What is the recommended treatment plan for a 70-year-old woman with rheumatoid arthritis?

Treatment of Rheumatoid Arthritis in a 70-Year-Old Woman

Start methotrexate 15 mg weekly immediately with folic acid supplementation, rapidly escalate to 20–25 mg weekly within 4–6 weeks, and add low-dose prednisone ≤10 mg daily as bridging therapy for up to 3 months while methotrexate takes effect. 1, 2

First-Line DMARD Strategy

• Methotrexate is the anchor DMARD and must be initiated as soon as the diagnosis is confirmed, regardless of serologic markers, because treatment delays lead to irreversible joint damage. 1, 2
• In a 70-year-old patient, start methotrexate at 10–15 mg weekly if renal function is reduced (eGFR <70 mL/min), then titrate gradually toward 20 mg weekly as tolerated, checking renal function every 4–6 weeks. 1
• If oral methotrexate is not tolerated or ineffective after 3 months at optimal dose, switch to subcutaneous administration before declaring treatment failure. 1, 3
• Mandatory folic acid 1 mg daily reduces methotrexate-related adverse effects and improves tolerability. 2

Glucocorticoid Bridging Therapy

• Add prednisone 5–10 mg daily at treatment initiation to provide rapid symptom control during the 6–12 week period before methotrexate becomes effective. 1, 2
• Limit glucocorticoid exposure to less than 3 months and taper as quickly as clinically feasible. 1, 2
• In patients ≥70 years, chronic corticosteroid exposure beyond 1–2 years markedly increases risks of fractures, cataracts, and cardiovascular disease; therefore, prolonged use must be avoided. 1, 2

Treatment Targets and Monitoring

• The primary goal is sustained clinical remission (SDAI ≤3.3, CDAI ≤2.8, or ACR-EULAR Boolean criteria: ≤1 tender joint, ≤1 swollen joint, CRP ≤1 mg/dL, patient global ≤1/10). 1, 2
• Low disease activity (SDAI ≤11 or CDAI ≤10) is an acceptable alternative when remission cannot be achieved, particularly in older patients with long-standing disease. 1, 2
• Assess disease activity every 1–3 months using composite measures (tender/swollen joint counts, patient and physician global assessments, ESR/CRP). 1, 2
• Expect at least 50% improvement in disease activity within the first 3 months of therapy; failure to reach this threshold mandates immediate escalation. 1, 2
• The treatment target must be reached within 6 months; if not, therapy must be escalated or modified. 1, 2

Escalation Strategy for Inadequate Response

At 3 Months (<50% Improvement)

Without poor prognostic factors (low RF/anti-CCP, modest disease activity, no erosions):

• Add triple therapy: methotrexate + sulfasalazine (500 mg twice daily, escalating to 1000 mg twice daily) + hydroxychloroquine 400 mg daily. 1

With poor prognostic factors (high RF/anti-CCP titers, DAS28 >5.1, early erosive changes, or failure of two conventional DMARDs):

• Add a biologic DMARD to methotrexate. 1, 2
• In elderly patients (≥70 years), abatacept is preferred over TNF inhibitors because it provides comparable efficacy with a lower infection risk. 1
• Alternative first-line biologics include TNF inhibitors (adalimumab, etanercept, infliximab), IL-6 receptor antagonists (tocilizumab), or rituximab (particularly for seropositive patients). 4, 1
• Allow 3–6 months to fully assess efficacy of any newly introduced biologic before making further therapeutic changes. 1

At 6 Months (Target Not Achieved)

• If remission or low disease activity remains unattained despite prior escalation, switch to a biologic with a different mechanism of action rather than a second agent from the same class. 1
• JAK inhibitors (tofacitinib, baricitinib) are appropriate when biologics are unsuitable or after biologic failure. 4, 1

Baseline Safety Screening

• Before starting methotrexate, obtain complete blood count with differential, hepatic function tests, renal function tests, and chest radiograph. 1
• Tuberculosis screening (TST or IGRA) is mandatory prior to any biologic DMARD. 1, 5
• Administer age-appropriate vaccines, including recombinant herpes zoster vaccine, at least 2–4 weeks before starting biologic therapy. 1

Alternative First-Line Options

• When methotrexate is contraindicated or not tolerated early, leflunomide or sulfasalazine may be used as first-line conventional DMARDs. 6, 2
• In patients with chronic kidney disease, sulfasalazine is the preferred conventional DMARD when biologics are not immediately available. 6

Critical Pitfalls to Avoid

• Do not delay DMARD initiation while awaiting specific serologic thresholds; treatment must start at diagnosis. 1, 2
• Do not rely on NSAIDs or corticosteroids as sole therapy, as they provide only symptomatic relief without disease modification and do not prevent radiographic joint damage. 1, 2
• Do not continue ineffective therapy beyond 3–6 months without escalation, as ongoing joint damage accumulates and leads to irreversible disability. 1
• Do not underdose methotrexate; escalation to 20–25 mg weekly should be achieved before declaring treatment failure. 1, 2
• In elderly patients, closely monitor for development of infection or malignancy when using biologic DMARDs, as the frequency of serious infection and malignancy is higher in patients ≥65 years. 5