EULAR evidence-based recommendations for cardiovascular risk management in patients with rheumatoid arthritis and other forms of inflammatory arthritis

Cardiovascular risk in persons at risk of developing rheumatoid arthritis

Background

Rheumatoid arthritis (RA) is associated with an increased cardiovascular disease (CVD) risk which may start even before diagnosis. To explore this CVD risk prior to RA, we determined multiple risk factors and two 10-year clinical risk scores in a cohort of individuals at-risk of RA. We also analyzed associations with arthritis development and autoantibody status and compared a subset of at-risk individuals to an age and sex matched seronegative control group.

Methods

In a cohort of 555 consecutive arthralgia patients positive for rheumatoid factor (RF) and / or anti-citrullinated protein antibody (ACPA) we retrospectively identified patients with preclinical arthritis (i.e. those who developed arthritis), and non-arthritis patients (those without arthritis development during maximum 5 years follow up). Demographics, CVD risk factors and the 10-year cardiovascular risk according to the SCORE and QRISK3 system were determined at baseline.

Results

Preclinical arthritis patients (n = 188) had a higher heart rate (68 vs 63 bpm, p = 0.048) and lower cholesterol (5.2 mmol/l vs 5.5, p = 0.006), HDL (1.0 mmol/l vs 1.1, p0.003) and ApoB (0.85 g/l vs 0.91, p = 0.011) compared to non-arthritis patients (n = 367). Lipid levels were associated with ACPA status in both the preclinical arthritis and non-arthritis group. Ten-year CVD risk scores did not differ between preclinical arthritis and non-arthritis patients, in total, 7% (SCORE) and 8% (QRISK3) of seropositive arthralgia patients were classified as high risk. Seropositive at-risk patients (n = 71) had higher total cholesterol (5.4 vs 4.9, p<0.001), TC/HDL ratio (4.0 vs 3.0, p<0.001), triglycerides (1.4 vs 1.0, p = 0.001), ApoB (1.0 vs 0.9, p = 0.019) and 10-year risk scores (median SCORE 1.0 vs 0.0, p = 0.030 and median QRISK3 4.4 vs 3.1, p<0.001) compared to seronegative controls.

Conclusion

Our results suggest that lipid changes commence prior to RA diagnosis and that ACPAs might play a role.

Effect of methotrexate use on the development of type 2 diabetes in rheumatoid arthritis patients: A systematic review and meta-analysis

BACKGROUND

The high risk of cardiovascular disease is well recognized in rheumatoid arthritis. Type 2 diabetes also attributes to this increase in risk. Rheumatoid arthritis is a chronic inflammatory condition, which aggravates insulin resistance, placing the patients at a higher risk of type 2 diabetes and subsequent cardiovascular outcomes. Methotrexate treatment, as a gold standard anti-inflammatory drug in the treatment of rheumatoid arthritis has shown beneficial effects on cardiovascular health. However, its impact on type 2 diabetes is still unknown.

OBJECTIVE

To assess the strength of the association between exposure to methotrexate and the rate of development of type 2 diabetes in rheumatoid arthritis patients.

METHODS

All rheumatoid arthritis studies reporting the use of methotrexate as an exposure and type 2 diabetes as an outcome were searched until March 2020 using MEDLINE, Cochrane and Scopus databases. Studies were included if the diagnosis of rheumatoid arthritis was made according to current guidelines or by a rheumatologist, and if there was information about methotrexate exposure and the type 2 diabetes outcome. The author and an independent assessor evaluated the articles for eligibility. Meta-analyses combined relative risk estimates from each study where raw counts were available.

RESULTS

Sixteen studies reporting sufficient data for inclusion in the meta-analyses were identified. Methotrexate showed a promising effect on the risk of type 2 diabetes as this risk decreased in rheumatoid arthritis patients using methotrexate (Relative risk 0.48, 95% CI 0.16, 1.43).

CONCLUSION

Rheumatoid arthritis patients on methotrexate treatment had a lower risk of developing type 2 diabetes compared to rheumatoid arthritis patients not exposed to methotrexate. This finding highlights the need for future, randomized control trials to confirm the beneficial effect of methotrexate on type 2 diabetes in the rheumatoid arthritis population.

Considerations for improving quality of care of patients with rheumatoid arthritis and associated comorbidities

OBJECTIVE

Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disorder with a global prevalence of approximately 0.5-1%. Patients with RA are at an increased risk of developing comorbidities (eg, cardiovascular disease, pulmonary disease, diabetes and depression). Despite this, there are limited recommendations for the management and implementation of associated comorbidities. This study aimed to identify good practice interventions in the care of RA and associated comorbidities.

METHODS

A combination of primary research (180+ interviews with specialists across 12 European rheumatology centres) and secondary research (literature review of existing publications and guidelines/recommendations) were used to identify challenges in management and corresponding good practice interventions. Findings were prioritised and reviewed by a group of 18 rheumatology experts including rheumatologists, comorbidity experts, a patient representative and a highly specialised nurse.

RESULTS

Challenges throughout the patient pathway (including delays in diagnosis and referral, shortage of rheumatologists, limited awareness of primary care professionals) and 18 good practice interventions were identified in the study. The expert group segmented and prioritised interventions according to three distinct stages of the disease: (1) suspected RA, (2) recent diagnosis of RA and (3) established RA. Examples of good practice interventions included enabling self-management (self-monitoring and disease management support, for example, lifestyle adaptations); early arthritis clinic; rapid access to care (online referral, triage, ultrasound-guided diagnosis); dedicated comorbidity specialists; enhanced communication with primary care (hotline, education sessions); and integrating patient registries into daily clinical practice.

CONCLUSION

Learning from implementation of good practice interventions in centres across Europe provides an opportunity to more widely improved care for patients with RA and associated comorbidities.

Similar risk of cardiovascular events in idiopathic inflammatory myopathy and rheumatoid arthritis in the first 5 years after diagnosis

OBJECTIVES

To estimate the incidence of cardiovascular (CV) events in idiopathic inflammatory myopathy (IIM) compared to patients with rheumatoid arthritis (RA) and the general population. To explore the contribution of traditional CV risk factors to any difference observed.

METHODS

A retrospective matched population-based cohort study was conducted using UK Clinical Practice Research Datalink (CPRD) from 1987 to 2013. The incidence of CV events was calculated for each cohort over time and compared using Cox proportional hazards models. Multivariable analyses were used to adjust for traditional CV risk factors.

RESULTS

A total of 603 patients with IIM 4047 RA and 4061 healthy controls were included. The rate of CV events in IIM was significantly greater than healthy controls [hazard ratio (HR) 1.47 (95% confidence interval (CI) 1.18-1.83)] and remained significant after adjustment for CV risk factors [HR 1.38 (95% CI 1.11-1.72)]. Risk was similar between IIM and RA [HR 1.01 (95% CI 0.78-1.31)]. The rate of myocardial infarction [HR 1.61 (95% CI 1.27-2.04)] but not stroke [HR 0.92 (95% CI 0.59-1.44)] was significantly greater in IIM compared to healthy controls. After the first 5 years, the rate of CV events for RA remained significantly greater compared to the control group, but appeared to return to that of the healthy controls in the IIM group.

CONCLUSION

IIM is associated with an increased risk of CV events in the first 5 years after diagnosis similar to that of RA. Beyond 5 years, the risk appears to return to that of the general population in IIM but not RA. Key Points • The excess risk of cardiovascular events in IIM is similar to that found in RA. • The excess risk of cardiovascular events is greatest in the first 5 years after diagnosis.

Points to consider in cardiovascular disease risk management among patients with rheumatoid arthritis living in South Africa, an unequal middle income country

BACKGROUND

It is plausible that optimal cardiovascular disease (CVD) risk management differs in patients with rheumatoid arthritis (RA) from low or middle income compared to high income populations. This study aimed at producing evidence-based points to consider for CVD prevention in South African RA patients.

METHODS

Five rheumatologists, one cardiologist and one epidemiologist with experience in CVD risk management in RA patients, as well as two patient representatives, two health professionals and one radiologist, one rheumatology fellow and 11 rheumatologists that treat RA patients regularly contributed. Systematic literature searches were performed and the level of evidence was determined according to standard guidelines.

RESULTS

Eighteen points to consider were formulated. These were grouped into 6 categories that comprised overall CVD risk assessment and management (n = 4), and specific interventions aimed at reducing CVD risk including RA control with disease modifying anti-rheumatic drugs, glucocorticoids and non-steroidal anti-inflammatory drugs (n = 3), lipid lowering agents (n = 8), antihypertensive drugs (n = 1), low dose aspirin (n = 1) and lifestyle modification (n = 1). Each point to consider differs partially or completely from recommendations previously reported for CVD risk management in RA patients from high income populations. Currently recommended CVD risk calculators do not reliably identify South African black RA patients with very high-risk atherosclerosis as represented by carotid artery plaque presence on ultrasound.

CONCLUSIONS

Our findings indicate that optimal cardiovascular risk management likely differs substantially in RA patients from low or middle income compared to high income populations. There is an urgent need for future multicentre longitudinal studies on CVD risk in black African patients with RA.

Glucocorticoids in rheumatoid arthritis: the silent companion in the therapeutic strategy

INTRODUCTION

Glucocorticoids (GCs) are key actors in RA management, despite the increasing number of available drugs. In fact, due to their efficacy and safety, the combination therapy between GCs and conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) is still recommended in the early phase of RA treatment, because improving the long-term results.

AREAS COVERED

In this paper, we reviewed the role of GCs in RA management, focusing on mechanisms of action as well as the benefit/risk ratio of GCs and newer therapeutic formulations. Furthermore, we analyzed GCs DMARDs proprieties on disease activity and their long-term effects on radiographic damage. We designed a narrative review aimed to provide an overview concerning GCs in RA management.

EXPERT OPINION

A large amount of evidence supports the use of GCs in RA, especially in the earliest phases of the disease. Besides GCs symptomatic effects due to their strong anti-inflammatory effects, data from several randomized clinical trials have shown a substantial benefit of low-dose GCs in inhibiting the radiographic damage, thus highlighting GCs DMARDs properties. Besides their recognized role in the treatment of early RA, systematic monitoring of adverse events should be recommended to minimize GCs toxicity.

EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update

OBJECTIVES

To provide an update of the European League Against Rheumatism (EULAR) rheumatoid arthritis (RA) management recommendations to account for the most recent developments in the field.

METHODS

An international task force considered new evidence supporting or contradicting previous recommendations and novel therapies and strategic insights based on two systematic literature searches on efficacy and safety of disease-modifying antirheumatic drugs (DMARDs) since the last update (2016) until 2019. A predefined voting process was applied, current levels of evidence and strengths of recommendation were assigned and participants ultimately voted independently on their level of agreement with each of the items.

RESULTS

The task force agreed on 5 overarching principles and 12 recommendations concerning use of conventional synthetic (cs) DMARDs (methotrexate (MTX), leflunomide, sulfasalazine); glucocorticoids (GCs); biological (b) DMARDs (tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab), abatacept, rituximab, tocilizumab, sarilumab and biosimilar (bs) DMARDs) and targeted synthetic (ts) DMARDs (the Janus kinase (JAK) inhibitors tofacitinib, baricitinib, filgotinib, upadacitinib). Guidance on monotherapy, combination therapy, treatment strategies (treat-to-target) and tapering on sustained clinical remission is provided. Cost and sequencing of b/tsDMARDs are addressed. Initially, MTX plus GCs and upon insufficient response to this therapy within 3 to 6 months, stratification according to risk factors is recommended. With poor prognostic factors (presence of autoantibodies, high disease activity, early erosions or failure of two csDMARDs), any bDMARD or JAK inhibitor should be added to the csDMARD. If this fails, any other bDMARD (from another or the same class) or tsDMARD is recommended. On sustained remission, DMARDs may be tapered, but not be stopped. Levels of evidence and levels of agreement were mostly high.

CONCLUSIONS

These updated EULAR recommendations provide consensus on the management of RA with respect to benefit, safety, preferences and cost.

Pharmacological management of cardiovascular risk in chronic inflammatory rheumatic diseases

INTRODUCTION

Cardiovascular comorbidity is a major burden in patients with chronic inflammatory rheumatic diseases and a significant determinant of their outcome. In addition to optimal management of the underlying inflammatory condition according to current guidelines, individual cardiovascular risk factors, particularly dyslipidaemia, hypertension, and impaired glucose tolerance should be assessed regularly and guide risk stratification and requirement for treatment.

AREAS DISCUSSED

We critically reviewed manuscripts and guidelines on the pharmacological management of dyslipidaemia, hypertension, and diabetes in patients with chronic inflammatory rheumatic diseases (PubMed, MEDLINE, EMBASE, Scopus, Web of Science and Google Scholar, up to 1 March 2020). Lifestyle changes are of paramount importance for the management of these risk factors. In the current narrative review, we discuss pharmacological therapies available and emerging therapies aiming to help patients achieve recommended targets, depending on their individual risk.

EXPERT OPINION

CVD risk is increased in people with chronic inflammatory rheumatic diseases. Cardiovascular risk factor management is an essential part of their care. Although relevant guidance exists, there are still major gaps in knowledge and risk factor management implementation in these patient groups. Some practical guidance based on our interpretation of existing data and experience in the field is provided in this review.

Statin use in patients with non-HMGCR idiopathic inflammatory myopathies: A retrospective study

Background

Statins are the most widely used lipid lowering therapies which reduce cardiovascular risk, but are associated with muscular adverse events (AEs). Idiopathic inflammatory myopathies (IIM) are autoimmune diseases of the muscle with higher risk of cardiovascular disease. More data is needed regarding statin safety in patients with intrinsic muscle disease such as IIM.

Hypothesis

Statins are tolerated in patients with IIM without leading to significant increase in muscular AEs.

Methods

Statin use was retrospectively examined in a longitudinal IIM cohort. Safety analysis included assessment of muscular and nonmuscular AEs by chart review. IIM patients receiving a statin during the cohort follow‐up period were matched to IIM patients not receiving a statin for comparative analysis of longitudinal outcomes.

Results

33/214 patients had a history of statin use. 63% started for primary prevention, while others were started for clinical ASCVD events, vascular surgery, IIM related heart failure, and cardiac transplantation. A high intensity statin was used in nine patients with non‐HMGCR myositis, and tolerated in 8/9 patients. Statin related muscular AE was noted in three patients. There were no cases of rhabdomyolysis, or statin related nonmuscular AEs in a median observation period of 5 years. In patients newly started on statins during cohort follow‐up (n = 7) there was no change in disease activity after statin initiation. Long term outcomes were not different between statin and nonstatin IIM control groups.

Conclusion

Statins were well tolerated in patients with non‐HMGCR positive IIM. Given the accelerated atherosclerotic risk in IIM patients, further prospective studies of statin safety in IIM patients are warranted.

Prevention and adherence in Rheumatic and Musculoskeletal disease

Rheumatic and Musculoskeletal Diseases (RMDs) are chronic conditions that affect a substantial number of people. RMDs are significantly related to co-morbidity. Therefore, focusing on prevention in RMDs is of importance to promote and maintain health. Prevention includes primary-, secondary-, tertiary-, and clinical prevention. Primary prevention aims to prevent the onset of disease before the disease process begins, secondary prevention includes detecting and reducing disease and risk factors at the earliest possible point, and tertiary prevention aims to limit the influence of a recognized or verified disease and to address or reduce further development or worsening of the disease, including physical and psychosocial disability. Clinical prevention attempts to integrate prevention into the disease management to limit disease progression and prevent complications and relapse. This chapter will focus on the evidence for prevention and highlight how innovations and trends can contribute by using digital technologies as an example.

Carotid plaques as predictors of cardiovascular events in patients with Rheumatoid Arthritis. Results from a 5-year-prospective follow-up study

OBJECTIVE

To investigate if the Systematic Coronary Risk Evaluation (SCORE) and the QRISK3 algorithms as well as the carotid ultrasound are useful predictors of cardiovascular (CV) events and death in a prospectively defined population-based rheumatoid arthritis (RA) inception cohort.

METHODS

A set of 327 consecutive RA patients without history of diabetes, chronic kidney disease or CV events were studied by carotid ultrasound between 2012 and 2013. At that time, CV risk was calculated according to the modified EULAR systematic coronary risk evaluation (mSCORE) for RA. A five-year prospective follow-up study was conducted by survival analysis models. The EULAR mSCORE based on the 2015/2016 updated EULAR recommendations and the QRISK3 algorithms were retrospectively tested using baseline data.

RESULTS

After 1,984.25 patient-years of follow-up, 23 had died and 27 had experienced CV events. Linearized mortality rate was 1.16/100 patient-years (95% confidence interval [CI]: 0.74--1.73). Adjusting for age, gender and disease duration, a model with carotid plaques (Hazard ratio [HR]: 6.10 [95% CI:0.74--50.0]; p = 0.09) and another model with carotid plaques and QRISK3 (HR for carotid plaques: 6.12 [95% CI: 0.74--50.5]; p = 0.09 and HR for each 1% in QRISK3: 1.03 [95% CI: 0.99--1.07], p = 0.11, respectively were the best predictors of death whereas a model with carotid plaques (HR: 5.25 [95% CI:1.41--19.50]; p = 0.01) and another model with carotid plaques and QRISK3 (HR for carotid plaques: 5.13 [95% CI: 1.36--19.3]; p = 0.02 and HR for each 1% in QRISK3: 1.03 [95% CI: 0.99--1.07], p = 0.12, respectively, were the best predictors of CV events. In contrast, the mSCORE was a weaker predictor of the risk of death or CV events.

CONCLUSIONS

The presence of carotid plaques predicts the development of CV events and death in patients with RA. The predictable capacity of carotid plaques and QRISK3 is higher than that of mSCORE in RA patients.

Prevalence and pattern of comorbidities in chronic rheumatic and musculoskeletal diseases: the COMORD study

Increased risk of comorbidities has been reported in Rheumatic and Musculoskeletal Diseases (RMD). We aimed to evaluate the prevalence and pattern of comorbidities in RMD patients nationwide, to identify multimorbidity clusters and to evaluate the gap between recommendations and real screening. Cross-sectional, multicentric nationwide study. Prevalence of comorbidities was calculated according to six EULAR axes. Latent Class Analysis identified multimorbidity clusters. Comorbidities' screening was compared to international and local recommendations. In 769 patients (307 RA, 213 OA, 63 SLE, 103 axSpA, and 83 pSA), the most frequent comorbidities were cardiovascular risk factors and diseases (CVRFD) (hypertension 36.5%, hypercholesterolemia 30.7%, obesity 22.7%, smoking 22.1%, diabetes 10.4%, myocardial infarction 6.6%), osteoporosis (20.7%) and depression (18.1%). Three clusters of multimorbidity were identified: OA, RA and axSpA. The most optimal screening was found for CVRF (> = 93%) and osteoporosis (53%). For malignancies, mammograms were the most optimally prescribed (56%) followed by pap smears (32%) and colonoscopy (21%). Optimal influenza and pneumococcus vaccination were found in 22% and 17%, respectively. Comorbidities were prevalent in RMD and followed specific multimorbidity patterns. Optimal screening was adequate for CVRFD but suboptimal for malignant neoplasms, osteoporosis, and vaccination. The current study identified health priorities, serving as a framework for the implementation of future comorbidity management standardized programs, led by the rheumatologist and coordinated by specialized health care professionals.

Risk of acute arterial events associated with treatment of inflammatory bowel diseases: nationwide French cohort study

OBJECTIVE

Patients with IBD are at increased risk of acute arterial events. Antitumour necrosis factor (TNF) agents and thiopurines may, via their anti-inflammatory properties, lower the risk of acute arterial events. The aim of this study was to assess the impact of thiopurines and anti-TNFs on the risk of acute arterial events in patients with IBD.

DESIGN

Patients aged 18 years or older and affiliated to the French national health insurance with a diagnosis of IBD were followed up from 1 April 2010 until 31 December 2014. The risks of acute arterial events (including ischaemic heart disease, cerebrovascular disease and peripheral artery disease) were compared between thiopurines and anti-TNFs exposed and unexposed patients with marginal structural Cox proportional hazard models adjusting for baseline and time-varying demographics, medications, traditional cardiovascular risk factors, comorbidities and IBD disease activity.

RESULTS

Among 177 827 patients with IBD (96 111 (54%) women, mean age at cohort entry 46.2 years (SD 16.3), 90 205 (50.7%) with Crohn's disease (CD)), 4145 incident acute arterial events occurred (incidence rates: 5.4 per 1000 person-years). Compared with unexposed patients, exposure to anti-TNFs (HR 0.79, 95% CI 0.66 to 0.95), but not to thiopurines (HR 0.93, 95% CI 0.82 to 1.05), was associated with a decreased risk of acute arterial events. The magnitude in risk reduction was highest in men with CD exposed to anti-TNFs (HR 0.54, 95% CI 0.40 to 0.72).

CONCLUSION

Exposure to anti-TNFs is associated with a decreased risk of acute arterial events in patients with IBD, particularly in men with CD.

Assessment of subclinical atherosclerotic cardiovascular disease in patients with ankylosing spondylitis

Objective:

The aim of the present study was to compare patients with ankylosing spondylitis (AS) with healthy controls with respect to subclinical atherosclerotic cardiovascular disease (CVD).

Methods:

A total of 44 patients with AS with no history of CVD, diabetes mellitus, hypertension, chronic kidney disease, and lipid-lowering drug use were compared with 40 age- and sex-matched healthy controls with respect to carotid intima-media thickness (CIMT) and pulse wave velocity (PWV), which are surrogate markers of subclinical atherosclerosis. Correlation analysis was also performed to examine the association between surrogate markers and disease activity with inflammation [Ankylosing spondylitis disease activity score with C-reactive protein (ASDAS-CRP)].

Results:

In addition to age and sex, both groups were comparable with respect to cigarette smoking, body mass index, and high-density lipoprotein cholesterol (p=0.425, p=0.325, and p=0.103, respectively). The level of total cholesterol was significantly lower in patients with AS (p=0.002). Nonsteroidal anti-inflammatory drug and tumor necrosis factor alpha inhibitor use ratios in patients with AS were 79.5% and 65.9%, respectively. There was no significant difference between both groups regarding PWV and CIMT (p=0.788 and p=0.253, respectively). In patients with AS, there was a significant correlation between ASDAS-CRP and CIMT (r=0.315, p=0.038), but the correlation between ASDAS-CRP and PWV was not significant (r=−0.183, p=0.234).

Conclusion:

The results of the present study could not provide sufficient evidence whether disease activity with inflammation caused subclinical atherosclerotic CVD in patients with AS without overt CVD. The increased atherosclerotic CVD risk is most probably multifactorial in patients with AS, but the extent of the contribution of disease activity with inflammation to increased atherosclerosis is controversial.

Screening of Hyperlipidemia Among Patients With Rheumatoid Arthritis in the United States

OBJECTIVE

To determine the proportion of primary lipid screening among patients with rheumatoid arthritis (RA) and compare it with those among patients with diabetes mellitus (DM) and patients with neither RA nor DM, and to assess whether primary lipid screening varied according to the health care provider (rheumatologist versus non-rheumatologist).

METHODS

We analyzed claims data from US private and public health plans from 2006-2010. Eligibility requirements included continuous medical and pharmacy coverage for ≥12 months (baseline period) and >2 physician diagnoses and relevant medications to define RA, DM, RA and DM, or neither condition. Among the 330,695 eligible participants, we calculated the proportion with a lipid profile ordered during the 2 years following baseline. Time-varying Cox proportional hazard models were used to determine the probability of hyperlipidemia screening in participants with RA according to provider specialty.

RESULTS

More than half of the patients were ages 41-71 years. Among patients with RA (n = 12,182), DM (n = 62,834), RA and DM (n = 1,082), and those who did not have either condition (n = 167,811), the proportion screened for hyperlipidemia was 37%, 60%, 55%, and 41%, respectively. Patients with RA who visited a rheumatologist and a non-rheumatology clinician during follow-up had a 55% (95% confidence interval 1.36-1.78) higher screening probability than those who only visited a rheumatologist.

CONCLUSION

Primary lipid screening was suboptimal among patients with RA. It was also lower for patients with DM and minimally different from the general population. Screening was higher for RA patients who received care from both a rheumatologist and a non-rheumatologist (e.g., primary care physician).

Role of the eNOS Uncoupling and the Nitric Oxide Metabolic Pathway in the Pathogenesis of Autoimmune Rheumatic Diseases

Atherosclerosis and its clinical complications constitute the major healthcare problems of the world population. Due to the central role of endothelium throughout the atherosclerotic disease process, endothelial dysfunction is regarded as a common mechanism for various cardiovascular (CV) disorders. It is well established that patients with rheumatic autoimmune diseases are characterized by significantly increased prevalence of cardiovascular morbidity and mortality compared with the general population. The current European guidelines on cardiovascular disease (CVD) prevention in clinical practice recommend to use a 1,5-factor multiplier for CV risk in rheumatoid arthritis as well as in other autoimmune inflammatory diseases. However, mechanisms of accelerated atherosclerosis in these diseases, especially in the absence of traditional risk factors, still remain unclear. Oxidative stress plays the major role in the endothelial dysfunction and recently is strongly attributed to endothelial NO synthase dysfunction (eNOS uncoupling). Converted to a superoxide-producing enzyme, uncoupled eNOS not only leads to reduction of the nitric oxide (NO) generation but also potentiates the preexisting oxidative stress, which contributes significantly to atherogenesis. However, to date, there are no systemic analyses on the role of eNOS uncoupling in the excess CV mortality linked with autoimmune rheumatic diseases. The current review paper addresses this issue.

Cardiovascular risk factors and outcomes in early rheumatoid arthritis: a population-based study

OBJECTIVE

To assess the burden of cardiovascular disease (CVD) at and prior to diagnosis in people with early rheumatoid arthritis (RA) and subsequent CVD in these patients.

METHODS

A retrospective case-control study using a large English primary care database. People with RA (n=6591) diagnosed between 2004 and 2016 (inclusive) were identified using a validated algorithm, matched 1:1 by age and gender to those without RA (n=6591) and followed for a median of 5.4 years. We assessed differences in CVD at, before and after diagnosis, and the impact of traditional and RA-related risk factors (C reactive protein, RA-related autoantibodies and medication use) on incident CVD (a composite of myocardial infarction (MI), stroke or heart failure).

RESULTS

RA cases and their matched controls were both of mean age 58.7 (SD 15.5) at cohort entry, and 67.5% were female. Some CVD risk factors were more common at RA diagnosis including smoking and diabetes; however, total and low-density lipoprotein cholesterol were lower in patients with RA. CVD was more common in RA at cohort entry; stroke (3.9% vs 2.7%, p<0.001), heart failure (1.6% vs 1.0%, p=0.001), and non-significantly MI (3.1% vs 2.8%, p=0.092). Excess CVD developed in the 5 years preceding diagnosis. After adjustment for traditional and RA-related risk factors, RA was associated with greater risk of post-diagnosis CVD (HR 1.33, 95% CI 1.07 to 1.65, p=0.010).

CONCLUSIONS

An excess of stroke and heart failure occurs before diagnosis of RA. There is excess risk for further cardiovascular events after diagnosis, which is not explained by differences in traditional CVD or RA-related risk factors at diagnosis.

Cardiovascular target organ damage in premenopausal systemic lupus erythematosus patients and in controls: Are there any differences?

OBJECTIVE

to analyze the presence of cardiac and vascular preclinical damage in premenopausal women with systemic lupus erythematosus (SLE) and controls, matched for demographic characteristics and for other cardiovascular risk factors.

METHODS

33 women (mean age 32 ± 7 years) with SLE clinically stable (SLEDAI Score 2.5 ± +1.5) and 33 controls, matched (MC) for sex, age, body mass index (BMI), clinic blood pressure (BP) and antihypertensive treatment (if present) underwent: 24-h BP monitoring, echocardiography with tissue Doppler analysis for left ventricular (LV) structure, systolic and diastolic function, echo-tracking carotid ultrasound for intima-media thickness (IMT) and carotid distensibility measurement, and pulse wave velocity measurement for aortic stiffness (PWV).

RESULTS

by definition no difference was observed for age, sex, BMI and clinic BP values; Framingham risk score was low in SLE and MC (1.3 ± 2.7 vs 1.5 ± 2.3%, p = ns). 24-h BP was similar in SLE and in MC. Systolic function parameters, including LV longitudinal systolic function, an early index of LV systolic dysfunction, were reduced in SLE as compared to MC. Carotid IMT and carotid and aortic stiffness parameters were not different in SLE and MC. At multivariate regression analysis, PWV was independently associated with LV mass in controls and with the steroid weekly dose in SLE patients.

CONCLUSIONS

in young patients with SLE and low activity index of the disease, we did not observe significant vascular alterations as compared to controls with similar CV risk. The early LV systolic impairment observed in SLE patients needs confirmation.

Development and validation of a nomogram to predict coronary heart disease in patients with rheumatoid arthritis in northern China

We developed and validated a nomogram to predict coronary heart disease (CHD) in patients with rheumatoid arthritis (RA) in northern China. We analyzed a cohort of RA patients admitted to the Department of Rheumatology and Immunology of the First Affiliated Hospital of China Medical University from 2011 to 2017. To select a high-performance model for clinical data prediction, we evaluated the F1-scores of six machine learning models. Based on the results, we selected multivariable logistic regression analysis for the development of a prediction model. We then generated an individualized prediction nomogram that included age, sex, hypertension, anti-cyclic citrullinated peptide antibody positivity, the erythrocyte sedimentation rate, and serum LDL-cholesterol, triglyceride and HDL-cholesterol levels. The prediction model exhibited better discrimination than the Framingham Risk Score in predicting CHD in RA patients. The area under the curve of the prediction model was 0.77, with a sensitivity of 63.9% and a specificity of 77.2%. The nomogram exhibited good calibration and clinical usefulness. In conclusion, our prediction model was more accurate than the Framingham Risk Score in predicting CHD in RA patients. Our nomogram combining various risk factors can be used for the individualized preoperative prediction of CHD in patients with RA.

Mortality is increased in patients with rheumatoid arthritis or diabetes compared to the general population - the Nord-Trøndelag Health Study

Persons with rheumatoid arthritis (RA) or diabetes have increased risk of cardiovascular disease (CVD) and higher death rates compared to the general population. This study used data from the population-based Nord-Trøndelag Health Study (HUNT) and the Norwegian Cause of Death registry to compare all-cause mortality rates for RA or diabetes patients to the general population. We used Cox regression with age as time variable, adjusting for sex, smoking, body mass index, hypertension, total cholesterol, creatinine and previous CVD. To achieve proportional hazards, an interaction term with an age group variable (≤75 years or >75 years) was included for diabetes, smoking and previous CVD. Median follow-up was 18.1 years. Mortality occurred for 123 (32%) of the RA patients, 1,280 (44%) of the diabetes patients, 17 (52%) of the patients with both diseases and 11,641 (18%) of the controls. Both diseases were associated with statistically significantly increased mortality rates. The hazard ratio (HR) for RA was 1.24 (95% CI: 1.03-1.44). The HR of diabetes was 1.82 (1.60-2.04) for individuals ≤75 years old and 1.49 (1.39-1.59) for individuals >75 years. Diabetes had a significantly higher HR for death than RA for participants ≤75 years, but not significantly different for participants >75 years.

Preventive Role of Resveratrol Against Inflammatory Cytokines and Related Diseases

BACKGROUND

Immunity is the ultimate barrier between foreign stimuli and a host cell. Unwanted immune responses can threaten the host cells and may eventually damage a vital organ. Overproduction of inflammatory cytokines may also lead to autoimmune diseases. Inflammatory cells and pro-inflammatory cytokines can eventually progress to renal, cardiac, brain, hepatic, pancreatic and ocular inflammation that can result in severe damage in the long run. Evidence also suggests that inflammation may lead to atherosclerosis, Alzheimer's, hypertension, stroke, cysts and cancers.

METHODS

This study was designed to correlate the possible molecular mechanisms for inflammatory diseases and prevent biochemical changes owing to inflammatory cytokines by using Resveratrol. Therefore, we searched and accumulated very recent literature on inflammatory disorders and Resveratrol. We scoured PubMed, Scopus, Science Direct, PLoS One and Google Scholar to gather papers and related information.

RESULTS

Reports show that inflammatory diseases are very complex, as multiple cascade systems are involved; therefore, they are quite difficult to cure. However, our literature search also correlates some possible molecular interactions by which inflammation can be prevented. We noticed that Resveratrol is a potent lead component and has multiple activities against harmful inflammatory cytokines and related microRNA. Our study also suggests that the anti-inflammatory properties of Resveratrol have been highly studied on animal models, cell lines and human subjects and proven to be very effective in reducing inflammatory cell production and pro-inflammatory cytokine accumulation. Our tables and figures also demonstrate recent findings and possible preventive activities to minimize inflammatory diseases.

CONCLUSION

This study would outline the role of harmful inflammatory cytokines as well as how they accelerate pathophysiology and progress to an inflammatory disorder. Therefore, this study might show a potential therapeutic value of using Resveratrol by health professionals in preventing inflammatory disorders.

Strategies for implementation of guideline recommended cardiovascular risk management for patients with rheumatoid arthritis: results from a questionnaire survey of expert rheumatology centers

The aim was to study the different strategies used to implement cardiovascular risk evaluation and management for patients with rheumatoid arthritis (RA) in daily clinical practice. A questionnaire survey was performed among both the members of the international Trans-Atlantic Cardiovascular Risk Consortium for Rheumatoid Arthritis (ATACC-RA) as well as the Survey of cardiovascular disease risk factors (CVD-RF) in patients with RA (SURF-RA) group. The questionnaire included 18 questions with the overarching topics: (1) organization and responsibility of cardiovascular risk management (CVRM); (2) screening of CVD-RFs; (3) overview current CVRM status; and (4) availability of data regarding CVRM. Based on the answers, two researchers (JW, PR) independently categorized the different strategies. Thirteen out of 27 rheumatology centers responded to the questionnaire. One rheumatology center did not have organized CVRM for their RA patients. Among the other centers, three strategies to organize CVRM in daily practice were distinguished: (1) the rheumatologist performs CVRM during outpatient visits (n = 6); (2) cardiologists and rheumatologists co-operate in a cardio-rheuma-clinic/team with different tasks and responsibilities (n = 3); and (3) the general practitioner screens and intervenes on CVD-RFs (n = 3). Each CVRM strategy was based on agreements between medical professionals and was also dependent on the national healthcare system and available financial resources. Three strategies were identified for CVRM implementation in daily clinical practice based on who is primarily responsible for performing CVRM. More research is warranted to compare their relative merits and effectiveness in relation to CVRM.

Impairment of myocardial functions and arterial stiffness in patients with lichen planus

BACKGROUND

Lichen planus is a chronic inflammatory mucocutaneous disease. Recent studies have suggested that it is associated with an increased risk of cardiovascular comorbidities.

OBJECTIVE

The purpose of this study was to assess and compare arterial stiffness and cardiovascular hemodynamics in patients with lichen planus and a healthy control group.

METHODS

Fifty-five patients with lichen planus and 42 healthy controls were enrolled. All patients underwent echocardiographic examination, and arterial stiffness was measured using applanation tonometry.

RESULTS

No statistically significant difference was determined between the patient and control groups in terms of arterial stiffness, but stiffness was markedly higher in patients with erosive lichen planus compared to the control group and other patients (p=0.006, and p=0.023, respectively). Moderate positive correlation was determined between duration of disease and arterial stiffness. Impairment of systolic and diastolic functions was also determined in patients with lichen planus compared to the control group (p<0.001, and p=0.005, respectively).

STUDY LIMITATIONS

Relatively low number of patients.

CONCLUSION

The positive correlation observed between duration of disease and arterial stiffness in patients with lichen planus suggests that these patients should be followed-up in terms of cardiovascular risk in the presence of resistant and long-term disease, particularly in case of erosive lichen planus.

Outreach to Promote Management of Cardiovascular Risk in Primary Care Among Patients With Rheumatoid Arthritis Seen in Rheumatology Practice

Objective

Rheumatoid arthritis (RA) confers a 1.5‐ to 2.0‐fold increased risk of cardiovascular disease (CVD). A prior multifaceted quality improvement approach to improving CVD preventive care increased CVD risk factor assessments, but there was no significant effect on the management of risk factors. We tested the impact of adding a proactive outreach strategy promoting primary care treatment of CVD risk factors among patients with RA through their rheumatology practice.

Methods

Through electronic health record searches, we identified patients with RA who were potential candidates for hypertension treatment initiation or intensification, statin therapy, or a smoking‐cessation intervention. A nonclinician care manager contacted patients by phone and mail on behalf of the rheumatologists, provided information about the identified risk factor(s), recommend follow‐up with primary care physicians (PCPs), sent correspondence to PCPs, and followed up with patients to see what actions had been taken. We measured preventive cardiology quality indicators and compared preintervention and intervention time periods using interrupted time series methods.

Results

During the 6‐month intervention period, the proportion of patients prescribed at least moderate‐intensity statin treatment for primary prevention rose from 18.4% to 23.8%. The rate of increase was 1.06% greater per month than during the preceding period (P < 0.001). Rates of increase in hypertension diagnosis and control improved more rapidly during this phase (P < 0.001 for each) and reversed preceding negative trends.

Conclusion

Implementing proactive nonclinician outreach to encourage primary care–based treatment of CVD risk factors was associated with increases in statin prescribing and in hypertension diagnosis and control. Smoking was not affected.

When the first visit to the rheumatologist is established rheumatoid arthritis

The outlook for people living with rheumatoid arthritis (RA) has improved tremendously in a generation. Major contributions to this include recognition of the importance of early treatment initiation, improved understanding of the pathobiology, the identification of therapeutic targets and their subsequent validation in clinic trials and the realisation of the importance of 'tight control' of inflammatory responses. Despite these advances, many patients meeting classification criteria present for the first time to a rheumatologist with longstanding symptoms. There is no definition as to when RA becomes 'established'. But there is evidence that a 'window of opportunity' exists over about 12-16 weeks symptom duration, during which treatment intervention gives rise to the most optimal outcomes. This review addresses issues regarding the management of patients presenting outside the window of opportunity in terms of heterogeneity of presentation, assessment, therapeutic goals and treatment options as well as the importance of a multidisciplinary approach to holistic care.

Impact of Cumulative Inflammation, Cardiac Risk Factors, and Medication Exposure on Coronary Atherosclerosis Progression in Rheumatoid Arthritis

OBJECTIVE

To explore incidence and progression of coronary atherosclerosis and identify determinants in patients with rheumatoid arthritis (RA). We specifically evaluated the impact of inflammation, cardiac risk factors, duration of medication exposure, and their interactions on coronary plaque progression.

METHODS

One hundred one participants with baseline coronary computed tomography angiography findings underwent follow-up assessment a mean ± SD of 83 ± 3.6 months after baseline. Plaque burden was reported as the segment involvement score (describing the number of coronary segments with plaque) and the segment stenosis score (characterizing the cumulative plaque stenosis over all evaluable segments). Plaque composition was classified as noncalcified, mixed, or calcified. Coronary artery calcium (CAC) was quantified using the Agatston method.

RESULTS

Total plaque increased in 48% of patients, and progression was predicted by older age, higher cumulative inflammation, and total prednisone dose (P < 0.05). CAC progressors were older, more obese, hypertensive, and had higher cumulative inflammation compared to nonprogressors (P < 0.05). Longer exposure to biologics was associated with lower likelihood of noncalcified plaque progression, lesion remodeling, and constrained CAC change in patients without baseline calcification, independent of inflammation, prednisone dose, or statin exposure (all P < 0.05). Longer statin treatment further restricted noncalcified plaque progression and attenuated the effect of inflammation on increased plaque and CAC (P < 0.05). Stringent systolic blood pressure (BP) control further weakened the effect of inflammation on total plaque progression.

CONCLUSION

Inflammation was a consistent and independent predictor of coronary atherosclerosis progression in RA. It should therefore be specifically targeted toward mitigating cardiovascular risk. Biologic disease-modifying antirheumatic drugs, statins, and BP control may further constrain plaque progression directly or indirectly.

Primary care providers' awareness, knowledge, and practice with regard to cardiovascular risk in patients with rheumatoid arthritis : PCPs' awareness, knowledge, and practice with regard to CV risks in patients with RA

Rheumatoid arthritis (RA) is a systemic auto-inflammatory disease associated with increased cardiovascular risk. Early identification and aggressive cardiovascular risk factor modification are critical for improvement in morbidity and mortality in patients with RA. This study is a cross-sectional survey with the purpose of evaluating primary care providers' awareness, practice patterns, and satisfaction with continuing medical education on cardiovascular risk in patients with RA. Our study showed that 71% of clinicians felt that the CME on RA patient management regarding CV risk factors is inadequate. Only 37% of providers reported feeling well prepared to manage CV risk for RA patients. Only 15% of participants were actively initiating a discussion regarding CV risk with RA patients. A better understanding of the educational needs and practice patterns of primary care providers may warrant the development of strategies for cardiovascular risk management in patients with RA.

Sex and Cardiovascular Involvement in Inflammatory Joint Diseases

The term inflammatory joint disease (IJD) encompasses a group of chronic conditions with predominant joint involvement. They share an increased risk of cardiovascular (CV) complications. However, the implication of the sex in the risk of CV disease in IJD has not been specifically addressed. The aim of this work is to assess the influence of sex on the clinical expression of CV manifestations associated to IJD. With this objective, an update of the current knowledge of the sex influence on CV disease in patients with IJD was conducted. A PubMed database search of the most relevant literature on this topic was performed mainly based on studies published in English over the last 10 years. Although most studies on IJD were not specifically designed to address sex differences regarding CV complications, it seems that men with rheumatoid arthritis (RA) are at higher risk of pericarditis, ischemic heart disease, heart failure (HF) with reduced ejection fraction (EF), and CV mortality than women with RA. In contrast, HF with preserved EF and diastolic dysfunction is more frequent in women with RA. Men with ankylosing spondylitis present more frequently disorders of the conduction system and aortic valvulopathy than women. A limited number of studies addressed CV differences according to sex in psoriatic arthritis. Although there are some differences according to sex in the clinical expression of CV complications in patients with IJD, much research is still needed to better identify the implication of sex in the risk of CV disease in these patients.

[Case of a Сombination of Lupus Erythematosus, Antiphospholipid Syndrome and Myocardial Infarction]

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease of unknown etiology characterized by a wide range of clinical manifestations with damage to various organs and systems of the body. There are bad prognostic factors for SLE: damage to the heart, kidney, central nervous system, the development of hematological crises and secondary antiphospholipid syndrome. A number of authors consider systemic lupus erythematosus a "new" risk factor for atherosclerosis. The overall risk of myocardial infarction (MI) in patients with SLE is 10 times higher than in the general population. The article presents clinical case report of the development of myocardial infarction in a woman with SLE, receiving therapy for secondary antiphospholipid syndrome.

A quality improvement intervention failed to significantly increase pneumococcal and influenza vaccination rates in immunosuppressed inflammatory arthritis patients

OBJECTIVES

Pneumococcal and influenza vaccination rates have been suboptimal in studies of immunosuppressed patients. We aimed to assess barriers to and increase rates of 23-valent pneumococcal polysaccharide vaccine (PPSV23) and influenza vaccination in this group. The primary endpoint was a statistically significant increase in adequate PPSV23 and influenza vaccination.

METHODS

In 2017, rheumatology outpatients completed an anonymous questionnaire recording vaccination knowledge, status, and barriers. Simultaneously, a low-cost multifaceted quality improvement (QI) intervention was performed. All outpatients on oral steroids, immunosuppressant conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or biologics disease-modifying antirheumatic drugs (bDMARDs) were included in the study. In 2018, post-intervention, the clinic was re-assessed. Demographics, diagnosis, medications, smart phone access, and willingness to use this for vaccination reminders were assessed for independent vaccination predictors using binary logistic regression analysis.

RESULTS

Four hundred twenty-five patients were included (72.6% rheumatoid arthritis, 74% women, 45.6% ≥ 60 years old). From 2017 to 2018, PPSV23 vaccination rates changed from 41.0 to 47.2% (P = 0.29) and influenza from 61.8 to 62.1% (P = 0.95). The most common reason for non-vaccination was lack of awareness. Following the intervention, this changed for influenza (36.7 to 34.2%) and PPSV23 (82.1 to 76.4%). General practitioners performed most vaccinations, only 3.6% were delivered in the hospital. Significant predictors of PPSV23 vaccination were older age {≥ 80 years had an OR 41.66 (95% CI 3.69-469.8, P = 0.003), compared with ≤ 39 years}, bDMARD use (OR 2.80, 95% CI 1.24-6.32, P = 0.013), and adequate influenza vaccination (OR 9.01, 95% CI 4.40-18.42, P < 0.001). Up-to-date PPSV23 vaccination (OR 8.93, 95% CI 4.39-18.17, P < 0.001) predicted influenza vaccination.

CONCLUSIONS

PPSV23 and influenza vaccination rates were suboptimal. The intervention did not cause a statistically significant change in vaccination rates. Point-of-care vaccination may be more effective.Key Points• Low vaccination rates amongst immunosuppressed inflammatory arthritis outpatients• Less than 5% of vaccinations occurred in hospital• There was no statistically significant difference in the rates of adequate PPSV23 (41.0 to 47.2%) or influenza (61.8 to 62.1%) vaccination following our intervention.

Cardiovascular Disease Risk in Older Adults and Elderly Patients with Rheumatoid Arthritis: What Role Can Disease-Modifying Antirheumatic Drugs Play in Cardiovascular Risk Reduction?

The prevalence of rheumatoid arthritis (RA), the most common autoimmune inflammatory arthritis, is increasing, partly due to the aging of the general population. RA is an independent risk factor for the development of cardiovascular disease (CVD). Older adults and elderly patients with RA develop CVD at a younger age compared with their general population peers. Both the traditional cardiovascular risk factors (age, sex, smoking, diabetes mellitus, hypertension), and systemic inflammation (i.e. high disease activity) are contributors to accelerated CVD in people with RA. Of the disease-modifying antirheumatic drugs (DMARDs) used for RA treatment, methotrexate, triple combination oral therapy (methotrexate, sulfasalazine, and hydroxychloroquine), tumor necrosis factor inhibitor biologicals, and abatacept have the strongest data in favor of the reduction of cardiovascular events in patients with RA. A treat-to-target strategy should be employed in older adults and elderly patients with RA to ensure appropriate reduction in cardiovascular risk, which can also prevent short- and long-term musculoskeletal disability. Our review findings are in line with the 2016 European League Against Rheumatism guideline recommendations, specifically: (1) RA disease activity should be controlled with an optimal DMARD regimen using a treat-to-target approach; (2) the lipid profile should be assessed and monitored in every older adult and elderly RA patient; (3) CVD risk factors, including smoking cessation, blood pressure, and blood glucose control, should be optimized; (4) RA treatment should be initiated as soon as possible; and (5) shared decision making regarding the treatment of patients with RA should include a discussion on the potential amelioration of increased cardiovascular risk.

Predisposing factors to nonfatal cardiovascular events in women with systemic lupus erythematosus. An observational, cross-sectional, multicenter study in Spain from the risk/systemic lupus erythematosus thematic network

Very few studies have been published on cardiovascular morbidity in Spanish patients diagnosed with systemic lupus erythematosus (SLE). Moreover, knowledge of the predictive factors for the occurrence of nonfatal events in this group of patients is scarce.This was a multicenter, observational, cross-sectional study designed to ascertain the prevalence of nonfatal cardiovascular risk factors and cardiovascular events (CVEs) in 335 Spanish women diagnosed with SLE between 2003 and 2013.The average patient age was 36.0 years (range: 26.4-45.6); 35 patients (10.7%) experienced at least 1 CVE, which most frequently affected the brain, followed by the heart, and finally, the peripheral vasculature. Both the number of admissions because of SLE (95% confidence interval [CI] odds ratio [OR] = 1.024-1.27, P = .017) and the systemic lupus international collaborating clinics (SLICC) chronicity index score (95% CI OR = 1.479-2.400, P = .000) resulted in an increase in the OR of these patients presenting a CVE. Regarding the classic risk factors, only the interaction between hypertension (HT) and treatment with antihypertensive drugs influenced the presence of CVEs (95% CI OR = 2.165-10.377, P = .000). The presence of a family history of early cardiovascular disease was also related to CVEs (95% CI OR = 2.355-40.544, P = .002). Binary logistic regression including the above factors resulted in a model in which the 3 main variables in each group persisted, implying that they must be independent of each other. However, the weight of the interaction between the family history of early cardiovascular disease and the interaction between HT and the use of antihypertensives was higher than for the number of admissions for SLE.The SLE disease activity over time (measured using the SLICC) and the number of hospital admissions due to the disease itself, both increase the risk of women with SLE presenting a CVE. Classic cardiovascular risk factors, especially HT and its treatment, as well as a family history of early CVEs, should be considered when assessing the risk of nonfatal CVEs in women with SLE.

Long-term safety and efficacy of sarilumab plus methotrexate on disease activity, physical function and radiographic progression: 5 years of sarilumab plus methotrexate treatment

Objective

In MOBILITY (NCT01061736), sarilumab significantly reduced disease activity, improved physical function and inhibited radiographic progression at week 52 versus placebo in patients with rheumatoid arthritis (RA) and an inadequate response to methotrexate. We report 5-year safety, efficacy and radiographic outcomes of sarilumab from NCT01061736 and the open-label extension (EXTEND; NCT01146652), in which patients received sarilumab 200 mg every 2 weeks (q2w) + methotrexate.

Methods

Patients (n=1197) with moderately to severely active RA were initially randomised to placebo, sarilumab 150 mg or sarilumab 200 mg subcutaneously q2w plus weekly methotrexate for 52 weeks. Completers were eligible to enrol in the open-label extension and receive sarilumab 200 mg q2w + methotrexate.

Results

Overall, 901 patients entered the open-label extension. The safety profile remained stable over 5-year follow-up and consistent with interleukin-6 receptor blockade. Absolute neutrophil count <1000 cells/mm³ was observed but not associated with increased infection rate. Initial treatment with sarilumab 200 mg + methotrexate was associated with reduced radiographic progression over 5 years versus sarilumab 150 mg + methotrexate or placebo + methotrexate (mean±SE change from baseline in van der Heijde-modified Total Sharp Score: 1.46±0.27, 2.35±0.28 and 3.68±0.27, respectively (p<0.001 for each sarilumab dose versus placebo)). Clinical efficacy was sustained through 5 years according to Disease Activity Score (28-joint count) using C reactive protein, Clinical Disease Activity Index (CDAI) and Health Assessment Questionnaire-Disability Index. The number of patients achieving CDAI ≤2.8 at 5 years was similar among initial randomisation groups (placebo, 76/398 (19%); sarilumab 150 mg, 68/400 (17%); sarilumab 200 mg, 84/399 (21%)).

Conclusion

Clinical efficacy, including inhibition of radiographic progression, reduction in disease activity and improvement in physical function, was sustained with sarilumab + methotrexate over 5 years. Safety appeared stable over the 5-year period.

Tumor necrosis factor inhibitors are associated with reduced complement activation in spondylarthropathies: An observational study

BACKGROUND

The complement system is involved in pathogenesis of cardiovascular disease, and might play a role in accelerated atherogenesis in spondylarthropathies (SpA). Hence, we examined complement activation in SpA, and its relationship to antirheumatic treatment, inflammatory and cardiovascular markers.

METHODS

From PSARA, a prospective observational study, we examined 51 SpA patients (31 psoriatic arthritis (PsA), and 20 ankylosing spondylitis (AS)), starting tumor necrosis factor (TNF) inhibitor alone (n = 25), combined with methotrexate (MTX) (n = 10), or MTX monotherapy (n = 16). Complement activation was determined by the soluble terminal complement complex (sC5b-9), inflammation by erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), and endothelial function by finger plethysmography (Endopat) at baseline, after 6 weeks and 6 months of treatment.

RESULTS

SpA patients had sC5b-9 levels at (PsA) or above (AS) the upper limit of the estimated reference range. Median sC5b-9 levels decreased significantly from baseline to 6 weeks, with no significant difference between the AS and PsA group. Notably, a significant reduction in sC5b-9 was observed after administration of TNF inhibitor ± MTX, whereas no significant changes were observed in patients treated with MTX alone. Between 6 weeks and 6 months, sC5b-9 remained stable across all subgroups. Reduction in sC5b-9 was independently related to decreased ESR and CRP, and to increased high density cholesterol and total cholesterol. Reduction in sC5b-9 from baseline to 6 weeks was associated with improved EF in age and gender adjusted analyses.

CONCLUSION

TNF-inhibition, but not MTX monotherapy, led to rapid and sustained reduction of complement activation in SpA. Thus, the observed decrease in cardiovascular morbidity in patients treated with TNF-inhibitors might be partly due to its beneficial effect on complement.

TRIAL REGISTRATION

Clinical Trials (NCT00902005), retrospectively registered on the 14th of May 2009.

Comorbidity burden in systemic sclerosis: beyond disease-specific complications

Systemic sclerosis (SSc) is a chronic, systemic disease characterized by fibrosis of the skin and internal organs, vasculopathy, and auto-immune activation. On the top of severe organ involvement such as interstitial lung and myocardial fibrosis, pulmonary hypertension, and renal crisis, individuals diagnosed with SSc may suffer from a number of comorbidities. This is a narrative review according to published recommendations and we searched the online databases MEDLINE and EMBASE using as key words the following terms: systemic sclerosis, scleroderma, myocardial fibrosis in combination with micro- and macro-vascular disease, cardiac involvement, atherosclerosis, cardiovascular disease and coronary arteries, infections, cancer, depression, osteoporosis, and dyslipidemia. Although data are usually inconclusive it appears that comorbidities with significant impact on life expectancy, namely cardiovascular disease, infections, and cancer as well as phycological disorders affecting emotional and mental health are highly prevalent in SSc population. Thereafter, the aim of this review is to summarize the occurrence and the clinical significance of such comorbidities in SSc population and to discuss how rheumatologists can incorporate the management of these conditions in daily clinical practice.

Vascular Inflammation and Oxidative Stress: Major Triggers for Cardiovascular Disease

Cardiovascular disease is a leading cause of death and reduced quality of life, proven by the latest data of the Global Burden of Disease Study, and is only gaining in prevalence worldwide. Clinical trials have identified chronic inflammatory disorders as cardiovascular risks, and recent research has revealed a contribution by various inflammatory cells to vascular oxidative stress. Atherosclerosis and cardiovascular disease are closely associated with inflammation, probably due to the close interaction of inflammation with oxidative stress. Classical therapies for inflammatory disorders have demonstrated protective effects in various models of cardiovascular disease; especially established drugs with pleiotropic immunomodulatory properties have proven beneficial cardiovascular effects; normalization of oxidative stress seems to be a common feature of these therapies. The close link between inflammation and redox balance was also supported by reports on aggravated inflammatory phenotype in the absence of antioxidant defense proteins (e.g., superoxide dismutases, heme oxygenase-1, and glutathione peroxidases) or overexpression of reactive oxygen species producing enzymes (e.g., NADPH oxidases). The value of immunomodulation for the treatment of cardiovascular disease was recently supported by large-scale clinical trials demonstrating reduced cardiovascular mortality in patients with established atherosclerotic disease when treated by highly specific anti-inflammatory therapies (e.g., using monoclonal antibodies against cytokines). Modern antidiabetic cardiovascular drugs (e.g., SGLT2 inhibitors, DPP-4 inhibitors, and GLP-1 analogs) seem to share these immunomodulatory properties and display potent antioxidant effects, all of which may explain their successful lowering of cardiovascular risk.

Association Between Comorbidities and Quality of Life in Psoriatic Arthritis: Results from a Multicentric Cross-sectional Study

OBJECTIVE

In psoriatic arthritis (PsA), comorbidities add to the burden of disease, which may lead to poorer quality of life. The purpose of this study was to evaluate the relationship between comorbidities and quality of life (QOL).

METHODS

Patients from a multicentric, cross-sectional study on comorbidities in PsA were included in the analysis. Data on comorbidities were collected and were subsequently used to compute the modified Rheumatic Disease Comorbidity Index (mRDCI). The Medical Outcomes Study Short Form-36 questionnaire physical (PCS) and mental component summary (MCS) scales were used to assess QOL.

RESULTS

In total, 124 recruited patients fulfilled the ClASsification for Psoriatic ARthritis criteria (CASPAR): 62.1% were male; mean age and mean disease duration were 52.6 ± 12.6 years and 11.3 ± 9.6 years, respectively. The number of comorbid conditions was 2.0 ± 1.3, with 30.6% of the sample having currently or a history of 3 or more comorbidities. In the multivariate linear regression analysis, only anxiety remained significantly related to mental health (p < 0.0001). Anxiety alone accounted for 28.7% of the variance in MCS scores. Moreover, MCS was also significantly associated with the mRDCI score, which explained 4.9% of the variance in MCS [β = -1.56 (standard error 0.64), R² = 0.049, p = 0.0167]. In contrast, PCS was not significantly associated either with type or number of comorbidities.

CONCLUSION

In this study, the type of comorbidity appeared to have a greater effect than the number of comorbidities. Indeed, anxiety in PsA was independently associated with QOL and would thus be an important factor to take into account in daily clinical practice.

Screening for and management of comorbidities after a nurse-led program: results of a 3-year longitudinal study in 769 established rheumatoid arthritis patients

Background/purpose

Cardiovascular (CV) risk, cancer, infections and osteoporosis should be screened for in rheumatoid arthritis (RA). The objective was to assess 3-year effects of a nurse visit for comorbidity counselling.

Methods

This was an open long-term (3 years) extension of the Comorbidities and Education in Rheumatoid Arthritis 6-month randomised controlled trial in which patients with definite, stable RA were visiting a nurse for comorbidity counselling. Comorbidity status was assessed and nurses provided advice on screening and management, at baseline and 3 years later. A score was developed to quantify comorbidity screening and management: 0–100, where lower scores indicate better screening and management. The score was compared between baseline and 3-year assessment using a Wilcoxon test for paired data.

Results

Of the 970 recruited patients, 776 (80%) were followed-up at 2–4 years and 769 (79%) had available data for comorbidities at both time points: mean (±SD) age 58 (±11) years and mean disease duration 14 (±10) years; 614 (80%) were women, the mean Disease Activity Score 28 was 3.0±1.3, and 538 (70%) were receiving a biologic. At baseline, the mean comorbidity screening score was 36.6 (±19.9) and it improved at 3 years to 24.3 (±17.8) (p<0.0001), thus with a relative improvement of 33% (improvement of 12 points). CV risk screening, vaccination status and bone densitometry performance improved the most.

Conclusions

Comorbidity screening was suboptimal but improved notably over 3 years, after a nurse-led programme aiming at checking systematically for comorbidity screening and giving patient advice. This long-term efficacy pleads in favour of nurse-led interventions to better address comorbidities in RA.

Trial registration number

NCT01315652

Biologics and Cardiovascular Disease

The advent of biologic therapy has enhanced our ability to augment disease in an increasingly targeted manner. The use of biologics in cardiovascular disease (CVD) has steadily increased over the past several decades. Much of the early data on biologics and CVD were derived from their use in rheumatologic populations. Atherosclerosis, myocardial infarction, and heart failure have been closely linked to the inflammatory response. Accordingly, cytokines such as tumor necrosis factor (TNF)-alpha and interleukin (IL)-1 have been targeted. Noninflammatory mediators, such as proprotein convertase subtilisin kexin type 9 (PCSK9), have been selected for therapeutic intervention as well. Furthermore, RNA interference (RNAi) therapy has emerged and may serve as another targeted therapeutic mechanism. Herein, we will review the history, obstacles, and advances in using biologic therapy for CVD.