Problems in treating rheumatoid arthritis – Harvard Health

Initial treatment for active rheumatoid arthritis (RA) should be aggressive. Doctors may prescribe powerful medications to slow the immune system's chronic attack on the lining of the joints. The medications should be given as quickly as possible to prevent debilitating disability.

Unfortunately, according to recent evidence, most people diagnosed after age 65 (up to a third of all people with rheumatoid arthritis) do not receive optimal treatment. Here's why this might be the case for people with “late-onset” RA, and what you can do about it.

Current findings

In a study published on December 5, 2023 in ACR Open RheumatologyResearchers used Medicare data from 2008 to 2017 to identify people with a new diagnosis of late-onset RA. Of more than 33,000 people who fit the profile, only 29% received a drug that can modify the disease within the first year of diagnosis, even though such treatment is recommended in current clinical practice guidelines.

“This is in contrast to 70 to 80 percent of younger adults with rheumatoid arthritis who receive disease-modifying drugs shortly after diagnosis,” says Dr. Devyani Misra, a geriatrician, rheumatologist and researcher at Beth Israel Deaconess Hospital, affiliated with Harvard University.

Why disease-modifying drugs are important

The most effective drugs for rheumatoid arthritis not only relieve symptoms but also slow the progression of the disease. This helps reduce the extent of joint destruction and curb the loss of joint function.

In most cases, initial treatment is a nonbiologic disease-modifying antirheumatic drug (DMARD) such as methotrexate (Otrexup, Trexall), usually taken in tablet form or by self-injection.

If a nonbiologic DMARD does not provide significant improvement within one to two months, you may be offered a newer type of DMARD, such as one of the following.

Biological DMARDs, such as etanercept (Enbrel), rituximab (Rituxan) or tocilizumab (Actemra) have a more targeted effect on the function of the immune system than non-biological DMARDs. They are usually administered as an infusion or self-injected.

Janus kinase inhibitors, like tofacitinib (Xeljanz) have anti-inflammatory effects like other DMARDs. They are taken in tablet form.

Until these drugs start working (within weeks to months), doctors may recommend low-dose nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) or corticosteroids such as prednisone. However, these drugs do not protect joints from damage, and long-term use can cause significant side effects.

What is the problem?

Many factors prevent people with rheumatoid arthritis from receiving the most effective medications. Here are some examples.

Cost. Biologic DMARDs and Janus kinase inhibitors are expensive, costing up to $20,000 or more annually. Although they are often covered by insurance, copayments and deductibles can add up to hundreds or thousands of dollars per year.

Side effects. All three classes of DMARD drugs (like all drugs) can have side effects. For example, nonbiologic DMARDs can cause fatigue and liver problems; biologic DMARDs increase the risk of infections, especially tuberculosis; and taking Janus kinase inhibitors can cause shingles, allergic reactions, diarrhea, headaches, runny or stuffy nose, or sore throat. Dr. Misra says some people refuse the drugs to avoid these risks.

Coexisting conditions. When late-onset RA develops, some people have other conditions that complicate treatment, such as heart or kidney problems. “Even aging itself can complicate treatment of rheumatoid arthritis, because liver, kidney and intestinal function decline with age and the immune system becomes somewhat dysfunctional,” says Dr. Misra.

Perceived frailty. “Some healthcare providers worry about the side effects of medications affecting someone they consider frail, and they choose the least aggressive treatment, such as a corticosteroid to relieve symptoms,” says Dr. Misra. “But I often prescribe DMARDs to older patients, and the medications are effective and well tolerated.”

Cognitive impairment. “Cognitive impairment affects the ability to follow medication instructions, laboratory monitoring and follow-up visits in the clinic. It is an ethical dilemma to decide how aggressively we want to treat these patients,” says Dr. Misra.

Accessibility to healthcare. In the United States, about 1.5 million people have rheumatoid arthritis, but there are only about 6,000 rheumatologists (doctors who are experts in treating the disease and most commonly prescribe DMARDs), so you may not be able to find a specialist in your city who can handle the challenges of late-onset RA. And even if you do, you may not have the transportation, money or physical strength for in-person visits or infusions.

What you can do

If you are not receiving DMARD treatment for rheumatoid arthritis but think you should, talk to your doctor about workarounds to make treatment more feasible. Here are some examples.

If you cannot give yourself injections. Better alternatives may be infusions or oral medication.

If you cannot come to a clinic. It may be possible for a service to perform blood tests or infusions at home.

If you cannot take methotrexate. If methotrexate is not an option due to a drug allergy or liver or kidney disease, another medication may be more appropriate.

If you suffer from cognitive impairment. “You may be able to have a family member or nurse administer your medication, or use an electronic pill dispenser,” suggests Dr. Misra.

If the medication is too expensive. Ask your pharmacist about manufacturer coupons and patient assistance programs that can help reduce the cost of RA medications.

If you are concerned about side effects. “Often we can find a drug that is the least harmful but still relieves the symptoms,” says Dr. Misra. “Or we can provide other therapies, such as physical or occupational therapy, topical creams, or heat and ice therapy. When we combine them all, they often provide pain relief. It's about improving your quality of life, which is deteriorating without treatment. And you're not too old for treatment.”

Image: © Halfpoint Images/Getty Images