Diagnosis and Management of Late-Onset Spondyloarthritis: Implications of Treat-to-Target Recommendations

Spondyloarthritis (SpA) is usually observed in young patients while onset in the elderly is less common. Late-onset forms of SpA may become more common due to longer life expectancy. The clinical spectrum of late-onset SpA is as broad as in young people, with a predominance of peripheral SpA over pure axial disease. The Assessment of SpondyloArthritis international Society (ASAS) has developed new criteria for axial or peripheral SpA that allow patients aged under 45 years at the time of disease onset to be identified. These criteria are not theoretically adapted for the classification of patients with late-onset disease but they are useful for the diagnosis. Similarly, magnetic resonance imaging (MRI) is now widely used for the early recognition of sacroiliitis or spinal inflammation in SpA, and sacroiliitis as evidenced by MRI is included in the ASAS criteria for axial SpA. Nevertheless, the utility of sacroiliac joint and/or spine inflammation as detected by MRI has mostly been described in young patients with ankylosing spondylitis, SpA, or inflammatory back pain, but not in the elderly. The management of SpA is now more focused on remission or, alternatively, low disease activity, according to the treat-to-target recommendations. Such an optimized approach to therapy is thought to improve patient outcomes and ultimately long-term quality of life. The same principles of treatment should apply in the elderly, but require certain adjustments, especially with biological agents. Tumor necrosis factor-alpha blocking agents are very effective in SpA, but seem slightly less effective in the elderly and are associated with an increased risk of infection in this population. A careful and rigorous evaluation is thus required before initiating these agents in elderly subjects.