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Singh N, Gold LS, Lee J, Wysham KD, Andrews JS, Makris UE, England BR, George MD, Baker JF, Jarvik J, Heagerty PJ, Singh S. Frailty and Risk of Serious Infections in Patients With Rheumatoid Arthritis Treated With Biologic or Targeted-Synthetic Disease-Modifying Antirheumatic Drugs. Arthritis Care Res (Hoboken) 2024; 76:627-635. [PMID: 38116680 PMCID: PMC11039374 DOI: 10.1002/acr.25282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/24/2023] [Accepted: 12/28/2023] [Indexed: 12/21/2023]
Abstract
OBJECTIVE It remains unknown whether frailty status portends an increased risk of adverse outcomes in patients with rheumatoid arthritis (RA) initiating biologic or targeted-synthetic (b/ts) disease-modifying antirheumatic drugs (DMARDs). The objective of our study was to evaluate the association between frailty and serious infections in a younger population of patients (<65 years old) with RA who initiated b/tsDMARDs. METHODS Using MarketScan data, we identified new users of tumor necrosis factor inhibitors (TNFi), non-TNFi biologic DMARDs, or Janus kinase inhibitors (JAKi) between 2008 and 2019 among those with RA. Patients' baseline frailty risk score was calculated using a Claims-Based Frailty Index (≥0.2 defined as frail) 12 months prior to drug initiation. The primary outcome was time to serious infection; secondarily, we examined time-to-any infection and all-cause hospitalizations. We used Cox proportional hazards to estimate adjusted hazard ratios and 95% confidence intervals (95% CIs) and assessed the significance of interaction terms between frailty status and drug class. RESULTS A total of 57,980 patients, mean (±SD) age 48.1 ± 10.1 were included; 48,139 (83%) started TNFi, 8,111 (14%) non-TNFi biologics, and 1,730 (3%) JAKi. Among these, 3,560 (6%) were categorized as frail. Frailty was associated with a 50% increased risk of serious infections (adjusted hazard ratio [95% CI] 1.5, 1.2-1.9) and 40% higher risk of inpatient admissions (1.4 [1.3-1.6]) compared with nonfrail patients among those who initiated TNFi. Frailty was also associated with a higher risk of any infection relative to nonfrail patients among those on TNFi (1.2 [1.1-1.3]) or non-TNFi (1.2 [1.0-1.4]) or JAKi (1.4 [1.0-2.0]). CONCLUSION Frailty is an important predictor for the risk of adverse outcomes among patients with RA treated with biologic or targeted-synthetic DMARDs.
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Affiliation(s)
- Namrata Singh
- Division of Rheumatology, University of Washington, Seattle, WA
- VA Puget Sound Health Care System, Seattle, WA
| | - Laura S. Gold
- Department of Radiology, University of Washington, Seattle, WA
| | - Jiha Lee
- University of Michigan, Ann Arbor, MI
| | - Katherine D Wysham
- Division of Rheumatology, University of Washington, Seattle, WA
- VA Puget Sound Health Care System, Seattle, WA
- Department of Radiology, University of Washington, Seattle, WA
| | | | - Una E. Makris
- Division of Rheumatic Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Bryant R. England
- University of Nebraska Medical Center & VA Nebraska-Western Iowa Healthcare System, Omaha, NE
| | - Michael D. George
- Division of Rheumatology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Joshua F. Baker
- Division of Rheumatology, Hospital of the University of Pennsylvania, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Jeffrey Jarvik
- Department of Radiology, University of Washington, Seattle, WA
| | - Patrick J. Heagerty
- Department of Radiology, University of Washington, Seattle, WA
- Department of Biostatistics, University of Washington
| | - Siddharth Singh
- Division of Gastroenterology, University of California at San Diego, San Diego, CA
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Jiang Y, Zhong S, Tan H, Fu Y, Lai J, Liu L, Weng J, Chen H, He S. Study on the mechanism of action of Saposhnikovia divaricata and its key phytochemical on rheumatoid arthritis based on network pharmacology and bioinformatics. J Ethnopharmacol 2024; 322:117586. [PMID: 38104871 DOI: 10.1016/j.jep.2023.117586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 12/07/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Saposhnikovia divaricata (Turcz.) Schischk (SD; called "fangfeng" in China) has been widely used in the clinical treatment of rheumatoid arthritis (RA) and has shown well therapeutic effects, but the specific mechanisms of action of its bioactive phytochemicals remain unclear. AIM OF THE STUDY This study aimed to investigate the molecular biological mechanism of SD in treating RA through a pharmacology-based strategy. The SD-specific core ingredient Prangenidin was screened for further in-depth study. MATERIALS AND METHODS The bioactive phytochemicals of SD and potential targets for the treatment of RA were screened by network pharmacology, and phytochemicals-related parameters such as pharmacology, and toxicology were evaluated. The protein interaction network was established to screen the core targets, and the correlation between the core targets and RA was further validated by bioinformatics strategy. Finally, molecular docking of core components and corresponding targets was performed. The in vitro experiments were performed to elucidate the regulation of Prangenidin on MH7A cells and on the PI3K/AKT pathway, and the in vivo therapeutic effect of Prangenidin was validated in collagen-induced arthritis (CIA) mice. RESULTS A total of 18 bioactive phytochemicals and 66 potential target genes intersecting with the screened RA disease target genes were identified from SD. Finally, core ingredients such as wogonin, beta-sitosterol, 5-O-Methylvisamminol, and prangenidin and core targets such as PTGS2, RELA, and AKT1 were obtained. The underlying mechanism of SD in treating RA might be achieved by regulating pathways such as PI3K/AKT, IL-17 pathway, apoptosis, and multiple biological processes to exert anti-inflammatory and immunomodulatory effects. Molecular docking confirmed that all core ingredients and key targets had great docking activity. Prangenidin inhibited viability, migration, and invasion, and induced apoptosis in MH7A cells. Prangenidin also reduced the production of IL-1β, IL-6, IL-8, MMP-1, and MMP-3. Molecular analysis showed that Prangenidin exerts its regulatory effect on MH7A cells by inhibiting PI3K/AKT pathway. Treatment with Prangenidin ameliorated synovial inflammation in the joints of mice with CIA. CONCLUSION Our findings provide insights into the therapeutic effects of SD on RA, successfully predicting the effective ingredients and potential targets, which could suggest a novel theoretical basis for further exploration of its molecular mechanisms. It also revealed that Prangenidin inhibited viability, migration, invasion, cytokine, and MMPs expression, and induced apoptosis in RA FLSs via the PI3K/AKT pathway.
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Affiliation(s)
- Yong Jiang
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, 518033, China; Department of Spine Surgery, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, 518033, China
| | - Shuxin Zhong
- Department of Medical Biochemistry and Molecular Biology, School of Medicine, Jinan University, Guangzhou, 510632, China
| | - Huangsheng Tan
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, 518033, China; Department of Spine Surgery, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, 518033, China
| | - Yuanfei Fu
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, 518033, China; Department of Spine Surgery, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, 518033, China
| | - Juyi Lai
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, 518033, China; Department of Spine Surgery, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, 518033, China
| | - Lijin Liu
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, 518033, China
| | - Juanling Weng
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, 518033, China
| | - Hanwei Chen
- Department of Radiology, Panyu Health Management Center (Panyu Rehabilitation Hospital), Guangzhou, 511495, China.
| | - Shenghua He
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, 518033, China; Department of Spine Surgery, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, 518033, China.
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Loecker CN, Schmaderer MS, Wysham KD, Pozehl B, Zimmerman L, England BR. Psychometric Properties of Frailty Instruments in Adults With Rheumatoid Arthritis: A Systematic Review. ACR Open Rheumatol 2024; 6:91-102. [PMID: 38083820 PMCID: PMC10867294 DOI: 10.1002/acr2.11640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/09/2023] [Accepted: 11/15/2023] [Indexed: 02/16/2024] Open
Abstract
OBJECTIVE Examine psychometric properties of frailty instruments used in adults with rheumatoid arthritis (RA) to inform selection of frailty instruments for clinical and research use. METHODS A systematic review was registered in PROSPERO. Studies measuring frailty in adults with RA published before May 25, 2022, were searched in six electronic databases. Level of evidence of psychometric properties were synthesized and graded for each frailty instrument using Consensus-Based Standards for the Selection of Health Measurement Instruments methodology. RESULTS There were 22 articles included in the review, and psychometric properties of 16 frailty instruments were examined. RA cohorts were predominantly female with moderate RA disease activity, mean age was 60.1 years, and frailty prevalence ranged widely from 10% to 85%. Construct validity was the only psychometric property routinely examined for frailty instruments in RA, and nearly all (14/16) performed favorably in this domain. Frailty correlated most frequently with older age, higher RA disease activity, and worse physical function. Internal consistency, measurement error, and content validity were examined infrequently. Reliability and responsiveness data were not reported. Six frailty instruments were rated highest in adults with RA: three adaptations of Fried's Criteria, 32-Item and 45-Item Frailty Indexes, and the Comprehensive Rheumatologic Assessment of Frailty. CONCLUSION Six frailty instruments possessed the highest-rated psychometric properties in RA. These instruments demonstrated construct validity of frailty with important outcomes in RA. Frailty assessment shows promise to inform risk stratification in RA, but studies are needed to evaluate reliability, responsiveness, and validity to support accuracy of frailty measurement in adults with RA who may have disease-related features that differentially impact outcomes.
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Affiliation(s)
| | | | - Katherine D. Wysham
- US Department of Veterans Affairs Puget Sound Health Care System and University of WashingtonSeattle
| | - Bunny Pozehl
- University of Nebraska Medical Center College of NursingOmaha
| | - Lani Zimmerman
- University of Nebraska Medical Center College of NursingLincoln
| | - Bryant R. England
- US Department of Veterans Affairs Nebraska‐Western Iowa Health Care System and University of Nebraska Medical CenterOmaha
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Buehring B, Mueller C, Parvaee R, Andreica I, Kiefer D, Kiltz U, Tsiami S, Pourhassan M, Westhoff T, Wirth R, Baraliakos X, Babel N, Braun J. [Frequency and severity of sarcopenia in patients with inflammatory and noninflammatory musculoskeletal diseases : Results of a monocentric study in a tertiary care center]. Z Rheumatol 2023; 82:563-572. [PMID: 36877305 DOI: 10.1007/s00393-023-01332-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2023] [Indexed: 03/07/2023]
Abstract
INTRODUCTION Sarcopenia (SP) is defined as the pathological loss of muscle mass and function. This is a clinically relevant problem, especially in geriatric patients, because SP is associated with falls, frailty, loss of function, and increased mortality. People with inflammatory and degenerative rheumatic musculoskeletal disorders (RMD) are also at risk for developing SP; however, there is little research on the prevalence of this health disorder in this patient group using currently available SP criteria. OBJECTIVE To investigate the prevalence and severity of SP in patients with RMD. METHODS A total of 141 consecutive patients over 65 years of age with rheumatoid arthritis (RA), spondylarthritis (SpA), vasculitis, and noninflammatory musculoskeletal diseases were recruited in a cross-sectional study at a tertiary care center. The European Working Group on Sarcopenia in Older People (EWGSOP 1 and 2) definitions of presarcopenia, SP, and severe SP were used to determine the prevalence. Lean mass as a parameter of muscle mass and bone density were measured by dual X‑ray absorptiometry (DXA). Handgrip strength and the short physical performance battery (SPPB) were performed in a standardized manner. Furthermore, the frequency of falls and the presence of frailty were determined. Student's T-test and the χ2-test were used for statistics. RESULTS Of the patients included 73% were female, the mean age was 73 years and 80% had an inflammatory RMD. According to EWGSOP 2, 58.9% of participants probable had SP due to low muscle function. When muscle mass was added for confirmation, the prevalence of SP was 10.6%, 5.6% of whom had severe SP. The prevalence was numerically but not statistically different between inflammatory (11.5%) and noninflammatory RMD (7.1%). The prevalence of SP was highest in patients with RA (9.5%) and vasculitis (24%), and lowest in SpA (4%). Both osteoporosis (40% vs. 18.5%) and falls (15% vs. 8.6%) occurred more frequently in patients with SP than those without SP. DISCUSSION This study showed a relatively high prevalence of SP, especially in patients with RA and vasculitis. In patients at risk, measures to detect SP should routinely be performed in a standardized manner in the clinical practice. The high frequency of muscle function deficits in this study population supports the importance of measuring muscle mass in addition to bone density with DXA to confirm SP.
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Affiliation(s)
- B Buehring
- Rheumazentrum Ruhrgebiet, Ruhr-Universität Bochum, Herne, Deutschland.
- Klinik für Rheumatologie, Immunologie und Osteologie, Bergisches Rheuma - Zentrum, Klinisches Osteologisches Schwerpunktzentrum DVO, Europäisches Expertenzentrum Systemische Sklerose, Krankenhaus St. Josef, Akademisches Lehrkrankenhaus der Heinrich-Heine-Universität Düsseldorf, Bergstr. 6-12, 42105, Wuppertal, Deutschland.
| | - C Mueller
- Rheumazentrum Ruhrgebiet, Ruhr-Universität Bochum, Herne, Deutschland
| | - R Parvaee
- Rheumazentrum Ruhrgebiet, Ruhr-Universität Bochum, Herne, Deutschland
| | - I Andreica
- Rheumazentrum Ruhrgebiet, Ruhr-Universität Bochum, Herne, Deutschland
| | - D Kiefer
- Rheumazentrum Ruhrgebiet, Ruhr-Universität Bochum, Herne, Deutschland
| | - U Kiltz
- Rheumazentrum Ruhrgebiet, Ruhr-Universität Bochum, Herne, Deutschland
| | - S Tsiami
- Rheumazentrum Ruhrgebiet, Ruhr-Universität Bochum, Herne, Deutschland
| | - M Pourhassan
- Marienhospital Herne, Ruhr-Universität Bochum, Herne, Deutschland
| | - T Westhoff
- Marienhospital Herne, Ruhr-Universität Bochum, Herne, Deutschland
| | - R Wirth
- Marienhospital Herne, Ruhr-Universität Bochum, Herne, Deutschland
| | - X Baraliakos
- Rheumazentrum Ruhrgebiet, Ruhr-Universität Bochum, Herne, Deutschland
| | - N Babel
- Marienhospital Herne, Ruhr-Universität Bochum, Herne, Deutschland
| | - J Braun
- Rheumazentrum Ruhrgebiet, Ruhr-Universität Bochum, Herne, Deutschland
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Baione V, Canevelli M, Belvisi D, Buscarinu MC, Bellucci G, Fantozzi R, Nicoletti CG, Malatuni G, Cortese A, De Giglio L, Tartaglia M, Ferrazzano G, Malimpensa L, Leodori G, Bruno G, Ferraro E, Marfia GA, Centonze D, Salvetti M, Conte A. Frailty and relapse activity in multiple sclerosis: A longitudinal observation. Mult Scler Relat Disord 2023; 72:104603. [PMID: 36905818 DOI: 10.1016/j.msard.2023.104603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/17/2023] [Accepted: 03/02/2023] [Indexed: 03/07/2023]
Abstract
Recent cross-sectional investigations suggest a relationship between frailty, as measured by Frailty Index (FI), and multiple sclerosis (MS). However, if and how frailty is associated with relapse activity in MS is still unknown. To explore this issue, a one-year follow-up study involving 471 patients was conducted. A univariate regression model showed an inverse association between baseline FI score and the presence of relapse, which was also confirmed in the multivariate model. These results suggest that frailty may reflect pathophysiological mechanisms involved in MS disease activity and that the FI may be used as an enrichment criterion in clinical trials.
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Affiliation(s)
- Viola Baione
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Marco Canevelli
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy; Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Daniele Belvisi
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy; IRCCS Neuromed, Pozzilli, IS, Italy
| | - Maria Chiara Buscarinu
- Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS), Sapienza, University of Rome, Rome, Italy
| | - Gianmarco Bellucci
- Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS), Sapienza, University of Rome, Rome, Italy
| | | | - Carolina Gabri Nicoletti
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | - Giorgia Malatuni
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | | | | | - Matteo Tartaglia
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Gina Ferrazzano
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | | | - Giorgio Leodori
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy; IRCCS Neuromed, Pozzilli, IS, Italy
| | - Giuseppe Bruno
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | | | - Girolama Alessandra Marfia
- IRCCS Neuromed, Pozzilli, IS, Italy; Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | - Diego Centonze
- IRCCS Neuromed, Pozzilli, IS, Italy; Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | - Marco Salvetti
- IRCCS Neuromed, Pozzilli, IS, Italy; Department of Neurosciences, Mental Health, and Sensory Organs (NESMOS), Sapienza, University of Rome, Rome, Italy
| | - Antonella Conte
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy; IRCCS Neuromed, Pozzilli, IS, Italy.
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Fons A, Kalisvaart K, Maljaars J. Frailty and Inflammatory Bowel Disease: A Scoping Review of Current Evidence. J Clin Med 2023; 12:jcm12020533. [PMID: 36675461 PMCID: PMC9860672 DOI: 10.3390/jcm12020533] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/30/2022] [Accepted: 01/02/2023] [Indexed: 01/11/2023] Open
Abstract
Frailty is increasingly recognized as an important concept in patients with Inflammatory Bowel Disease (IBD). The aim of this scoping review is to summarize the current literature on frailty in IBD. We will discuss the definition of frailty, frailty assessment methods, the prevalence of frailty, risk factors for frailty and the prognostic value of frailty in IBD. A scoping literature search was performed using the PubMed database. Frailty prevalence varied from 6% to 53.9%, depending on the population and frailty assessment method. Frailty was associated with a range of adverse outcomes, including an increased risk for all-cause hospitalization and readmission, mortality in non-surgical setting, IBD-related hospitalization and readmission. Therefore, frailty assessment should become integrated as part of routine clinical care for older patients with IBD.
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Affiliation(s)
- Anne Fons
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands
- Department of Geriatric Medicine, Spaarne Gasthuis, 2035 RC Haarlem, The Netherlands
- Correspondence: ; Tel.: +31-71-526-3507
| | - Kees Kalisvaart
- Department of Geriatric Medicine, Spaarne Gasthuis, 2035 RC Haarlem, The Netherlands
| | - Jeroen Maljaars
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands
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Gao Y, Cai W, Zhou Y, Li Y, Cheng J, Wei F. Immunosenescence of T cells: a key player in rheumatoid arthritis. Inflamm Res 2022; 71:1449-1462. [DOI: 10.1007/s00011-022-01649-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 09/12/2022] [Accepted: 09/15/2022] [Indexed: 11/05/2022] Open
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Abstract
Difficult-to-treat rheumatoid arthritis is a heterogeneous term in which patients may present with difficulties in their management for different reasons. This can ultimately lead to patients being exposed to multiple treatments because of inefficacy (resulting from mechanisms intrinsic to rheumatoid arthritis or from non-inflammatory causes such as chronic pain syndrome or structural damage, among others), toxicity or adverse effects that may be linked to comorbidities. One particular group in which such characteristics may be more patent is older patients. Increasing life expectancy, an ageing population and the late onset of rheumatoid arthritis have led to an increased interest in the particularities of treating older patients. This may pose a challenge for physicians, as ageing has implications for optimal patient treatment owing to the potential presence of comorbidities, the risk of adverse events and perceptions of disease status by both physicians and patients. All of these factors may have implications for classifying and managing patients aged > 65 years as difficult-to-treat rheumatoid arthritis, as these patients could be misclassified. This can occur when a significant proportion may still exhibit signs of active disease but not necessarily be difficult to treat because the treatment criterion has not been fulfilled. Alternatively, patients may be exposed to multiple biologic/targeted disease-modifying antirheumatic drugs because of contraindications and/or comorbid conditions. Treatment-to-target strategies and an adequate assessment of inflammatory rheumatoid arthritis activity in older patients should be undertaken, taking special care with associated comorbidities, polypharmacy and risk profiles. Such an approach can help to ensure appropriate treatment for older adults and avoid the misclassification of difficult-to-treat patients.
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Affiliation(s)
| | - Alejandro Balsa
- Rheumatology Department, Hospital Universitario La Paz, Madrid, Spain
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