Older age onset rheumatoid arthritis with or without osteoarthritis

The problem of residual pain in the assessment of rheumatoid arthritis activity

Residual pain is a major unmet medical need observed in patients suffering from rheumatoid arthritis (RA), which decreases their quality of life, even after achieving remission or low disease activity. The article has two aims: 1) to present mechanisms involved in the pathophysiology of residual pain, both inflammatory and non-inflammatory, i.e. neuropathic and nociplastic pain, as well as secondary pain syndromes, i.e. osteoarthritis and fibromyalgia, which can contribute to residual pain; 2) to show the limitations of current disease activity measures recommended by European Alliance of Associations for Rheumatology (EULAR) and American College of Rheumatology (ACR), which raise the need for a separate assessment of pain, and examples of methods that could be used by medical professionals to assess the pain and make a differential diagnosis. In conclusion, establishing a valid method to assess pain is essential to identify the pathomechanism of residual pain and to create treatments tailored specifically to individual RA patients.

Consideration of differences in drug usage between young-onset and elderly-onset rheumatoid arthritis with target of low disease activity

OBJECTIVES

Elderly-onset rheumatoid arthritis (EORA) is reported to differ from young-onset rheumatoid arthritis (YORA) with regard to patient background and drug treatment. We examined the amount of drug administered to patients who achieved low disease activity (LDA) for rheumatoid arthritis at our hospital.

METHODS

Demographics, clinical history, and treatments were compared between patients with EORA (n = 70) and YORA (n = 190).

RESULTS

There was a significant difference in the average age (73.8 vs. 57.8 years), disease duration (6.66 vs. 14.7 years), and sex (62.9% males vs. 83.7% females), but no difference in rheumatoid factor positivity (85.3% vs. 80.7%), anti-citrullinated peptide antibody positivity (86.5% vs. 87.7%), simplified disease activity index (4.28 vs. 4.59), or disease activity score 28-CRP (1.99 vs. 2.04) in the EORA and YORA groups, respectively. There were also no significant differences in prednisolone use (37.1% vs. 36.3%), amount of methotrexate administered (MTX) (1.45 vs. 1.41 mg), and MTX use (55.7% vs. 65.3%). However, the MTX dose (2.89 vs. 4.09 mg/week, p = .011) and overall biologics use (32.9% vs. 56.3%, p = .0012) were significantly lower in patients with EORA than in those with YORA.

CONCLUSION

Patients with EORA may be able to achieve LDA with lower drug dosage than those with YORA.

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.

Association of HLA-DRB1 genotype with younger age onset and elder age onset rheumatoid arthritis in Japanese populations

Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by joint destructions and human leukocyte antigen (HLA)-DRB1 is an important genetic risk factor for RA and influences the phenotype of RA. The clinical features of elder age onset RA (EORA) were known to be different from those of younger age onset RA (YORA). Previous studies reported the different association pattern of DRB1 alleles with YORA or EORA. The associations of DRB1 genotype with these RA subsets remained almost unknown. We investigated the genotype association of DRB1 with YORA or EORA in Japanese populations.HLA genotyping was performed in Japanese RA patients and the association of allele or genotype carrier frequencies were analyzed.The genotype frequency of DRB104:05/DRB104:06 (P = .0204, OR 7.69, 95%CI 1.39-42.72), DRB104:05/DRB112:01 (P = .0050, OR 5.53, 95%CI 1.71-17.88), and DRB104:05/DRB115:01 (P = .0124, OR 3.34, 95%CI 1.39-8.02) in YORA was higher than EORA. However, the frequencies of DRB101:01/DRB104:05 in YORA was tended to be lower than EORA (P = .0784, OR 0.14, 95%CI 0.01-2.42). The gene dosage effect of the shared epitope alleles was detected in EORA, but not in YORA. Trans-complementing DQ heterodimer molecules, formed by DQA1 and DQB1 of the haplotypes with and without shared epitope alleles, might explain the higher genotype frequencies of "shared epitope /not shared epitope". Linear regression analyses showed the primary role of DQB104:01 allele for the age at onset of RA.This is the first report for the associations of DRB1 genotype with YORA or EORA in the Japanese population and the differential distribution of the genotypes was noted between these RA subsets. The involvement of DQ molecules for the age at onset of RA was suggested.

An autumn tale: geriatric rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by erosive arthritis and systemic organ involvement. The disease may affect all ages and both sexes; usually it is seen in young women aged 25-45. Recent studies have shown that RA is among the most common inflammatory disease in older age groups. While elderly-onset rheumatoid arthritis (EORA) is still discussed in the literature, it is generally accepted as a disease beginning after 65 years of age. Compared with young-onset rheumatoid arthritis (YORA), it was found that EORA had different characteristics. EORA is characterized by more equal gender distribution, higher frequency of acute onset with constitutional symptoms, more frequent involvement of large joints, and lower frequency of rheumatoid factor (RF) positivity. Earlier diagnosis, less erosive disease and less disease-modifying antirheumatic drug usage were reported as distinguishing EORA from YORA patients. These various clinical presentations may cause difficulties in diagnosis and differential diagnosis of EORA. However, different clinical and treatment approaches may be needed in these patients. In this article, the clinical and laboratory characteristics, prognosis and treatment principles of EORA will be discussed in light of recent literature data.

A case-control study of rheumatoid arthritis revealed abdominal obesity and environmental risk factor interactions in northern China

BACKGROUND

The aim of this study was to evaluate new and previously hypothesized environmental risk factors and their interaction with rheumatoid arthritis (RA).

METHODS

Four hundred patients recently diagnosed with RA and 400 controls frequency-matched by gender and birth year using Propensity Score Matching (PSM) were selected from northern China. Investigation was performed using self-reported data from interviewer-administered surveys. Associations between exposure variables and risk of RA were evaluated using multifactor non-conditional logistic regression.

RESULTS

It showed that damp localities, draft indoor, abdominal obesity (AO), and family history of RA among first-degree relatives were independent risk factors and drinking of milk was independent protective factors for RA. Besides these risk factors, in women, infrequent delivery times, early age at menopause, and late age at menarche were also independent risk factors for RA. Both the additive model and the multiplication model suggested that there was an interaction relationship between AO and damp localities (p < .001), and only the additive model suggested that there was interaction relationship between AO and no milk drinking (p < .001) in our study population. In women, there was interaction relationship between AO and damp localities (p < .001) and between AO and age at menopause (p < .001).

CONCLUSIONS

In northern China, damp localities, draft indoor, AO, family history of RA among first-degree relatives, and no milk drinking may be important risk factors of RA patients.

Differentiation between Polymyalgia Rheumatica (PMR) and Elderly-Onset Rheumatoid Arthritis Using 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography: Is Enthesitis a New Pathological Lesion in PMR?

Background

It is difficult to differentiate polymyalgia rheumatica (PMR) from elderly-onset rheumatoid arthritis (EORA) in clinical practice. We compared FDG-PET/CT findings between patients with PMR and those with EORA and extracted factors useful for differentiating the two disorders.

Methods

We compared abnormal FDG accumulation sites and maximum standardized uptake value (SUVmax) between 15 patients with PMR and 7 with EORA in whom FDG-PET/CT was performed.

Results

The proportion of patients in the PMR group with abnormal FDG accumulation at the following 9 sites on FDG-PET/CT was significantly higher than that in the EORA group: periarticular region of the scapulohumeral joint, enthesis of the pectineus muscle, vicinity of the enthesis of the rectus femoris muscle, lateral side of the greater trochanter, ischial tuberosity, hip joint, spinous process of the lower cervical vertebra, intervertebral joint of the lumbar vertebra, and spinous process of the lumbar vertebra. The PET/CT score was evaluated at 9 sites consisting of the abovementioned sites. The median score in the PMR group was 8, which was significantly higher than that of 0 in the EORA group (P = 0.0003). ROC curve analysis was performed with the PET/CT scores, and a score of 5 was shown to maximize the area under the ROC curve (sensitivity: 86.7%, specificity: 86.7%).

Conclusions

FDG-PET/CT is useful for differentiating PMR from EORA. In patients with PMR, abnormal FDG accumulation was observed at the entheses, suggesting the presence of enthesitis in addition to bursitis and synovitis.

Pattern of Young and Old Onset Rheumatoid Arthritis (YORA and EORA) Among a Group of Egyptian Patients with Rheumatoid Arthritis

Objective:

Rheumatoid arthritis (RA) differs depending on the age of disease onset. The differences between EORA and YORA are important because they have clinical and therapeutic implications.

Method:

1185 patients were ranked after classification according to age at onset of the disease into YORA I (16–40 years), YORA II (41–60 years) and EORA >60 years. All patients groups were compared, based on disease duration, disease activity, severity parameters and drug history.

Results:

YORA I included 298 patients, 28.85% were males, with mean age of 29.4 ± 6 years and disease duration 4 ± 3.3 y, YORA II included 539 patients, 33.77% males, age 49.7 ± 6.1 y and disease duration 6.5 ± 5.6 y. EORA included 348 RA patients 40.5% males, age 67.1 ± 6.6 y, disease duration 9.95 ± 7.2 y. Activity was increased in EORA compared to YORA I and YORA II, while severity decreased in EORA. ESR, CRP and degree of anemia were higher in EORA. RF titer was higher in YORA. Small joints of the hands and feet were more involved in YORA, while, large joints in EORA.

Rheumatoid nodules were increased in YORA I than EORA P = 0.04. Polymyalgia rheumatica was exclusively present in EORA group 25 patients 7.2%.

Methotrexate was used in both YORA and EORA, with a higher mean of dosage in YORA than EORA. Multiple DMARDs in EORA was 57.9%, and biologics in 0.8% was which was significantly lower compared with YORA I, 86.3% and 1.7%, with P = 0.001.

Conclusion:

EORA has more active and less disabling and affects more males than YORA. The use of biologic therapy and combination DMARD therapy was less in EORA.

[Management of elderly-onset rheumatoid arthritis]

In addition to population-growth in the elderly, development of new therapeutic agents for rheumatoid arthritis (RA) contributes to an increase in the number of elderly patients with RA. It is also reported that the age of RA onset is going higher. Elderly-onset RA (EORA) is defined as RA developing after the age of 60 years. In RA patients, significant damage can be detected radiographically within the first 2 years after the initial presentation of symptoms; therefore, appropriate treatment should be administered at the earliest. Meanwhile, caution should be exercised in prescribing disease-modifying antirheumatic drugs (DMARDs) to elderly patients because the associated risk of adverse effects and toxicity is elevated in the elderly. However, excessive caution may prevent elderly patients from being implemented the ideal therapy. Compared to young patients with RA, patients with EORA are less frequently treated with biological agents or multiple DMARDs treatment and more frequently treated with prednisone. Some patients with EORA do not receive optimal treatment during the early stage of RA, when the disease is highly active and joint destruction rapidly progresses. EORA should be treated with appropriate DMARDs instead of corticosteroids in order to maintain the risk of infection minimal and the patients' physical function maximal.

Late onset rheumatoid arthritis: clinical and laboratory comparisons with younger onset patients

We aimed to compare the clinical and laboratory profiles of the patients presenting late onset rheumatoid arthritis (LORA) with younger onset rheumatoid arthritis (YORA) patients. During the period between January 1995 and December 2004, 124 patients with LORA were identified from a retrospective chart review of inpatients and outpatients. They were compared with 150 YORA patients examined during the same period including their clinical and laboratory findings. The mean ages of the patients with LORA and YORA were 71.7+/-5.9 years, and 52.1+/-11.5 years, respectively. The gender ratio (female/male) was 1.48 in LORA and 2.85 in YORA (p = 0.012). The average ages of the disease onset were 42.2+/-10.4 years in YORA and 68.4+/-4.6 years in LORA. The duration of the diagnosis was longer in LORA than in YORA (20.7+/-14.3 months versus 10.3+/-6.2 months, p < 0.001). Rheumatoid arthritis (RA) duration was shorter in LORA than in YORA (43.5+/-64.4 months versus 126.3+/-101.0 months, p < 0.001). Although LORA patients had more significant frequent shoulder joint involvements (p < 0.001), proximal interphalangeal (PIP), metacarpophalangeal (MCP), elbow, metatarsophalangeal (MTP) and ankle involvements were common in YORA. Wrist, knee and hip involvements were not different in the groups. Classical rheumatoid hand deformities, interstitial lung disease and Sjögren's syndrome (SS) were significantly lower in LORA than in YORA. LORA patients had more common weight loss, myalgia, lymphadenopathy, polymyalgia rheumatica (PMR)-like syndrome and neuropathy. The frequencies of RF, ANA, anti-SSA/Ro and anti-SSB/La positivities were lower in LORA than in YORA, whereas elevated erythrocyte sedimentation rates (ESR), C-reactive protein (CRP) and anemia associated with chronic disease were higher in LORA. Patients with LORA, according to the accepted international criteria, present with different clinical and laboratory profiles when compared with younger patients. These results suggest that age may influence the presentation of RA at onset.

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.

Autoimmunity and geriatrics: clinical significance of autoimmune manifestations in the elderly

The immune system undergoes continuous morphologic and functional changes throughout the years, and it is now believed that the immune response has its peak function in puberty and gradually decreases with age (immunosenescence). Recent studies in healthy octogenarian patients suggest that the immune system, instead of suffering a generalized deterioration, undergoes a remodelling/readjustment of its major functions. Increase in two contrasting phenomena coexist in immunosenescence: on the one hand, a decrease in the capacity of the immune response and, on the other hand autoantibody production. The possible consequences of this progressive 'ageing' of the immune system are the increase in autoimmune phenomena, incidence of neoplasia and predisposition to infections. The study of autoimmune manifestations in elderly populations should be considered a priority for future medical research because of increasing life expectancy, especially in developed countries. This review analyses the main immune disorders associated with immunosenescence, the prevalence and clinical significance of autoantibodies in the elderly and the clinical expression of the main autoimmune diseases in older patients.

Elderly-onset rheumatoid arthritis

It is appreciated that age has a modifying effect on the clinical presentations of disorders such as hyperthyroidism and systemic lupus erythematosus. Similarly in EORA, there seems to be a change in the disease phenotype when it is compared to YORA. These differences are significant not only in highlighting the importance of the aging process on the immune system but also because they have medical and therapeutic implications. Improved classification has greatly improved our understanding and treatment of systemic lupus erythematosus, juvenile chronic arthritis, and seronegative spondyloarthropathies. Similarly, appreciating the differences, and similarities, between YORA and EORA should advance the choice of therapeutic options and potentially move closer to defining pathogenesis and origin.

Rheumatoid arthritis in the elderly

Rheumatoid arthritis of late onset (LORA) referred as the subset of rheumatoid arthritis with age of onset over 60 years old, seems to differ from young onset disease (YORA) by a more equal sex distribution, a higher frequency of abrupt disease onset, more large joint complaints and less extraarticular features. Different immunogenetic associations are also reported between the two age groups. The percentages of rheumatoid factor (RF) and C-reactive protein (CRP) positivity differ in various surveys in both groups examined. Favorable prognostic factors could be considered the absence of rheumatoid factor activity and the presence of pitting edema of the hands. Greek patients with LORAS appear not to have differences in comparison to their younger counterparts. Disease modifying drugs and low doses of prednisone are the mainstream of therapy with need for further caution in the aged group.

Association of oestrogen receptor gene polymorphisms with age at onset of rheumatoid arthritis

OBJECTIVE

In view of the possible role of oestrogens in the pathogenesis of rheumatoid arthritis (RA), this study investigated the association between oestrogen receptor (OR) gene polymorphisms and RA.

METHODS

Pvu II and Xba I restriction fragment length polymorphisms of the OR gene were analysed in 70 male and 240 female patients with RA, and in 300 male and 350 female controls. The absence or presence of restriction sites were represented as P, p (Pvu II) or X, x (Xba I). The distribution of OR genotypes was compared between the RA and control subjects by sex. RA patients were divided into subgroups according to their OR genotypes, then the age at onset, seropositivity, and rheumatoid nodule positivity were compared between the subgroups.

RESULTS

The OR genotype frequency of distribution did not have significant differences between the male RA and male controls nor between the female RA and female controls. In women with RA, there was a significant difference of age at onset between the subgroups (uncorrected p = 0.047, corrected p = 0.94). Female patients with the OR genotype PPxx (homozygote of Px) tended to have developed RA at a younger age, whereas those with PPXX and ppxx (lack of Px haplotype) developed RA at an older age. In men with RA, there was no association between the OR genotype and age at onset. In seropositivity and rheumatoid nodule positivity, there was no significant difference between subgroups for either sex.

CONCLUSIONS

Some variants of the OR gene are related to the onset of RA in women in certain age periods, suggesting the role of the interaction between the OR gene and serum concentrations of oestrogen at the onset of the disease.

Predictive factors in rheumatoid arthritis

Rheumatoid arthritis (RA), a chronic polyarticular disease affecting about 1% of the adult population of the world, produces significant joint destruction, physical impairment, work disability, and early mortality. Patients with RA may have a slowly or rapidly progressive disease or a self-limited one. To design a rational treatment program for all patients, the clinician must identify early on whether patients are destined to have a rapidly progressive disease. This article reviews socioeconomic, psychological, immunogenetic, and disease-related features that may help to identify such patients.

Rheumatoid arthritis in the elderly: is it a different disease?

Controversy has surrounded the question of whether rheumatoid arthritis (RA) afflicting the elderly is a different disease than RA in younger patients. Resolution of this complex question requires careful consideration of the pathogenesis of the disease and its diagnosis and prognosis. Meaningful analysis of these factors optimally derives from a critical review of all relevant medical literature (i.e., an evidence-based approach); however, methodologic inconsistencies and other difficulties with the literature on this subject largely preclude definitive interpretation. This review examines the evidence concerning various aspects of RA in the elderly population.

Rheumatoid arthritis in the elderly. Prevalence and optimal management

Elderly-onset rheumatoid arthritis (EORA), defined as rheumatoid arthritis (RA) with onset at age 60 years or over, differs slightly from younger-onset RA by a more equal gender distribution, a higher frequency of acute systemic onset with involvement of the shoulder, a higher disease activity, and, in later stages, more radiographic damage and functional decline. Several subsets of EORA are recognised, such as rheumatoid factor-positive RA, polymyalgia rheumatica and 'remitting seronegative symmetrical synovitis with pitting oedema'. These conditions can be difficult to distinguish from crystal-induced arthritis, osteoarthritis and paraneoplastic arthritis. The efficacy and tolerability of second-line drugs is similar in both age groups, but in the elderly caution is needed with the use of nonsteroidal anti-inflammatory drugs and prednisone.

Elderly-onset rheumatoid arthritis

Elderly-onset rheumatoid arthritis (EORA), defined as rheumatoid arthritis (RA) with onset at age 60 years or over, differs slightly at presentation from younger-onset RA (YORA) by a more equal gender distribution, a higher frequency of acute onset with systemic features, more frequent involvement of the shoulder, and higher disease activity. Longitudinal studies have showed more disease activity, radiographic damage, and functional decline in patients with EORA than in those with YORA. These differences were only found in seropositive patients. Seropositive EORA was reported to be associated with HLA-DR4, in contrast to seronegative EORA. Possible heterogeneity in the pathogenesis of seronegative EORA is supported by the recognition of subsets that overlap with the clinical manifestations of other syndromes such as polymyalgia rheumatica and remitting seronegative symmetrical synovitis with pitting edema. In addition, crystal-induced arthritis and inflammatory osteoarthritis may be difficult to distinguish from EORA. The efficacy and toxicity of second-line drugs is similar in both age groups, but in the elderly caution is needed with the use of nonsteroidal antiinflammatory drugs and prednisone.

Differences in anti-Fab antibodies in adult and late onset rheumatoid arthritis

In the present study the ratio of antigen-bound anti-IgG-Fab antibodies (hidden aFab) to free aFab was found to be significantly increased in patients with adult onset rheumatoid arthritis (AORA) as compared to late onset rheumatoid arthritis (LORA). The overall amount of aFab was similar in both groups. The difference was only seen in seropositive patients. Within the seropositive AORA group, the aFab ratio was correlated with the duration and the stage of disease but not with the patients' age at investigation. This might reflect a higher affinity of anti-Fab antibodies and/or a greater diversity of the idiotypic repertoire in adult onset disease resulting in the formation of immune complexes, the stability of which might be enhanced further by the presence of rheumatoid factors. Although a pathophysiological involvement of aFab cannot be concluded from our observations, it is conceivable that different immunoregulatory mechanisms could be operative in RA with onset at different ages.

DR4 prevalence related to the age at disease onset in female patients with rheumatoid arthritis

The prevalence of HLA-DR4 in relation to age at disease onset was calculated in 226 consecutive female patients with definite or classical rheumatoid arthritis (RA). A slight increase in the prevalence of DR4 with age at RA onset was found. This appeared to be due to the low percentage of rheumatoid factor (RF) positivity in the youngest age groups; the DR4 prevalence in the RF positive patients was constant for all decades--that is, approximately 60%. A previously reported declining trend of DR4 prevalence in women with RA in relation to age of RA onset may be due to the disease heterogeneity of the patients included in that study.