Treatment Options for Elderly RA Patients with Multiple DMARD Intolerances
Introduction to Treatment Options
- The American College of Rheumatology recommends rituximab in combination with a JAK inhibitor (tofacitinib, baricitinib, or upadacitinib) as the most appropriate next-line therapy for elderly RA patients with multiple DMARD intolerances 1, 2
Biologic Therapy
- The American College of Rheumatology guidelines explicitly state that rituximab should be used after TNF inhibitor failure, which aligns with the treatment history of patients who have failed TNF inhibitors 1, 2
- Abatacept (T cell costimulatory inhibitor) is recommended for patients with inadequate response to conventional DMARDs and TNF inhibitors 1
- Tocilizumab or sarilumab (IL-6 receptor inhibitors) are equally appropriate alternatives for patients who have failed conventional DMARDs and TNF inhibitors 1, 2
JAK Inhibitors as Targeted Synthetic DMARDs
- JAK inhibitors (tofacitinib, baricitinib, or upadacitinib) can be used as an alternative or combination approach for patients with inadequate response to conventional DMARDs 1, 2
- The 2021 ACR guidelines place JAK inhibitors on equal footing with biologics for patients with inadequate response to conventional DMARDs 1
Monitoring and Adjustment of Therapy
- Disease activity assessment every 1-3 months during active disease is mandatory, and therapy must be adjusted if no improvement is seen by 3 months 2, 3, 4
- If treatment target (remission or low disease activity) is not reached by 6 months, therapy must be changed 1, 2, 4
Glucocorticoid Bridge Therapy
- The American College of Rheumatology recommends adding low-dose prednisone (≤10 mg/day) as bridge therapy while initiating the new biologic agent, and tapering glucocorticoids as rapidly as clinically feasible, ideally within 3 months 1, 4