What are the initial treatment recommendations for arthritis in the elderly?

From the Guidelines

The initial treatment for arthritis in the elderly should prioritize non-pharmacological interventions and, when necessary, pharmacological options starting with the safest and most effective choices, such as methotrexate as the anchor drug for those at risk of persistent disease, alongside careful consideration of NSAIDs and systemic glucocorticoids for symptom management. When considering the management of arthritis in the elderly, it's crucial to weigh the benefits and risks of various treatment options, keeping in mind the goal of minimizing morbidity, mortality, and improving quality of life. According to the 2016 update of the EULAR recommendations for the management of early arthritis 1, patients at risk of persistent arthritis should be started on Disease-Modifying Antirheumatic Drugs (DMARDs) as early as possible, ideally within 3 months, with methotrexate considered the anchor drug unless contraindicated. Key considerations in the treatment approach include:

• The use of NSAIDs at the minimum effective dose for the shortest time possible, after evaluating gastrointestinal, renal, and cardiovascular risks 1.
• Systemic glucocorticoids may be used at the lowest dose necessary as a temporary (<6 months) adjunctive treatment for reducing pain, swelling, and structural progression, with intra-articular glucocorticoid injections considered for local symptoms of inflammation 1.
• Non-pharmacological interventions, such as dynamic exercises and occupational therapy, should be considered as adjuncts to drug treatment in patients with early arthritis 1.
• Patient education and overall patient care, including smoking cessation, dental care, weight control, assessment of vaccination status, and management of comorbidities, are essential components of arthritis management in the elderly 1. Given the complexity and individual variability in arthritis presentation among the elderly, a personalized approach that balances the need for effective symptom control with the minimization of treatment risks is paramount.

From the FDA Drug Label

2.3 Dosage for Rheumatoid Arthritis in Adults The recommended dosage is: Initial dosage: 400 mg to 600 mg daily as a single daily dose or two divided doses.

• Initial treatment recommendations for arthritis in the elderly using hydroxychloroquine are to administer 400 mg to 600 mg daily as a single daily dose or two divided doses 2.
• The action of hydroxychloroquine is cumulative and may require weeks to months for maximum therapeutic effect.
• For methotrexate, the recommended starting dosage for adult rheumatoid arthritis is single oral doses of 7.5 mg once weekly, or divided oral dosages of 2.5 mg at 12 hour intervals for 3 doses given as a course once weekly 3.

From the Research

Initial Treatment Recommendations for Arthritis in the Elderly

The initial treatment recommendations for arthritis in the elderly involve a combination of non-pharmacological and pharmacological interventions.

• Non-pharmacological interventions include education, self-management strategies, weight control, and regular physical activity and exercise 4.
• Pharmacological interventions may include non-steroidal anti-inflammatory drugs (NSAIDs) as first-line therapy for osteoarthritis (OA) 5, 6.
• For rheumatoid arthritis (RA), disease-modifying antirheumatic drugs (DMARDs) are recommended as first-line therapy, with biological-response modifiers and glucocorticoids also being used 7, 8.

Considerations for Treatment

When evaluating treatment options for older adults with arthritis, patient-specific parameters and comorbid conditions must be considered 6.

• The selection of NSAIDs should be based on the patient's profile and the drug's pharmacological properties, as well as the potential risk of cardiovascular, gastrointestinal, and renal adverse events 5.
• The use of any pharmacological agent in the elderly should be tempered with caution regarding increased sensitivity to medications, drug-drug interactions, and associated comorbidities 4.
• Treatment should be multimodal and tailored to the individual patient, with attention given to the co-morbidities of pain as well as the global health status of the patient 4.

Treatment Options

Treatment options for arthritis in the elderly include:

• Acetaminophen and NSAIDs for mild-to-moderate pain 6
• Tramadol or opioids for severe pain associated with OA 6
• DMARDs, biological-response modifiers, and glucocorticoids for RA 7, 8
• Topical applications, such as those containing NSAIDs, for symptom relief with minimal risk 4
• Intra-articular and soft-tissue injections of corticosteroids for symptom relief with minimal risk 4