Management of inflammatory rheumatic conditions in the elderly.

The number of elderly people with chronic inflammatory rheumatic diseases is increasing. This heterogeneous and comorbid population is at particular risk of cardiovascular, neoplastic, infectious and iatrogenic complications. The development of biotherapies has paved the way for innovative therapeutic strategies, which are associated with toxicities. In this review, we have focused on the scientific and therapeutic changes impacting the management of elderly patients affected by RA, SpA or PsA. A multidimensional health assessment resulting in an integrated therapeutic strategy was identified as a major research direction for improving the management of elderly patients.

A randomised, double-blind, placebo-controlled study assessing the efficacy of high doses of vitamin D on functional disability in patients with rheumatoid arthritis.

OBJECTIVES: To evaluate the short-term efficacy of vitamin D (cholecalciferol) supplementation on functional disability in RA patients. METHODS: 1) Patients: RA (ACR 1987 revised criteria) in non-remission (DAS28 >2.6) whose treatment was not expected to be changed over a 3-month period following inclusion and presenting with vitD deficits (serum 25OHD <30ng/mL). 2) Study design: prospective randomised placebo-controlled trial (NCT02243800). 3) Study arms: either vitD ampoules (cholecalciferol 100,000IU) or placebo. 4) Outcome measures: primary: improvement in patients' functional disability using the Health Assessment questionnaire (HAQ); secondary: improvement in DAS28ESR, DAS28CRP, ESR, CRP, RAID score, fatigue (EVA and FACIT), and SF36. RESULTS: Overall, 59 patients were included, 83.1% females, aged 59.8±10.9 years on average, with RA for 17.0±9.7 years. Thirty patients received placebo and 29 vitD. At 6 months, HAQ scores tended to be increased in the placebo group (+0.08±0.25), while slightly numerically decreased in the vitD group (-0.03±0.23) (p=0.11). After adjusting for age, gender, season, and initial vitD status, the between-group difference achieved statistically significance (p=0.046). After adjusting for age, gender, season, and initial vitD status, there was no significant difference in the secondary criteria between the 2 groups except for ESR and CRP (p=0.002 and 0.04, respectively). CONCLUSIONS: In this randomised, double-blind, placebo-controlled clinical trial in patients with RA and VitD deficiency, high doses of cholecalciferol resulted in a statistically significant improvement in functional disability at month 6, which, however, was clinically not relevant.

Rheumatoid arthritis in the elderly in the era of tight control.

The principles of treating rheumatoid arthritis (RA) have changed considerably in recent years. Disease-modifying treatment (if possible, methotrexate) should be started as soon as the diagnosis of RA is made. The purpose of treatment is to achieve remission or, alternatively, low disease activity, and patients should be assessed every 1-3 months if they have early RA in order to achieve this aim. The same principles of treatment should apply in the elderly. However, it is more difficult to assess RA activity in the elderly. Overall disease activity and/or pain may be overestimated, as elderly patients may suffer from other diseases. Conversely, the number of joints with synovitis can be underestimated compared with young patients, and regular ultrasound assessment should therefore be considered. Treatment may be more difficult because of concomitant diseases and the increase in drug-related side effects. The role of corticosteroids is still controversial as their short-term symptomatic effects on clinical activity and potential medium-term effect on structural deterioration are counter-balanced by their side effects. Dosages of methotrexate need to be adjusted for creatinine clearance. The anti-tumor necrosis factors (TNFs) appear to be slightly less effective in the elderly. The frequency of adverse effects of anti-TNFs is higher in an elderly population, although the same is seen with comparator disease-modifying treatments. Limited information is available for rituximab and tocilizumab. Uncertainties remain about the management of RA in the elderly as there have been few studies in this population. The safety of the biotherapies therefore still needs to be confirmed, together with the benefit-risk balance of corticosteroid therapy compared with biological therapy.