Late‐onset rheumatoid arthritis versus elderly‐onset rheumatoid arthritis: understanding the key differences: comment on the article by Lee et al

We carefully reviewed the recent article by Lee et al1 on late-onset rheumatoid arthritis (LORA) treatment. As the global population ages, the incidence of rheumatoid arthritis (RA) onset after the age of 65 is increasing. However, challenges remain owing to the lack of standardized terminology, clearly defined age thresholds, established classification criteria, and comprehensive international guidelines. The article employs the term “late-onset rheumatoid arthritis.” A PubMed search revealed that 261 articles include this term, whereas “elderly-onset rheumatoid arthritis” (EORA) appeared in 4,839 results (as of March 24, 2025). However, the terms “elderly” and “aged” are discouraged in medical writing, as highlighted by the American Medical Association.2 The spelling “late onset rheumatoid arthritis” (without the hyphen) is more common than the hyphenated form. The guidelines of the Japan College of Rheumatology,3 currently the only national guidelines on this topic, recommend using LORA instead of EORA. Given these inconsistencies, it is essential to establish a unified terminology. It is also important to distinguish RA that develops at an older age (LORA or EORA) from RA that persists into an older age (young-onset RA [YORA]). With advances in treatment strategies such as treat-to-target, more patients with YORA are reaching an older age, further complicating the classification. Another major inconsistency concerns the age threshold used to define LORA and EORA. The World Health Organization classifies individuals aged 60 to 74 years as “elderly,” suggesting that age 60 may be the most appropriate cutoff for LORA or EORA. Most studies have used this threshold.4 However, the article in American College of Rheumatology (ACR) Open Rheumatology1 uses 66 years, whereas the Japanese guidelines3 and many other sources defined it as 65 or 66 years. In the United States of America, Medicare eligibility begins at age 65, whereas individuals aged 60 to 64 years may be enrolled in commercial insurance or Medicaid or may be uninsured. Existing rheumatic disease registries are not designed to specifically identify LORA and often lack sufficient sample size or statistical power to support meaningful analyses in this population. This limitation underscores the need for a consensus definition to guide harmonized data collection and facilitate more robust, generalizable research. We think the best age threshold is 65 years, but it needs discussion (ACR Open Rheumatology and the ACR Convergence 2025 might be the best place for that). The absence of international guidelines significantly limits the provision of optimal care for patients with LORA or EORA. We highlighted this need five years ago5; however, minimal progress has been made. Recent Japanese recommendations3 are essential, but international guidelines from organizations such as the ACR are urgently required. The current RA classification criteria6 may not be fully applicable to older adults, potentially leading to diagnostic errors, including overdiagnosis. In older patients, anti–citrullinated protein antibody positivity may have a better diagnostic value than rheumatoid factor positivity. The negative predictive markers, such as hyperuricemia or monosodium urate crystals in synovial fluid, should be considered. Extensive, international, multicenter cohort studies are required to develop more specific classification criteria for LORA or EORA.5, 7 Although this issue has been discussed for approximately 70 years, best practices for treating older adult patients remain uncertain.8 The problem is becoming more pressing owing to aging populations, the increasing prevalence of autoimmune diseases, and the long-term effects of the COVID-19 pandemic.9 We anticipate a significant increase in the number of patients with LORA. It is critical to establish an international expert group to develop guidelines. ACR Open Rheumatology, an official journal of the ACR, serves as an excellent platform for this debate. We also hope that the ACR Convergence 2025 will serve as an ideal venue for this discussion. Disclosure Form: Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

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