Missed opportunities in the treatment of elderly patients with rheumatoid arthritis

OBJECTIVE: To investigate whether there is a difference in waiting time between indication and start of anti-TNF-alpha therapy in younger and older RA patients. METHODS: The study was carried out in the Nijmegen inception cohort of early RA. All patients meeting indications for anti-TNF-alpha therapy according to the Dutch reimbursement criteria were included in the analysis. Time from indication to start of anti-TNF-alpha therapy or censoring was calculated in all patients. Multivariable Cox regression analysis was used to investigate the influence of age at indication on the time to commencement of anti-TNF-alpha treatment. Hazard ratios were calculated for groups in age quartiles. The model was corrected for 28-joint disease activity score (DAS28), disease duration, gender, the Charlson comorbidity index and episodes of serious illnesses between indication and anti-TNF-alpha therapy or censoring. RESULTS: From the 487 eligible patients, 215 patients started anti-TNF-alpha treatment during their follow-up (44%). Age significantly influenced the time to receiving anti-TNF-alpha after first indication, adjusting for confounders (HR = 0.975/year, P < 0.001). The same analysis using age quartiles showed that the younger age groups had a higher chance of receiving anti-TNF-alpha treatment within an equal period of time than older patients [HR 2.67 (95% CI 1.64, 4.35); 2.30 (1.43, 3.71); 1.79 (1.14, 2.81) with increasing age; the eldest group as reference]. The eldest patients had significantly higher DAS28 values prior to anti-TNF-alpha treatment than younger patients. CONCLUSION: Elderly RA patients were less likely to receive anti-TNF-alpha treatment within an equal period of time compared with younger patients, taking disease activity, disease duration and comorbidities into account.