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    Many Older People With Rheumatoid Arthritis Are Undermedicated



    Your doctor may not be treating rheumatoid-arthritis (RA) as aggressively if you are older than 65 years and have RA. The guidelines were updated in 2021 and recommend early treatment with DMARDs (diseasemodifying antirheumatic drug), which are medications that reduce pain and prevent joint injury. A study by UofM Medicine researchers in January 2022 in ACR Open Rheumatology found that older patients were receiving this treatment less often than those with RA.

    Rheumatoid arthritis is a progressive condition. Early, aggressive treatment can reduce fatigue and prevent irreversible damage to the joints.

    Do DMARDs get underused by older adults?

    The National Ambulatory Medicine Care Survey was used by the research team to examine almost 8 million ambulatory visits of patients 65 years and older between 2005 and 2016. This analysis was done for RA, which is an inflammatory autoimmune disorder that has more than 1 million Americans. “We found that, while the guidelines recommend that everyone with RA should receive some type of treatment, only half of the older adults are receiving any treatment. This is lower than we expected. This number is closer than 80 percent in the younger population. The DMARDs are being undertreated in general. Jiha Lee MD, MHS, a UofM Health rheumatologist and the lead author of this study, says that even among these, biologics have significant changed the outcome with rheumatoid arthritis and are now being prescribed in lower amounts in older people.”

    The study concluded that “DMARD use in older adults with RA is still low from both rheumatologists as well as PCPs [primary-care physicians]”, even though American College of Rheumatology guidelines recommend a more aggressive and earlier treatment of RA.

    Primary Care doctors as well as rheumatologists may use DMARDs.

    It is also interesting to note that 74% of visits were with rheumatologists, while the remainder were with primary care doctors PCPs. According to the study, DMARD use was noted at 56% of rheumatologists and 30% of PCP visits. 20 percent of DMARD-related visits by rheumatologists had at least two DMARDs, compared to 6 percent for PCP visits.

    Undertreated RA increases the likelihood of disease activity, irreversible joint damage, and other problems

    “If the disease is not treated properly, there are a host of possible consequences. There are many consequences, including a decrease in quality of life, an increase in depression, and an increase in pain. Vinicius Domingues MD, a rheumatologist in Daytona Beach, Florida and medical advisor to CreakyJoints, says, “I think it’s one of the things we should pay attention too.”

    Why is there such a disparity in the treatment of older people vs. younger people? Younger People?

    Dr. Lee believes that ageism may be a factor in the differences in prescribing. She cites research in Rheumatology that showed that rheumatologists were given the same case scenario as an RA patient but only changed the ages. The rheumatologists were less likely than older patients to recommend aggressive treatment when they were presented with the same disease script. She says, “There might be some hesitancy from the patient’s side, but it also could be the same hesitancy from the physician side.”

    There are also other concerns:

    • People over 50 are more likely to take more medication, which means there is more risk of drug interactions. Patients and doctors may hesitate to add more drugs to their regimen.
    • People with other diseases may find it worrying that biologics can depress their immune system.
    • Patients who are older may not be as inclined to make necessary changes.

    Aggressive treatment is also needed for older people with RA.

    There are many other factors that can influence this, which we still don’t fully understand. Lee says that this doesn’t mean older patients should receive less aggressive treatment, if better outcomes can be achieved.

    Dr. Domingues concurs, “The risk for side effects increases with age, so doctors often want to protect them, but in reality, you’re doing them a disservice if you don’t treat the disease.”

    Doctors must initiate treatment discussion, patients should aim to make informed decisions

    “Doctors must get informed consent from patients. Describe to the patient the risks and benefits. If you get a yes answer, then you can move on. If you get a no, then you look for a medication with fewer side effects. If nothing is possible, you can try to find an alternative medication that has a lower side-effect profile. But, remember, the patient’s decision at the end, and you must include them in the discussion,” Domingues explains.

    Primary Care Doctor vs. Rheumatologist Treatment

    As mentioned earlier, PCPs are more likely to prescribe RA than rheumatologists. Lee recommends that you see a rheumatologist rather than a PCP if possible. While it is possible to get an early diagnosis from your primary care physician, they are not responsible for prescribing DMARDS. Lee says that while it is always appreciated that they provide early treatment, they should refer you to a specialist.

    People with RA must self-advocate

    Your doctor should be consulted if you feel that your older patients are experiencing symptoms that aren’t being controlled. Your doctor may dismiss your concerns by saying “You’re 78. That’s how 78 feels like.” You should seek out another doctor. Domingues believes patients should be empowered to voice their concerns. You must voice your concerns regarding trying to distinguish between osteoarthritis and inflammatory arthritis. If you are still experiencing joint pain, stiffness, or swelling, it is important to tell your doctor. If your doctor refuses to listen, seek a second opinion.

    Lee says, “We see patients in office visits, but patients live with it on a daily basis.” It is important for patients to be informed about their symptoms and communicate this information to their doctor. This will help them to make the best possible medication choices.



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