Background/Purpose: High-risk medications (HRMs) may increase the risk of adverse events such as falls and fractures, hospitalizations, hospital length of stay, and death in older adults. We hypothesized that older adults with rheumatic disease, especially those with multiple comorbidities, had significant use of HRMs. We aimed to characterize HRM use, sources of prescription, and predictors of HRM exposure in older adults in a large national registry of older adults with rheumatic conditions.

Methods: We analyzed 2021 data from practices enrolled in the Rheumatology Informatics System for Effectiveness (RISE) registry linked to Medicare parts A, B, D. Patients ≥65 years old with ≥2 RISE visits, continuous Medicare enrollment, and a qualifying rheumatic diagnosis were included (SLE, RA, PsA, axSpA, SS, SSc, Gout, OA). HRM exposure was defined according to the Merit-Based Incentive Payment System Clinical Quality Measure #238 “Use of High-Risk Medications in Older Adults”. We determined prescriber specialty using National Provider Identifiers (NPI) and a list of provider specialties from the Centers for Medicare & Medicaid Services to categorize prescribers as rheumatologist, non-rheumatologist MD, a rheumatology affiliated NP or PA, or a NP or PA not affiliated with a rheumatology practice. We reported the frequency and percent of patients exposed to the top 10 most common high-risk medications by primary rheumatic diagnosis. We constructed a series of logit linear models predicting exposure to any high-risk medication using generalized estimating equations to adjust for patients nested within practices.

Results: Out of the 49,210 patients (mean age 76±6.5, 75.4% women, 87.7% non-Hispanic white) meeting inclusion criteria, 30.6% received ≥1 HRM in 2021; 7.6% received ≥2 HRMs. The top most-used high-risk medications included cyclobenzaprine (6.6% of full sample; 21.7% among patients with any HRMs) and zolpidem (4.0% of full sample; 13.2% among patients with any HRMs), among others (Table 1). Four of the ten most common prescriptions were for psychotropic medications. Prescriptions primarily originated from non-rheumatology physicians (67.1%) or non-rheumatology affiliated NP or PA (9.9%). In adjusted models, patients with SS and axSpA had the highest odds of receiving a HRM when compared with RA (OR 1.48, 95% CI 1.2 – 1.4 and OR 1.42, 95% CI 1.24 – 1.62); (Table 2). Patients with fibromyalgia, mood disorder or anxiety disorder, and patients with higher Charlson Comorbidity Index (3-4+) also had higher odds of receiving a HRM (Table 2).

Conclusion: Thirty percent of older adults with rheumatic diseases received at least one high-risk medication. The most common medications prescribed were cyclobenzaprine and zolpidem, suggesting that this population has significant pain and sleep dysfunction prompting use of HRMs. Further research is warranted to identify optimal strategies and medications to balance symptom relief with patient safety, ensuring that pain, mood, and insomnia in older adults with rheumatic disease are effectively managed without incurring undue harm in this vulnerable population.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/thirty-percent-of-older-adults-with-rheumatic-disease-receive-high-risk-medication/