Elderly-onset Rheumatoid Arthritis Research Articles

Elderly-onset rheumatoid arthritis — clinical findings and treatment features (systematic literature review)

Background. Elderly-onset rheumatoid arthritis ­(EORA) is characterized by the disease onset after 60 years. Gi­ven the importance of the global increase in the proportion of older people in the population and the potential consequences, the problem of diagnosis and treatment of EORA is quite relevant. Purpose: to analyze the current literature data on the peculiarities of the clinical picture, differential diagnosis, and treatment of patients with EORA, taking into account comorbidity. Materials and methods. An analytical review of literature data was conducted using information analysis of the databases PubMed, Web of Science, Scopus, and Google Scholar for the period 2013–2023, but it did not exclude key works that were published earlier, using the keywords “elderly-onset rheumatoid arthritis”, “rheumatoid arthritis”, “diagnosis”, “treatment”, “prognosis”. Results. A review of the lite­rature demonstrated that while previous studies have mainly argued that EORA is a milder form of the disease with a favorable prognosis, recent studies have shown greater disease activity and severity, as well as worse clinical, functional, and radiological outcomes. Despite recent advances in the understanding of RA pathogenesis and new treatment strategies, there is still controversy regarding the management of EORA patients. Clinical practice shows that most patients with EORA are prescribed purely nonsteroidal anti-inflammatory drugs (NSAID) and glucocorticoids (GC) without the addition of disease-modifying antirheumatic drugs (DMARD). Real-world data have demonstrated that the treatment of elderly patients with RA is often unsatisfactory due to concerns about the possible side effects of DMARD, the presence of comorbidities, polypharmacy, and cognitive dysfunction in elderly patients. Conclusions. EORA presents a unique clinical profile, such patients require individualized treatment strategies, mandatory addition or switch to DMARD based on disease activity, comorbidities, and safety considerations to optimize treatment outcomes and minimize GC and NSAIDs intake, thereby improving the quality of treatment of elderly patients.

Comparison of retention of biologics in Japanese patients with elderly-onset rheumatoid arthritis-the ANSWER cohort study.

This multicentre, retrospective study aimed to compare retention and reasons for discontinuation between Janus kinase inhibitors (JAKi) and biologic disease-modifying antirheumatic drugs in patients with elderly-onset rheumatoid arthritis (EORA). Patients with RA enrolled in a Japanese multicentre observational registry between 2015 and 2022 were included. EORA was defined as RA with onset at 60 or over. To adjust confounding factors by indication for initiation of tumor necrosis factor inhibitors (TNFi), interleukin-6 inhibitors (IL-6i), cytotoxic T-lymphocyte associated antigen 4 immunoglobulin (CTLA4-Ig) blockers, or JAKi, a propensity score based on baseline characteristics was used to compare drug retention. To assess the reasons for discontinuation, retention rates for ineffectiveness, adverse events, and remission were analyzed as secondary outcomes. A total of 572 patients with 835 treatment courses were identified (314 TNFi, 175 IL-6i, 228 CTLA4-Ig, and 118 JAKi). After adjusting for differences in baseline characteristics, drug retention was significantly higher for IL-6i (HR = 0.38, 95%CI = 0.27-0.55, p< 0.01) as compared with TNFi. Discontinuation due to lack of effectiveness was lower with the JAKi (HR = 0.38, 95%CI = 0.22-0.66, p< 0.01) and the IL-6i (HR = 0.29, 95%CI = 0.19-0.46, p< 0.01) as compared with the TNFi although the CTLA4-Ig had a similar HR to TNFi. The adjusted incidence of discontinuation due to adverse event was higher in the JAKi (HR = 2.86, 95%CI = 1.46-5.59, p< 0.01) than the TNFi. In EORA patients, IL-6i and JAKi had longer retention and less discontinuation due to ineffectiveness than TNFi. The potential risks of JAKi should be approached with an individualized perspective.

Characteristics of Elderly-Onset Rheumatoid Arthritis Patients With COVID-19

Abstract This study aimed to investigate the clinical characteristics of elderly-onset rheumatoid arthritis (EORA) patients with COVID-19. We retrospectively enrolled EORA patients diagnosed with COVID-19 from December 2022 through February 2023 and followed them up. Demographic characteristics of the patients and clinical data on COVID-19 were collected, and EORA-related data at the onset of rheumatoid arthritis and during COVID-19 episodes were evaluated. A total of 102 EORA outpatients were enrolled and stratified into the COVID-19 group (n = 60) and the non–COVID-19 group (n = 42). In the COVID-19 group, 56 (93.3%) had symptoms, 8 (13.3%) had viral pneumonia, and 4 (6.7%) developed severe COVID-19. Multivariate logistic regression analysis showed that lack of COVID-19 vaccination (P = 0.016 and P = 0.030, respectively) and having interstitial lung disease (P = 0.013 and P = 0.001, respectively) were independent risk factors for viral pneumonia and severe COVID-19. Compared with the general population, EORA patients did not show significantly higher susceptibility to COVID-19 or a higher risk of severe COVID-19. However, EORA patients with interstitial lung disease require special consideration during COVID-19 episodes.

La artritis reumatoide de inicio en el anciano recibe terapias menos agresivas que la artritis reumatoide de inicio en el adulto en una cohorte argentina

ObjectivesWhen rheumatoid arthritis (RA) starts after the age of 60 it is called elderly-onset rheumatoid arthritis (EORA) and when it starts earlier, young-onset rheumatoid arthritis (YORA). There are few Latin American studies that compared both groups. The objective of the study was to evaluate differences in the clinical characteristics, evolution and treatment among patients with RA with onset before or after 60years of age. Materials and methodsObservational study of patients with RA attended consecutively in four centers in Argentina. Sociodemographic data, comorbidities, clinical manifestations at diagnosis, presence of rheumatoid factor and/or anti-CCP (cyclic citrullinated peptide) and treatments received were collected. At the last visit, swollen and tender joints, assessment of disease activity by the patient and physician, the presence of radiographic erosions, and functional status using the HAQ-DI were recorded. ResultsFifty-one patients from each group were analyzed. The EORA group had a significantly higher proportion of smokers (58.8% vs. 35.3%, P=.029), cardiovascular history (54.9% vs. 21.6%, P=.001), abrupt onset (49% vs. 29.4%, P=.034) or with symptoms similar to PMR (19.6% vs. 0%, P=.001). Lower methotrexate doses were used in the EORA group: 19mg (15-25) vs. 21.9mg (20-25) (P=.0036) and more frequently did not receive bDMARDs or tsDMARDs. Discussion and conclusionsThe benefits of intensive treatment in patients with RA have been described. In this study, the use of DMARDs in the EORA group was less intensive, suggesting that advanced age constitutes a barrier in the therapeutic choice.

Elderly-Onset Rheumatoid Arthritis: Characteristics and Treatment Options.

Elderly-onset rheumatoid arthritis (EORA) is a distinct clinical entity defined as the onset of rheumatoid arthritis (RA) in individuals aged over 60 years. EORA presents unique clinical features, including a more equitable distribution of sexes, a potential predilection for male involvement, a higher incidence of acute onset characterized by constitutional symptoms, a propensity for systemic manifestations, elevated sedimentation rates at disease onset, a reduced occurrence of rheumatoid factor positivity, increased titers of anti-citrullinated protein antibodies, a preference for involvement of large joints, elevated disease activity, the presence of bone erosions, and heightened patient disability. RA is recognized to consist of three partially overlapping subsets. One subset mirrors the classical RA clinical presentation, while the remaining subsets exhibit either a polymyalgia rheumatica-like phenotype or present with remitting seronegative symmetrical synovitis accompanied by pitting edema syndrome. In the initial stages of EORA management, non-steroidal anti-inflammatory drugs (NSAIDs) are not typically the first-line treatment choice, because seniors are much more prone to develop side effects due to NSAIDs, and the use of NSAIDs is in reality contraindicated to the majority of seniors due to comorbidities. Disease-modifying antirheumatic drugs (DMARDs), frequently methotrexate, are introduced immediately after the diagnosis is made. In cases where elderly patients demonstrate resistance to conventional DMARD therapy, the introduction of biological or targeted synthetic DMARDs becomes a viable treatment option. EORA presents a unique clinical profile, necessitating tailored treatment strategies. Our study emphasizes the challenges of NSAID use in seniors, highlighting the imperative shift toward DMARDs such as methotrexate. Future research should explore personalized DMARD approaches based on disease activity, comorbidities, and safety considerations, aiming to optimize treatment outcomes and minimize glucocorticoid reliance, thereby enhancing the quality of care for EORA patients.

Association of Hydroxychloroquine Use with a Dose-Dependent Decrease in Mortality Risk in Patients with Elderly-Onset Rheumatoid Arthritis.

Elderly-onset rheumatoid arthritis (EORA) is associated with an increased mortality risk; however, the effect of conventional synthetic, biologics or targeted synthetic disease-modifying anti-rheumatic drugs (csDMARDs, bDMARDs or tsDMARDs) on the EORA-specific mortality risk is unknown. In this study, we investigated the risk factors for all-cause mortality of patients with EORA. Data of EORA patients diagnosed with RA at age > 60years between January 2007 and June 2021 were extracted from the electronic health record of Taichung Veterans General Hospital, Taiwan. Multivariable Cox regression was used to calculate the hazard ratio (HR) and 95% confidence interval (CI). The survival of patients with EORA was analyzed by Kaplan-Meier method. Among the 980 EORA patients who were enrolled (survivors 852 and non-survivor 128), the significant mortality-associated risk factors [HR (95% CI)] included higher age (1.10 [1.07-1.12], p < 0.001), male sex (1.92 [1.22-3.00], p = 0.004), current smoker (2.31 [1.10-4.87], p = 0.027) and underlying malignancy (1.89 [1.20-2.97], p = 0.006). Hydroxychloroquine treatment conferred protection against mortality in patients with EORA (HR 0.30, 95% CI 0.14-0.64, p = 0.002). Patients with malignancy who did not receive hydroxychloroquine treatment had the highest mortality risk compared with their counterparts. Patients with a monthly cumulative dose of hydroxychloroquine dose < 1374.5mg had the lowest survival rate compared to patients who received hydroxychloroquine 1374.5-5778.5 and ≥ 5778.5mg. Hydroxychloroquine treatment is associated with survival benefits in patients with EORA, and prospective studies are needed to validate the abovementioned findings.

Serum metabolomic profiling identifies potential biomarkers in arthritis in older adults: an exploratory study.

Seronegative elderly-onset rheumatoid arthritis (EORA)neg and polymyalgia rheumatica (PMR) have similar clinical characteristics making them difficult to distinguish based on clinical features. We hypothesized that the study of serum metabolome could identify potential biomarkers of PMR vs. EORAneg. Arthritis in older adults (ARTIEL) is an observational prospective cohort with patients older than 60 years of age with newly diagnosed arthritis. Patients' blood samples were compared at baseline with 18 controls. A thorough clinical examination was conducted. A Bruker Avance 600MHz spectrometer was used to acquire Nuclear Magnetic Resonance (NMR) spectra of serum samples. Chenomx NMR suite 8.5 was used for metabolite identification and quantification.Student t-test, one-way ANOVA, binary linear regression and ROC curve, Pearson's correlation along with pathway analyses were conducted. Twenty-eight patients were diagnosed with EORAneg and 20 with PMR. EORAneg patients had a mean disease activity score (DAS)-Erythrocyte Sedimentation Rate (ESR) of 6.21 ± 1.00. All PMR patients reported shoulder pain, and 90% reported pelvic pain. Fifty-eight polar metabolites were identified. Of these, 3-hydroxybutyrate, acetate, glucose, glycine, lactate, and o-acetylcholine (o-ACh), were significantly different between groups. Of interest, IL-6 correlated with different metabolites in PMR and EORAneg suggesting different inflammatory activated pathways. Finally, lactate, o-ACh, taurine, and sex (female) were identified as distinguishable factors of PMR from EORAneg with a sensitivity of 90%, specificity of 92.3%, and an AUC of 0.925 (p < 0.001). These results suggest that EORAneg and PMR have different serum metabolomic profiles that might be related to their pathobiology and can be used as biomarker to discriminate between both diseases.

CD8+ Regulatory T Cell Deficiency in Elderly-Onset Rheumatoid Arthritis

Elderly-onset rheumatoid arthritis (EORA) is associated with higher disease activity and accelerated joint destruction compared with young-onset RA (YORA). However, the underlying immunological mechanism remains unclear. Regulatory T cells (Tregs) are an immunosuppressive T cell subset, and CD4+ Tregs are deficient and/or dysfunctional in RA; however, CD8+ Tregs have not been fully examined in RA. Here, we aimed to determine the role of CD8+ Tregs, particularly in EORA. A total of 40 patients (EORA, n = 17; YORA, n = 23) were cross-sectionally enrolled. Current disease activity and treatment were comparable between the two groups; however, levels of multiple cytokines, including IL-1β, TNFα, interferon (IFN)-γ, IL-2, and IL-10, were significantly increased in EORA. The number of CD4+ Tregs did not differ between the groups (p = 0.37), but those of CD8+ Tregs were significantly decreased in EORA (p = 0.0033). The number of CD8+ Tregs were inversely correlated with plasma matrix metalloprotease (MMP)-3 levels (r = -0.3331, p = 0.036). Our study results revealed an intrinsic deficiency of CD8+ Tregs in patients with EORA, which leaves synovitis unchecked with excessive MMP-3 release. A therapeutic approach to restore CD8+ Tregs may provide a new avenue for the treatment of EORA.

The effect of disease-modifying antirheumatic drugs on sleep and quality of life in older patients with rheumatoid arthritis.

The sleep quality is worse in rheumatoid arthritis (RA) patients than in healthy controls and it is more difficult to achieve a satisfactory quality of life after treatment with age. Our aim is to assess the quality of life and sleep in elderly onset RA patients and to analyze the effect of disease-modifying agents on sleep and quality of life. Thirty-four older patients with RA patients and 30 healthy controls are included in the study. Sleep quality was evaluated with the Pittsburg sleep quality index and quality of life with Short Form-36. Parametric/non-parametric tests and Spearman/Pearson correlation analysis were applied for the data according to the distribution. While the rate of poor sleep quality before treatment was 67.6%, the rate was 26.5% after treatment. There was a statistically significant difference before and after treatment in terms of subjective sleep quality, sleep latency, sleep duration, sleep efficiency, and scores for sleep disturbance. The mean steroid dose and Disease Activity Score-28 were higher in patients with poor sleep quality than in patients with good sleep quality. Patients with poor sleep quality had lower mean physical function, pain, general health, social function, emotional role difficulties, and energy/vitality values than patients with good sleep quality. Both sleep and quality of life improved after treatment in older patients with RA patients. In older patients, it should be regularly evaluated in terms of sleep and quality of life and appropriate treatment should be provided.

Differentiating between Seronegative Elderly-Onset Rheumatoid Arthritis and Polymyalgia Rheumatica: A Qualitative Synthesis of Narrative Reviews.

Elderly-onset rheumatoid arthritis (EORA) is prevalent among older patients, and its incidence is increasing due to aging societies. However, differentiating between EORA and polymyalgia rheumatica (PMR) is challenging for clinicians and hinders the initiation of effective treatment for rheumatoid arthritis among older generations, thereby allowing its progression. Therefore, we conducted a qualitative synthesis of narrative reviews via meta-ethnography regarding seronegative EORA diagnosis to clarify the methods to differentiate seronegative EORA from PMR. Three databases (PubMed, EMBASE, and Web of Science) were searched for relevant reviews published between January 2011 and October 2022. The extracted articles were synthesized using meta-ethnography, and 185 studies were selected following the protocol. Seven reviews were analyzed, and four themes and nine concepts were identified. The four themes included difficulty in differentiation, mandatory follow-up, and factors favoring rheumatoid arthritis and those favoring PMR. Factors favoring seronegative EORA and PMR should be considered for effective diagnosis and prompt initiation of disease-modifying anti-rheumatic drugs. Mandatory and long follow-ups of suspected patients are essential for differentiating the two diseases. The attitude of rheumatologists toward tentatively diagnosing seronegative EORA and flexibly modifying their hypotheses based on new or altered symptoms can aid in effective management and avoiding misdiagnosis.

Elderly-onset rheumatoid arthritis vs. polymyalgia rheumatica: Differences in pathogenesis.

Rheumatoid arthritis is a chronic autoimmune disease that mainly affects the facet joints. Elderly-onset rheumatoid arthritis appears to exhibit symptoms similar to those of polymyalgia rheumatica, characterized by morning stiffness and pain in the shoulder and hip joints. Both diseases develop in the elderly, and it is sometimes challenging to distinguish them. Here, we identify the differences in pathogenesis between elderly-onset rheumatoid arthritis and polymyalgia rheumatica to assist with a clear differential diagnosis and effective early intervention.

Temporomandibular joint involvement in elderly onset and young onset rheumatoid arthritis patients.

There are studies showing clinical and laboratory differences between elderly-onset rheumatoid arthritis and young-onset rheumatoid arthritis. Temporomandibular joint involvement in rheumatoid arthritis is not rare. In this study, we aimed to examine the temporomandibular joint involvement and magnetic resonance imaging findings in elderly-onset rheumatoid arthritis and young-onset rheumatoid arthritis patients. A total of 87 rheumatoid arthritis patients were investigated retrospectively. The onset ≥60 years was considered elderly-onset rheumatoid arthritis. Erosion, flattening, and resorption of the condyle, narrowing of the joint space, joint effusion, synovial hypertrophy, and synovitis were interpreted as temporomandibular joint involvement with magnetic resonance imaging. Patients' age, gender, rheumatoid factor, and anti-cyclic citrullinated peptide positivity, extra-articular findings, medical treatment, and disease activity score were noted. A total of 15 (17.2%) patients had elderly-onset rheumatoid arthritis. Temporomandibular joint involvement was detected in 67 (77%) patients; 9 (60%) of them were in the elderly-onset rheumatoid arthritis group (n=15) and 58 (80.6%) of them were in the young-onset rheumatoid arthritis group (n=72). Patients with temporomandibular joint involvement were significantly higher than those without temporomandibular joint involvement in both the elderly-onset rheumatoid arthritis and young-onset rheumatoid arthritis groups (p<0.001). No significant difference was found between elderly-onset rheumatoid arthritis and young-onset rheumatoid arthritis for the temporomandibular joint involvement (p=0.100). In the young-onset rheumatoid arthritis group, rheumatoid factor positivity and anti-cyclic citrullinated peptide positivity were more frequent in the patients with temporomandibular joint involvement (p=0.011, p=0.024). A comparison of the elderly-onset rheumatoid arthritis and young-onset rheumatoid arthritis patients showed no significant difference in the magnetic resonance imaging findings except for the resorption of the condyle. According to our findings, elderly-onset rheumatoid arthritis is not much different from young-onset rheumatoid arthritis in terms of temporomandibular joint involvement, magnetic resonance imaging findings, and clinical and laboratory features.

Development and Validation of Machine Learning Models for Prediction of Fracture Risk in Patients with Elderly-Onset Rheumatoid Arthritis.

ObjectiveFracture is a critical unfavorable prognostic factor in patients with rheumatoid arthritis(RA) and osteoporosis. At present, models involving clinical indices that accurately predict fracture are still uncommon. We addressed this gap by developing machine learning (ML)-based predictive models to individualize the risk of fracture in elderly patients with RA and osteoporosis and to identify a high-risk group for fracture.Methods487 patients diagnosed with RA and osteoporosis at the Central Hospital of Enshi Tujia and Miao Autonomous Prefecture were randomly divided into a training cohort (used for building the model) and a validation cohort (used for validating the model). Five ML-assisted models were developed from candidate clinical features using two-step estimation methods. The receiver operating characteristic curve (ROC), decision curve analysis (DCA), and clinical impact curve (CIC) were performed to evaluate the robustness and clinical practicability of each model.ResultsA total of twenty-two candidate variables were included, and the prediction model was established by an ML-based algorithm. The areas under the ROC curve (AUCs) of the random forest classifier (RFC) model, artificial neural network (ANN), support vector machine (SVM), eXtreme gradient boosting (XGBoost), decision tree (DT), probability of major osteoporotic fractures (PMOF), and probability of hip fracture (PHF) ranged from 0.695 to 0.878. Among them, RFC obtained the optimal prediction efficiency via adding serum selenium and clinical indices, that is, glucocorticoid, and erythrocyte sedimentation rate (ESR).ConclusionBased on the classic clinical parameters, the fracture risk of RA patients with osteoporosis can be accurately predicted. In particular, RFC prediction model shows good discrimination ability in identifying high-risk patients with fracture.

Secondary Failure of Tocilizumab in Treating Elderly-Onset Rheumatoid Arthritis With Systemic Symptoms Complicated by Diverticulum Perforation

The treatment of rheumatoid arthritis (RA) has advanced from the use of steroids to disease-modifying anti-rheumatic drugs (DMARDs) and biologics such as tumor necrosis factor (TNF) and interleukin-6 (IL-6) inhibitors. Historically, steroids have been the mainstream in the clinical treatment of RA; however, the development of DMARDs has changed the RA treatment structure. In addition, biologics can alleviate RA symptoms. This case report describes the secondary failure of tocilizumab in treating RA with fatigue symptoms. Treatment with tocilizumab decreases C-reactive protein (CRP) levels, which may make detecting RA exacerbation difficult; therefore, obtaining the patient's precise history and thorough physical examinations are necessary. This case demonstrates the complexity of treating elderly-onset RA and reports practical methods for effective treatment.

Is Elderly-Onset Rheumatoid Arthritis Different From Younger-Onset Rheumatoid Arthritis?

Objectives: To compare elderly-onset rheumatoid arthritis (EORA) patients with younger-onset rheumatoid arthritis (YORA) patients in terms of sociodemographic, clinical and radiological features, and treatment responses.&#x0D; Materials and Methods: 422 rheumatoid arthritis (RA) patients were evaluated retrospectively. Patients with the age of onset of disease symptoms ≥60 were considered EORA, and those 0.05). &#x0D; Conclusion: There is no difference in many clinical and laboratory findings, especially disease activity scores and radiographic scores, in patients with EORA and YORA.

POS0522 ASSOCIATED FACTORS WITH PHYSICAL DYSFUNCTION OF ELDERLY-ONSET RHEUMATOID ARTHRITIS TREATED WITH A TREAT-TO-TARGET STRATEGY

BackgroundAchievement of normal physical function is an important outcome for older patients. Previous studies of younger cohorts showed that aging, comorbidities, and joint damage influenced the physical function of patients with RA who achieved clinical remission or low disease activity (LDA). We previously demonstrated that a treat-to-target (T2T) strategy for methotrexate (MTX)-naïve elderly-onset RA (EORA) was effective with an acceptable safety profile. It showed that 60.9% of 197 patients achieved HAQ Disability Index (HAQ-DI) ≤0.5 at three years by following the T2T strategy targeting LDA (1).ObjectivesWe aimed to evaluate associated factors with HAQ-DI in the T2T strategy targeting LDA for patients with EORA during three-year observational period.MethodsTreatment was adjusted to target LDA with conventional synthetic disease-modifying antirheumatic drugs (DMARDs), followed by biological DMARDs (bDMARDs) in 197 MTX-naïve EORA patients (mean age 74.9 years) with moderate-to-high disease activity. HAQ-DI was evaluated at week 0, 24, 52, 76, 104, 128, and 156. To evaluate associated factors with SDAI and HAQ-DI over the 36-month follow-up, Bayesian hierarchical logistic regression modeling was applied for 1067 periods from the 197 patients.ResultsAt baseline, the enrolled 197 patients with EORA who had normal physical function (HAQ-DI ≤0.5) in 29.4%, HAQ-DI &gt;0.5 and &lt;1.5 in 36.5%, and HAQ-DI ≥1.5 in 33.0%, and the mean age (standard deviation [SD]) in each group was 72.7 (5.9), 74.8 (7.3), and 75.6 (6.7), respectively. Baseline SDAI increased in the group with higher HAQ-DI. The proportions of patients with each comorbidity and estimated creatinine clearance at baseline were not significantly different across the 3 groups.In the multilevel logistic model, the association of MTX, bDMARDs, and GC use with changes in SDAI in each period was evaluated. Age, sex, and comorbidities (chronic lung disease, cardiovascular disease, history of malignancy, osteoporosis, history of serious infections, and osteoarthritis) were included as inter-individual factors. The model indicated that the use of bDMARDs was associated with a reduction of the SDAI (ΔSDAI: -9.75, SD 0.75, p&lt;0.001), while neither MTX (ΔSDAI: -1.25, SD 1.13, p=0.270) nor GCs (ΔSDAI: -0.78, SD 0.88, p=0.372) was associated with changes in SDAI. Chronic lung diseases (ΔSDAI: 4.64, SD 1.44, p=0.001) and osteoporosis (ΔSDAI: 3.78, SD 1.46, p=0.001) at baseline were associated with the increment of SDAI.The association of age, sex, the comorbidities, and MTX, bDMARDs, and GC use with physical function in each period was evaluated by the multilevel logistic model. The model indicated that older age (ΔHAQ-DI: 0.03, SD 0.01, p &lt;0.001), chronic lung diseases (ΔHAQ-DI: 0.15, SD 0.10, p=0.001), and osteoporosis (ΔHAQ-DI: 0.30, SD 0.10, p=0.010) at baseline were associated with the increment of HAQ-DI. When the mean SDAI during the observation period was added to the model as an inter-individual factor, the associations of HAQ-DI with the chronic lung diseases and osteoporosis at baseline were not statistically significant.ConclusionThese data indicate that bDMARDs had a central role in reducing disease activity in the T2T strategy targeting LDA in EORA patients. Chronic lung diseases and osteoporosis at baseline were associated with increase in disease activity and worsening of physical function. However, disease activity had a greater impact on physical function than the comorbidities at baseline.

Polymyalgia Rheumatica, an Age-Related Rheumatic Disease

Polymyalgia rheumatica (PMR) is an age-related chronic inflammatory disease with rheumatic features at the fore. In addition to the high-grade systemic inflammation, it is characterized by typical “polymyalgic” musculoskeletal symptoms, including diffuse and severe pain and prolonged morning stiffness of the shoulder girdle, pelvic girdle, and neck. PMR is a member of the so-called giant cell arteritis complex; however, in spite of the marked systemic inflammation in PMR, the local vasculitis process aborts. The pathological background is synovitis, with a predominant inflammation of the extra-articular synovial structures. Synovitis of PMR is mild, transient, and non-erosive. Distal musculoskeletal symptoms are also observed but are more variable and less recognizable than the predominant proximal polymyalgic syndrome. PMR often overlaps with elderly-onset seronegative arthritides, elderly-onset rheumatoid arthritis, late-onset seronegative spondylarthritis, and the RS3PE1 syndrome. Although glucocorticoids are the cornerstone of PMR therapy, considerable hope is attached to tocilizumab, an IL-6 receptor inhibitor.

Comparison of complications during 1-year follow-up between remitting seronegative symmetrical synovitis with pitting edema syndrome and elderly-onset rheumatoid arthritis

Remitting seronegative symmetrical synovitis with pitting edema syndrome (RS3PE), a rheumatic disease affecting the elderly, responds well to corticosteroids; however, our RS3PE patients' corticosteroid therapy is longer than expected. Elderly-onset rheumatoid arthritis (EORA) patients are reported to be at a significantly increased risk for steroid-related side effects including cardiovascular diseases (CVDs). To clarify the complications during a 1-year follow-up in corticosteroid-treated RS3PE patients compared to EORA patients. We retrospectively analyzed the records of 47 RS3PE patients (28 men, 19 women, age 78.4 ± 7.5 years) and 46 EORA patients (10 men, 36 women; 77.0 ± 6.8 yrs) to compare the complications over a 1-year follow-up. The RS3PE and EORA groups' average initial PSL doses were 16.5 ± 7.2 mg/day and 7.3 ± 4.6 mg/day, respectively. During the 1-year follow-up after treatment, there was no significant increase in CVDs in both groups. However, infections occurred in nine RS3PE patients, which is a significantly higher incidence compared to the EORA patients with infections (n = 3). The initial PSL dose was the independent variable associated with the incidence of infection. Infections were significantly increased during elderly RS3PE patients' steroid therapy. The initial corticosteroid dose was an infection-risk factor. Key messages Infections are increased during steroid therapy in elderly patients with RS3PE syndrome. The initial dose of corticosteroids was one of the risk factors for infections.

Comparison between Young and Elderly Onsetof Rheumatoid Arthritis in a Romanian Cohort

Rheumatoid arthritis (RA) is a chronic inflammatory disease that predominantly affects middle-aged adults in the third to fifth decades of life, but can also occur at any age. Significant differences were observed between patients with the diagnose of the disease under the age of 65 years – young- onset of RA (YORA) and those with the onset over the age of 65 years -elderly-onset of RA (EORA). The literature has shown that patients in the EORA group, in comparison to the young, have more severe onset, shorter duration of morning stiffness, lower frequency of sero- positivity and a more important biological inflammatory syndrome. Objective: Describe and compare the clinical characteristics, laboratory features, functional status, therapeutic approach and disease progression in elderly-onset and young-onset rheumatoid arthritis (RA) patients. Materials and methods: This retrospective, transversal study included 102 patients diagnosed with rheumatoid arthritis according to the ACR / EULAR criteria and who had at least 3 visits to our clinic, the last one during 2019-2020. Depending on the age at disease onset, we divided them into 2 groups- EORA and YORA and analyzed them comparing the clinical, laboratory and treatment data obtained at diagnosis. Subsequently we studied the evolution of the disease activity and the therapy efficiency at 6 months of follow-up and at the last hospitalization for each group. Results: The percentage of women is similar and predominant in both groups, YORA and EORA (68.3% and 71.8%). YORA was associated with a longer disease length and a prolonged symptom duration prior to the diagnosis in comparison to EORA (p&lt;0.001 and P=0.002). Extra-articular manifestations were more frequent in elderly onset RA patients at diagnosis, especially the presence of rheumatoid nodules (46.2% vs 22.2%. p=0.011) and weight loss (82.1% vs 34.9%, p&lt;0.001). Anemia was statistically associated with the EORA group (p=0.037). Analyzing the radiological findings, there was a greater number of patients who showed erosions (48.7%) and geodes (28.2%) in EORA, than in YORA group (33.3% and 19.0%). The prevalence of specific auto-antibodies positivity as anti-CCP was higher in YORA (76.2% vs 53.8%, p=0.019), as well as the positivity of Rheumatoid factor (RF) (84.1% vs 61.5%, p=0.010). The majority of patients began treatment with synthetic DMARD monotherapy, 54.0% of YORA and 64.1% of EORA. Methotrexate was the main drug administrated in both groups (61.5% in EORA and 54.0% in YORA, p-value= 0.602). Other medications, such as Sulfasalazine and Leflunomide, were less preferred in the two groups. Biologic therapy was preferred in younger patients than in those with RA at 65 years of age or over (69.8% vs 35.9%, p=0.001). Disease activity measured with DAS28(CRP) score was similar between the two groups at baseline, but significantly lower for YORA patients measured at the last hospitalization (p=0.020), treat to target (low disease activity and remission) being achieved in 53% of cases in the YORA group versus 23% of EORA patients (p=0.002). Conclusions: The definite diagnosis of RA was delayed in YORA patients in comparison to EORA patients and the extra-articular manifestations of the disease were more frequently found in the EORA group. Seropositivity was statistically significantly associated with the YORA group. Anemia was predominant in patients with disease onset over 65 years old. Both groups underwent DMARDs therapy in the early stages of the disease, but biologic therapy was more often administered in younger patients. Disease activity at diagnosis was similar in both groups, but in dynamic, the treat to target endpoint was achieved more frequent in YORA population.

Usefulness of ultrasound as a predictor of elderly-onset rheumatoid arthritis with polymyalgia rheumatica-like onset.

Differentiation between polymyalgia rheumatica (PMR) and elderly-onset rheumatoid arthritis (EORA), especially in elderly patients, is often difficult due to similarities in symptoms and serological kinetics. In this study, we aimed to analyse the predictors of EORA with PMR-like onset. Seventy-two patients diagnosed with PMR, who attended our hospital for routine care and underwent musculoskeletal ultrasonography at that time were evaluated. Synovitis was evaluated semi-quantitatively (0-3) by grey scale (GS) and power Doppler (PD) in 24 joints [both hands (wrist, metacarpophalageal, and proximal interphalangeal joints) and both shoulder joints]. Overall, 18 patients had rheumatoid arthritis (25.0%); the mean age was 75.0 years, and 34.7% and 65.3% were male and female, respectively. In PMR and PMR/EORA groups, multivariate logistic analysis showed that rheumatoid factor positivity, GS ≥2 of hand joints, and PD ≥1 of hand joints were independent factors with significant differences. At least one of the three factors had a sensitivity of 88.9% and specificity of 92.6%. The presence of at least one of the criteria: rheumatoid factor positivity, GS ≥ 2, and PD ≥ 1 of hand joints, suggested the possibility of developing EORA within 1 year of PMR diagnosis.