Sonomoto Koshiro, Tanaka Yoshiya
Department of Clinical Nursing, School of Health Sciences, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan.
The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan.
Int J Rheum Dis. 2025 Apr;28(4):e70232. doi: 10.1111/1756-185X.70232.
As the world's most rapidly aging society, Japan has faced significant challenges in the management of rheumatoid arthritis (RA) in elderly patients. Biologic and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) have improved disease control, but concerns remain regarding the risk of infection and malignancy, especially in the elderly population. This review presents real-world data from FIRST registry, a prospective cohort following a total of 5500 patients over 20 years, and highlights strategies to balance efficacy and safety. Registry shows an increasing age of patients initiating b/tsDMARDs and an increase in comorbidities such as cardiovascular disease, chronic kidney disease, and malignancies. Infection control-including prophylaxis against pneumocystis pneumonia, screening for non-tuberculous mycobacteria, and vaccination-has been associated with a lower incidence of serious infections. Similarly, a proactive malignancy management strategy that includes computed tomography (CT) screening and multidisciplinary care has been correlated with improved detection of early-stage cancers and fewer treatment discontinuations due to malignancy. While these findings represent associations rather than direct causal effects, they reflect the evolving landscape of RA management over two decades. Meanwhile, the registry highlights unmet needs, particularly in patients with prior b/tsDMARD exposure, who often experience lower response rates. In addition, while clinical remission rates have improved, functional outcomes remain suboptimal, particularly in older patients. To address these challenges, personalized treatment selection is being explored. By sharing Japan's experience in managing RA in an aging society, this review provides insights into strategies that may be applicable to other aging populations worldwide.
作为世界上老龄化速度最快的社会，日本在老年类风湿关节炎（RA）患者的管理上面临着重大挑战。生物制剂和靶向合成改善病情抗风湿药（b/tsDMARDs）改善了疾病控制，但对于感染和恶性肿瘤风险仍存在担忧，尤其是在老年人群中。本综述展示了来自FIRST注册研究的真实世界数据，这是一项对5500名患者进行了20年随访的前瞻性队列研究，并强调了平衡疗效和安全性的策略。注册研究显示，开始使用b/tsDMARDs的患者年龄在增加，心血管疾病、慢性肾脏病和恶性肿瘤等合并症也在增加。感染控制——包括预防肺孢子菌肺炎、筛查非结核分枝杆菌和接种疫苗——与严重感染发生率较低相关。同样，包括计算机断层扫描（CT）筛查和多学科护理在内的积极的恶性肿瘤管理策略与早期癌症的更好检测以及因恶性肿瘤导致的治疗中断减少相关。虽然这些发现代表的是关联而非直接因果效应，但它们反映了二十年来RA管理的不断变化的格局。同时，注册研究突出了未满足的需求，特别是在既往使用过b/tsDMARDs的患者中，他们通常反应率较低。此外，虽然临床缓解率有所提高，但功能结局仍不理想，尤其是在老年患者中。为应对这些挑战，正在探索个性化的治疗选择。通过分享日本在老龄化社会中管理RA的经验，本综述为可能适用于全球其他老龄化人群的策略提供了见解。
