From Rheumatology News:
Cardiovascular disease is the leading contributor to excess mortality in patients with established rheumatoid arthritis. While the risks of both premature and accelerated atherosclerotic cardiovascular disease in rheumatoid arthritis are not completely explained by traditional risk factors, the increased prevalence of hypertension, dyslipidemia, obesity, smoking, and inactivity are clearly contributing factors.
Dyslipidemia has been identified as a major culprit. For example, in the QUEST-RA (Quantitative Patient Questionnaires in Standard Monitoring of Patients With Rheumatoid Arthritis) project, disordered lipoprotein metabolism was independently associated with the occurrence of cardiovascular events in the study's 4,363 patients (Arthritis Res. Ther. 2008 March 6 [doi: 10.1186/ar2383]).
Dyslipidemia in rheumatoid arthritis often presents with normal or decreased low-density lipoprotein (LDL) cholesterol, low high-density lipoprotein (HDL) cholesterol, and high triglycerides, similar to that observed in inflammatory and infectious diseases in general, according to Dr. Yusuf Yazici, a rheumatologist at New York University Hospital for Joint Diseases. Additionally, the condition appears to be directly associated with disease activity, whereby higher disease activity is linked to lower total cholesterol levels and further reduced HDL levels, leading to an unfavorable atherogenic index.
Although disease suppression via disease-modifying antirheumatic drugs as well as tumor necrosis factor-blocking agents has been shown to have moderately favorable effects on the lipid profiles of RA patients, additional lifestyle and drug interventions are often warranted to minimize the risk of cardiovascular events, said Dr. Yazici. Unfortunately, cardiovascular screening in patients with rheumatic diseases is not performed routinely, and when it is performed, identified risk factors often remain untreated, leaving patients vulnerable to cardiovascular morbidity and, potentially, mortality. EULAR recently called on rheumatologists to aggressively manage cardiovascular risk factors in patients with RA, AS, and PsA (RHEUMATOLOGY NEWS, December 2008, p. 6).
In this month's column, Dr. Yazici stresses the role of the rheumatologist in the management of dyslipidemia in RA.
RHEUMATOLOGY NEWS: What are the underlying mechanisms for dyslipidemia in rheumatoid arthritis?
Dr. Yazici: The literature is not clear on exactly what happens to the lipid levels in RA patients before, during, or after treatment, yet we know that untreated RA and the associated inflammation leads to increased cardiovascular events and death. As such, every effort should be made to control the conventional risk factors for cardiac events, including dyslipidemia. And the first step to controlling lipid levels is to monitor them.
RN: Who should be monitoring lipid status in rheumatoid arthritis patients?
Dr. Yazici: Rheumatologists should routinely assess their rheumatoid arthritis patients for dyslipidemia and try to correct it through diet, exercise, and, if necessary, medication, working together with the patient's primary care physician and cardiologist.
RN: With respect to treatment of dyslipidemia, should rheumatologists manage the condition or should they refer patients back to their primary care physicians or to preventive cardiologists?
Dr. Yazici: Rheumatologists should take an active role in the treatment of dyslipidemia, working in concert with primary care physicians or cardiologists. As rheumatologists, we also are internists and it is well within our domain to treat this condition, not only in RA but also in systemic lupus erythematosus, where there are also data to suggest increased risk of cardiovascular events and the need to minimize risk factors.
RN: Are statins contraindicated in RA?
Dr. Yazici: Statins have well-defined risk profiles, which of course is need to be taken into account, along with the fact that most RA patients are on DMARDs, which pose potential—though rare—liver problems. The possibility of further increased risk of liver problems with multiple medications has to be considered. Additionally, muscle damage that can be seen with statins has to be considered when RA patients present with muscle pains and weakness. These are all well-recognized risks that can be monitored routinely by rheumatologists. Overall, the benefit of treating hyperlipidemia/dyslipidemia very likely outweighs the small risks associated with treatment.
RN: Are the statin treatment protocols (timing/dosing/monitoring) different for RA patients than the general population?
Dr. Yazici: The treatment protocols are not different. Current guidelines for patients with only elevated levels, or a history of cardiovascular events and elevated levels, and the various other subgroups, should be used when deciding on drug choice and monitoring.