Elderly patient populations face vulnerabilities to adverse effects and interaction because of complex medication regimes and comorbid conditions, and an educational session during ACR Convergence 2020 offered important advice about how to best serve these patients.
During Pharmacotherapy Pearls for the Older Rheumatic Disease Patient, Ananta Subedi, MD, and Suraj Rajasimhan, PharmD, spoke about the specific risks that impact older rheumatology patients. Registered attendees have on-demand access to watch a replay of the session through Wednesday, March 11, 2021.
Dr. Subedi, rheumatology attending, WakeMed Physician Practices, Raleigh, NC, opened the session with a look at how aging impacts pharmacokinetics and pharmacodynamics of a variety of rheumatologic medications.
One of the biggest challenges for managing rheumatic disease in older patients comes from age bias, Dr. Subedi said. Elderly-onset rheumatoid arthritis was treated less frequently with biologics and combination DMARDs than those who had RA onset at an earlier age. There also tended to be overuse of NSAIDs and corticosteroids to treat older patients, leading to a higher incidence of adverse outcomes.
RA increased the risk of cognitive impairment, Dr. Subedi noted. Patients taking biologics had less cognitive impairment, while those taking corticosteroids and where were +RF had higher cognitive impairment.
“This illustrates the role of inflammation in causing cognitive impairment, but be aware that there is a general assumption that cognitive impairment could lead to medication non-adherence,” Dr. Subedi said.
Other challenges to disease management in older populations besides cognitive impairment include low income and poor social support.
Dr. Subedi said that improving care for older patients with rheumatologic diseases requires care providers to remain cognizant of co-morbidities and polypharmacy issues. Appropriate DMARD use appears to be a safer option than NSAIDs and corticosteroids, but adequate vaccinations must take place prior to DMARD use, along with regular monitoring of kidney and liver function. Patient education is also important.
Dr. Rajasimhan, clinical pharmacy specialist, National Institutes of Health, said that age-related declines in renal and hepatic function have significant impacts on drug metabolism and elimination. Older adults with polypharmacy have a predisposition for drug-drug interactions and adverse effect, so a detailed medication history must take place during every visit as part of an interprofessional, patient-centered approach that includes a clinical pharmacist. Patients also must be educated about the risks and benefits of herbal supplements.
Methotrexate can lead to decreased drug and metabolite clearance, Dr. Rajasimhan said, so it’s critical to monitor glomerular filtration rate (GFR) and reduce the dose as necessary while using caution with concomitant drugs that may affect GFR. Folic acid does improve tolerability. Hydroxychloroquine requires frequent monitoring and dose adjustments because of renal insufficiency.
JAK inhibitors require evaluation of renal and hepatic function before starting therapy in older patients, Dr. Rajasimhan said. The risk of herpes zoster appears to be higher in older populations. Also assess for tuberculosis and drug interactions, he said, especially CYP-3A4 or 2C19 inhibitors with tofacitinib. “With the newer agents like JAK inhibitors and biologics, infections are an important complication, and vaccinating these patients before therapy can mitigate some of these risks,” Dr. Rajasimhan said.