Elderly-onset rheumatoid arthritis is a unique disease subset associated with poor overall outcomes: response to the letter by Haroon and Ayamer

© 2020 Elsevier Inc. All rights reserved.We thank Haroon and Ayamer for their interest in our study, and for reporting their data on the outcomes of elderly-onset rheumatoid arthritis (EORA). Their findings mostly overlap ours, in describing a population with greater male gender representation, similar frequency of seropositivity, and severe, rapidly-deforming disease, requiring more intensive disease-modifying anti-rheumatoid (DMARD) therapy, in comparison to its younger-onset RA (YORA) counterpart. Of note, long-term low dose glucocorticoid therapy was often needed in this subgroup of patients, with frequent flares observed following tapering. In line with this, a recent study also showed that patients with EORA, but not YORA, had a lower risk of biologic DMARD discontinuation if concurrently treated with glucocorticoids. Overall, these findings are in accordance with the concept that EORA is a unique subset characterized by poor prognosis at multiple levels. This contradicts a previously held view of EORA as a benign form of disease. In fact, recent studies — including our own in a cohort of untreated patients with early arthritis — have shown that EORA is associated with worse clinical and imaging outcomes. Moreover, we could demonstrate that the poor features of EORA were also mirrored at the synovial tissue level, with pathologically-resistant disease that was less responsive to promptly started immunosuppressive treatment.This work was supported by the Medical Research Council (grant number 36661, to PEAC); Arthritis Research UK (now Versus Arthritis; Experimental Arthritis Treatment Centre Grant, number 20022, to Centre for Experimental Medicine and Rheumatology); Fundação para a Ciência e Tecnologia (Interno Doutorando Bursary reference SFRH/SINTD/95030/2013, to VCR); European League Against Rheumatism (EULAR Scientific Training Bursary 2014, to VCR); and Sociedade Portuguesa de Reumatologia (Fundo de Apoio à Investigação da SPR 2015, to VCR).