Treat-to-target strategies are feasible in elderly-onset rheumatoid arthritis given its reassuring risk-benefit profile.

To compare 2-year pharmacotherapy needs and adverse events (AEs) profiles between patients with elderly-onset rheumatoid arthritis (EORA) and young-onset RA (YORA) under a treat-to-target (T2T) strategy with a fixed medication protocol. Data from the treatment in the Rotterdam Early Arthritis cohort trial, a multicentre randomised controlled study, were analysed. Patients with RA (1987/2010 criteria) were classified as EORA (>65 years) or YORA (18-65 years). Disease Activity Score based on 44 swollen and 53 tender joint counts (DAS44) trajectories, active disease and sustained remission were assessed using mixed-effects models. Protocol-guided disease-modifying antirheumatic drug (DMARD) and glucocorticoid (GC) use, difficult-to-treat (D2T) RA prevalence and AEs were evaluated descriptively. Cox proportional hazards models examined time to first biologic (b)DMARD initiation, bDMARD survival and DMARD-free remission. Among 425 patients with RA, 98 (23%) had EORA (mean age 73 years, SD 5) and 327 (77%) had YORA (mean age 48 years, SD 11). Patients with EORA were more often male (50% vs 28%) and had more comorbidities (76% vs 49%). DAS44 trajectories were similar (mean difference 0.03, 95% CI -0.13 to 0.18), but EORA had less often active disease (OR 0.8, 95% CI 0.4 to 1.5) and more often sustained remission (OR 1.5, 95% CI 0.6 to 3.4). bDMARD initiation rate was lower and slower in EORA than YORA (28% vs 38%; HR 0.7, 95% CI 0.4 to 1). First bDMARD survival and GC use were comparable. D2T-RA was rare (EORA 2% vs YORA 6%) and treatment adjustments due to AEs were similar (43% vs 47%). A T2T approach is feasible and effective in EORA, given its reassuring risk-benefit profile, while recognising the need for individualised management.