Understanding Biologics and Their Use in Older Adults
Biologics are a class of medications derived from living organisms that target specific parts of the immune system. This targeted approach has revolutionized the treatment of many immune-mediated inflammatory diseases (IMIDs), including rheumatoid arthritis (RA), psoriasis, and inflammatory bowel disease (IBD).
The aging process leads to natural declines in immune function, leaving older adults more vulnerable to infections. Older adults are also more likely to have co-existing health conditions (comorbidities) and be on multiple medications, which complicates treatment decisions.
Comparing Biologic Safety in Older vs. Younger Patients
Clinical trials for biologics have historically underrepresented older adults, but real-world data and meta-analyses are starting to provide more insights into their safety and effectiveness in this age group.
Infection Risk
A primary concern is the increased risk of infection among older adults taking biologics. A meta-analysis found a higher prevalence of infections in older biologic users compared to younger users (13% vs. 6%). This risk was notable in those on anti-TNF therapy. Common infections include upper respiratory infections, while more serious ones like pneumonia have also been reported. The risk is often linked to underlying comorbidities rather than solely the biologic.
Malignancy Risk
While concerns existed about biologics increasing cancer risk, observational studies and meta-analyses have been largely reassuring, especially when comparing older biologic users to older patients not using biologics. One meta-analysis found no significant difference in the odds of malignancy or death between these groups. The added risk from modern biologic therapy may be minimal, though the association might vary by biologic class.
Cardiovascular Events
Biologics typically do not directly affect blood pressure. However, older adults with inflammatory conditions are at increased risk of heart disease, and some anti-TNF biologics have been linked to worsened congestive heart failure in specific patient groups. Careful risk assessment is necessary.
How Comorbidities Affect Treatment
Multiple health issues in older adults impact biologic use:
- Higher Comorbidity Burden: This increases susceptibility to adverse events.
- Polypharmacy: Multiple medications can lead to drug interactions.
- Renal and Hepatic Function: Age-related decline in organ function can affect how medications are processed, potentially impacting traditional DMARDs used with biologics.
Optimizing Biologic Therapy for Older Patients
A personalized, conservative approach with thorough pre-screening and consistent monitoring is recommended for older adults starting biologics.
Pre-Treatment Health Maintenance Checklist
Before starting therapy, physicians should perform a comprehensive assessment:
- Infection Screening: Test for latent infections (tuberculosis, viral hepatitis) and ensure vaccinations are current.
- Cardiovascular Assessment: Evaluate cardiovascular risk.
- Malignancy History: Review cancer history; anti-TNF therapy may be avoided in patients with a history of lymphoproliferative disorders.
Monitoring During Treatment
Ongoing monitoring is crucial:
- Regular Lab Tests: Perform routine bloodwork to check for infection or side effects.
- Symptom Vigilance: Be alert for signs of infection.
- Drug-Drug Interactions: Regularly review the patient's medication list.
Comparison: Biologics vs. Traditional Systemic Therapy
| Feature | Biologics | Traditional Systemic Therapy (e.g., Methotrexate) |
|---|---|---|
| Mechanism | Targeted immune modulation | Broad immune suppression |
| Infection Risk | Increased risk compared to younger patients, often linked to comorbidities | Can also increase infection risk |
| Organ Toxicity | Generally lower risk of organ toxicity | Significant risk of liver and kidney damage |
| Drug-Drug Interactions | Potential interactions exist; often fewer than with traditional drugs | Many potential interactions, complicated by polypharmacy |
| Administration | Injectable (subcutaneous or IV) | Oral or injectable |
| Effectiveness | Highly effective for moderate-to-severe disease | Often less effective and associated with higher toxicity |
| Monitoring | Less intensive monitoring for organ toxicity, but need vigilant infection checks | Requires intensive monitoring for liver function, kidney function, and blood counts |
Despite the risks, studies show biologics to be effective in treating IMIDs in older adults, improving disease control and quality of life. In some cases, they offer a safer alternative to older, more toxic systemic treatments.
The Role of Shared Decision-Making
The decision to start a biologic should involve the patient, caregivers, and healthcare team, discussing benefits and risks based on the patient's overall health and goals. Physicians should consider biologics for appropriate older patients, not withholding them solely due to age. Some newer biologics may have more favorable safety profiles, such as lower infection risk, compared to older classes. Listening to patient concerns and prioritizing quality of life are crucial for a personalized strategy where benefits outweigh risks.
For more information on drug safety and managing complex health conditions, consider visiting the National Institutes of Health website.
Conclusion
Biologics can be safe and effective for older adults with inflammatory conditions, but require careful risk management, particularly for infection. While the risk of infection is higher compared to younger adults or non-biologic users, the potential for better disease control and a potentially more favorable safety profile compared to traditional systemic therapies makes biologics a valuable option for managing chronic conditions in the aging population. A personalized, evidence-based approach is key to optimizing outcomes and improving quality of life.
Key Learnings
Overall Safety: Biologics can be a safe and effective option for older adults with immune-mediated diseases, especially when other treatments fail or are too toxic.
Increased Infection Risk: Compared to younger patients, older adults using biologics face a higher risk of infection, which necessitates vigilant monitoring.
Pre-Screening is Essential: Doctors should screen for latent infections and update vaccinations before starting biologic therapy in older adults.
Malignancy Risk Considerations: While older age itself is a risk factor for cancer, meta-analyses have found no significant difference in overall malignancy or death between older biologic users and older non-users.
Comorbidities Influence Risk: The presence of multiple health conditions (comorbidities) in older adults can be a primary driver of infection risk, rather than the biologic medication alone.
Personalized Treatment: The best approach involves shared decision-making and a personalized plan that carefully balances the benefits of disease control with potential risks.
