Compared with the youngest group in the study, patients 65–80 years old were 58% less likely to get a biologic & those 80 or older were 80% less likely to get a biologic.
Almost half of the cohort (49%; 8,465 patients) received glucocorticoids at baseline, with a similar frequency across age groups. Greater use was seen in patients with higher Charlson comorbidity scores, depression, asthma and other respiratory conditions, and those treated concomitantly with hydroxychloroquine.
There were 3,263 patients in the study who received biologic therapy within two years of starting methotrexate, a cumulative incidence of 12.6% at one year and 20.6% at two years, according to the article. Results revealed biologic use decreased as the age of each group increased and was dramatically lower in older and non-white patients, as well as those with a greater comorbidity burden.
Compared with those who were younger than 50 years old, patients who were 50–65 were 26% less likely to get a biologic, according to the study. Patients 65–80 were 58% less likely to get a biologic and those 80 or older were 80% less likely to get a biologic compared with the youngest group in the study.
“We were surprised by how dramatic those findings were,” says Dr. George. “Even people just 65 and above were much less likely to be treated with a biologic therapy. It was really a very dramatic difference by age.”
Dr. George says a number of reasons may explain why older patients are less likely to be treated with biologics than younger people. It could be patient preference—older patients may resist trying newer therapies—for example. Another possibility is that physicians worry about infection or side effects in older populations, given that biologics used to treat the disease often come with a black box warning of serious risk of infection.
The finding that non-white patients get biologic treatment with less frequency is something that has been shown in previous studies, as well, says Dr. George. Why this occurs, although not addressed in the study, is an area of great importance that deserves further investigation, he says.
“There’s a lot of variation in how we are using biologic therapies,” says Dr. George.
“Patients who are older and patients who have other health problems are much less likely to be treated with a biologic therapy than patients who are younger and healthier,” he says. “But when we look at the alternative, we find that these patients are just as likely or more likely to be treated with prednisone, even though that might potentially be riskier.”
Treatment guidelines recommend conventional therapy be used first, before use of a biologic for patients with serious infection is considered, says Dr. George. Another piece of the puzzle to consider is the use of steroids.
Prednisone and other glucocorticoids are commonly used to effectively treat symptoms of RA, but even at moderate doses they have substantial side effects and safety issues, says Dr. George. Patients using long-term doses of prednisone above 10 mg a day could be at risk of infection, weight gain, diabetes, osteoporosis and other adverse outcomes.
Future research needs to look at the tradeoffs between prednisone and biologic use for healthy people and people who are sicker and older, says Dr. George.
“The treatment for rheumatoid arthritis has really been revolutionized in the past two decades,” says Dr. George. “We have an ever-expanding number of options to treat rheumatoid arthritis. [Treatment is] much more effective than in the past, but all medications come with some potential for side effects. So the challenge is to figure out how to best use these medications to make people better, but at the same time maximize safety.”