RA after 70: Too Old for bioDMARDs? Save

In RA, the two most common peaks of incidence are thirties and fifties; however a significant percentage of patients above the age of 70 present with active RA -of early or later onset- and require adapted treatment.

Importantly, treating people living with RMDs above the age of 70 -or elderly RA- represent several challenges, in particular due to a higher number of comorbidities and treatments. These elements lead to multimorbidity and elderly RA patients require a treatment strategy tailored to their specific needs. 

On the other hand, the impact of multimorbidity on treatment safety profile in RA elderly have not been comprehensively studied yet. It is commonly accepted that bioDMARDs represent a higher risk of serious infections (SI) than csDMARDs in this age group based on reports from observational studies. On the contrary, meta-analysis of RCTs have not reported much increase of SI with bioDMARDs in that specific population, although this could be explained by a selection bias with usually healthier population in trials.

In that context, in OP0116, Strangfeld et al. explored the risk of SI on a cohort of elderly patients treated with bioDMARDs and tsDMARDs. They analyzed the prospective, longitudinal RABBIT register including all patients above the age of 70, enrolled with a new start of a DMARD after at least one csDMARD failure. 

They observed 626 SI among 2274 patients. In patients receiving bio or tsDMARDs the hazard ratio was not superior to csDMARDs; suggesting no increased risk of SI on bioDMARDs or JAKi compared to others drugs. On the other hand, GC use, especially even with a dosage considered a s”low” dosage (HR 1.6, 95% CI: 1.2 – 2.2 for ≤ 10 mg/d) and other variables such as high disease activity measured by DAS28-ESR  (HR 1.1, 95% CI: 1.0 – 1.2 per 1 point increase), or, not very surprisingly, comorbidities such as COPD or pulmonary fibrosis (HR 1. 8, 95% CI: 1.3 – 2.4), chronic kidney disease (HR 1.5, 95% CI: 1.2 – 1.9) and diabetes mellitus (HR 1.3, 95% CI: 1.0 – 1.7) were associated with an increased risk of SI. 

Overall, this study suggests that a disease better controlled -even if it involves prescribing bioDMARDs or JAKi – is better to reduce the risk of SI than a less aggressive therapeutic strategy with csDMARDs leading to a poorer disease control.

These data are overall reassuring in terms of safety of bioDMARDS and JAKi in elderly RA; although the number of patients treated with JAKi in this cohort (n=108) remain low and further data assessing safety in this population is required.