RA treatment aims at suppression of inflammatory manifestation of the disease, reduction of swellings, pain of joints, halting of radiographic progression (damage visible on radiographs), improvement of the quality of life and elimination of fatigue and depression. RA treatment starts with application of non-steroidal antirheumatic drugs which are followed by so-called basal or “disease-modifying” medications, including methotrexate, sulphasalazine, gold salts, antimalarial drugs, leflunomide and others. In the recent 10 years, the severe, resistant forms of RA have started to be addressed by a targeted elimination of inflammatory factors, pro-inflammatory cytokines, the most important of which is the tumour necrosis factor alpha (TNF-alpha).

TNF-alpha is the decisive factor that stimulates the immune system cells to generate additional inflammatory factors, involved both in inflammatory damage to joint structures and in organ, i.e. extra-articular, manifestations of RA.

Is biological therapy possible also in elderly-onset RA? According to prominent rheumatologists, such therapy is possible, and the outcomes are very good, although special care is required in the treatment of patients with hypertension, ischaemic heart disease, tumour disease or infections. It is essential that assessment to rule out hidden form of tuberculosis be carried out before the treatment is started. When respecting these criteria, the application of biological therapy is safe, poses no risks and achieves good outcomes, similarly as in the treatment of RA developed in middle age. RA treatment by TNF-alpha inhibitors leads provably to suppression of inflammatory activity, halting of radiographic progression and substantial improvement of quality of life also in EORA patients.

Currently, nine biologic drugs are available for RA treatment, namely, five anti-TNF inhibitors (infliximab, adalimumab and etanercept, golimumab, certolizumab), anti-IL6-tocilizumab, anti-CTL4-abatacept, anti-CD20 rituximab and anti-IL1-anakinra. Most experience has been obtained in treatment of elderly patients with the use of anti-TNFs, etanercept, infliximab and adalimumab particularly.

In the group of patients older than 60 years, it is necessary to rule out active infection as elderly patients are more susceptible to secondary infection, including activation of latent tuberculosis, due to decreased non-specific immunity and increased comorbidity; a potential source of infection may be also a permanent catheter.

It should be noted in this respect that higher doses of TNF antagonists may be harmful in NYHA class III or IV patients in terms of heart failure. Frequency of heart failure was examined in 13,171 patients with RA, treated with TNF antagonists. It has been found out that in addition to common risk factors for heart disease, such as gender, hypertension and ischemic heart disease, the annual incidence of heart failure was 0.2 % of patients receiving etanercept or infliximab as compared to those without this medication [11].

Fleischmann et al. [4] have pointed out that long-term use of etanercept in inflammatory rheumatic diseases does not differ in terms of adverse effects between young and elderly patients. Assessment covered a total of 3296 persons younger and 597 persons older than 65 years. Demyelinating disease was observed in younger RA patients, whereas in persons over the age of 65 years, the demyelinating process was absent.

The frequency of respiratory infections was higher in patients under the age of 65. The analysis included 18 clinical studies of rheumatoid arthritis (RA), two studies of psoriatic arthritis (PsA) and two studies of ankylosing spondylitis (AS) patients. RA patients older than 65 years accounted for 17.3 %, PsA patients for 5.3 % and AS patients for 1.4 %; however, the frequency of respiratory infections was higher in patients under the age of 65. RA, PsA and AS are diseases that are associated with increased mortality, primarily due to cardiovascular and tumorous diseases and infections. The reduction of median life span ranges between 5 and 15 years [11].

In their studies, Fleischmann et al. [4] and Bathon et al. [1] reported that the application of etanercept is safe and persons older than 65 years are at no greater risk of adverse effects than younger subjects. Bathon’s study [1] focused also on efficacy of treatment. The results of application of etanercept in both groups have confirmed that etanercept and MTX suppress RA activity in elderly as well as in younger patients. In the elderly group, the positive effect lasted for 6 years. Radiographic progression was low in both groups of patients treated with a combination of methotrexate and etanercept as compared to placebo or (MTX) group receiving methotrexate alone.

In other studies, the authors [1] concentrated on safety and efficacy of etanercept in RA patients from the viewpoint of their age. The results showed higher incidence of serious adverse effects in the group of elderly patients which, however, in this group did not differ from the control group, whether receiving placebo or MTX. In elderly patients, a slower response was recorded in ACR20, ACR50 and ACR70 values. In both groups, however, the disease activity decreased and functions improved as compared to the control group. The combination with MTX was in both groups more effective than monotherapy. Effects of treatment in elderly patients were sustained for 6 months during the follow-up period; radiographic progression did not differ between the two groups and was slower with combined treatment than with monotherapy.