Rheumatoid arthritis (RA) is a persistent autoimmune condition that primarily impacts the joints, causing inflammation, pain, and potential joint damage. Prompt and effective treatment is vital for managing RA, particularly when diagnosed later in life. However, recent findings indicate that many older adults with late-onset RA are not receiving the most effective treatments, which could help prevent long-term disability. Understanding why this occurs and exploring potential solutions can aid those affected in receiving the care they need.

The Importance of Early and Aggressive Treatment

Early and aggressive treatment for RA is crucial to slow disease progression and avoid significant joint damage. The most effective RA medications not only alleviate symptoms but also help modify the disease’s course. The standard first-line treatment typically involves nonbiologic disease-modifying antirheumatic drugs (DMARDs), such as methotrexate, which can be taken as pills or administered via injections.

If a nonbiologic DMARD proves inadequate, newer types of DMARDs may be considered:

• Biologic DMARDs, such as etanercept (Enbrel) or rituximab (Rituxan), target specific immune system pathways and are administered via injections or infusions.
• Janus kinase inhibitors, like tofacitinib (Xeljanz), are oral medications that also help reduce inflammation.

These treatments may take weeks to months to show results. During this period, doctors might prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids to manage symptoms, but these do not prevent joint damage and can have significant side effects if used long-term.

Recent Evidence on Late-Onset RA Treatment

A study published on December 5, 2023, in ACR Open Rheumatology examined Medicare data from 2008 to 2017 to explore the treatment of late-onset RA. The study found that only 29% of individuals diagnosed with RA after age 65 received disease-modifying medications within the first year of diagnosis. In comparison, 70% to 80% of younger adults with RA received such treatments promptly.

Barriers to Optimal Treatment

Several factors contribute to the delay in receiving effective treatment for late-onset RA:

1. Cost: Biologic DMARDs and Janus kinase inhibitors can be very expensive, often exceeding $20,000 annually. Although insurance may cover some costs, high copays and deductibles can still make these medications financially challenging.
2. Side Effects: All DMARDs can cause side effects, which may discourage patients from starting or continuing treatment. Nonbiologic DMARDs can lead to fatigue and liver issues; biologics may increase the risk of infections; and Janus kinase inhibitors can cause side effects such as shingles and allergic reactions.
3. Coexisting Conditions: By the time late-onset RA is diagnosed, many individuals may have other health conditions, like heart or kidney problems, complicating treatment. Aging itself can affect liver and kidney function and immune system performance, making RA management more complex.
4. Perceived Frailty: Some healthcare providers may hesitate to prescribe aggressive treatments to older patients perceived as frail, opting instead for less potent options such as corticosteroids.
5. Cognitive Impairment: Cognitive decline can affect a patient’s ability to manage complex medication regimens and attend follow-up appointments, presenting ethical dilemmas about the aggressiveness of treatment.
6. Accessibility: With approximately 6,000 rheumatologists in the U.S. for over 1.5 million RA patients, accessing specialized care can be difficult. Challenges such as transportation issues or physical limitations can further impede treatment.

Steps You Can Take

If you are not receiving optimal treatment for RA, consider these strategies:

• Medication Administration: If self-injections are problematic, ask about alternative options such as oral medications or infusions.
• Home Care: Explore services that provide home-based blood work or infusions.
• Alternative Medications: If methotrexate is not suitable, discuss other medication options with your doctor.
• Support for Cognitive Impairment: Consider having a family member, caregiver, or visiting nurse assist with medication management or use an electronic pill dispenser.
• Financial Assistance: Check with your pharmacist about manufacturer coupons or patient assistance programs to help reduce medication costs.
• Managing Side Effects: Work with your healthcare provider to find the most appropriate medication with minimal side effects, or explore complementary therapies such as physical therapy, topical creams, or heat and ice treatments.

Dr. Devyani Misra, a geriatrician and rheumatologist at Harvard-affiliated Beth Israel Deaconess Hospital, stresses that age should not preclude effective RA treatment. With the right approach, RA can be managed effectively, enhancing quality of life even in later years.