Do Statins Reduce Cardiovascular Disease in Rheumatoid Arthritis? Save

In the current edition of the Journal of Rheumatology, Drs Heslinga and Nurmohamed address the issue of lipid management in rheumatoid arthritis (RA) patients at risk for cardiovascular disease (CVD).

CVD risk in RA elevated and roughly equals that seen in patients with diabetes. A study from Denmark demonstrated the same risk of of MI in RA and diabetes (incidence rate ratio (IRR) equal to 1.7). These data and others underscore the need for effective managment of both RA and CVD risk factors.

However, they point out that despite the increase CVD risk in RA and the need for CVD prevention, there is repeated evidence of poor efforts to manage CVD risk in RA patients.  They point to  lack of statin and cardiovascular endpoint trials in RA as a contributing factor.

In RA, it may be best to assess the lipid profile when disease activity is low or absent, because inflammation complicates interpretation of lipid levels. In RA, and inflammation, leads to a decrease in total cholesterol, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) and that these low levels are "paradoxically” associated with an increased cardiovascular risk.

The next important issue is whether statin treatment is effective in RA, and if so, what is the goal of lipid-lowering treatments. 

Until recently few studies have addressed the issue of statins in RA, although most of these post-hoc studies suggest statins are as effective in RA as they are in the general population.

The TRACE-RA trial (reported in the Journal of Rheumatology) found a nonsignificant 34% risk reduction for CVD in the statin group. The trial was terminated prematurely. (Citation source http://buff.ly/2eOMxrb)

The TRACE-RA data are similar to that reported from An, et al, who analyzed the Kaiser Permanente database.  They studied two cohorts of patients with RA (n = 1522 and n = 1746) matched against a general control persons (n = 6511) and osteoarthritis patients (n = 2544). All subjects had hyperlipidemia as well as statin therapy. (http://buff.ly/2eOMxrb)

With more than 3 years follow-up they convincingly demonstrated that lowering LDL-C concentrations similarly resulted in significant reduction in CV events in RA groups and controls. These data further support previous findings about the beneficial effects of statins on CV risk in RA.

The authors believe that there is no doubt about the efficacy of statin therapy in RA.

However, in daily practice, underuse of lipid-lowering/statin therapy persists. Comorbidities such as hypertension and hyperlipidemia are often undertreated and all of this could be compounded by undertreatment in RA inflammation itself.

There remains a significant issue as to who is responsible for CVD risk assessment and management. Rheumatologists are keen to the issue, and often teach patients and colleagues on the CVD risk of inlammatory RA. Yet, most Rheumatologist point to the primary care physician (PCP) as one who needs to manage and treat CV risk factors.

The European League Against Rheumatism task force for CVD risk management recommends that the treating rheumatologist ensure that CVD risk management is performed in patients with RA. Thus, the rheumatologist needs to ensure that the problem is well managed by effective communication with the patient and the PCP.