What is Elderly-onset Rheumatoid Arthritis and How Should it be Treated?
By Nathan Wei
Elderly onset rheumatoid arthritis (EORA) is a misnomer since it refers to rheumatoid arthritis affecting people 60 years of age or older. Since this author recently reached the age of 60 and certainly doesn’t consider himself elderly, the definition should be changed.
Rheumatoid arthritis (RA) affects 2% of those 60 years old and older and is generally more common among women. When RA presents in patients past the age of 60, it may present with an acute onset, with significant inflammatory symptoms, and predominant upper extremity involvement, eg. shoulders. Inflammatory markers in the blood such as the erythrocyte sedimentation rate (ESR) may be greatly elevated.
Diagnostic testing is similar to that for diagnosing RA in younger individuals. Acute phase reactants for inflammation such as the ESR and CRP will invariably be abnormal. Serologic testing for rheumatoid factor and anti-cyclic citrullinated protein (anti-CCP) are helpful.
The diagnostic imaging procedure of choice is probably magnetic resonance imaging (MRI), although diagnostic ultrasound may be useful.
Other disease processes that need to be excluded include: calcium pyrophosphate deposition disease (CPPD), osteoarthritis, gout, polymyalgia rheumatica (PMR), arthritis associated with infections such as hepatitis B,C , and immunodeficiency virus. Tuberculosis and fungal infections such as histoplasmosis, coccidiomycosis, and blastomycosis can also present with inflammation of many joints.
Endocrine disorders such as diabetes and Cushing’s disease may also present with diagnostic challenges.
Malignancy is another consideration. An inflammatory arthritis affecting many joints in a patient over the age of 60 should lead the physician to working up the patient for an underlying malignancy. Also, certain malignancies such as lymphoma are increased in incidence in patients with rheumatoid arthritis.
The treatment of EORA presents special challenges. First, a patient with RA past the age of 60 probably has other medical conditions. Second, they are probably on multiple medications. The diagnosis may be confounded by the fact the both ESR and rheumatoid factor can be elevated in older patients who don’t have RA. Finally, treatment with medications needs to be tempered with the knowledge that potential side-effects may be increased in this population where drug metabolism is less certain than that of younger patients.
Nonetheless, the approach to therapy for patients with EORA is not substantially different from the treatment strategies employed for younger patients.
Non-steroidal anti-inflammatory drugs (NSAIDS) are often used early on in younger patients. However, in older patients who may develop kidney and liver toxicity with these agents, the use of NSAIDS is probably a strategy that has to be watched closely.
Low dose prednisone (5-10mgs) given as a single morning dose provides symptomatic relief and can serve as a “bridge” until the effects of second line agents begin. The potential complications of long-term prednisone therapy such as osteoporosis and cataracts, among others, will be more of a concern than for younger patients.
Second line agents consist of two groups. They are the disease-modifying anti-rheumatic drugs (DMARDS) and the biologic drugs.
Disease-modifying drugs such as methotrexate, hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine), and leflunomide (Arava) are all potentially useful. Obviously, with older patients, potential toxicities and drug interactions need to be monitored for carefully.
Biologic therapies can also be used for patients with EORA. TNF inhibitors such as etanercept (Enbrel), adalimumab (Humira), infliximab (Remicade, and the two newer agents golimumab (Simponi), and certolizumab (Cimzia) are all effective and well tolerated in the older population of patients with rheumatoid arthritis.
Second line biologics such as rituximab (Rituxan) and abatacept (Orencia) have also been used in patients with EORA with results comparable to that for younger patients.
Advancing age should not, by itself, be a contraindication to the use of biologic therapies. The aim for older patients, as it is with younger patients, is to establish remission. This may be even more important in older patients since independence is cherished more. Finally, since cardiovascular events are an established complication of rheumatoid arthritis and are also more common in older adults, every effort should be instituted to establish and maintain remission.
ABOUT RHEUMATOID ARTHRITIS?
im patient of rheumatoid arthritis for last 12 year.I hv visited many doctor but im still sick.
I want to know which type of daily routine is beneficial for me?
n what type of foods are beneficial for me?
you can also suggest another information about it
THANK U.
follow this method for one month..you will be cured..
Disease or financial setback or family proble, is due to placement of planets in bad places in the person’s horoscope and also due to hereditary causes..a soul can enter into the womb of a woman whose sins match the sins of previous birth of this soul..this is secret of creation..a soul cant take birth in a wealthy family or pious family,if it has got previous sins..
.when your forefathers have these diseases you will get them…sometimes due to sins of your forefathers and foremothers ,diseases are caused…when there are such sins ,your horoscope will contain placement of good planets in bad places…diseases may develop in a person due to sins of that particular individual…sins means viiolation of natural law…eating fast foods,nonveg,sweets etc come under this category…evil thinking and evil doing come under the category of serious sins..
such sins and doshas in horoscopes can be repaired or modified by doing tapas or penance…
it is due to eating wrong and negative foods and negative style of life… follow this method for two month…you will improve from 15th day…
holistic healing method..
when the body is having a disease, the patient should not be given a nutritious food… he should be asked to fast for 7 or 10 day… but he can take unlimited fruits(not sweet) and uncooked vegetables… this is also called semi-fasting method…during semi-fasting, the bodies energies will be conserved to fight and throw out the disease…that is why , patients are asked to stop so many negative foods …all high nutritious foods are negative foods for sick people…
.
a person requires so much culture and intelligence, to understand the basic principles of holistic healing … this is part of yoga and spirituality…this is great indian science…
i am telling you about indian thinking, which the new generation has forgotten or is ignorant of culture…though this is called hindu thinking , these methods are prevalent in china,egypt japan,and east asia…
that is why , i am doing this service to sick people in yahoo and otherwise,for the last 25 years freely, to awaken people of their slumber…this is great indian method,which does not require any expenditure to cure any type of disease…
Holistic healing method….
1avoid milk ,curd,buttermilk,coffee,tea,horlicks,,
sweets,sweet fruits,
,nonveg,cashewnuts,almonds,peas,cooldr…
fish,eggs,f,alcohols for 30days.these are all
negative foods for a person with disease…unless these
foods are stopped ,he or she cant clean the body,blood
and nerves…persons without disease can take them…
2.daily eat 300 gms of uncooked cucumber( or 60 gms of uncooked bittergourd or 300 gms of blackgrapes containing seeds.)
4daily eat 20 gms of ginger uncooked..
5.daily eat 30 uncooked leaves of ponna ganti aku-telugu(ponnan kanni keera-tamil) and 20 uncooked leaves of coriander..
and 3 betel leaves..(after one week take 6 betel leaves)
6.you can eat rice items,wheat items ,ragi balls,jowar items of food..dont take ragi malt.
7,you can take daily oranges,promagenates,watermelons,pineapp…
good wishes,
k.umamaheswara rao
kumrao99@yahoo.co.in
2nd method:-
colour ray therapy of sunlight—–(this is part of holistic healing)
the sunlight has got 7 colours… red and yellow colour rays have got healing property to cure most of the diseases.
purchase a sheet of red colour celliphone paper from a local book shop or paper shop….it is transparent and glazed. it will cost rs6 or 7…divide into 4 pieces…each piece should measure 5in by7in.
then lie down in sunlight … keep one of the pieces of yellow coloured silaphan paper on stomach , so that sunlight falls on the red or yellow paper (which is placed on stomach)…you should not wear any banian or shirt,when you lie
down in sunlight…
allow the sunlight to pass through the paper for 7 min…then yellow or red rays will enter into your body and clean all ailments in your body…after one week ,you can increase the time to 10 min daily(for elders) and 6min for children.it should not be used for children less than 3 years.
many diseases like blood pressure,sugar,arthritis,pains
,ulcers,acidity,skin disease,virus
fevers,cold,bronchitis,piles,fissures,… will be cured with this me
What can we do to educate our doctors?
Dictionaries define the word ’doctor’ as ‘learned’, ‘teacher’, ‘most highly qualified’ etc. However, at least in our country, doctors are among the most ignorant. It may be natural for a doctor not to know much about hydro-geology. It may be possible for him not to be aware of the latest breakthroughs in astro-physics. But for a doctor not know much about Medicine, or not to be aware of the developments in his specialty is not only untenable, but also dangerous and criminal. Yet, there are thousands of doctors in our country who do not know much about Medicine, as it is practised today. Most of these doctors, it will be surprising to know, are very busy practitioners. I personally know of professors of Medicine who advise patients of Rheumatoid Arthritis to get Ayurvedic help since there is no drug in Modern Medicine (still erroneously and unfortunately called Allopathy, meaning “approximate”) for this disease. This is when even the most basic of textbooks of Medicine has a few pages discussing the drugs available for the treatment of this disease. Of course, the treatment of Rheumatoid Arthritis, like that of most other medical illnesses, is developing and improving continually.
“Harrison’s Principles of Internal Medicine”, the most trusted and respected resource on General Medicine all over the world, says, “Medicine is an ever-changing science.” It is estimated that about 50% of the medical knowledge is replaced by new, scientifically researched, proven and more robust information every ten years. This would mean that a person who qualified ten years ago and since has not tried to update his knowledge is 50% outdated. He may be more dangerous than the diseases that he treats!
One important contribution for ignorant doctors come from private medical colleges. People purchase their degrees from these business institutions. Not much is taught or learned in most of these places.
Paradoxically, it is frequently a blessing for a doctor not to know much. If one knows enough and well, relevant differential diagnoses (the other likely possibilities that must be excluded) will come to the mind when seeing a patient. It may make investigating and treating rather difficult, given the peculiar milieu of our country.
It is important to introduce new legislation that makes it compulsory for doctors to renew their license every year after passing an examination designed to prove that their medical knowledge is up-to-date. It is unclear why the Government are reluctant to make any move in this direction, though one can make a few guesses.
Please note that this querry relates specifically to the situation in India. I know that most of what is discussed here do not apply to many other countries, especially the U.S and the U.K.
Well, I am post-graduate physician, presently working as a registrar in Cardiology.
Medicine is not a failure! We have eliminated a few dreadful diseases, small pox being a notable example. We strive to eradicate more diseases, but then to this end, we need a fuller participation of the wider society, internationally. Today, people live longer, and the quality of life has significantly increased. Today, diseases get diagnosed and treated whereas in the past, people used to die from poorly understood and mostly untreated conditions loosely termed “consumption”. Health is the state of complete physical, mental, social and spiritual well being, and not just the lack of bodily sickness or infirmity. The physician mostly takes care of the physical derangement. Of course, a fully evolved system of Medicine should address the other aspects of ailments. We already have Community Medicine that takes care of preventive aspects of Medicine. Escalating health care costs, obesity, diabetes, the HIV pandemic etc. are symptoms of a much more devastating and emergent social disease.
What can i use for rheumatoid arthritis?
Hi, i am a 41 female patient with RA for 4 years,and i have been on many types of NSAID from cox-2 to naproxen..And now i cant use them anymore because of this new cardiovascular condition of mine..I cant take asprin because of the ulcer..What shall i do ?Please help me whith some information..I have heard of minocycline ,is it a new treatment and does it realy work?
My leukemia treatment, and dosing issues (methotrexate)?
I was diagnosed with Acute Lymphoblastic Leukemia in the summer of 2007. I was 17 at the time and I knew I’d be getting countless “poisons” pumped into me for treatment, and obviously it’s logical to assume there would be many side effects from it ( there was ); this brings me to say only recently have I began to research the drugs I was taking for the illness.
I started to research because I was having quite a hard time with hair loss, I know hair loss is pretty much guaranteed because when I was in the height of treatment I lost about 70% of it and the rest was left as a weird fuzz.
Take note that the height or “harshest” time of treatment was at the end of 2008, beginning of 2009 (when I lost most of my hair).
So anyways, almost a year later my hair pretty much filled back in except it has stayed pretty thin on the temple areas and top and resembles the classic male-pattern baldness, except all I have is the receding hair line and thinness on top (hair in the in shape of a V), there is no thinning or spots elsewhere on my head (vertex, crown) as I would expect with heredity-acquired baldness.
*Forgot to mention all the males on both sides of my family have full heads of hair
This made me look into the chemotherapy-agents I was taking at home, I thought they might be making me progressively thinner.
I am ordered to take as of now, once-a-week, x23 5mg pills of methotrexate. This drug, as I found, is very commonly used for patients with rheumatoid arthritis, and also used for cancer patients as an immunosuppressive agent; which as you could assume, would be the main part of treatment with an excessive amount of white blood cells with leukemia.
My problem is this, after reading many reports and submissions from various places around the net on methotrexate (askapatient, RA-forums, etc) it not only became clear that some of these people were experiencing the progressive thinning as I was,
but that they were taking a -considerably- lower dose than me.
I somewhat expected this, as anyone might see the correlation between an immune system suppression drug and its needed dose escalation.
After doing the math, I’ve found that I am currently taking orally, 57.5 mg of methotrexate per week. With FDA guidelines saying not to exceed 30mg a week, I just wonder…..I know “guidelines” aren’t followed religiously with a lot of medications, but almost doubling the guideline recommended? Really?
So after all of this background information, my question(s):
Can anybody in the medical field tell me-
if there is a maximum life dose of methotrexate, and the effects if it is exceeded?
From http://www.drugs.com/dosage/methotrexate.html#Usual_Adult_Dose_for_Acute_Lymphoblastic_Leukemia :
“Usual Adult Dose for Acute Lymphoblastic Leukemia
Maintenance (during remission): 15 mg/m2 IM or orally twice a week.”
What does this equate to (assuming the dose amount is correlated with weight) for a person weighing on average 180 lbs?
Sorry for the long read…
I know I should bring this up with the doctor, but I have a feeling he will shrug it off, it just makes me really wonder if they really know what they are doing, even by the FDA standards of MTX’s maximum weekly dosage of 30mg’s, taking 57.5mg is 191% over the norm.
More surprisingly, to find this out that with this particular medication folinic acid can be (and should be, as recommended in many clinical studies) given following methotrexate treatment to substantially reduce the side effects (while proven to not hinder the immunosuppressive function) why this was not given or even mentioned…
No, I have never had a bone marrow transplant at all.
But I am most definitely going to ask the doctor when my appointment comes around. Seems a little unnecessary to me, and I also forgot to mention the countless intrathecal injections of MTX I’ve had an are still having on a monthly basis.
I am wondering if you have had a bone marrow transplant/stem cell transplant. If you have, that would account for the higher dose for the immunosuppression. After my transplant, i was on a different med than you, but for immunosuppression, and I was on a higher dose than typically given for other reasons.
FDA standards mean nothing.
Ask your doctor to explain this to you, and then demand he explain it if he shrugs you off. If you dont like his explanation, look for a second opinion.
Do you feel like the Physicians work for you or the other way around?
My neice has Lupus Erythematosus and Fibromyalgia. She is always in severe and I do mean severe pain. She had been seen by a certified nurse practitioner and then began seeing a new physician and always had a Rheumatologist. Because she felt as if she wasn’t getting along with the CNP, she sought out a new physician. She visited the new physician 4 times, got her medications and had just sent a letter to the CNP to inform her that she no longer wanted to be a patient. The CNP however beat her to the punch. She received a termination letter from the CNP basically letting her go in 30 days because of communication breakdown and narcotics abuse. Now, from what my neice told me, she informed the new primary of her previously seeing a CNP and that she was not satisfied. However, you know how it is when you visit a physician. You all might mesh and you might not. At any rate, she had refills on prescriptions from all three physicians and she got them filled, not all at the same time. But, she was so hurt because she stated that morally, her CNP had an obligation to speak with her if she felt that something was wrong, and I agree. She had been seeing this CNP for over 6 years and truth be told, was only seeing her because of a friend of the family. She is known in the streets to give you whatever you want. However, my neice wasn’t seeing her for that. I felt that the CNP threw her away as if she was a piece of trash. A similar situation happened with a friend of the family and through the Michigan Automated Prescription System, the state of Michigan notified her primary to pull a report from this system. The system showed that she was seeing another physician and getting her prescription with him. Because of her being red-flagged of sorts, she too was also terminated from her primary thus causing her to be so despondent that she blew off her head with a .357 magnum. Because of the doctors termination letter, she tought that she would never ever be able to find another doctor. Okay, now my neice has the new primary, whom she just loves and has her Rheumatologist as well. But yesterday, she asked me. Abuela (Although I am her aunt), do you think that I will get in trouble? My answer to her was a resounding NO! You have a right to go and see any doctor that you want. I did of course reiterate that out of fairness to the new physician, you should let them know if you still have prescriptions and/or any medications that still need to be filled. I feel bad for her because her conscience is soooo heavy. If it where not for patients, physicians would not be in business. Why do they act as if they are doing us a favor and why do they often treat everyone as potential drug addicts? My neice’s fingers are so turned and twisted, you would think that she has Rheumatoid Arthritis and I know that Lupus and RA are in the same family. She is scared to go back to her Rheumatologist because of this new Mapping system. However, I told her that she has every right to talk with her doctor, whether it’s doctor 1, 2 or 3. And if her Rheumatologist no longer wants to treat her then dammit, find someone else. My father always said, one monkey don’t stop no show! What do you all think yahoo community? Did I give her the correct information. I love her and would never intentionally steer her or anyone wrong.
Medicine has been an enormous failure in so many ways. What else can you think of that has hyper-inflation year after year and produces very little for the increase in cost.
People are obese, unhealthy, and sick. Medical care costs ten times more now than it did only 15 years ago, but our life expetancy hasn’t changed by any measurable amount, and in fact may be declining. Many think that today’s children my be the first generation to die at a younger age than their parents.
Medicine hasn’t cured anything in 50 years. We still have cancer, diabetes, aids, herpes, influenza, autism, pneumonia, and many other horrible diseases and at HIGHER rates than they were a generation ago. Our treatments for many of these diseases cost tens of thousands of dollars a year (if not a month) and have not increased our life in terms of years or quality. There is no prevention, only bandaids and pills. There is no cure, only tests and more tests.
Healthcare is indeed a failure, unless you are one of those getting rich from it.
(whew!)
Oh.. what a poor girl.. How old is she?
Some physician and nurses are always like that!! But hack that, no need to worry, you can always have another Physician and you can always go and see any Physician you want any time!
Yes, Patients have the right to change their doctors if they don’t want any more.
Um, Good to hear that that girl has a new primary now.
Hope everything would be okay with that Rheumatologist and her new primary.
SENSE IT LOOK LIKE YOU HAVE, TRIED EVERYTHING THAT I WAS GOING TO TELL YOU, JUST STICK WITH YOUR DOCTOR, AND COLD ICE PK. TO THE AFFECTED AREA