Second‐line agents (disease‐modifying agents or slow‐acting antirheumatoid drugs) are well established for synovitis that persists despite treatment with non‐steroidal anti‐inflammatory agents. Indications for their use in the elderly are similar to those in younger people, but the elderly are at higher risk of adverse reactions. Therefore, lower doses, more cautious patient selection and more frequent monitoring for adverse reactions are recommended. Low dose corticosteroids are often effective in the elderly and obviate the need for second‐line agents.