Evaluation of treatment patterns and prescription medication use among older adults with late-onset rheumatoid arthritis
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PROJECT SUMMARY / ABSTRACT Rheumatoid arthritis (RA) is a chronic, debilitating and costly disease that disproportionally affects older adults. Disease modifying antirheumatic drugs (DMARDs) improve outcomes of RA and, in recent years, the treatment paradigm has evolved to promote early initiation, escalation, and combination of DMARDs. And yet, older adults are less likely to receive aggressive treatment due to issues of polypharmacy and multimorbidity. Older adults with late-onset RA (LORA) experience higher disease activity, more radiographic progression, and greater functional decline. Thus, less aggressive treatment raises greater concerns for poorer outcomes and greater levels of disability among older adults with LORA. In addition to achieving disease remission, pain control is an important goal in the treatment of RA and prescription medications including NSAIDS, glucocorticoids and opioids are in common use among patients with RA. However, these prescription medications are generally considered inappropriate for use in older adults because of associated adverse effects such as risk of falls, fractures and osteoporosis. Moreover, older adults have more limited tolerance to common adverse effects of medications and are more prone to the additive or even multiplicative risk of polypharmacy, further complicating the care of medically complex older adults with RA. Information on use of DMARDs for new diagnosis of LORA, and potential unintentional reliance on other prescription medication use is scarce because older adults are often excluded from randomized controlled trials. This leaves a gap in our understanding of how, in the face of polypharmacy and multimorbidity, variation in patterns of treatment impact outcomes for medically complex older adults with RA. In the absence of trial data, large observational studies that leverage administrative data serve an important role in filling this type of scientific knowledge gap and also allow for understanding drivers of treatment choices in usual care. In this retrospective cohort study using Medicare data we propose to achieve 2 aims. In Aim 1, we will characterize patterns of and factors associated with DMRADs and other prescription medication use among older adults with a new diagnosis of LORA. And in Aim 2 we will compare outcomes related to treatment and timing of DMARD-initiation for new cases of LORA. This proposal provides a real-world and population-level study of the care received by older RA patients treated with DMARDs. Preliminary data and analyses obtained from this study will form the basis of future career development awards to address unique challenges related to prescribing high risk medications for older adults. Support from the GEMSSTAR award, mentorship, and training will be invaluable as I progress towards a career as an independent researcher focused on the design, implementation and evaluation of care models to improve quality of care in older patients with rheumatic diseases.
