Tumour Necrosis Factor-α Antagonists in the Management of Rheumatoid Arthritis in the Elderly A Review of Their Efficacy and Safety

Rheumatoid arthritis (RA) is a chronic inflammatory disease that frequently affects people aged >= 65 years, causing significant impairment with pain and functional disability. Elderly RA patients have specific problems, including co-morbid diseases, numerous concomitant medications, greater number of damaged joints as a result of longer disease duration and often a more severe disease presentation in elderly-onset RA. These factors, together with an age-related decline in the immune defence mechanisms, make elderly patients more vulnerable. The new era of biologic medications has made intensive treatment of RA patients possible. Anti-tumour necrosis factor-alpha (anti-TNF alpha) agents can cause a dramatic improvement in disease activity and functional capacity, making complete remission of RA a possible target. TNF alpha has been shown to play an important role in both the healthy aging process and age-related diseases such as RA. Targeting this cytokine in elderly patients is therefore reasonable. However, it is not clear whether treatment effects can be reached to the same extent in both elderly and younger patients and whether anti-TNF alpha treatment specifically increases the risk of certain adverse events in elderly RA patients. This review discusses the currently available evidence relating to the efficacy and safety of anti-TNF alpha medication in RA patients aged >= 65 years treated in clinical trials and observational studies. Despite a slightly less robust effect in elderly patients, anti-TNFa treatment has a similar long-term efficacy in patients aged >= 65 years and patients aged < 65 years. The majority of the study results showed that anti-TNF alpha treatment does not elevate the risk of infections beyond the risk found in age-matched controls. When a moderate increase in risk was found, this occurred equally in elderly and younger patients. Furthermore, whereas anti-TNF alpha agents were found to be relatively safe in the treatment of elderly RA patients, treatment with corticosteroids significantly elevated the risk of serious infections. Corticosteroids are frequently used in elderly patients, but the evidence suggests that preference should increasingly be given to anti-TNF alpha agents, for which the expected benefits will mostly outweigh the modestly increased risks of associated adverse events.