF-α therapy in a Chinese cohort of patients with rheumatoid arthritis

The aim of this retrospective study was to examine the predictors of discontinuation of anti-tumor necrosis factor (TNF) therapy due to adverse events in Chinese patients with rheumatoid arthritis (RA). Anti-TNF-related adverse events were recorded and analyzed in 217 consecutive patients with RA followed in our institution from 2003 to 2010. Time to discontinuation of anti-TNF-α therapy was estimated using survival analysis techniques. The anti-TNF agents administered were etanercept in 181 patients and adalimumab in 36 patients. The mean age at diagnosis was 45.2 ± 13.5 years, and mean age at initiation of anti-TNF therapy was 51.8 ± 13.0 years. The mean duration of anti-TNF agent use was 36.0 ± 26.5 months (range, 1.4-87.0; median, 26.4 months). Of the 217 patients, 39 (18.0 %) developed adverse events [etanercept in 34 (18.8 %] and adalimumab in 5 (13.9 %)] during the treatment period (tuberculosis in 5, bacterial infections in 19, virus infection in 7, neuropathy in 3, malignancy in 3, other drug-related events in 1, and appendicitis in 1). In patients with RA, older age (≥55 years) at initiation of anti-TNF therapy [odds ratio (OR), 3.20; 95 % confidence interval (CI), 1.67-6.20; p < 0.001], Cr ≥1.5 mg/dL (OR, 5.72; 95 % CI, 1.17-27.90; p = 0.031), and occurrence of adverse events (OR, 3.82; 95 % CI, 1.75-8.35; p = 0.001) were associated with increased likelihood of discontinuation of anti-TNF treatment. In the present study, a significant proportion (7.8 %, 17/217) of patients with RA discontinued anti-TNF treatment because of adverse events. In the elderly and in patients with renal insufficiency, caution is needed when starting anti-TNF treatment.

Do patients with elderly-onset rheumatoid arthritis have severe functional disability?

OBJECTIVE

To identify the clinical features of elderly-onset rheumatoid arthritis (EORA) and their impact on disease outcome.

METHODS

A total of 3169 rheumatoid arthritis (RA) patients were recruited as part of the Korean Observational Study Network for Arthritis, the nationwide cohort of South Korea. Patients were stratified according to age at disease onset: <40 years (younger age-onset RA, n = 1167), between the ages of 40 and 59 (middle-aged-onset RA, n = 1516), and ≥60 years (EORA, n = 486). To evaluate the significance of differences in clinical features among these 3 groups, we performed analysis of variance (anova) and the χ(2) test. We used multivariable logistic regression analysis to examine the association of onset age with functional disability measured with Health Assessment Questionnaire-Disability Index (HAQDI).

RESULTS

EORA patients were associated with high HAQDI (≥1) in bivariable analysis [odds ratio (OR) 1.36, confidence interval (CI) 1.04-1.77]. However, in multivariable analysis, not elderly onset but patients' age, female gender, high disease activity, disease duration over 10 years, and comorbidity with cardiovascular disease were associated with high HAQDI. Only in a predefined subgroup with disease duration <10 years, elderly onset was an independent influencing factor for the functional disability of RA patients (OR 3.04, CI 1.85-5.67: disease duration of <5 years, OR 3.07, CI 1.64-5.74: disease duration of 5 to 10 years).

CONCLUSIONS

Disease onset in older age was associated independently with functional disability of RA patients who have relatively short disease duration.

Insecticide use and risk of rheumatoid arthritis and systemic lupus erythematosus in the Women's Health Initiative Observational Study

OBJECTIVE

Farming and agricultural pesticide use has been associated with 2 autoimmune rheumatic diseases, rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). However, risk associated with other residential or work place insecticide use is unknown.

METHODS

We analyzed data from the Women's Health Initiative Observational Study (n=76,861 postmenopausal women, ages 50-79 years). Incident cases (n=213: 178 for RA, 27 for SLE, and 8 for both) were identified based on self-report and use of disease-modifying antirheumatic drugs at year 3 of followup. We examined self-reported residential or work place insecticide use (personally mixing/applying by self and application by others) in relation to RA/SLE risk, overall and in relation to farm history. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were adjusted for age, race, region, education, occupation, smoking, reproductive factors, asthma, other autoimmune diseases, and comorbidities.

RESULTS

Compared with never used, personal use of insecticides was associated with increased RA/SLE risk, with significant trends for greater frequency (HR 2.04, 95% CI 1.17-3.56 for ≥6 times/year) and duration (HR 1.97, 95% CI 1.20-3.23 for ≥20 years). Risk was also associated with long-term insecticide application by others (HR 1.85, 95% CI 1.07-3.20 for ≥20 years) and frequent application by others among women with a farm history (HR 2.73, 95% CI 1.10-6.78 for ≥6 times/year).

CONCLUSION

These results suggest residential and work place insecticide exposure is associated with the risk of autoimmune rheumatic diseases in postmenopausal women. Although these findings require replication in other populations, they support a role for environmental pesticide exposure in the development of autoimmune rheumatic diseases.

Efficacy and safety of anti-tumour necrosis factor in elderly patients with rheumatoid arthritis: an observational study

This study aims to compare the efficacy and safety of anti-TNF agents in elderly (aged >or=65 years) and younger patients (aged 18-65 years) with active RA. The study involved 1,114 RA patients treated with anti-TNF drugs and followed-up for >6 months by LORHEN group, who were divided into two cohorts on the basis of their age (311 aged >or=65 and 803 aged <65 years) in order to evaluate 3-year outcomes and treatment discontinuations. Drug effectiveness was assessed by disease activity (DAS28 and EULAR response), functional status (HAQ) and serological parameters (ESR) at baseline and during anti-TNFalpha therapy; safety was evaluated on the basis of drug discontinuation rates. At baseline, the elderly patients showed greater disease activity (DAS28, ESR) and loss of joint function (HAQ, functional class; p < 0.05). During therapy, clinical and laboratory parameters (DAS28, ESR) improved in both groups without any statistically significant difference between them, whereas the difference in HAQ remained after 36 months of treatment (p < 0.05). Anti-TNFalpha therapy was discontinued by 123 of the elderly (42%) and 282 of the younger patients (36.6%) because of loss of efficacy (17.4% vs. 16.7%), severe adverse events (21.8% vs. 16.9%) or other reasons (2.7% vs. 3%). The number of adverse events was significantly higher in the elderly patients (p < 0.05). Anti-TNFalpha treatment reduced disease activity and led to functional improvement in both groups, although the baseline difference in HAQ remained statistically significant at the end of the follow-up. The elderly patients experienced more infective events.

Clinical approaches to early inflammatory arthritis

Several advances have been made in the understanding of the pathogenesis, as well as in the clinical evaluation and treatment, of early inflammatory arthritis. The presence of anti-citrullinated protein antibodies (ACPAs) has emerged as a major new biomarker for use in clinical practice. The presence of ACPAs can be used to divide patients with early arthritis into subsets that are phenotypically similar but have varying pathogenetic and prognostic features. Although the detection of ACPAs is a major development in the diagnosis and prognosis of rheumatoid arthritis (RA), prediction of the outcome of arthritis at the individual level can still be much improved. For patients diagnosed with RA, and who have active polyarthritis, treatment is not dependent on the assessment of prognostic factors, as these patients are best treated with combination therapy; over 40% of these patients achieve remission with such treatment. In patients who present with oligoarthritis, however, management should be based on the assessment of prognostic factors. The success of early treatment of inflammatory arthritis and the recognition of a measurable preclinical phase of RA offer hope that treating the disease before it becomes clinically active might be possible.

Presentation and severity of rheumatoid arthritis at diagnosis in Senegal

OBJECTIVE

Early effective treatment slows structural damage in RA but requires an early diagnosis. Our objective was to determine symptoms duration and presentation patterns of RA at diagnosis in Senegal.

METHODS

We conducted a cross-sectional study over a 2-year period (from March 2006 to February 2008) at the rheumatology clinic of the Le Dantec teaching hospital in Dakar, Senegal. Consecutive new patients who met ACR criteria for RA were included.

RESULTS

We included 100 patients, 88 females and 12 males, with a mean age of 40.3 +/- 15.5 years and a mean symptoms duration of 54 months. One-fourth of the patients had a positive family history. Pain was the main reason for the rheumatology clinic visit. Mean pain score was 64.3 mm on a 100-mm visual analogue scale. Nocturnal arousals were reported by 69% of the patients and morning stiffness for >1 h by 74%. The tender and swollen joint counts were 10 or higher in 87% and 36% of the patients, respectively, and the mean disease activity score on 28 joints (DAS28) was 6.49 +/- 1.34. Sicca syndrome (n = 13) and rheumatoid nodules (n = 3) were the main extra-articular manifestations. Laboratory evidence of inflammation was found in 87% and RF in 78% of the patients. Antibodies to cyclic citrullinated peptides (anti-CCPs) were detected in 26 of the 29 patients. Radiographical lesions were visible in 56% of the patients; mean modified Sharp score was 21.76 +/- 47.74.

CONCLUSION

The diagnosis of RA is delayed in Senegal, and the disease is highly active at diagnosis, although 44 patients have no erosions, and extra-articular manifestations are rare.

Is remitting seronegative symmetrical synovitis with pitting edema (RS3PE) a subset of rheumatoid arthritis?

OBJECTIVES

To contrast and compare the spectrum of remitting seronegative symmetrical synovitis with pitting edema (RS3PE) with rheumatoid arthritis (RA) using an illustrative case.

METHODS

The relevant English literature of RS3PE was searched using the keywords "RS3PE" alone and in combination with terms such as neoplasia and rheumatic disease. Original and review articles were reviewed and the clinical setting was exemplified with a case report.

RESULTS

RS3PE initially was reported to represent a form of RA. However, RS3PE has clinical features that are different from both early- and late-onset RA, such as lack of bony erosions and rheumatoid factor. RS3PE is thought to involve vascular endothelial growth factor, suggesting an infectious etiology, generally has an excellent prognosis, and is associated with neoplasia not commonly seen in RA, and the RA associated human leukocyte antigen (HLA) DRB1 genotype is absent.

CONCLUSIONS

Based on the clinical, laboratory, suspected infectious etiology, genetic differences, and types of associated malignancies, RS3PE appears to be a distinct entity rather than a subset of RA.

Power Doppler ultrasonography of symptomatic rheumatoid arthritis ankles revealed a positive association between tenosynovitis and rheumatoid factor

The aim of this study was to characterize the pathological conditions of symptomatic ankles in patients with rheumatoid arthritis (RA) using power Doppler sonography (PDS). We analyzed 17 consecutive ultrasonography (US) records of RA patients with symptomatic ankles who underwent B-mode ultrasonography (BUS) combined with PDS of their ankles in our department because of clinical need. Correlations between US findings and clinical and serological data were assessed. The diagnostic capabilities of BUS and PDS were also compared. Common US findings were talocrural synovitis (76%), subtalar synovitis (71%), and talonavicular synovitis (59%). Tenosynovitis around the ankle was detected in ten patients (59%), including several cases of tenosynovitis of tibialis posterior (41%) and tenosynovitis of peroneus longus and brevis (35%). Achilles tendon enthesitis was detected in six patients, and retrocalcaneal bursitis was detected in five. Compared with BUS, PDS offers demonstrably superior diagnostic capability for the detection of rheumatoid ankle diseases, especially subtalar joint synovitis and peroneal tenosynovitis. Rheumatoid factor (RF) levels were significantly higher in patients with tenosynovitis than in patients without tenosynovitis. PDS is an excellent modality for diagnosing both intra- and extracapsular synovitis in rheumatoid ankles. Using PDS, we found positive association between ankle tenosynovitis and RF levels in RA patients.

Clinical expression, but not disease outcome, may vary according to age at disease onset in psoriatic spondylitis

OBJECTIVES

To investigate whether the clinical expression and disease outcome in psoriatic spondylitis (PsS) may vary according to age at disease onset.

METHODS

This study included 70 patients from a unique outpatient spondylitis clinic followed on a regular basis with a standard protocol. Patients were diagnosed with PsS according to ESSG criteria plus radiographic sacroiliitis (SI). Outcome parameters included: disease activity, functional evaluation, radiological damage, mobility restriction, and enthesitis score. Patients were divided into those with disease onset before 40 years (young-onset PsS) and those with onset over this age (late-onset PsS). Clinical features and outcome parameters were compared between groups.

RESULTS

There were 44 men and 26 women. Thirty-nine (M:F ratio 1.8) patients had disease onset before 40 years and 31 (M:F ratio 1.6) over this age. HLA-B27 correlated with PsS susceptibility (34% vs 7%, RR 6.4, p<0.0004), but it was found over-represented in young-onset PsS compared to late-onset cases (51% vs 13%, p=0.001). Young-onset cases tended to have a higher frequency of family history (26% vs 13%), bilateral SI (62% vs 29%, p=0.013), isolated axial pattern (31% vs 13%), and enthesitis (54% vs 29%, p=0.09). In late-onset PsS there was a higher frequency of unilateral SI (71% vs 38%, p=0.013), polyarthritis (45% vs 23%, p=0.022), and silent axial disease (32% vs 10%, p=0.022). Outcome parameters were similar between groups.

CONCLUSIONS

Clinical picture but not outcome parameters, varies according to age at disease onset in PsS. The correlation between HLA-B27 and young-onset PsS supports the notion that disease susceptibility and disease expression are not driven by the same gene in this entity.

Rheumatic Disease in the Elderly: Rheumatoid Arthritis

This article summarizes the different aspects of rheumatoid arthritis and the spectrum of diseases that can present as rheumatoid arthritis in the elderly population. With the ageing of the western population, different forms of inflammatory arthritis' prevalence and incidence are increasing in elderly persons. Difficulties in establishing the diagnosis and introducing new treatment modalities in this patient group pose a great challenge for clinicians. The management of inflammatory arthritis in the elderly requires special consideration in regard to the comorbidities and increased frequency of adverse events. There is substantial need for improving aspects of diagnostic and therapeutic interventions that will reduce the impact of inflammatory arthritis in the growing elderly population.

Polymyalgia rheumatica: diagnosis and treatment

Polymyalgia rheumatica (PMR) typically manifests as inflammatory pain in the shoulder and/or pelvic girdles in a patient over 50 years of age. This condition was long underrecognized and therefore underdiagnosed. Today, however, overdiagnosis may occur. Physicians must be aware that many conditions may simulate PMR, including diseases that carry a grim prognosis or require urgent treatment. PMR may be the first manifestation of giant cell arteritis, and a painstaking search for other signs is mandatory. PMR may inaugurate other rheumatologic diseases such as rheumatoid arthritis, RS3PE syndrome, spondyloarthropathy, systemic lupus erythematosus (SLE), myopathy, vasculitis, and chondrocalcinosis. Finally, PMR may be the first manifestation of an endocrine disorder, a malignancy, or an infection. Failure to respond to glucocorticoid therapy should suggest giant cell arteritis, malignant disease, or infection. Ultrasonography may assist in the diagnosis by showing bilateral subdeltoid bursitis. Glucocorticoids are the mainstay of the treatment of PMR. Although the optimal starting dosage and tapering schedule are not agreed on, a low starting dosage and slow tapering may decrease the relapse rate. Methotrexate is probably useful when glucocorticoid dependency develops. In contrast, TNF-alpha antagonists are probably ineffective.

Do patients with older-onset rheumatoid arthritis receive less aggressive treatment?

Rheumatoid arthritis among elderly people is an increasingly important health concern. Despite several cross-sectional studies, it has not been clearly established whether there are important clinical differences between elderly-onset rheumatoid arthritis (EORA) and younger-onset rheumatoid arthritis (YORA). The aim of this study was to compare disease activity and treatment in EORA and YORA, using the Consortium of Rheumatology Researchers of North America (CORRONA) registry, a database generated by rheumatologist investigators across the USA. From the CORRONA registry database of 9381 patients with rheumatoid arthritis, 2101 patients with disease onset after the age of 60 years (EORA) were matched, on the basis of disease duration, with 2101 patients with disease onset between the ages of 40 and 60 years (YORA). The primary outcome measures were the proportion of patients on methotrexate, multiple disease-modifying antirheumatic drugs (DMARD) and biological agents (etanercept, infliximab, adalimumab and kineret) in each group. Disease activity and severity differed slightly between the EORA and YORA groups: Disability Index of the Health Assessment Questionnaire: 0.30 v 0.35; tender joint count: 3.7 v 4.7; swollen joint count: 5.3 v 5.2; Disease Activity Score 28: 3.8 v 3.6; patient global assessment: 29.1 v 30.9; physician global assessment: 24.9 v 26.3; patient pain assessment: 31.4 v 34.9. Regarding treatment, the use of methotrexate use was slightly more common among patients with EORA (63.9%) than among those with YORA (59.6%), although the mean methotrexate dose among the YORA group was higher than that in the EORA group. The percentage of patients with EORA who were on multiple DMARD treatment (30.9%) or on biological agents (25%) was considerably lower than that of patients with YORA (40.5% and 33.1%, respectively; p<0.0001). Toxicity related to treatment was very minimal in both groups, whereas toxicities related to methotrexate were more common in the YORA group. Patients with EORA receive biological treatment and combination DMARD treatment less frequently than those with YORA, despite identical disease duration and comparable disease severity and activity.

Safety and efficacy of etanercept in the elderly

Recent advances in the understanding of the pathophysiology and aggressive treatment of rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis have dramatically changed the outcomes of patients with these diseases over the past 7 years. Much of the progress in therapy is due to the change in the treatment paradigm in which early, aggressive therapy has become the norm and the introduction of therapies that target the disease processes, specifically the overproduction of tumor necrosis factor-α. Etanercept was the first anti-tumor necrosis factor-α therapy approved for use in rheumatoid arthritis, juvenile rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis. It has been shown to have an excellent risk:benefit ratio in clinical trials as well as postmarketing surveillance. However, there has been limited information regarding the safety and efficacy of etanercept in patients aged 65 years or over, which is the focus of this review.

Rheumatic disease in the elderly: rheumatoid arthritis

This review summarizes the different aspects of rheumatoid arthritis and the spectrum of diseases that can present as rheumatoid arthritis-like arthritis in the elderly population. With the aging of Western population, different forms of inflammatory arthritis' prevalence and incidence are increasing in the elderly persons. Difficulties in establishing the diagnosis and introducing new treatment modalities in this patient group poses a great challenge for the clinicians. The management of inflammatory arthritis in the elderly requires special consideration in regard to the comorbidities and increased frequency of adverse events. There is definitely a substantial need for improving different aspects of diagnostic and therapeutic interventions that will reduce the impact of inflammatory arthritis in the growing elderly population.

Outcome of late-onset rheumatoid arthritis

The objective of this study was to determine possible differences in the outcome of patients with rheumatoid arthritis (RA) with disease onset early and late in life. As part of a broader outcome study of RA which included patients seen in the division of Rheumatology of Hospital Universitario Marqués de Valdecilla of Santander, Cantabria (Northern Spain) with disease duration between 2 and 7 years, we selected patients with an age at disease onset of <or=45 or >or=65 years. The medical records of all eligible patients were reviewed for relevant clinical and laboratory variables; the patients were then further evaluated for disease activity using biological tests and joint indices such as joint counts and Thompson's Index, functional capacity using the American College of Rheumatology (ACR) functional classification (ACR-FC) and the modified Health Assessment Questionnaire (M-HAQ), and anatomical damage using the number of joint damage (NJD) and radiographs read by the Sharp's scoring method for joint erosion (JE), joint narrowing (JN), and overall. Patients in both subsets were then compared. For the multivariable analyses all patients in the original larger cohort were included, so that age could be used as a continuous variable and the power of the analyses could increase; 31 younger (mean age+/-SD: 36+/-7 years) and 35 older (73+/-6 years) patients were available for assessment. No differences in disease duration and gender distribution were observed. Likewise, both subsets had similar levels of disease activity, both articular indices, and biological markers. In contrast, elderly patients showed more functional limitations as per the M-HAQ [median (interquartile range): 0.4 (0.13-1.2) vs 0.13 (0-0.6), p=0.007] and greater anatomical damage as per the NJD [median (interquartile range): 2 (0-4) and 0 (0-2), respectively, p=0.04] and the JE, JN, and total Sharp Index score (p=0.001, 0.02, and 0.001, respectively). Although older patients took fewer disease-modifying antirheumatic drugs (DMARD) and combined DMARD treatments (2.5+/-1.4 vs 1.9+/-1.3, p=0.05 and 0.8+/-1.1 vs 0.3+/-0.6, p=0.01, respectively), multivariable analysis demonstrated an independent association between age at disease onset and the number of DMARD and functional and anatomical decline. Late-onset RA does not present a better prognosis than the early-onset form of the disease. At the very least the disease is comparable between both patient groups. However, disease compounded by age-associated factors may in fact have a worse prognosis late than early in life.

Management Issues with Elderly-Onset Rheumatoid Arthritis

Elderly-onset rheumatoid arthritis (EORA) is defined as rheumatoid arthritis (RA) starting at >60 years of age. EORA is characterised by a lower female/male ratio compared with RA in younger patients and it more frequently has an acute onset accompanied by constitutional symptoms. Two incompletely overlapping subsets of RA have been recognised: one exhibits the classical RA clinical picture while the other has a polymyalgia rheumatica-like appearance, characterised by shoulder involvement, absence of rheumatoid factor and, usually, by a nonerosive course. Identification of anti-cyclic citrullinated peptide antibodies is useful for distinguishing the latter subset from true polymyalgia rheumatica. Elderly-onset spondyloarthritis, crystal-related arthritis, remitting seronegative symmetrical synovitis with pitting oedema syndrome and hepatitis C virus-related arthritis must also be considered in the differential diagnosis. EORA treatment requires prudence because of the increase in age-related risks pertaining principally to the renal, cardiovascular and gastrointestinal systems. No groups of molecules usually employed for RA therapy in younger subjects (analgesics, NSAIDs, corticosteroids, disease-modifying antirheumatic drugs, anticytokine drugs) can be excluded a priori from the treatment of EORA patients. Nevertheless, the risk/benefit ratio relating to their use must be accurately evaluated for every single patient. Recently marketed compounds such as leflunomide and tumour necrosis factor-alpha antagonists have also increased the therapeutic opportunities for aged RA patients.

Increased radiographic damage scores at the onset of seropositive rheumatoid arthritis in older patients are associated with osteoarthritis of the hands, but not with more rapid progression of damage

OBJECTIVE

To investigate the impact of patient age at symptom onset on radiographic joint damage at study entry, and on subsequent progression of damage in a cohort of patients with early seropositive rheumatoid arthritis (RA).

METHODS

We studied 186 patients with RA of <15 months' duration. All patients had active disease and had not received disease-modifying antirheumatic drugs. At study entry and during followup, total Sharp scores (TSS), RA-associated joint space narrowing (RA-JSN), and erosions were determined on hand and foot radiographs. Baseline radiographs were also scored for osteoarthritis (OA)-related JSN (OA-JSN) and osteophytes. Older patients (>55 years) and younger patients (</=55 years) were compared by t-test, Mann-Whitney U test, chi-square, or Fisher's exact test. Multiple linear regression models were also constructed.

RESULTS

The older group (n = 74) had a higher baseline total Sharp score (median 6.21) compared with the younger group (n = 112) (median 2.33) (P = 0.0002). This was mainly due to a higher baseline JSN score in the older group (median 3.96 versus 1.08) and not to differences in erosion score (median 0.91 versus 0.70). Disease activity and duration of RA symptoms were similar in the 2 groups, as were progression rates of the TSS, JSN score, and erosion score. At baseline, 26% of patients had osteophytes, with a prevalence of 13% in the younger age group and 50% in the older group. The presence of OA-JSN was highly correlated with the presence of osteophytes (r = 0.72). Also, increased age and RA-JSN were associated with increased severity of osteophytes and OA-JSN at baseline. Multiple linear regression analysis showed that both age and hand osteophytes contributed to the increase in baseline RA-JSN score and TSS, but not to erosion score.

CONCLUSION

In a cohort of patients with early RA, an increase in the baseline RA-JSN score and TSS can be accounted for in part by the presence of hand OA.