Elderly-onset seronegative inflammatory arthritis: A narrative review and practical approach

Elderly-onset seronegative inflammatory arthritis encompasses a heterogenous group of inflammatory joint disorders presenting in older adults (>60 years) in the absence of rheumatoid factor and/or anti-cyclic citrullinated peptide antibodies. Its recognition is increasingly important in a rapidly aging global population in whom seronegative disease is more common. In older adults, immune senescence, inflammaging and multimorbidity may alter disease phenotype and complicate diagnosis and management. Careful clinical evaluation of nature and distribution of joint pains, constitutional, extra-articular/systemic features and patient-specific risk factors, with adjunctive laboratory, imaging and joint fluid analyses is necessary to distinguish diagnostic mimics. In this article, we describe the common causes of elderly-onset seronegative inflammatory arthritis and describe a practical diagnostic approach and treatment framework for such cases. In elderly persons, management should be tailored to the patient's premorbid health, functional status and goals-of-care, to balance therapeutic benefit with vulnerability to adverse effects such as glucocorticoid toxicity, immunosuppression-related infections and cytopenias. A "start low, go slow" approach to glucocorticoids and disease-modifying antirheumatic drugs based on shared decision-making on established treatment goals is recommended in frail older adults.