Diagnosis and Management of Late-Onset Spondyloarthritis: Implications of Treat-to-Target Recommendations

Abstract

Spondyloarthritis (SpA) is usually observed in young patients while onset in the elderly is less common. Late-onset forms of SpA may become more common due to longer life expectancy. The clinical spectrum of late-onset SpA is as broad as in young people, with a predominance of peripheral SpA over pure axial disease. The Assessment of SpondyloArthritis international Society (ASAS) has developed new criteria for axial or peripheral SpA that allow patients aged under 45 years at the time of disease onset to be identified. These criteria are not theoretically adapted for the classification of patients with late-onset disease but they are useful for the diagnosis. Similarly, magnetic resonance imaging (MRI) is now widely used for the early recognition of sacroiliitis or spinal inflammation in SpA, and sacroiliitis as evidenced by MRI is included in the ASAS criteria for axial SpA. Nevertheless, the utility of sacroiliac joint and/or spine inflammation as detected by MRI has mostly been described in young patients with ankylosing spondylitis, SpA, or inflammatory back pain, but not in the elderly. The management of SpA is now more focused on remission or, alternatively, low disease activity, according to the treat-to-target recommendations. Such an optimized approach to therapy is thought to improve patient outcomes and ultimately long-term quality of life. The same principles of treatment should apply in the elderly, but require certain adjustments, especially with biological agents. Tumor necrosis factor-α blocking agents are very effective in SpA, but seem slightly less effective in the elderly and are associated with an increased risk of infection in this population. A careful and rigorous evaluation is thus required before initiating these agents in elderly subjects.

Imaging Findings Suggestive of Axial Spondyloarthritis in Diffuse Idiopathic Skeletal Hyperostosis

“…Indeed, axial SpA diagnosis generally occurs at a young age, while a DISH diagnosis is fairly more frequent in the elderly. This distinction is a critical issue for proper controlled studies of the overlap between DISH and axial SpA, and there is an unmet need of investigations of radiologic features of axial SpA in adults ages >45 years (14). Another weakness is that a single radiologist performed all reads, and that he was not blind from the diagnosis of DISH.…”

“…Although their clinical and radiologic results are often pragmatically described as radically opposed, differential diagnosis between DISH and axial SpA might be a challenging issue in clinical practice in certain settings (12). For instance, while DISH is observed mostly in the elderly and axial SpA usually concerns younger adults, DISH can also occur at ages <45 years (13,14). Moreover, if DISH can entail spinal pain and stiffness that resemble more mechanical back pain (e.g., due to spondylosis) than axial SpA, some observations have reported typical axial SpA features in DISH patients, such as limitation of spinal mobility and postural abnormalities (15).…”

Effectiveness and drug retention of biologic disease-modifying antirheumatic drugs in Korean patients with late-onset ankylosing spondylitis: Retrospective Cohort Study

“…The demand for bDMARD prescription would increase if it was shown to have a higher retention rate. However, there is insu cient data on the long-term drug e cacy and retention rate in patients with LOAS [10].…”

Characteristics of late-onset spondyloarthritis in Japan

“…[12–14] The number of such patients is expected to increase with longer life expectancy. [11,13–16] Later- or late-onset SpA (LOSpA) [11,13,15,16] has not been precisely defined, but most studies have used onset at 50 years or older to classify such patients. [13] Previous studies that assessed areas with high HLA B27 prevalence revealed differences between characteristics of early-onset SpA (EOSpA) and LOSpA.…”