Rev. Bras. Reumatol. vol.57 número5

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r e v b r a s r e u m a t o l . 2017;57(5):491–494

w w w . r e u m a t o l o g i a . c o m . b r

REVISTA

BRASILEIRA

DE

REUMATOLOGIA

Brief

communication

Rheumatoid

arthritis

in

elderly

and

young

patients

Artrite

reumatoide

do

idoso

e

do

jovem

Ariane

Carla

Horiuchi,

Luiz

Henrique

Cardoso

Pereira,

Bárbara

Stadler

Kahlow,

Marilia

Barreto

Silva,

Thelma

L. Skare

∗

HospitalUniversitárioEvangélicodeCuritiba,Servic¸odeReumatologia,Curitiba,PR,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received16January2014

Accepted24June2015

Availableonline27October2015

Introduction

There isa wide variabilityin the formsofpresentation of

rheumatoid arthritis(RA). Theage ofonset ofthis disease

seems tobe acritical factor in its clinical spectrum.1 _It _is

considered thata patientsuffers elderly onset rheumatoid

arthritis(EORA) whenthe disease beganat theage of≥60

years.1,2_This_form_of_RA_contributes_with_10–33%_of_cases_of

disease.3

TheprevalenceofRAincreaseswithageandisestimated

tooccurinupto2.2%ofthepopulation>55years.4_The_genetic

influence,especiallyofHLAclass2genes,5,6 _acts_not_only_in

theincidencerate,accordingtotheageofonset,4,7,8_but_also_in

promotingtheappearanceofclinicalpeculiaritiesineachage

group.9_Individuals_with_disease_onset_at_a_younger_age_have_a

higherprevalenceofHLADRB1*04;inthosewithalateonset,

HLADRB1*01prevails.8 _On_the _other_hand,_elderly_patients

withtheseronegative,polymyalgia-likeformshowincreasing

prevalenceofHLADRB1*13/*14.10

In contrast to the disease beginning in young

individ-uals(youngonsetrheumatoidarthritis,orYORA),EORAseem

tofollowamoreacutecourse,inassociationwithsystemic

∗

Correspondingauthor.

E-mail:tskare@onda.com.br(T.L.Skare).

phenomenasuchasfever,fatigueandweightloss,aswellas

withtheinvolvementoflargerjointsandhigherprevalence

ofatypical formsofonsetasRS3PE (remittingseronegative

symmetricalsynovitiswithpittingedema)andpolymyalgia

rheumatica-like forms.1 _However,_the _statement _that, _with

increasingage,theprognosisbecomesmoresevereoreven

thattherearedifferencesinthecourseofthediseaseforyoung

andelderlypeople,assomeauthorsclaim,1,4,5,11_is_a

contro-versialmatter,sincetheliteratureisnotunanimousonthis

point.5,8,11_A_Brazilian_study _could_not_detect_differences_in

prognosisforbothgroups.6

ThetreatmentofEORApatientspursuits thesame goals

asthose ofYORApatients, i.e.tocontroltheclinical

mani-festations,preventstructuraldamage,preservefunctionand

autonomyoftheindividual,andalsopreventexcess

mortal-itycausedbythedisease.1_But_some_authors_have_observed

thatthetreatmentofelderlypatientsiscarriedoutdifferently,

withlessaggressivenessopposedtothatforYORApatients.2,4

Thisfindingisjustifiedforthefearofprescribing

modifying-disease drugs in more vulnerable people, with greater

possibilityofdruginteractionduetomultipleco-morbidities

towhichtheelderlyindividualisusuallysubject.2,3

http://dx.doi.org/10.1016/j.rbre.2015.06.002

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rev bras reumatol.2017;57(5):491–494

Table1–Comparisonofdemographic,clinicalandserologicaldatabetweenpatientswithelderlyonsetrheumatoid arthritis(EORA)andyoungonsetrheumatoidarthritis(YORA).

EORA n=62

YORA n=111

p

Gender(male/female) 14/48 11/100 0.02

Tobaccoexposure(currentsmokersand formersmokers)

34/60(56.5%) 52/110(47.2%) 0.24

Racea_(African_{descent/Caucasian)} _14/62 _32/100 _0.19

Rheumatoidnodules 3/54(5.5%) 5/106(4.7%) 1.00

Interstitialpneumonitisb _7/51_(13.7%) _4/91_(4.3%) _0.056

DAS-28 1–6.7

Mean=3.45±1.49

1–7.2

Mean=3.69±1.56

0.39

HealthAssessmentQuestionnaire(HAQ) 0–3

Median=1 IQR=0.12–1.62

0–2.75 Median=1.43 IQR=0.62–2.00

0.04

Presenceofrheumatoidfactor(RF) 49/62(79.0%) 61/104(58.6%) 0.007

Presenceofantinuclearantibodies(ANA) 16/58(27.5%) 41/104(39.0%) 0.13

Associationwithhypothyroidism 7/56(12.5%) 22/106(20.7%) 0.19

a _According_to_the_patient’s_{self-declaration.}

b _Found_by_{high-resolution}_CT_of_the_chest.

Withincreasinglongevity and growth ofthepopulation

over60years,itisimportanttorecognizethecharacteristics

ofthelocalpopulationwithEORAtoimprovethequalityof

healthcareofferedtothesepatients.Inthisstudy,wesought

toevaluatethedemographic,clinical,serologicaland

treat-mentprofilesofthelocalpopulationwithEORAcomparedto

patientswithYORA.

Patients

and

methods

This is a study approved by the Research Ethics

Commit-tee.RApatientswho met atleastfourofthe classification

criteriaoftheAmericanCollegeofRheumatology(1987)for

RA12 _and _being _diagnosed _with _EORA1 _who _attended _to _a

singlerheumatologyoutpatientclinicofatertiarycare

cen-ter during the period of one year (August 2012 to August

2013)werestudied.Thisisanobservational,analytical,

cross-sectionalstudyofaconveniencesamplewherepatientswith

EORA(n=62) andwithYORA(n=111)properlymatchedfor

diseasedurationwerecompared.Dataaboutdemographics,

presenceofnodules,extra-articularmanifestationsofRA,the

presence of autoantibodies as rheumatoid factor (RF) and

antinuclear antibody (ANA), and use of medications were

obtainedretrospectively through a reviewof their medical

records.InflammatoryactivityindexessuchasDAS(Disease

ActivityScore)2813_and _of_functional_capacity_measured_by

HAQ(HealthAssessmentQuestionnaire)14_were_obtained

dur-ingthestudyperiod.

Dataweregatheredinfrequencyandcontingencytables;

Chi-squaredandFischertestswere usedforcomparisonof

nominal data; and Mann–Whitney and non-paired t tests

wereappliedtonumericaldata.Thesampledistributionwas

studiedbyD’Agostinoand Persontest. Measuresofcentral

tendency were expressed as mean and standard deviation

for Gaussian variables; and as median and interquartile

range(IQR)fornon-Gaussianvariables.Resultswithp≤0.05

were considered statistically significant. The calculations

weremadewiththeaidoftheGraphPadPrism(version5.0)

software.

Results

At disease onset, YORA patients (n=111) were aged 32–58

(median=45,IQR=39.0–51.0)years;andEORApatients(n=62)

wereaged60–83(median=63.0,IQR=60.7–70.0)years.InEORA

group, the disease duration time was 1–16 (median=3.0;

IQR=1.0–6.5)years;andinYORAgroup,thediseaseduration

timewas1–13(median=5.0;IQR=2.0–8.0)years(p=0.21).In

Table1,onecanobservethecomparisonbetweenthesetwo

groupsregardingdemographic,serologicalandclinical

char-acteristics;itisworthnotingthedifferencefoundforgender,

HAQandRFbetweenthegroups.InEORAgrouptherewere

41.6%patientswithlowactivityorremissionbyDAS28(<3.2)

asopposedto38.7%inYORAgroup(p=0.85).Asregardsthe

useofmedications,nodifferencewasfoundbetweengroups,

ascanbeseeninTable2.

Discussion

TheresultsofthisstudydemonstratethatEORAinBrazilis

morecommoninmaleindividuals,andthatpatientswiththis

formofRAhavebetterHAQthatofpatientswithYORAwith

thesamediseaseduration.Thefindingthatmalesaremore

affectedinolderagegroupsisafactalreadywidelyrecognized

intheliterature.1,15 _The_Norfolk_Arthritis_Register,11_i.e. _the

Englisharthritisregistry,showsthat theincidenceofRAin

mengraduallyincreaseswithage,whileinwomenitincreases

from45years,reachingaplateauat75years,fromwhichthe

incidencestartstodecline.Bajocchietal.16_described_a_gender

distributionratioof1.5–2womento1manintheelderlyversus

4–4.5womenfor1maninyoungerpeople.

Itwasalsoobservedinthepresentstudythatthefunctional

statemeasuredbyHAQhadlowervaluesinelderly

individu-als.Thisfactisinterestingandisopposedtotheideathatolder

people, despitewhether or notsufferingfrom arheumatic

disease,mayshowfunctionalimpairmentrelatedtothe

weak-nessinherenttoolderpeople.Thiscanbeexplained,ifahigher

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Table2–Comparisonoftreatmentsusedinpatientswithelderlyonsetrheumatoidarthritis(EORA)versusyoungonset rheumatoidarthritis(YORA).

EORA n=62

YORA n=111

p

Corticosteroiduse(numberofpatients) 48/62(77.4%) 85/103(82.5%) Doseofcorticosteroidmg/day(prednisoneor

equivalent)

2.5and20.0 Median=10.0 IQR=5.0–10.0

2.50–20.00 Median=5.0 IQR=5.0–10.0

0.17

Methotrexate 49/62(79.0%) 82/105(78.0%) 0.88

Antimalarials 32/62(51.6%) 44/105(41.0%) 0.22

Leflunomide 15/62(16.1%) 28/105(26.2%) 0.72

Anti-TNF␣ 4/62(6.4%) 6/104(5.7%) 1.00

thatpatientswithEORAhadabetterprognosisandachieved easierand faster remission. Onthe other hand, aSpanish study18 _shows _that_patients _with_elderly_onset _rheumatoid

arthritishaveworsefunctionalandanatomicalindexesversus

correspondingyoungersubjects.Data fromthisstudy favor

theconceptthatRAintheelderlyisnotamoreserious

condi-tionthaninyoungsubjects.However,Nazetal.19_showed_that

olderageatthetimeofdiagnosisisassociatedwithincreased

cardiovascularmortality,suggestingtheneedforan

aggres-sivetreatmenttoavoidprematuredeath.

Tutuncu et al.7 _{investigating} _prescribing _habits _of ₁₉₂

rheumatologists, describe that patients with EORA receive

less treatmentthan those with YORA,despite anidentical

durationofdiseaseandcomparableactivityandseverity.As

alreadymentioned,olderpeople havemoreco-morbidities,

areathigherriskofpolypharmacyandaresubjecttoahigher

prevalenceofsideeffectsbychanges indrug

pharmacody-namicsandpharmacokinetics.1,2 _The_recognition_that_RA_is

adisease withapoorprognosisandthatthecontrolofthe

inflammatoryprocessimpactsdecisivelyonfunctional

capac-ityandsurvivalofthepatient,mayhavebeenresponsiblefor

achangeofattitudetowardthisagegroupinrecentyears.In

thisstudy,wecouldnotdetectdifferencesintheuseofdrugs

inthetwodiseaseonsetranges,showingthatcurrentlythe

aggressivenessintreatmentdoesnotvaryaccordingtothe

ageofonset,andasimilarcontrolofinflammation,measured

byDAS28,wasobtainedinbothpopulations.

Thisstudyhassomelimitations.Duetotheretrospective

natureofthestudy,itwasnotpossibletoaccesscertain

infor-mation such as, for instance, the prevalence ofsecondary

Sjögrensyndromeinbothgroups.Interestingly,weobserved

alowertendencyforinvestigationofsuchkindofsymptoms

in the older age group. Itmay be that such fact occurred

byattributing the sicca symptoms to their own age, or to

the concomitant use ofother drugs, such asdiuretics and

antidepressants,commoninolderpeople.Anotherlimitation

isthefactthatonlyindividualswhoalreadyhavecompleted

fourACR (1987)classificationcriteriaforRAwere included.

Thischoicewasmadebecausethisisaretrospectivestudy;

thus,thequalityofinformationisdependentonthecorrect

completionofmedicalrecords.Itistherefore importantto

stressthattheabovefindingsareonlyvalidforthistypeof

patients.Subjectswithatypical formsofRA,suchasthose

with preferential involvement of large joints, polymyalgia

rheumatica-likeformsandRS3PEhavenotbeenstudied.On

theotherhand,thissameselectiveprocessallowedthe

inclu-sionofindividualswithamoreaccuratediagnosis,withthe

exclusionofotherdiseasesthat,intheelderly,maysimulate

RA,suchasmicrocrystallinediseases.Thestrategyusedfor

ourinclusioncriterionofpatientsmayalsohavebeen

respon-sibleforthehigherprevalenceofpositiveRFinEORAfoundin

thisstudy,sincemostauthorshavedescribedthisvariableas

beinglowerthanthatfoundinyoungsubjects.1,11_Although

theliteraturementionsthathealthyelderlyarelikelytohave

ahigherprevalenceofRF,afactattributedsolelytoage,itis

interestingtonotethatthisfindingcouldnotbeprovenina

studyof336healthypatientsinourregion.20_Therefore,_the

higher prevalenceofthis autoantibodyfoundin thisstudy

cannot be justifiedby immunesystem changes associated

withtheagingprocess.Furthermore,itisworthnotingthat

thecutoffpointusedfordefiningEORAinthisstudywas60

years,1_which_makes_this_population_somewhat_younger_and

lesssubjecttoimmunosenescencethanthatfromother

stud-ies,wherethecutoffpointof65yearswasadopted.8

Moreover,inthisstudyacomparisongroupmatchedfor

diseasedurationwasincluded,whichallowedamorerealistic

analysisoftheeffectsofthediseaseonthefunctionalcapacity

ofthedifferentgroups.

An interesting observation was the finding of a trend

toward theappearance ofinterstitialpneumonitisinEORA

individuals.Althoughthisextra-articularmanifestationwas

notassociatedwithageatdiseaseonset,ithasbeenfound

morefrequentlyinmaleindividuals21_who,_in_turn,_are_more

commoninEORAgroups.Oneshouldtakeintoaccountthat

this finding may be influenced by the fact that this study

wasperformedinatertiarycenter,withaheavierreferralof

patientswithmoreseveredisease.

Inconclusion,itcanbesaidthat,inourregion,patients

withEORAhavehigherprevalenceofmaleindividuals and

that, despiteequaltreatment and control ofinflammatory

activityinbothgroups,patientswithYORAhaveaworse

func-tionalperformance.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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