‘More work to be done’: DMARD use remains low in older adults with rheumatoid arthritis
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Despite guidelines recommending early and aggressive therapy in rheumatoid arthritis, disease-modifying antirheumatic drug adoption for older patients remains low, according to data published in ACR Open Rheumatology.
“These medications have really changed the landscape of rheumatology, allowing low disease activity and remission to be achieved in people with rheumatoid arthritis, and now there needs to be a shifting consideration of how we can better target their use among older adults,” Jiha Lee, MD, MHS, the lead author of the paper and a rheumatologist at the University of Michigan, in Ann Arbor, said in a press release. “The prescription rates for these disease-modifying drugs have improved over the past few decades, but there is more work to be done to ensure older adults are on optimized treatment.”
Lee and colleagues compared DMARD use among older patients who attended RA-related ambulatory visits from rheumatologists and primary care physicians. They analyzed National Ambulatory Medical Care Survey data from 2005 through 2016, including information on all rheumatology and primary care visits for patients aged older than 65 who had RA recorded as one of their top diagnoses related to the visit.
The authors categorized DMARD use either “any DMARD,” “any conventional synthetic DMARD (csDMARD)” or “any biologic DMARD (bDMARD)” use.
Five csDMARDS, including methotrexate, leflunomide, azathioprine, hydroxychloroquine and sulfasalazine, and nine bDMARDS, including adalimumab (Humira, AbbVie), etanercept (Enbrel, Amgen), certolizumab (Cimzia, UCB), golimumab (Simponi, Janssen), infliximab (Remicade, Janssen), abatacept (Orencia, Bristol Myers Squibb), anakinra (Kineret, SOBI), tofacitinib (Xeljanz, Pfizer) and tocilizumab (Actemra, Genentech), were identified based only on the first eight listed drugs to be consistent across all years, the authors wrote.
Finally, the researchers recorded independent variables including demographic characteristics, diagnosis, reasons for visits, medication and provider specialties.
In all, Lee and colleagues included 7,873,246 visits in their analysis. Of those, 74% were with rheumatologists.
According to the researchers, DMARD use of any kind was recorded at 56% of rheumatology visits and 30% of primary care visits. Among visits where any kind of DMARD use was recorded, 20% of rheumatology visits recorded two or more, while only 6% of primary care visits recorded two or more. Over the study period, there was no statistically significant difference in conventional synthetic DMARD use. Biologic DMARD use was “likely to incrementally increase” at rheumatology visits, compared with primary care visits (P = .003), the researchers wrote.
“The world population is aging, and rheumatologists must be prepared to care for older adults with rheumatic diseases while addressing additional diseases and medications they may have,” Lee said in the release. “We can work more closely with primary care providers and learn from our colleagues in geriatrics and adopt age-friendly approaches to improve prescribing practices for older adults with rheumatoid arthritis.”
Reference:
Study: Older adults with rheumatoid arthritis still undermedicated, despite aggressive guidelines. Study: Older adults with rheumatoid arthritis still undermedicated, despite aggressive guidelines (umich.edu). April 7, 2022. Accessed April 12, 2022.
Perspective
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Jonathan Greer, MD, FACR, FACP
The data from Lee and colleagues is important but not surprising. There is a clear need to treat geriatric patients more aggressively and earlier to control the destructive features of rheumatoid arthritis.
Working in a geographic location that has a high Medicare penetration, I unfortunately see this quite frequently. Using nonsteroidal anti-inflammatory drugs, hydroxychloroquine, prednisone, sulfasalazine, methotrexate and other disease modifying antirheumatic drugs can certainly be implemented, but more often than not these medications are insufficient in controlling the disease.
Although the authors propose employing more primary care practitioners to use advanced therapies, this may not be practical given the limitations they have in diagnosing and treating a myriad of diseases, as well as limited knowledge of biologics and small targeted molecules. Using advanced practice providers — nurse practitioners and physician assistants — may be more appropriate in expanding the reach of rheumatologists.
It is nevertheless incumbent upon us as rheumatologists to treat these patients earlier and more aggressively with targeted therapies. Although it is true that comorbidities may play a role in limiting some choices in the elderly, the large armamentarium of advanced therapies today should allow us to prescribe something that would be appropriate.
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David A. McLain, MD, MACR, FACP, FRCP
The percentage of patients receiving conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs) for rheumatoid arthritis in this big data study of older adults is low, with an overall percentage of 45% for the combination of rheumatologists and primary care providers (PCPs). Rheumatologists alone had 56% DMARD use in RA patients, while PCPs had 30% DMARD use.
In my own practice, I have patients with RA who are not on DMARDs. We need an ICD code to describe these subgroups of RA patients, as to why they are not on DMARDs, particularly for quality-of-care analyses by insurers. One subgroup of patients has been through a number of csDMARDs, biologic DMARDs, and even targeted small molecule DMARDs, and has failed to respond, or have had significant adverse drug reactions, or both, to them. These patients are no longer interested in taking DMARDs and are satisfied to take steroids and/or pain medications as their only treatment.
There is another subgroup that is not interested in, or afraid, of DMARDs and decline any drug in these classes. This group is not large but presents a challenge to the rheumatologist. Some, after progressing with their arthritis and developing visible deformities, will eventually agree to DMARDs. Others never do. Some in my experience continue to try herbal or other over-the-counter remedies.
Another subgroup of RA patients presents with joint pain and positive serologies and is treated aggressively. They respond to treatment and over the years eventually stop DMARDs. They continue to carry the diagnosis of rheumatoid arthritis, as they should, but they appear to be in remission/low disease activity or burned out. They are no longer on DMARDs.
In this big-data analysis, even considering the subgroups noted above, the low percentage of patients on DMARDs with RA treated by rheumatologists is a surprise.
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