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Special concerns, and defining the ideal candidate for therapy
ABSTRACT: The aging process is difficult, involving multisystem functional decline, and the pharmacokinetics of medications are altered in the older population, resulting in increased risks. Concerns associated with biologic therapy are demonstrated in case reports. Analysis of the literature about biologic therapy for rheumatologic conditions in the geriatric population, such as rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis, is limited by a lack of data about older subjects in clinical trials. Safety concerns in older patients include infection, hepatitis B, and infusion reaction risks. For some older patients, biologic therapy is indicated, given the lack of effectiveness of previous therapies, and it provides humane treatment. However, the threshold is much higher in this population than in adults of younger age because of the increased risks. (J Musculoskel Med. 2010;27:175-180)
Actress Bette Davis said/Aging ain't for sissies. "The aging process is difficult, involving multisystem functional decline in which defects in multiple homeostatic mechanisms are acquired, resulting in a markedly reduced capacity to respond to stress. Although the process is highly time-dependent and mirrors chronological age, in any given person it can be highly variable.1,2 (For more on difficulties in aging, see the Box, "Organ-specific manifestations of aging," on page 176.)
In addition, the pharmacokinetics of medications are altered in the older population, resulting in increased risks with their use. As the geriatric population continues to grow, the need for physicians to become more familiar with the special considerations related to medication use in these patients is increasing accordingly.
A number of specific concerns are associated with biologic therapy for older patients. In discussing its use in the geriatric population, several aspects must be considered before an analysis of data that describe outcomes is helpful.
In this article, I discuss the treatment of older patients who have rheumatoid arthritis (RA) and other rheumatologic conditions with biologic agents, particularly the anti-tumor necrosis factor a (anti-TNF-a) therapies. A brief description of 3 actual patients who exemplify some specific concerns will be described, followed by a discussion of the physiology of aging, as well as the effects of aging on the immune system. A review of the literature documenting the outcomes of biologic therapy in older patients with various...