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      Biologics Prescribing for Rheumatoid Arthritis in Older Patients: A Single-Center Retrospective Cross-Sectional Study

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      Author(s): 1 , , 2 , 3
      Publication date (Electronic):
      Journal: Rheumatology and Therapy
      Publisher: Springer Healthcare
      Keywords: Aging, Rheumatoid arthritis, Biological therapy

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          Abstract

          Introduction

          Appropriate medical treatment can reduce the morbidity and mortality associated with rheumatoid arthritis (RA). Studies have shown that older patients with RA may be treated less aggressively than their younger counterparts, despite evidence suggesting that biologic treatments may be safe and efficacious in older age groups. The aim of this study was to assess whether patient age was associated with biologic treatment for RA in a single center in the United Kingdom.

          Methods

          This was a retrospective cross-sectional analysis of clinic records for all patients with RA reviewed over 1 year in our center. Data were also collected on healthcare use in patients aged 65 years and older as a surrogate marker of comorbidity.

          Results

          In total, 856 patients with RA were identified, of which 22.8% were on biologic treatment. Patients on biologics were younger (mean age 58.9 years) compared to the mean age of all patients (61.4 years). Of patients aged less than 65 years, 27.2% were receiving biologic treatment, while only 15.2% of patients aged 65 years or older were on biologics. Increasing age was significantly associated with a lower likelihood of receiving biologic treatment. However, in patients 65 years or older, there was no significant difference in overall healthcare use between those on biologic treatment and those not. Patients treated with prednisolone were found to have a greater number of admissions.

          Conclusion

          In our center, older patients are less likely to receive biologic treatment than younger patients. Among older patients we found no difference in healthcare use between those treated with biologics and those not, suggesting similar levels of comorbidity. Potential contributors are discussed, but further assessment is required to determine the reasons for this observation.

          Electronic supplementary material

          The online version of this article (doi:10.1007/s40744-015-0021-z) contains supplementary material, which is available to authorized users.

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          Most cited references28

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          Gaps in care for rheumatoid arthritis: a population study.

          Diane Lacaille, J Esdaile, D Guh … (2005)
          Treatment guidelines for rheumatoid arthritis (RA) now recommend early, aggressive, and persistent use of disease-modifying antirheumatic drugs (DMARDs) to prevent joint damage in all people with active inflammation, and evaluation by a rheumatologist, when possible. This research assesses whether care for RA, at a population level, is consistent with current treatment guidelines. Using administrative billing data from the Ministry of Health in 1996-2000, all prevalent RA cases in British Columbia, Canada were identified. Data were obtained on all medications and all provincially-funded health care services. We identified 27,710 RA cases, yielding a prevalence rate of 0.76%, consistent with epidemiologic studies. DMARD use was inappropriately low. Only 43% of the entire RA cohort received a DMARD at least once over 5 years, and 35% over 2 years. When used, DMARDs were started in a timely fashion, but were not used consistently. Care by a rheumatologist increased DMARD use 31-fold. Yet, only 48% and 34% saw a rheumatologist over 5 and 2 years, respectively. DMARD use was significantly more frequent, persistent, and more often used as combination therapy with continuous rheumatologist care. DMARDs were used by 84% and 73%, 40%, and 10% of people followed by rheumatologists continuously and intermittently, internists, and family physicians, respectively (P < 0.001). NSAID use, physiotherapy, and orthopedic surgeries were similar across these 4 care groups. RA care in the British Columbia population was not consistent with current treatment guidelines. Efforts to educate family physicians and consumers about the shift in RA treatment paradigms and to improve access to rheumatologists are needed.
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            Anti-tumor necrosis factor alpha therapy and the risk of serious bacterial infections in elderly patients with rheumatoid arthritis.

            Jeffrey Katz, Raisa Levin, Sebastian Schneeweiss … (2007)
            To assess the association between the initiation of anti-tumor necrosis factor alpha (anti-TNFalpha) therapy and the risk of serious bacterial infections in routine care. This was a cohort study of patients with rheumatoid arthritis (RA) in whom specific disease-modifying antirheumatic drugs (DMARDs) were initiated. Patients were Medicare beneficiaries ages 65 years and older (mean age 76.5 years) who were concurrently enrolled in the Pharmaceutical Assistance Contract for the Elderly provided by the state of Pennsylvania. A total of 15,597 RA patients in whom a DMARD was initiated between January 1, 1995 and December 31, 2003 were identified using linked data on all prescription drug dispensings, physician services, and hospitalizations. Initiation of anti-TNFalpha therapy, cytotoxic agents other than methotrexate (MTX), noncytotoxic agents, and glucocorticoids was compared with initiation of MTX. The main outcome measure was serious bacterial infections that required hospitalization. The incidence of serious bacterial infections was, on average, 2.2 per 100 patient-years in this population (95% confidence interval [95% CI] 2.0-2.4). Glucocorticoid use doubled the rate of serious bacterial infections as compared with MTX use, independent of previous DMARD use (rate ratio [RR] 2.1 [95% CI 1.5-3.1]), with a clear dose-response relationship for dosages >5 mg/day (for or = 20 mg/day, RR 5.48 [P for trend < 0.0001]). Adjusted models showed no increase in the rate of serious infections among initiators of anti-TNFalpha therapy (RR 1.0 [95% CI 0.6-1.7]) or other DMARDs as compared with initiators of MTX. In a large cohort of patients with RA, we found no increase in serious bacterial infections among users of anti-TNFalpha therapy compared with users of MTX. Glucocorticoid use was associated with a dose-dependent increase in such infections.
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              Do patients with older-onset rheumatoid arthritis receive less aggressive treatment?

              Z Tutuncu, Laura Kavanaugh, Steven Reed … (2006)
              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.
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                Author and article information

                Contributors
                Klara Morsley: klara.m@doctors.org.uk
                Journal
                Journal ID (nlm-ta): Rheumatol Ther
                Journal ID (iso-abbrev): Rheumatol Ther
                Title: Rheumatology and Therapy
                Publisher: Springer Healthcare (Cheshire )
                ISSN (Print): 2198-6576
                ISSN (Electronic): 2198-6584
                Publication date (Electronic): 25 November 2015
                Publication date PMC-release: 25 November 2015
                Publication date Collection: December 2015
                Volume: 2
                Issue: 2
                Pages: 165-172
                Affiliations
                [1 ]Royal Berkshire Hospital, Reading, UK
                [2 ]Newham University Hospital, London, UK
                [3 ]Wexham Park Hospital, Slough, UK
                Article
                Publisher ID: 21
                DOI: 10.1007/s40744-015-0021-z
                PMC ID: 4883268
                PubMed ID: 27747537
                SO-VID: f92de424-3cfd-4c23-bc06-007e5c9fa3e1
                Copyright © © The Author(s) 2015
                History
                Date received : 3 October 2015
                Categories
                Subject: Original Research
                Custom metadata
                issue-copyright-statement © Springer Healthcare 2015

                Keywords: aging,rheumatoid arthritis,biological therapy
                Data availability:
                Keywords: aging, rheumatoid arthritis, biological therapy

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