Download PDF
Aktuelle Rheumatologie 2009; 34(5): 286-290
DOI: 10.1055/s-0029-1237358
Übersichtsarbeit

© Georg Thieme Verlag KG Stuttgart · New York

Besonderheiten Rheumatologischer Pharmakotherapie im Alter

Antirheumatic Drug Treatment in Elderly PatientsK. Krüger1
  • 1Praxiszentrum/Rheumatologie, Rheumatologie, München
Further Information

Publication History

Publication Date:
03 November 2009 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

Faktoren wie Multimorbidität und Multimedikation, häufige Nierenfunktionseinschränkung und weitere pharmakokinetische Besonderheiten sorgen dafür, dass die medikamentöse Behandlung des geriatrischen Rheumapatienten oft nicht ganz unkompliziert ist. Durch die Vielfalt der heutigen Behandlungsmöglichkeiten gelingt es jedoch dennoch, jeden älteren Rheumatiker therapeutisch gut zu versorgen. Leider werden in dieser Altersstufe kaum kontrollierte Studien durchgeführt, sodass das Vorgehen eher empirisch als evidenzbasiert begründet ist. Grundsätzlich empfiehlt sich ein vorsichtigeres Vorgehen bei Anfangsdosierung und Dosissteigerung. Problemlos sind in der Regel Glucocorticoide einsetzbar, ebenso sind milde Basistherapeutika wie Hydroxychloroquin und Sulfasalazin, aber auch Leflunomid einsetzbar. Das ansonsten in der Rheumatologie vielverwendete Methotrexat steht hingegen nur bei guter Nierenfunktion zur Verfügung. Bei hochaktiver RA kann durchaus auf Biologika zurückgegriffen werden, die auch in dieser Altersstufe gut wirken, allerdings mit höherem Infektionsrisiko verbunden sind.

Abstract

Factors like multimorbidity, multimedication, frequent impairment of renal function and pharmacokinetic differences make drug treatment in elderly patients a challenge. Nevertheless satisfactory treatment of the elderly RA patient is possible in most cases because of the many different treatment possibilities existing today. Unfortunately nearly all controlled studies exclude geriatric patients, and studiies targeting this population are rare which means drug treatment in the elderly is rather empirical than evidence-based. Basically the “go low go slow” principle is recommended for drug use in geriatric patients. Among the frequently applied antirheumatic drugs, the use of glucorticoids, hydroxychloroquine and sulphasalazine and leflunomide is rather uncomplicated whereas the DMARD “gold standard” methotrexate can be used only in patients without signs of renal insufficiency. In highly active disease, biologicals are effective also in geriatric RA patients but a higher rate of infectious complications in this age group has to be kept in mind.

Schlüsselwörter

Pharmakotherapie - Antirheumatika - geriatrische Patienten

Key words

drug treatment - antirheumatic drugs - elderly patients

Literatur

  • 1 Ranganath VK, Furst DE. Disease-Modifying Antirheumatic Drug use in the Elderly Rheumatoid Arthritis Patient.  Clin Geriatr Med. 2005;  21 649-669
    CrossrefPubMedSearch in Google Scholar
  • 2 Nair BR. Evidence based medicine for older people: available, accessible, acceptable, adaptable?.  Aust J Ageing. 2002;  21 58-60
    CrossrefPubMedSearch in Google Scholar
  • 3 Bolbrinker J, Schedensack G, Kölzsch. et al . Antihypertensive Pharmakotherapie und Nierenfunktion bei geriatrischen Notfallpatienten.  Dtsch Med Wochenschr. 2009;  134 802-806
    Thieme ConnectPubMedSearch in Google Scholar
  • 4 Fraenkel L, Rabidou N, Dhar R. Are rheumatologists’ treatment decisions influenced by patients’ age?.  Rheumatology. 2006;  45 1555-1557
    CrossrefPubMedSearch in Google Scholar
  • 5 Tutuncu Z, Reed G, Kremer J. et al . Do patients with older-onset rheumatoid arthritis receive less aggressive treatment?.  Ann Rheum Dis. 2006;  65 1226-1229
    CrossrefPubMedSearch in Google Scholar
  • 6 Radovits BJ, Fransen J, Eijsbouts AM. et al . Missed opportunities in the treatment of elderly patients with rheumatoid arthritis.  Ann Rheum Dis. 2009;  68 ((Suppl 3)) 321
    PubMedSearch in Google Scholar
  • 7 Tannenbaum H, Bombardier C, Davis P. et al . An Evidence-Based Approach to Prescribing Nonsteroidal Antiinflammatory Drugs. 3rd Canadian Consensus Conference.  J Rheumatol. 2006;  33 140-157
    PubMedSearch in Google Scholar
  • 8 Gabriel SE, Jaakkimainen L, Bombardier C. Risk for serious gastrointestinal complications related to use of nonsteroidal anti-inflammatory drugs.  A meta-analysis. Ann Intern Med. 1991;  115 787-796
    PubMedSearch in Google Scholar
  • 9 Rahme E, Bardou M, Dasgupta K. et al . Hospitalization for gastrointestinal bleeding associated with non-steroidal anti-inflammatory drugs among elderly patients using low-dose aspirin: a retrospective cohort study.  Rheumatology. 2007;  46 265-272
    PubMedSearch in Google Scholar
  • 10 Solomon DH, Glynn RJ, Rothman KJ. et al . Subgroup analyses to determine cardiovascular risk associated with nonsteroidal antiinflammatory drugs and coxibs in specific patient groups.  Arthritis Care Res. 2008;  59 1097-1104
    CrossrefPubMedSearch in Google Scholar
  • 11 Bjordal JM, Klovning A, Ljunggren AE. et al . Short-term efficacy of pharmacotherapeutic interventions in osteoarthritic knee pain: A meta-analysis of randomised placebo-controlled trials.  Eur J Pain. 2007;  11 125-138
    PubMedSearch in Google Scholar
  • 12 Rosenthal NR, Silverfield JC, Wu SC. et al . Tramadol/Acetaminophen Combination Tablets for the Treatment of Pain Associated with Osteoarthritis Flare in an Elderly Patient Population.  J Am Geriatr Soc. 2004;  52 374-380
    CrossrefPubMedSearch in Google Scholar
  • 13 Vestergaard P, Rejnmark L, Mosekilde L. Fracture risk associated with use of morphine and opiates.  J Intern Med. 2006;  260 76-87
    CrossrefPubMedSearch in Google Scholar
  • 14 Vestergaard P, Rejnmark L, Mosekilde L. Fracture risk associated with use of nonsteroidal anti-inflammatory drugs, acetylsalicylic acid, and acetaminophen and the effects of rheumatoid arthritis and osteoarthritis.  Calcif Tissue Int. 2006;  79 84-94
    CrossrefPubMedSearch in Google Scholar
  • 15 Ornatore KM, Logue G, Venuto RC. et al . Cortisol pharmacodynamics after methylprednisolone administration in young and elderly males.  J Clin Pharmacol. 1997;  37 304-311
    PubMedSearch in Google Scholar
  • 16 Hoes JN, Jacobs JWG, Boers M. et al . EULAR evidence-based recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases.  Ann Rheum Dis. 2007;  66 1560-1567
    CrossrefPubMedSearch in Google Scholar
  • 17 Maradit-Kremers H, Nicola PJ, Crowson CS. et al . Patient, disease, and therapy-related factors that influence discontinuation of disease-modifying antirheumatic drugs: a population-based incidence cohort of patients with rheumatoid arthritis.  J Rheumatol. 2006;  33 248-255
    PubMedSearch in Google Scholar
  • 18 Fiehn C, Kessler S. Ist das Therapieansprechen bei älteren Patienten mit rheumatoider Arthritis reduziert?.  Z Rheumatol. 2009;  68 69-74
    CrossrefPubMedSearch in Google Scholar
  • 19 Wilkieson CA, Madhok R, Hunter JA. et al . Toleration, side-effects and efficacy of sulphasalazine in rheumatoid arthritis patients of different ages.  Q J Med. 1993;  86 501-505
    PubMedSearch in Google Scholar
  • 20 Chan J, Sanders DC, Du L. et al . Leflunomide-associated pancytopenia with or without methotrexate.  Ann Pharmacother. 2004;  38 1206-1211
    CrossrefPubMedSearch in Google Scholar
  • 21 Bologna C, Viu P, Jorgensen C. et al . Effect of age on the efficacy and tolerance of methotrexate in rheumatoid arthritis.  Br J Rheumatol. 1996;  35 453-457
    CrossrefPubMedSearch in Google Scholar
  • 22 Bressolle F, Bologna C, Kinowski JM. et al . Total and free methotrexate pharmacokinetics in elderly patients with rheumatoid arthritis.  A comparison with young patients. J Rheumatol. 1997;  24 1903-1909
    PubMedSearch in Google Scholar
  • 23 Bressolle F, Bologna C, Kinowski JM. et al . Effects of moderate renal insufficiency on pharmacokinetics of methotrexate in rheumatoid arthritis patients.  Ann Rheum Dis. 1998;  57 110-113
    CrossrefPubMedSearch in Google Scholar
  • 24 Hirshberg B, Muszkat M, Schlesinger O. et al . Safety of low dose methotrexate in elderly patients with rheumatoid arthritis.  Postgrad Med J. 2000;  76 787-789
    CrossrefPubMedSearch in Google Scholar
  • 25 Bernatsky S, Ehrmann Feldman D. Discontinuation of methotrexate therapy in older patients with newly diagnosed rheumatoid arthritis: analysis of administrative health databases in Québec, Canada.  Drugs Aging. 2008;  25 879-884
    CrossrefPubMedSearch in Google Scholar
  • 26 Chevilotte-Maillard H, Ornetti P, Mistrih R. et al . Survival and safety of treatment with infliximab in the elderly population.  Rheumatology. 2005;  44 695-696
    CrossrefPubMedSearch in Google Scholar
  • 27 Bathon JM, Fleischmann RM, van der Heide DM. et al . Safety and efficacy of Etanercept treatment in elderly subjects with rheumatoid arthritis.  J Rheumatol. 2006;  33 234-243
    PubMedSearch in Google Scholar
  • 28 Radovits BJ, Kievit W, Fransen J. et al . Influence of Age on the Outcome of Anti-TNFalpha Therapy in Rheumatoid Arthritis.  Arthritis Rheum. 2008;  58 Abstr.  1620
    PubMedSearch in Google Scholar
  • 29 Sidiropoulos P, Flouri ID, Drosos A. et al . Geriatric patients receiving anti-TNFalpha agents have comparable to younger adults response but increased incidence of serious adverse events.  Ann Rheum Dis. 2008;  67 ((Suppl II)) 180
    PubMedSearch in Google Scholar
  • 30 Kremer JM, van Vollenhofen RF, Ridley DJ. et al . Relationship Between Patient Characteristics and the Development of Serious Infections in Patients Receiving Tocilizumab: Results from Long-term Extension Studies with a Follow-up Duration of 1.5 Years.  Arthritis Rheum. 2008;  58 Abstr.  1668
    PubMedSearch in Google Scholar

Korrespondenzadresse

Prof. Dr. Klaus Krüger

Praxiszentrum/Rheumatologie

Rheumatologie

Sankt Bonifatius Straße 5/II

81541 München

Phone: +49-(0)89-691-4222

Fax: +49-(0)89-6914230

Email: klaus.krueger@med.uni-muenchen.de