Treatment of Rheumatic Diseases in the Elderly: Minimizing Harm, Maximizing Benefit - PowerPoint Presentation

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Treatment of Rheumatic Diseases in the Elderly: Minimizing Harm, Maximizing Benefit

May 25, 2013

Mala Joneja, MD MEd FRCPC

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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

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Learning Objectives

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Not applicable

Disclosures

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Focus on RA‘Elderly’ is in the eye of the beholder-chronological age vs. biological age

-importance of comorbid disease, polypharmacyReflect on your personal experience

Discuss with colleagues

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A couple of stories…

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IntroductionsQuestion 1Reporting on question 1Summary

Question 2Reporting on question 2SummaryQuestion 3

Reporting on question 3

SummaryClosing

Workshop Format

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Question 1

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What are three challenges that you face in treating elderly patients with Rheumatoid Arthritis?

Question 1:

Treatment Issues in Elderly Patients

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Question 1 Reporting – see flip chart

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EORA = onset after 60 years of ageBut also consider YORA who age – Patients who developed RA at an age<60, growing into older years

Frail elderly

Different paths to RA in older adults:

Rheumatoid Arthritis in Older Adults

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Clinical Features of Elderly Onset

Rheumatoid ArthritisAge of onset >60 yr

Male:female

~1:1Acute presentationOligoarticular (two to six joints)

diseaseInvolvement of large and proximal jointsSystemic complaints, e.g., weight

loss

Absence of rheumatoid

nodules

Sicca

symptoms

common

Laboratory: high erythrocyte sedimentation rate; often negative rheumatoid factor

Elderly Onset Rheumatoid Arthritis

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Elderly are a heterogeneous groupPharmacokinetics=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 clearanceDecrease in GFR, though extent is unclear

No drugs are contraindicated because of age

Drug Treatment in the Elderly

Drug Metabolism

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Occur more frequentlyOften more severe

Sometimes delayed recognition – under-recognition of ADRs as being related to medicationIncreased 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

In the Elderly

Adverse Drug Reactions

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Also decline in physical function and high risk of deathA 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 admissionsDefinition – high susceptibility to disease

The Frail Elderly

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EORA itselfDisease 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?

Complex Interaction of Factors

Functional Disability

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Cognitive ImpairmentDepressionFallsIncontinence

MalnutritionWhat are these?

Geriatric Syndromes

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Increased risk in RAIncreased frequency of comorbidities

Multiple risk factorsMortality risk

Interruption of treatment

Increased risk

Infections

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Question 1: Summary

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Question 2

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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

Medications and Monitoring in the Elderly

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Question 2 Reporting – See Flip Chart

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MTX clearance decreases with decline in creatinine clearance

Dose adjustments required in patients with renal impairment, elderly includedNSAIDs may reduce

creatinine

clearance, displace MTXAge does not affect MTX efficacyBone marrow toxicity and CNS disturbances

Prolonged use with steroids can result in bone loss

Methotrexate – DMARD of Choice

Methotrexate

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Recommended for use in elderly patientsLower dose recommended

Combination therapy with MTX has not been studied in the elderlySome authors report a higher risk of pancytopenia with LEF and MTX combination

HTN is common adverse effect

Monotherapy

and Combination Therapy

Leflunomide

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Safe alternative to MTX

Sulfasalazine

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No suggestion that efficacy declines in ageKidneys are main route of elimination

Retinal toxicity

Hydroxychloroquine

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Anti-TNF agentsRituximab

Access - drug reimbursement, risk of toxicity

Biologic Therapy in Elderly RA Patients

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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

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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.

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Question 2 - Summary

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Question 3

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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

Maximizing Effectiveness and Minimizing Harm

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Question 3 Reporting – See Flip Chart

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Patients with EORA receive biological treatment and combination DMARD treatment less frequentlyDespite identical disease duration and comparable disease activity

Lower doses of MTXGreater use of prednisone

Not necessarily due to age bias, but perhaps good clinical practice

EORA

vs YORA patients

Treatment of Elderly RA Patients

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Getting older, and olderNot seeing a Rheumatologist

However, database studies can’t always capture potential contraindications and the individual patient’s personal preference

Not getting a DMARD …

Treatment of Elderly RA Patients

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Question 3 Summary

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Conclusion

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Thank you!Special thanks to Dr. Henry

Averns, Queen’s University

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