Addressing CV Risk in RA: Are we doing enough? Save

The increased risk of cardiovascular disease in patients with rheumatoid arthritis has long been known (1). The association between increased levels of inflammation in rheumatoid arthritis and inflammation within vessels leading to atherosclerotic disease with downstream major adverse cardiovascular events (MACE) has led to the need for dedicated recommendations for the management of cardiovascular disease in the context of rheumatic diseases, as well as the inclusion of cardiovascular disease assessment as part of, for example, annual review clinics within the UK national guidance (1, 2).

ORAL surveillance was a post-authorisation safety study of tofacitinib 5mg and 10mg versus tumour necrosis factor (TNF) inhibitors, focusing on rates of adverse events, including MACE (3). A higher incidence of MACE was observed with the use of tofacitinib. Statins are recommended in patients with a history of atherosclerotic disease or 10 year predicted risk of MACE. But, how many patients with rheumatoid arthritis, at risk of MACE, are actually taking a statin?

Abstract 1745 by Jon Giles et al sought to delineate this within ORAL surveillance, using a post-hoc analysis to clarify statin use by baseline cardiovascular risk profile, the impact of statins on lipid levels, and the association between statin use and incident MACE. 

The study demonstrated that 53% of patients with atherosclerotic cardiovascular disease, and 27% of patients with high risk of cardiovascular disease were taking a statin at baseline. Statin use was similar at baseline for patients taking TNF inhibitors and tofacitinib, but only a few used a high intensity statin. Initiation of a statin during the study was rare, but more frequent for those taking tofacitinib. Unsurprisingly, low density lipoprotein (LDL) levels and LDL:HDL ratio were lower in those patients taking a statin.

Observed rates of MACE were similar across the study population and across treatments, regardless of baseline statin use. When looking at patients with a history of atherosclerotic cardiovascular disease taking tofacitinib, frequency of MACE was lower in those patients taking statins at any timepoint, compared to those without. A similar pattern was not seen in patients taking TNF inhibitors. With regards to patients with atherosclerotic cardiovascular disease who were not taking statins, MACE was more frequent in patients taking tofacitinib when compared to TNF inhibitors.

There is clearly a startling gap in cardiovascular risk management in our patients with rheumatoid arthritis, albeit demonstrated here in a selective cohort of patients. It is known that patients with rheumatoid arthritis struggle to reach therapeutic levels of LDL when compared to people without the condition, so this makes it even more important to address cardiovascular risk in our patients from an early stage in the disease (4). Enhanced communication between specialties and between rheumatology and primary care, as well as a more holistic approach to management, may go some way to addressing this. Annual review clinics such as those embedded within the UK guidance can be helpful in this regard. Early identification and discussion with patients regarding their cardiovascular risk may also encourage an approach which encompasses the use of statins alongside self-management approaches.

References

1. Drosos GC, Vedder D, Houben E, Boekel L, Atzeni F, Badreh S, et al. EULAR recommendations for cardiovascular risk management in rheumatic and musculoskeletal diseases, including systemic lupus erythematosus and antiphospholipid syndrome. Annals of the Rheumatic Diseases. 2022;81(6):768-79.

2. Quality statement 5: Annual review | Rheumatoid arthritis in over 16s | Quality standards | NICE: NICE.

3. Ytterberg SR, Bhatt DL, Mikuls TR, Koch GG, Fleischmann R, Rivas JL, et al. Cardiovascular and Cancer Risk with Tofacitinib in Rheumatoid Arthritis. New England Journal of Medicine. 2022;386(4):316-26.

4. Myasoedova E, Gabriel SE, Green AB, Matteson EL, Crowson CS. Impact of Statin Use on Lipid Levels in Statin‐Naive Patients With Rheumatoid Arthritis Versus Non–Rheumatoid Arthritis Subjects: Results From a Population‐Based Study. Arthritis Care & Research. 2013;65(10):1592-9.