Advance-CTR Pilot Projects Program (2019)
"Impact of Aggressive Rheumatoid Arthritis Therapy on Osteoporotic Fractures in Older Rheumatoid Arthritis Patients"
Co-PI: Tingting Zhang, MD, PhD
Rheumatoid Arthritis (RA) is the most common inflammatory arthritis of the elderly (>60 year) population with a prevalence rate of 2%. It is an independent risk factor for osteoporosis and fractures likely due to: (1) systemic inflammation due to increased cytokine burden (IL6, TNF, IL2), (2) medication use like steroids which can cause osteoporosis AND (3) pain which can increase the fall risk and hence fracture risk. Older RA are often under-represented in clinical trials of biologic disease modifying agents (DMARDs) which are now becoming the cornerstone of RA management. In fact, it is expected that more than 2/3rd of patients with RA will need escalation of therapy from conventional DMARDs at 6 months. However, given the lack of evidence in the older population and the fear of infection associated with biologic DMARDs, escalation to these medications (ET) is often not done OR delayed in the course of disease resulting in accumulation of more severe disease at time of initiation. This non-escalation (nET) also lead to more reliance on steroids AND possibly non-steroidal and opioid medications. Untreated disease along with reliance on steroids, NSAIDs and opioids could further contribute to osteoporosis related morbidities in older population. Prior studies comparing biologic to conventional DMARDs (while assessing various outcomes) have often not sufficiently accounted for the selection bias introduced due to delayed initiation of one agent compared to another. It is our long term goal to improve the care of older RA patients. Given the morbidity and mortality associated with osteoporosis and related conditions, we aim at assessing the impact of ET as compared to nET on osteoporosis, fractures and falls. The goal of the current proposal is to establish the event rates in various treatment groups in an inception RA cohort.