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Treatment of Rheumatic Diseases in the Elderly: Minimizing Harm, Maximizing Benefit Mala Joneja, MD MEd FRCPC May 25, 2013 Learning Objectives • Identify factors that contribute to risk in the medical treatment of Rheumatic Diseases in the elderly population • Identify risks associated with specific pharmacological interventions in the elderly • Be aware of practice strategies to minimize risk in elderly patients 2 Disclosures • Not applicable Focus on RA ‘Elderly’ is in the eye of the beholder -chronological age vs. biological age -importance of comorbid disease, polypharmacy Reflect on your personal experience Discuss with colleagues A couple of stories… Workshop Format Introductions Question 1 Reporting on question 1 Summary Question 2 Reporting on question 2 Summary Question 3 Reporting on question 3 Summary Closing Question 1 7 Treatment Issues in Elderly Patients Question 1: What are three challenges that you face in treating elderly patients with Rheumatoid Arthritis? Question 1 Reporting – see flip chart Rheumatoid Arthritis in Older Adults Different paths to RA in older adults: EORA = onset after 60 years of age But also consider YORA who age – Patients who developed RA at an age<60, growing into older years Frail elderly Elderly Onset Rheumatoid Arthritis Clinical Features of Elderly Onset Rheumatoid Arthritis Age of onset >60 yr Male:female ~1:1 Acute presentation Oligoarticular (two to six joints) disease Involvement of large and proximal joints Systemic complaints, e.g., weight loss Absence of rheumatoid nodules Sicca symptoms common Laboratory: high erythrocyte sedimentation rate; often negative rheumatoid factor Drug Metabolism Drug Treatment in the Elderly • Elderly are a heterogeneous group • Pharmacokinetics=relationship between drug input and concentration of drug achieved over time • Most consistent change in pharmacokinetics in older adults=increase in interindividual variability • Reduced hepatic clearance and renal clearance • Decrease in GFR, though extent is unclear • No drugs are contraindicated because of age Adverse Drug Reactions In the Elderly • Occur more frequently • Often more severe • Sometimes delayed recognition – under-recognition of ADRs as being related to medication • Increased vulnerability due to comorbidity, altered pharmacokinetic changes and polypharmacy (resulting in drug-drug and drug-disease interactions) • Account for 5-10% hospitalizations • Important cause of morbidity and mortality The Frail Elderly Definition – high susceptibility to disease • Also decline in physical function and high risk of death • A key feature is loss of lean muscle mass • Associate with many risk factors for adverse drug events including: sarcopenia, less physiologic reserve, polypharmacy, compliance issues, hospital admissions Functional Disability Complex Interaction of Factors • • • • EORA itself Disease duration Concomitant OA, cardiac disease, lung disease, neuro disease If functional disability is increased in elderly patients, should we not treat their RA as aggressively as possible? Geriatric Syndromes What are these? Cognitive Impairment Depression Falls Incontinence Malnutrition Infections Increased risk • • • • • Increased risk in RA Increased frequency of comorbidities Multiple risk factors Mortality risk Interruption of treatment Question 1: Summary Question 2 23 Medications and Monitoring in the Elderly Question 2 Is your approach to the use of traditional DMARDs such as MTX, LEF, SAS and HCQ different in the elderly RA patient? Is your approach to the use of biologic treatment different for elderly RA patients? How? Question 2 Reporting – See Flip Chart Methotrexate Methotrexate – DMARD of Choice • MTX clearance decreases with decline in creatinine clearance • Dose adjustments required in patients with renal impairment, elderly included • NSAIDs may reduce creatinine clearance, displace MTX • Age does not affect MTX efficacy • Bone marrow toxicity and CNS disturbances • Prolonged use with steroids can result in bone loss Leflunomide Monotherapy and Combination Therapy • Recommended for use in elderly patients • Lower dose recommended • Combination therapy with MTX has not been studied in the elderly • Some authors report a higher risk of pancytopenia with LEF and MTX combination • HTN is common adverse effect Sulfasalazine • Safe alternative to MTX Hydroxychloroquine • No suggestion that efficacy declines in age • Kidneys are main route of elimination • Retinal toxicity Biologic Therapy in Elderly RA Patients • Anti-TNF agents • Rituximab • Access - drug reimbursement, risk of toxicity Safety of Novel Immunomodulatory Therapies: Optimizing Treatment Stratify: Identify the patient's risk of adverse effects based on various factors, such as comorbidities (e.g., chronic obstructive pulmonary disease and diabetes mellitus), age, concomitant medication use, and a history of similar events (e.g., opportunistic infection). Assess: Evaluate the patient for important risks (e.g., exposure to tuberculosis or hepatitis B or C virus infection, vaccination status, and status of comorbid conditions). Fend off: Optimize the patient's health before treatment (e.g., wherever possible, vaccinate against infections and treat and/or control the patient's comorbidities). Evaluate: Quickly evaluate adverse events, remembering that both typical and atypical presentations may be seen. Treat: Aggressively manage adverse events to help minimize their severity. Yearly: Reevaluate the patient on a regular basis. Adapted with permission from Hennigan S, Kavanaugh A. Optimizing the use of TNF- inhibitors. J Musculoskel Med. 2007;24:293–298. Question 2 - Summary Question 3 33 Maximizing Effectiveness and Minimizing Harm Question 3 How would you conduct a chart audit of elderly RA patients, as a quality assurance exercise, to ensure they are receiving optimal treatment? What factors would you assess? Question 3 Reporting – See Flip Chart Treatment of Elderly RA Patients EORA vs YORA patients • Patients with EORA receive biological treatment and combination DMARD treatment less frequently • Despite identical disease duration and comparable disease activity • Lower doses of MTX • Greater use of prednisone • Not necessarily due to age bias, but perhaps good clinical practice Treatment of Elderly RA Patients Not getting a DMARD … • Getting older, and older • Not seeing a Rheumatologist • However, database studies can’t always capture potential contraindications and the individual patient’s personal preference Question 3 Summary Conclusion Thank you! Special thanks to Dr. Henry Averns, Queen’s University Please complete your GREEN EVALUATION SHEETS