Living with Late-Onset Rheumatoid Arthritis

When I was diagnosed with rheumatoid arthritis (RA) in my early 60s, I was shocked. And embarrassed. A longtime health writer, I had always thought of RA as a disease that affects younger people, particularly women. While RA does peak between the ages of 30 and 50 and is more common in women, according to a 2023 study in Medicina, about one-third of cases develop in people 60 and older. This condition is called late-onset rheumatoid arthritis (LORA) and men are just as likely — or even more likely — to develop the disease.

For all age groups, the Cleveland Clinic reports that symptoms of this autoimmune disease include joint pain and stiffness, fatigue, fever, brain fog and loss of appetite. However, people with LORA may develop the disease more quickly and it may involve larger joints. That was true for Laurie Scosta Marcho of Shelton, Connecticut. "The pain came out of nowhere," says the 72-year-old, who was recently diagnosed with RA. "I had no idea what was going on. I had torn my meniscus in the past, and that's what I thought I did again because it was one of the larger joints."

According to Mount Sinai Health, left untreated, over time rheumatoid arthritis can deform your joints. Eventually, it leads to osteoporosis, characterized by bone loss. The inflammation from RA also can damage the lungs and heart and lead to an increased overall risk for cancer.  

In RA, a person's own immune system attacks their body's tissue, causing inflammation. This is different from osteoarthritis (OA), which develops when the cartilage surrounding a joint breaks down as you age. Because many people over 60 have some osteoarthritis, RA may initially be misdiagnosed as OA or gout and pseudogout, which are more common in older people. "And if you're treating the wrong thing," says Jeffrey Curtis, M.D., professor of medicine in the Division of Clinical Immunology and Rheumatology at the University of Alabama at Birmingham (UAB), "somebody with LORA just isn't going to get better."

To determine if someone has RA, a doctor will perform a physical exam and take a medical history. The doctor also will order blood tests checking for overall inflammation levels as well as specific RA markers such as rheumatoid factor (RF) and cyclic citrullinated peptide (CCP). To check for bone loss, the doctor may order an X-ray, ultrasound or MRI.

According to Curtis, only about 60% of older adults have RA factor. Patients can still be diagnosed with RA even if they do not test positive for RA factor, as in my case. I had many symptoms, did not test positive for other types of arthritis and my overall inflammatory markers were sky high.

Patients who are referred to a rheumatologist may have already been taking an over-the-counter  non-steroidal anti-inflammatory drug (NSAID) such as Advil. NSAIDs offer temporary pain relief, but don't slow the progression of RA.

The rheumatologist may initially prescribe a corticosteroid such as prednisone. Unlike other drugs used to treat RA, which can take weeks or months to relieve symptoms, prednisone works quickly. But prednisone can cause problems, including an increased risk of infection, heart disease, diabetes and osteoporosis. As RA itself can lead to bone loss, taking a drug that can cause or worsen osteoporosis is a particular concern.

Elizabeth Ortiz, M.D., CEO and founder of Connected Rheumatology, states that although prednisone can offer great relief, "It's a bridge that you have to quickly get off of. I always describe it to patients as the need to start a smarter medicine. Something that's more specific for the actual problem."

Disease-modifying antirheumatic drugs (DMARDs) are designed to calm an overactive immune system, which slows the progression of RA. The doctor might prescribe a conventional DMARD, given in pill form, as a first-line medication. Some common DMARDS include methotrexate, sulfasalazine and hydroxychloroquine. 

If conventional DMARDs are not effective, a doctor may add on or switch to a biologic. According to the NYU Langone Health website most biologics work "by blocking a chemical called tumor necrosis factor, which is thought to cause inflammation in the joints."

Biologics are given by subcutaneous (under the skin) injection or through an IV. Commonly used biologics include Humira, Enbrel and Orencia.

Side effects from conventional DMARDs and biologics include gastrointestinal distress, fatigue, hair loss, liver damage, blood clots, cardiovascular disease and an increased risk of cancer and infection. Because of these side effects, patients may be wary of taking them, including me. But I knew I could not stay on prednisone only, especially since I was already diagnosed with osteoporosis.

The good news according to Curtis is that "most medicines other than steroids like prednisone would not worsen osteoporosis and a few might help a bit."

As LORA is still often referred to as elderly-onset rheumatoid arthritis (EORA), ageism can play a part starting with the initial diagnosis. Both Curtis and Ortiz agree that ageism is a factor in treating LORA. Curtis states, "There is a bias that older people with RA shouldn't get as aggressive treatment or shouldn't get certain medicines. While that may be warranted based on certain people's medical histories or risk factors, I think that it is a conscious or unconscious bias."

According to Ortiz, even if an older patient has other diagnoses or is on other medications that make their RA more complicated to manage, the doctor "can't cop out and say, 'well, we're just going to give you a little prednisone, give you a little Advil and manage it that way.'"

Because of these biases, Ortiz believes that it is vital that patients with LORA "speak up about what your priorities are for your health and what you want to be able to do."

Although RA can be difficult to manage, Ortiz notes that great progress has been made in the field of rheumatology. "Thirty years ago, all we had to treat RA was aspirin and prednisone. You would just watch people become disabled. And now we don't see that anymore because of the new medications."

Curtis states there is a lot of interest in precision medicine, which are diagnostic tests that match the right medicine for RA to the patient. "The hope is that this would require a blood test and not a synovial biopsy," where fluid is taken directly from the patient's joint for testing.

Another area of interest is vagus nerve stimulation, which involves implanting a device in a patient's neck. In vagal nerve therapy, Curtis states, "you use the body's own immune system to modulate an autoimmune disease like rheumatoid arthritis. If that treatment works, you don't have to keep taking pills or shots or infusions. You wouldn't have to worry about some of the side effects or the infection or cancer risks because this device shouldn't have any of that."

For Marcho, remaining optimistic is vital when dealing with her diagnosis. "I don't know what tomorrow is going to bring," she says. "But I do know with all the stuff I've been through in my 72 years that a positive attitude is the No. 1 thing to have about everything." As someone who is determined to live as active and pain-free a life as possible, I couldn't agree more.

Jennifer Landau is a freelance writer who has published several books and numerous articles in the health and wellness space. Her work has appeared in Men’s Health, Autism Parenting Magazine and across a wide range of online patient communities. You can find her at jenniferlandau.com. Read More