Treatment-resistant synovitis and radiographic progression are increased in elderly-onset rheumatoid arthritis patients: findings from a prospective observational longitudinal early arthritis cohort study

Romao, V.C.; Humby, F.; Kelly, S.; Cicco, M. di; Mahto, A.; Lazarou, I.; ... ; Pitzalis, C. (2020)

Article / Letter to editor

Background: Clinical outcomes in elderly-onset rheumatoid arthritis (EORA), starting after the age of 60, are conflicting. Thus, we aimed to investigate in a unique biopsy-driven, treatment-naive early arthritis cohort, the relationship between synovial pathobiology of elderly- (EORA) and younger-onset rheumatoid arthritis (YORA) patients through clinical, imaging and treatment response outcome-measures.Methods: Patients (n = 140) with early RA (<12months) starting before (YORA, n = 99) or after (EORA, n = 41) age 60 had an ultrasound-guided synovial biopsy prior to conventional immunosuppressive therapy and after 6 months. Clinical, ultrasound and radiographic data were collected prospectively and compared between groups and against immunohistological features. Using multivariate logistic regression, we determined predictors of clinical response (disease activity score-28-erythrocyte sedimentation rate [DAS28-ESR]<3.2) at 6months and radiographic progression (>= 1-unit-increase in Sharp van der Heijde [SvdH] score) at 12months.Results: EORA patients were more frequently male and presented most commonly with an abrupt, polymyalgia rheumatica-like onset and extra-articular features. Both before and after treatment, DAS28-ESR was similar but ultrasound synovial-thickening (p<0.05) and power-Doppler (p<0.01) synovitis and SvdH (p<0.001) scores were higher in EORA patients. EORA was independently associated with poor treatment response at 6 months (OR=0.28, p = 0.047) and radiographic progression at 12 months (OR=4.08, p = 0.029). Synovial pathotype, synovitis scores and cellular infiltration were similar before treatment, but a pauci-immune-fibroid pathotype tended to be more common in YORA at 6 months (p = 0.093). Moreover, YORA patients had a marked improvement of all synovitis parameters (p<0.001), whereas EORA presented only mild decreases in synovitis (p<0.05), sublining macrophage (p<0.05) and T cell scores (p<0.05), with no significant changes in lining macrophages, B cells or plasma cells.Conclusion: Early EORA presents differently and has a worse overall prognosis than YORA, with poorer clinical, histological, ultrasonographic and radiographic outcomes. (C) 2020 Elsevier Inc. All rights reserved.

• Rheumatoid arthritis
• Elderly-onset
• Synovitis
• Synovial pathobiology
• Radiographic progression

• All authors: Romao, V.C.; Humby, F.; Kelly, S.; Cicco, M. di; Mahto, A.; Lazarou, I.; Hands, R.; Rocher-Ros, V.; Heijde, D. van der; Fonseca, J.E.; Pitzalis, C.
• Date: 2020-08-01
• Journal: Seminars in Arthritis and Rheumatism
• Volume: 50
• Issue: 4
• Pages: 735 - 743
• DOI: doi:10.1016/j.semarthrit.2020.03.018