Rheumatoid arthritis in the elderly in the era of tight control

The principles of treating rheumatoid arthritis (RA) have changed considerably in recent years. Disease-modifying treatment (if possible, methotrexate) should be started as soon as the diagnosis of RA is made. The purpose of treatment is to achieve remission or, alternatively, low disease activity, and patients should be assessed every 1-3 months if they have early RA in order to achieve this aim. The same principles of treatment should apply in the elderly. However, it is more difficult to assess RA activity in the elderly. Overall disease activity and/or pain may be overestimated, as elderly patients may suffer from other diseases. Conversely, the number of joints with synovitis can be underestimated compared with young patients, and regular ultrasound assessment should therefore be considered. Treatment may be more difficult because of concomitant diseases and the increase in drug-related side effects. The role of corticosteroids is still controversial as their short-term symptomatic effects on clinical activity and potential medium-term effect on structural deterioration are counter-balanced by their side effects. Dosages of methotrexate need to be adjusted for creatinine clearance. The anti-tumor necrosis factors (TNFs) appear to be slightly less effective in the elderly. The frequency of adverse effects of anti-TNFs is higher in an elderly population, although the same is seen with comparator disease-modifying treatments. Limited information is available for rituximab and tocilizumab. Uncertainties remain about the management of RA in the elderly as there have been few studies in this population. The safety of the biotherapies therefore still needs to be confirmed, together with the benefit-risk balance of corticosteroid therapy compared with biological therapy.