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.

Prevalence of vitamin D deficiency in rheumatoid arthritis and association with disease activity and cardiovascular risk factors: data from the COMEDRA study.

OBJECTIVES: The relationship between vitamin D and rheumatoid arthritis (RA) activity remains controversial. RA is a cardiovascular risk factor. A low level of vitamin D may increase blood pressure (BP) and decrease HDL-cholesterol. We aimed to determine the prevalence of vitamin D deficiency in RA patients compared to controls, and also to investigate the relationship between vitamin D and RA activity, and between vitamin D and cardiovascular risk factors. METHODS: Patients in the COMEDRA study with established inactive RA (1987 ACR criteria) were matched with subjects from the NUTRINET-SANTE cohort (age, gender, latitude, sampling season). Vitamin D deficiency was defined as <10 ng/mL, and insufficiency as 10 to 29.9 ng/mL. RESULTS: Eight hundred and ninety-four RA patients were analysed, of which 861 were matched with controls. The prevalence of vitamin D insufficiency and deficiency was lower in RA patients than in controls: 480 (55.8%) vs. 508 (59%) and 31 (3.6%) vs. 45 (5.23%), respectively; p=0.04. There was an inverse correlation between vitamin D levels and RA activity assessed by DAS28-CRP (p=0.01), SDAI (p<0.001) and CDAI (p=0.001), but not DAS28-ESR after adjustment for age, gender, inclusion season, body mass index (BMI), vitamin D supplementation, disease duration, RF or anti-CCP status and RA treatments. Vitamin D levels were inversely correlated with BMI (p<0.001), but not with BP, total cholesterol, LDL-cholesterol, HDL-cholesterol or blood glucose. CONCLUSIONS: This study demonstrates that vitamin D is inversely correlated with RA activity and BMI, but not with other cardiovascular risk factors.

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.