Download Treatment of Rheumatic Diseases in the Elderly

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
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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
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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
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