Department of Rheumatology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.
Drugs Aging. 2009;26(8):647-64. doi: 10.2165/11316460-000000000-00000.
Rheumatoid arthritis (RA) is a chronic inflammatory disease that frequently affects people aged >or=65 years, causing significant impairment with pain and functional disability. Elderly RA patients have specific problems, including co-morbid diseases, numerous concomitant medications, greater number of damaged joints as a result of longer disease duration and often a more severe disease presentation in elderly-onset RA. These factors, together with an age-related decline in the immune defence mechanisms, make elderly patients more vulnerable. The new era of biologic medications has made intensive treatment of RA patients possible. Anti-tumour necrosis factor-alpha (anti-TNFalpha) agents can cause a dramatic improvement in disease activity and functional capacity, making complete remission of RA a possible target. TNFalpha has been shown to play an important role in both the healthy aging process and age-related diseases such as RA. Targeting this cytokine in elderly patients is therefore reasonable. However, it is not clear whether treatment effects can be reached to the same extent in both elderly and younger patients and whether anti-TNFalpha treatment specifically increases the risk of certain adverse events in elderly RA patients. This review discusses the currently available evidence relating to the efficacy and safety of anti-TNFalpha medication in RA patients aged >or=65 years treated in clinical trials and observational studies. Despite a slightly less robust effect in elderly patients, anti-TNFalpha treatment has a similar long-term efficacy in patients aged >or=65 years and patients aged <65 years. The majority of the study results showed that anti-TNFalpha treatment does not elevate the risk of infections beyond the risk found in age-matched controls. When a moderate increase in risk was found, this occurred equally in elderly and younger patients. Furthermore, whereas anti-TNFalpha agents were found to be relatively safe in the treatment of elderly RA patients, treatment with corticosteroids significantly elevated the risk of serious infections. Corticosteroids are frequently used in elderly patients, but the evidence suggests that preference should increasingly be given to anti-TNFalpha agents, for which the expected benefits will mostly outweigh the modestly increased risks of associated adverse events.
类风湿关节炎（RA）是一种慢性炎症性疾病，常影响年龄≥65 岁的人群，导致疼痛和功能障碍，对其造成显著损害。老年 RA 患者存在一些特殊问题，包括合并症、同时使用多种药物、疾病持续时间较长导致的更多关节受损，以及老年发病的 RA 患者常表现出更严重的疾病。这些因素，再加上与年龄相关的免疫防御机制下降，使老年患者更加脆弱。生物药物的新时代使得 RA 患者的强化治疗成为可能。抗肿瘤坏死因子-α（anti-TNFalpha）药物可显著改善疾病活动度和功能能力，使 RA 完全缓解成为可能的治疗目标。TNFalpha 在健康衰老过程和 RA 等与年龄相关的疾病中均发挥着重要作用。因此，针对这种细胞因子进行靶向治疗是合理的。然而，尚不清楚在老年和年轻患者中是否能达到相同程度的治疗效果，以及抗 TNFalpha 治疗是否会特异性增加老年 RA 患者发生某些不良事件的风险。本文讨论了目前在临床试验和观察性研究中，针对接受抗 TNFalpha 治疗的年龄≥65 岁 RA 患者的疗效和安全性的相关证据。尽管老年患者的疗效略逊一筹，但抗 TNFalpha 治疗在≥65 岁和<65 岁的患者中具有相似的长期疗效。大多数研究结果表明，抗 TNFalpha 治疗并未使感染风险超过年龄匹配对照的风险。当发现风险适度增加时，老年和年轻患者中发生的风险相同。此外，虽然抗 TNFalpha 药物在老年 RA 患者的治疗中相对安全，但皮质类固醇的治疗显著增加了严重感染的风险。皮质类固醇在老年患者中经常使用，但证据表明，应越来越多地选择抗 TNFalpha 药物，因为其预期的获益将在很大程度上超过相关不良事件的适度增加风险。
