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Kim JW, Yoon JS, Park S, Kim H, Lee JS, Choe JY. Risk of cardiovascular disease with high-dose versus low-dose use of non-steroidal anti-inflammatory drugs in ankylosing spondylitis. Ann Rheum Dis 2024; 83:1028-1033. [PMID: 38594057 DOI: 10.1136/ard-2023-225406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/29/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE To investigate the risk of cardiovascular disease (CVD) associated with increasing dose of a non-steroidal anti-inflammatory drug (NSAID) in patients with ankylosing spondylitis (AS). METHODS Using the Korean National Health Insurance database, patients newly diagnosed with AS without prior CVD between 2010 and 2018 were included in this nationwide cohort study. The primary outcome was CVD, a composite outcome of ischaemic heart disease, stroke or congestive heart failure. Exposure to NSAIDs was evaluated using a time-varying approach. The dose of NSAIDs was considered in each exposure period. Cox proportional hazard regression was used to investigate the risk of CVD associated with NSAID use. RESULTS Of the 19 775 patients (mean age, 36 years; 75% were male), 19 706 received NSAID treatment. During follow-up period of 98 290 person-years, 1663 cases of CVD occurred including 1157 cases of ischaemic heart disease, 301 cases of stroke and 613 cases of congestive heart failure. Increasing dose of NSAIDs was associated with incident CVD after adjusting for confounders (adjusted HR (aHR) 1.10; 95% CI 1.08 to 1.13). Specifically, increasing dose of NSAIDs was associated with incident ischaemic heart disease (aHR 1.08; 95% CI 1.05 to 1.11), stroke (aHR 1.09; 95% CI 1.04 to 1.15) and congestive heart failure (aHR 1.12; 95% CI 1.08 to 1.16). The association between NSAID dose and higher CVD risk was consistent in different subgroups. CONCLUSION In a real-world AS cohort, higher dose of NSAID treatment was associated with a higher risk of CVD, including ischaemic heart disease, stroke and congestive heart failure.
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Affiliation(s)
- Ji-Won Kim
- Division of Rheumatology, Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea (the Republic of)
| | - Jun Sik Yoon
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea (the Republic of)
| | - Sojeong Park
- Data Science Team, Hanmi Pharm Co Ltd, Seoul, Korea (the Republic of)
| | - Hasung Kim
- Data Science Team, Hanmi Pharm Co Ltd, Seoul, Korea (the Republic of)
| | - Ji Sung Lee
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (the Republic of)
| | - Jung-Yoon Choe
- Division of Rheumatology, Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea (the Republic of)
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Liu P, Shang J, Qi Z, Qiu S, Lai X, Shi L, Zhang Z, Li M, Yang L. Association of ankylosing spondylitis with cardiovascular disease: a bidirectional two-sample mendelian randomization study. Front Genet 2024; 15:1260247. [PMID: 38988836 PMCID: PMC11233527 DOI: 10.3389/fgene.2024.1260247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 06/04/2024] [Indexed: 07/12/2024] Open
Abstract
Backgrounds Current observational investigations hint at a potential linkage between ankylosing spondylitis and cardiovascular wellness. However, the nature of this causality remains to be elucidated. Consequently, this study is designed to evaluate the causal interconnection between ankylosing spondylitis and cardiovascular-related conditions utilizing a bidirectional two-sample Mendelian Randomization (MR) methodology. Methods In this study, we conducted Mendelian randomization (MR) analyses using genome-wide association study (GWAS) data. The fixed-effects inverse variance weighted (IVW) model was used as the primary analysis method, and MR-Egger regression and the weighted median method were employed as supplementary approaches. Horizontal pleiotropy and heterogeneity were evaluated using various statistical tests, including MR-PRESSO global test, MR-Egger intercept, and Cochran's Q test. Results The MR result demonstrated an increased risk of heart failure in individuals with ankylosing spondylitis (OR: 1.0132, 95% CI = 1.0043-1.0221, p = 0.003). The MR analysis results did not demonstrate a causal relationship between ankylosing spondylitis and other cardiovascular diseases, such as atrial fibrillation, coronary artery disease, ischemic stroke, myocardial infarction, and valvular heart disease (all p > 0.05). No evidence of reverse causality was found between ankylosing spondylitis and mentioned cardiovascular diseases in reverse MR analyses. Sensitivity analysis verified the reliability of the results. Conclusion Our MR study indicates a relationship between ankylosing spondylitis and an increased risk of heart failure. Further research is needed to confirm these findings and elucidate the underlying mechanisms involved.
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Affiliation(s)
- Pengyu Liu
- Department of Cardiology, Beijing Traditional Chinese Medicine Hospital, Capital Medical University, Beijing, China
| | - Juju Shang
- Department of Cardiology, Beijing Traditional Chinese Medicine Hospital, Capital Medical University, Beijing, China
| | - Zhi Qi
- Department of Ultrasound, Beijing Traditional Chinese Medicine Hospital, Capital Medical University, Beijing, China
| | - Shenglei Qiu
- Department of Cardiology, Beijing Traditional Chinese Medicine Hospital, Capital Medical University, Beijing, China
| | - Xiaolei Lai
- Department of Cardiology, Beijing Traditional Chinese Medicine Hospital, Capital Medical University, Beijing, China
| | - Lixiao Shi
- Department of Cardiology, Beijing Traditional Chinese Medicine Hospital, Capital Medical University, Beijing, China
| | - Zhenmin Zhang
- Department of Cardiology, Beijing Traditional Chinese Medicine Hospital, Capital Medical University, Beijing, China
| | - Mingxuan Li
- Department of Cardiology, Beijing Traditional Chinese Medicine Hospital, Capital Medical University, Beijing, China
| | - Linjing Yang
- Department of Cardiology, Beijing Traditional Chinese Medicine Hospital, Capital Medical University, Beijing, China
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Mocritcaia A, Chacur C, Adao Abe CD, Azuaga-Piñango AB, Frade-Sosa B, Sarmiento-Monroy JC, Alascio L, Gómez-Puerta JA, Sanmartí R, Cañete JD, Ramírez J. Clinical and structural damage outcomes in axial spondyloarthritis patients receiving NSAIDs or advanced therapies: a description of a real-life cohort. Front Med (Lausanne) 2024; 11:1425449. [PMID: 38966536 PMCID: PMC11222589 DOI: 10.3389/fmed.2024.1425449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 06/10/2024] [Indexed: 07/06/2024] Open
Abstract
Introduction This study aims to describe the clinical characteristics, disease activity, and structural damage in patients with axial spondyloarthritis (axSpA) who receive chronic treatment with nonsteroideal anti-inflammatory drugs (NSAIDs) or advanced therapies in a clinical setting. Methods Cross-sectional study on axSpA patients consecutively recruited from the outpatient clinic of a tertiary hospital. We collected data on clinical and demographic characteristics, as well as treatment patterns involving NSAIDs and advanced therapies. Structural damage was assessed using mSASSS. Results Overall, data from 193 axSpA patients (83% ankylosing spondylitis) were gathered, with a mean disease duration of 21.4 years. Of these, 85 patients (44%) were exclusively taking NSAIDs, while 108 (56%) were receiving advanced therapies, with TNF inhibitors being the predominant choice (93 out of 108, 86.1%). Among patients using NSAIDs, 64.7% followed an on-demand dosing regimen, while only 17.6% used full doses. Disease activity was low, with a mean BASDAI of 3.1 and a mean ASDAS-CRP of 1.8. In comparison to patients under chronic NSAID treatment, those taking advanced therapies were primarily male (69.4% versus 51.8%, p = 0.025) and significantly younger (mean age of 49 versus 53.9 years, p = 0.033). Additionally, patients on advanced therapies exhibited lower ASDAS-CRP (p = 0.046), although CRP serum levels and BASDAI scores did not differ between the two groups. In the multivariable analysis, therapy (NSAID versus biological treatment) was not independently associated with ASDAS-CRP, BASDAI or mSASSS. Conclusion This cross-sectional analysis of a real-world cohort of axSpA patients shows positive clinical and radiological outcomes for both NSAIDs and advanced therapies.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Julio Ramírez
- Rheumatology Department, Hospital Clínic, Barcelona, Spain
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4
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Hintenberger R, Affenzeller B, Vladychuk V, Pieringer H. Cardiovascular risk in axial spondyloarthritis-a systematic review. Clin Rheumatol 2023; 42:2621-2633. [PMID: 37418034 PMCID: PMC10497445 DOI: 10.1007/s10067-023-06655-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/25/2023] [Accepted: 05/28/2023] [Indexed: 07/08/2023]
Abstract
Cardiovascular manifestations are common in patients suffering axial spondyloarthritis and can result in substantial morbidity and disease burden. To give an overview of this important aspect of axial spondyloarthritis, we conducted a systematic literature search of all articles published between January 2000 and 25 May 2023 on cardiovascular manifestations. Using PubMed and SCOPUS, 123 out of 6792 articles were identified and included in this review. Non-radiographic axial spondyloarthritis seems to be underrepresented in studies; thus, more evidence for ankylosing spondylitis exists. All in all, we found some traditional risk factors that led to higher cardiovascular disease burden or major cardiovascular events. These specific risk factors seem to be more aggressive in patients with spondyloarthropathies and have a strong connection to high or long-standing disease activity. Since disease activity is a major driver of morbidity, diagnostic, therapeutic, and lifestyle interventions are crucial for better outcomes. Key Points • Several studies on axial spondyloarthritis and associated cardiovascular diseases have been conducted in the last few years addressing risk stratification of these patients including artificial intelligence. • Recent data suggest distinct manifestations of cardiovascular disease entities among men and women which the treating physician needs to be aware of. • Rheumatologists need to screen axial spondyloarthritis patients for emerging cardiovascular disease and should aim at reducing traditional risk factors like hyperlipidemia, hypertension, and smoking as well as disease activity.
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Affiliation(s)
- Rainer Hintenberger
- Department for Internal Medicine II, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstraße 9, 4020 Linz and Altenbergerstraße 69, 4040, Linz, Austria.
| | - Barbara Affenzeller
- Department for Internal Medicine II, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstraße 9, 4020 Linz and Altenbergerstraße 69, 4040, Linz, Austria
| | - Valeriia Vladychuk
- Department for Internal Medicine II, Kepler University Hospital GmbH, Krankenhausstraße 9, 4020, Linz, Austria
| | - Herwig Pieringer
- Diakonissen Hospital Linz, Linz, Austria and Paracelsus Private Medical University Salzburg, Salzburg, Austria
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Ma KSK, Lee YH, Lin CJ, Shih PC, Wei JCC. Management of extra-articular manifestations in spondyloarthritis. Int J Rheum Dis 2023; 26:183-186. [PMID: 36703270 DOI: 10.1111/1756-185x.14485] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/07/2022] [Accepted: 10/18/2022] [Indexed: 01/28/2023]
Affiliation(s)
- Kevin Sheng-Kai Ma
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Graduate Institute of Biomedical Electronics and Bioinformatics, College of Electrical Engineering and Computer Science, National Taiwan University, Taipei, Taiwan.,Department of Dermatology, Massachusetts General Hospital, Boston, USA
| | - Yung-Heng Lee
- Department of Orthopedics, Cishan Hospital, Ministry of Health and Welfare, Kaohsiung, Taiwan.,Institute of Medical Science and Technology, National Sun Yat-sen University, Kaohsiung, Taiwan.,Department of Senior Services Industry Management, Minghsin University of Science and Technology, Hsinchu, Taiwan.,Department of Recreation and Sport Management, Shu-Te University, Kaohsiung, Taiwan
| | - Chia-Jen Lin
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Po-Cheng Shih
- Division of Allergy, Immunology & Rheumatology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan.,Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - James Cheng-Chung Wei
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Division of Allergy, Immunology & Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan.,Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
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Ku CH, Lee YH, Wei JCC, Braun J. Current aspects for the treatment of axial spondyloarthritis. Int J Rheum Dis 2023; 26:5-7. [PMID: 36591903 DOI: 10.1111/1756-185x.14473] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 10/03/2022] [Indexed: 01/03/2023]
Affiliation(s)
- Chiao-Hsin Ku
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Yung-Heng Lee
- Department of Orthopedics, Cishan Hospital, Ministry of Health and Welfare, Kaohsiung, Taiwan.,Institute of Medical Science and Technology, National Sun Yat-sen University, Kaohsiung, Taiwan.,Department of Senior Services Industry Management, Minghsin University of Science and Technology, Hsinchu, Taiwan.,Department of Recreation and Sport Management, Shu-Te University, Kaohsiung, Taiwan
| | - James Cheng-Chung Wei
- Department of Allergy, Immunology & Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan.,Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
| | - Jürgen Braun
- Rheumazentrum Ruhrgebiet, Herne, Germany and Ruhr-University Bochum, Bochum, Germany
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7
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Shi LH, Lam SH, So H, Li EK, Li TK, Szeto CC, Tam LS. High inflammatory burden predicts cardiovascular events in patients with axial spondyloarthritis: a long-term follow-up study. Ther Adv Musculoskelet Dis 2022; 14:1759720X221122401. [PMID: 36105413 PMCID: PMC9465578 DOI: 10.1177/1759720x221122401] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/30/2022] [Indexed: 11/16/2022] Open
Abstract
Background Axial spondyloarthritis (axSpA) patients are at higher risk of cardiovascular (CV) disease (CVD) than the general population, partly due to consequences of inflammation or its treatment. But relationship between inflammation in axSpA and cardiovascular events (CVE) is unknown. Objectives To examine whether inflammatory burden over time can predict CVE independent of baseline CV risk factors in axSpA patients. Design A cohort analysis was performed in patients who had been recruited since January 2001. The primary outcome was a first CVE occurring between January 2001 and December 2020. Methods Three CVD risk scores were computed at baseline. The performance of the original and modified (*1.5 multiplication factor) CV risk algorithms were assessed. Time-varying Cox proportional hazard models and Kaplan-Meier survival analysis were used to assess whether inflammatory burden (Bath ankylosing spondylitis disease activity index [BASDAI] and inflammatory markers), nonsteroidal anti-inflammatory drugs (NSAIDs) and disease modifying antirheumatic drugs (DMARDs) can predict the development of first CVE. Results 463 patients (35 [26-45] years, male: 360 [77.8%]) were recruited. After a median follow-up of 12 (7-19) years, 61 patients (13.2%) experienced a first CVE. Traditional/modified CV risk scores underestimated CV risk. Erythrocyte sedimentation rate (ESR) ⩾ 20 mm/h was associated with a significantly higher risk of CVE during follow-up (HR: 2.07, 95%CI [1.10, 3.98], p = 0.008). Active disease as indicated by a rising BASDAI also showed positive trend towards a higher risk of developing CVE over time. After adjusting for CV risk scores in the multivariable models, high ESR level (ESR ⩾ 20 mm/h) over time remained significantly associated with a higher risk of developing CV events. Conclusion Increased inflammatory burden as reflected by elevated ESR levels (ESR ⩾ 20) was associated with increased risk of CVE, while the use of NSAIDs and DMARDs were not.
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Affiliation(s)
- Lin-Hong Shi
- Department of Medicine & Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Steven H Lam
- Department of Medicine & Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Ho So
- Department of Medicine & Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Edmund K Li
- Department of Medicine & Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Tena K Li
- Department of Medicine & Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Cheuk-Chun Szeto
- Department of Medicine & Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Lai-Shan Tam
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, New Territories 999077, Hong Kong
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8
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Huang JX, Lee YH, Cheng-Chung Wei J. Benefits of tumor necrosis factor inhibitors for cardiovascular disease in ankylosing spondylitis. Int Immunopharmacol 2022; 112:109207. [PMID: 36067655 DOI: 10.1016/j.intimp.2022.109207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/21/2022] [Accepted: 08/27/2022] [Indexed: 11/05/2022]
Abstract
Ankylosing spondylitis (AS) has been associated with an increased cardiovascular disease (CVD) risk, with current guidelines recommending multiple CVD-related risk assessment strategies. CVD risk prediction using a scoring model with lipids might be another promising alternative, for which ultrasound screening for subclinical atherosclerosis may be considered together with surrogate markers. Theoretically, tumor necrosis factor inhibitors (TNFi), which are known to inhibit endothelial activation and inflammation caused by the disease and underlying metabolic dysfunction, might prevent microvascular events. In this narrative review, we summarized the evidence of TNFi effects on CVD in AS. Although early case reports revealed that CVD occurred during TNFi treatment, more recent evidence shows that it could be successfully treated. Studies of TNFi on lipid changes and subclinical atherosclerosis have shown controversial results, possibly due to genetic predisposition, differences in affinity for membrane-bound TNF leading to insufficient inhibition of inflammation or primary failure response to TNFi, and not enough follow-up time to identify potential significance. Overall, patients vulnerable to CVD could benefit from long-term administration of TNFi when inflammation is under control. Besides healthy lifestyle modification, traditional CVD risk factors and metabolic syndrome-related diseases should be further assessed and treated if necessary.
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Affiliation(s)
- Jin-Xian Huang
- Division of Rheumatology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Yung-Heng Lee
- Department of Senior Services Industry Management, Minghsin University of Science and Technology, Hsinchu, Taiwan; Department of Recreation and Sport Management, Shu-Te University, Kaohsiung, Taiwan; Department of Orthopedics, Cishan Hospital, Ministry of Health and Welfare, Kaohsiung, Taiwan
| | - James Cheng-Chung Wei
- Department of Allergy, Immunology & Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan; Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan.
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9
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Hadi Y, Or T, Moady G, Atar S. Psoriasis and coronary heart disease-not as severe as predicted. QJM 2022; 115:388-392. [PMID: 34165570 DOI: 10.1093/qjmed/hcab173] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 06/12/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Psoriasis is a systemic disorder involved in several disease processes, including cancer, metabolic syndrome and cardiovascular disease (CVD). Previous studies showed that psoriasis is most likely an independent risk factor for CVD, yet the extent of its impact on CVD and the extent of coronary artery disease (CAD) remains unclear. We investigated the correlation of psoriasis to the severity of CAD in age and gender-matched patients with CAD with and without psoriasis. METHODS This is a retrospective, case-control study of 59 patients with psoriasis who underwent coronary angiography were matched using a computer software to 59 patients without psoriasis according to age, gender, smoking status, hyperlipidemia, hypertension and diabetes. CAD severity was defined according to number of affected vessels (single vs. multiple) and location of lesions (proximal vs. distal). RESULTS CAD severity was significantly higher in the control group compared to the psoriasis group (P = 0.038). Among patients with psoriasis, 20.3% were disease free or with low severity (42.4%), while only 37.3% had severe CAD. Among patients without psoriasis, the majority had severe CAD (57.6%), followed by low severity (30.5%) or disease free (11.9%). We did not find an association of prior treatment with anti-inflammatory medications and the severity of CAD. CONCLUSIONS Our results show that although psoriasis may be a risk factor for CAD, psoriatic patients have a less severe CAD compared to the general population. The use of anti-inflammatory medications does not explain this finding.
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Affiliation(s)
- Y Hadi
- Department of Cardiology, Galilee Medical Center, 1 Ben Tzvi Blvd., Nahariya 2210001, Israel
| | - T Or
- From the Azrieli Faculty of Medicine, 8 Szold St., Safed 1311502, Israel
- Department of Cardiology, Galilee Medical Center, 1 Ben Tzvi Blvd., Nahariya 2210001, Israel
| | - G Moady
- From the Azrieli Faculty of Medicine, 8 Szold St., Safed 1311502, Israel
- Department of Cardiology, Galilee Medical Center , 1 Ben Tzvi Blvd., Nahariya 2210001, Israel
| | - S Atar
- From the Azrieli Faculty of Medicine , 8 Szold St., Safed 1311502, Israel
- Department of Cardiology, Galilee Medical Center, 1 Ben Tzvi Blvd., Nahariya 2210001, Israel
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10
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Kao CM, Wang JS, Ho WL, Ko TM, Chen HM, Lin CH, Huang WN, Chen YH, Chen HH. Factors Associated with the Risk of Major Adverse Cardiovascular Events in Patients with Ankylosing Spondylitis: A Nationwide, Population-Based Case-Control Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19074098. [PMID: 35409780 PMCID: PMC8998897 DOI: 10.3390/ijerph19074098] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/22/2022] [Accepted: 03/28/2022] [Indexed: 01/27/2023]
Abstract
Background: Potential risk factors for major adverse cardiovascular events (MACE) in patients with ankylosing spondylitis (AS) requiring medical therapy should be investigated. Methods: We identified newly diagnosed AS patients without previous MACE from 2004 to 2012 using the National Health Insurance Research Database, matched MACE cases with non-MACE controls at a 1:4 ratio for age, gender, AS duration, and index date, and included 947 AS patients with MACE and 3896 matched controls for final analyses. By using conditional logistic regression analyses, we examined the associations of MACE with low income, urbanisation, comorbidities, common extra-articular manifestations (EAM), and medications, including nonsteroidal anti-inflammatory drugs (NSAID) of three categories (traditional NSAIDs, selective cyclooxygenase-2 inhibitors (COX-2i), and preferential COX-2is) with their annual cumulative defined daily dose (cDDD) within a year before MACE development. Results: MACE development was associated with the use of selective COX-2is (especially with annual cDDD > 132) and corticosteroids, residence in rural regions, and well-known associated comorbidities, but not with the use of traditional NSAIDs, preferential COX-2i, biologics, methotrexate, sulfasalazine, and common EAMs. Conclusions: The risk factors of MACE in newly diagnosed AS patients include residence in rural regions, well-known associated comorbidities, and the use of corticosteroids and selective COX-2is. A major limitation was the lack of information on individual lifestyle patterns and disease activity.
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Affiliation(s)
- Chung-Mao Kao
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-M.K.); (W.-N.H.); (Y.-H.C.)
| | - Jun-Sing Wang
- Division of Endocrinology and Metabolism, Department of Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan;
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- College of Medicine, National Chung Hsing University, Taichung 40227, Taiwan
| | - Wei-Li Ho
- Division of Allergy, Immunology and Rheumatology, Chiayi Branch, Taichung Veterans General Hospital, Chiayi 60090, Taiwan;
| | - Tai-Ming Ko
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu 30010, Taiwan;
- Institute of Bioinformatics and Systems Biology, National Yang Ming Chiao Tung University, Hsinchu 30010, Taiwan
- Institute of Biomedical Sciences, Academia Sinica, Taipei 11529, Taiwan
| | - Hsian-Min Chen
- Department of Medical Research, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (H.-M.C.); (C.-H.L.)
- Center for QUantitative Imaging in Medicine (CQUIM), Department of Medical Research, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- Department of Computer Science and Information Engineering, National United University, Miaoli 36063, Taiwan
- Institute of Biomedical Science and Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung 40227, Taiwan
| | - Ching-Heng Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (H.-M.C.); (C.-H.L.)
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung 40704, Taiwan
- Department of Healthcare Management, National Taipei University of Nursing and Health Sciences, Taipei 11219, Taiwan
- Department of Public Health, College of Medicine, Fu Jen Catholic University, New Taipei City 24205, Taiwan
| | - Wen-Nan Huang
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-M.K.); (W.-N.H.); (Y.-H.C.)
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- College of Medicine, National Chung Hsing University, Taichung 40227, Taiwan
| | - Yi-Hsing Chen
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-M.K.); (W.-N.H.); (Y.-H.C.)
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- College of Medicine, National Chung Hsing University, Taichung 40227, Taiwan
| | - Hsin-Hua Chen
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-M.K.); (W.-N.H.); (Y.-H.C.)
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung 40704, Taiwan
- Division of General Internal Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- Big Data Center, National Chung Hsing University, Taichung 40227, Taiwan
- Correspondence:
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da Cruz Lage R, Marques CDL, Oliveira TL, Resende GG, Kohem CL, Saad CG, Ximenes AC, Gonçalves CR, Bianchi WA, de Souza Meirelles E, Keiserman MW, Chiereghin A, Campanholo CB, Lyrio AM, Schainberg CG, Pieruccetti LB, Yazbek MA, Palominos PE, Goncalves RSG, Assad RL, Bonfiglioli R, Lima SMAAL, Carneiro S, Azevedo VF, Albuquerque CP, Bernardo WM, Sampaio-Barros PD, de Medeiros Pinheiro M. Brazilian recommendations for the use of nonsteroidal anti-inflammatory drugs in patients with axial spondyloarthritis. Adv Rheumatol 2021; 61:4. [PMID: 33468245 DOI: 10.1186/s42358-020-00160-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 12/29/2020] [Indexed: 01/04/2023] Open
Abstract
Spondyloarthritis (SpA) is a group of chronic inflammatory systemic diseases characterized by axial and/or peripheral joints inflammation, as well as extra-articular manifestations. Over some decades, nonsteroidal anti-inflammatory drugs (NSAIDs) have been the basis for the pharmacological treatment of patients with axial spondyloarthritis (axSpA). However, the emergence of the immunobiologic agents brought up the discussion about the role of NSAIDs in the management of these patients. The objective of this guideline is to provide recommendations for the use of NSAIDs for the treatment of axSpA. A panel of experts from the Brazilian Society of Rheumatology conducted a systematic review and meta-analysis of randomized clinical trials for 15 predefined questions. The Grading of Recommendations, Assessment, Development and Evaluation methodology to assess the quality of evidence and formulate recommendations were used, and at least 70% agreement of the voting panel was needed. Fourteen recommendations for the use of NSAIDs in the treatment of patients with axSpA were elaborated. The purpose of these recommendations is to support clinicians' decision making, without taking out his/her autonomy when prescribing for an individual patient.
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Affiliation(s)
- Ricardo da Cruz Lage
- Universidade Federal de Minas Gerais (UFMG), Alameda Álvaro Celso 175, Ambulatório Bias Fortes, 2° andar, Belo Horizonte, MG, 30150-260, Brazil.
| | | | | | - Gustavo Gomes Resende
- Universidade Federal de Minas Gerais (UFMG), Alameda Álvaro Celso 175, Ambulatório Bias Fortes, 2° andar, Belo Horizonte, MG, 30150-260, Brazil
| | | | | | | | | | | | | | | | - Adriano Chiereghin
- Pontifícia Universidade Católica (PUC) de Sorocaba, Sorocaba, SP, Brazil
| | | | - André Marun Lyrio
- Pontifícia Universidade Católica (PUC) de Campinas, Campinas, SP, Brazil
| | | | | | | | | | | | | | - Rubens Bonfiglioli
- Pontifícia Universidade Católica (PUC) de Campinas, Campinas, SP, Brazil
| | | | - Sueli Carneiro
- Universidade Federal do Rio De Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
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Walsh JA, Pei S, Penmetsa GK, Overbury RS, Clegg DO, Sauer BC. Identifying Patients With Axial Spondyloarthritis in Large Datasets: Expanding Possibilities for Observational Research. J Rheumatol 2020; 48:685-692. [PMID: 33259327 DOI: 10.3899/jrheum.200570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Observational research of axial spondyloarthritis (axSpA) is limited by a lack of methods for identifying diverse axSpA phenotypes in large datasets. Algorithms were previously designed to identify a broad spectrum of patients with axSpA, including patients not identifiable with diagnosis codes. The study objective was to estimate the performance of axSpA identification methods in the general Veterans Affairs (VA) population. METHODS A patient sample with known axSpA status (n = 300) was established with chart review. For feasibility, this sample was enriched with veterans with axSpA risk factors. Algorithm performance outcomes included sensitivities, positive predictive values (PPV), and F1 scores (an overall performance metric combining sensitivity and PPV). Performance was estimated with unweighted outcomes for the axSpA-enriched sample and inverse probability weighted (IPW) outcomes for the general VA population. These outcomes were also assessed for traditional identification methods using diagnosis codes for the ankylosing spondylitis (AS) subtype of axSpA. RESULTS The mean age was 54.7 and 92% were male. Unweighted F1 scores (0.59-0.74) were higher than IPW F1 scores (0.48-0.65). The full algorithm had the best overall performance (F1IPW 0.65). The Early Algorithm was the most inclusive (sensitivityIPW 0.90, PPVIPW 0.38). The traditional method using ≥ 2 AS diagnosis codes from rheumatology had the highest PPV (PPVIPW 0.84, sensitivityIPW 0.34). CONCLUSION The axSpA identification methods demonstrated a range of performance attributes in the general VA population that may be appropriate for various types of studies. The novel identification algorithms may expand the scope of research by enabling identification of more diverse axSpA populations.
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Affiliation(s)
- Jessica A Walsh
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA.
| | - Shaobo Pei
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA
| | - Gopi K Penmetsa
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA
| | - Rebecca S Overbury
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA
| | - Daniel O Clegg
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA
| | - Brian C Sauer
- J.A. Walsh, MD, MBA, MSCI, S. Pei, PhD, R.S. Overbury, MD, B.C. Sauer, PhD, G.K. Penmetsa, MD, D.O. Clegg, MD, Salt Lake City Veterans Affairs and University of Utah Medical Centers, Department of Internal Medicine, Divisions of Rheumatology and Epidemiology, Salt Lake City, Utah, USA
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Karmacharya P, Shahukhal R, Crowson CS, Murad MH, Davis JM, Shrestha P, Bekele D, Wright K, Chakradhar R, Dubreuil M. Effects of Therapies on Cardiovascular Events in Ankylosing Spondylitis: A Systematic Review and Meta-Analysis. Rheumatol Ther 2020; 7:993-1009. [PMID: 33170493 PMCID: PMC7695658 DOI: 10.1007/s40744-020-00248-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/19/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Non-steroidal anti-inflammatory drugs (NSAIDs) and tumor necrosis factor inhibitors (TNFi) are the most common therapies used in AS, however, the associated long-term cardiovascular risk is unclear. We performed a systematic review and meta-analysis on the association of therapies used for ankylosing spondylitis (AS) such as NSAIDs and TNFi on cardiovascular events (CVE) in AS. METHODS A comprehensive search was performed from database inception to May 29, 2020 to include controlled studies of AS treated with NSAIDs, oral small molecules, or biologics reporting CVE. Study-specific risk ratios (RR) were pooled using a random effects model. RESULTS Nine non-randomized studies from 1570 studies screened fulfilled inclusion criteria. Among NSAID users as a whole versus no NSAIDs, no increased risk of CVE (composite outcome) was observed; however, the risk of cerebrovascular accident was significantly lower (RR 0.58, 95% CI 0.37-0.93, I2 = 66%). Cox-2 inhibitor use was associated with reduced risk of all CVE (RR 0.48, 95% CI 0.33-0.70, I2 = 0%). Non-selective NSAIDs were not associated with any increased/decreased risk of any CVE. Meta-analysis of three studies of MI did not show a significant association with TNFi (RR 0.88, 95% CI 0.57-1.35, I2 = 76%). CONCLUSIONS In this meta-analysis of non-randomized studies, NSAID users as a whole and users of non-selective NSAIDs did not seem to have a higher risk of any CVE. Limited data suggest a lower risk of composite CVE outcome with Cox-2 inhibitors, unlike the increased risk reported in the general population. No significant association between TNFi and MI was observed. The certainty in evidence was very low due to all studies being observational. More studies are needed to study the association between TNFi use and CVE in general to evaluate a possible protective role in AS.
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Affiliation(s)
| | | | - Cynthia S Crowson
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, USA
| | - John M Davis
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Pragya Shrestha
- Precision Population Science Lab, Mayo Clinic, Rochester, MN, USA
| | - Delamo Bekele
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Kerry Wright
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
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Liew JW, Ward MM, Reveille JD, Weisman M, Brown MA, Lee M, Rahbar M, Heckbert SR, Gensler LS. Nonsteroidal Antiinflammatory Drug Use and Association With Incident Hypertension in Ankylosing Spondylitis. Arthritis Care Res (Hoboken) 2020; 72:1645-1652. [PMID: 31529687 PMCID: PMC7075727 DOI: 10.1002/acr.24070] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 09/10/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Nonsteroidal antiinflammatory drugs (NSAIDs) increase blood pressure and potentially cardiovascular burden, which may limit their use in ankylosing spondylitis (AS). Our objective was to determine the association of NSAID use with incident hypertension in a longitudinal AS cohort. METHODS Adults with AS were enrolled in a prospective cohort study of patient outcomes and examined every 4-6 months. Hypertension was defined by patient-reported hypertension; antihypertensive medication use; or, on 2 consecutive visits, systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg. Continuous NSAID use was dichotomized based on the validated NSAID index. We assessed the association of NSAID use as a time-varying exposure with the incidence of hypertension using Cox proportional hazards models. RESULTS Of the 1,282 patients in the cohort, 628 patients without baseline hypertension had at least 1 year of follow-up and were included in the analysis. Of these, 72% were male, the mean age at baseline was 39 ± 13 years, and 200 patients used NSAIDs continuously. On follow-up, 129 developed incident hypertension. After controlling for other variables, continuous NSAID use was associated with a hazard ratio of 1.12 for incident hypertension (95% confidence interval 1.04-1.20), compared to noncontinuous or no use. The association did not differ in subgroups defined by age, body mass index, biologic use, or disease activity. CONCLUSION In our prospective, longitudinal AS cohort, continuous NSAID use was associated with a 12% increased risk for the development of incident hypertension, as compared to noncontinuous or no NSAID use.
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Affiliation(s)
| | - Michael M Ward
- National Institute of Arthritis and Musculoskeletal and Skin Diseases/NIH, Bethesda, Maryland
| | - John D Reveille
- McGovern Medical School at the University of Texas Health Science Center at Houston, Houston
| | - Michael Weisman
- Cedars-Sinai Medical Center and David Geffen School of Medicine, University of California at Los Angeles
| | - Matthew A Brown
- Queensland University of Technology and Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - MinJae Lee
- McGovern Medical School at the University of Texas Health Science Center at Houston, Houston
| | - Mohammed Rahbar
- McGovern Medical School at the University of Texas Health Science Center at Houston, Houston
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15
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Lin KH, Luo CW, Chen SP, Tu DG, Lin MS, Kuan YH. α-Glucosidase Inhibitor Can Effectively Inhibit the Risk of Tuberculosis in Patients with Diabetes: A Nested Case-Control Study. BIOMED RESEARCH INTERNATIONAL 2020; 2020:8085106. [PMID: 32509871 PMCID: PMC7254087 DOI: 10.1155/2020/8085106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 04/23/2020] [Indexed: 11/23/2022]
Abstract
Diabetes mellitus (DM) and tuberculosis (TB) are major public health and economic burdens. DM increases Mycobacterium tuberculosis (M.tb) infection rates and treatment durations. This study evaluated the relationship between five classes of oral DM medications and TB infection risk in DM patients. We used longitudinal records from the Taiwan Longitudinal Health Insurance Research Database. DM patients were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 250 and A code A181. TB patients were identified using ICD-9-CM code 010.x-017.x. Oral DM medications were divided into five classes: sulfonylureas, biguanides, meglitinides, α-glucosidase inhibitors (AGIs), and thiazolidinediones. Users were classified as nonusers, low-concentration users, and high-concentration users. The incidence rate ratio (IRR) was derived using multivariate Poisson regression to calculate the relative risk of TB infection. DM patients using low- and high-concentration AGIs had significantly lower TB infection risks compared with nonusers. The IRRs of the sulfonylureas and AGI users were [CI] 0.693-0.948) and (95% CI 0.651-0.995), respectively. The other four classes of medications exhibited no significant effect on TB infection risk in DM patients. Furthermore, DM patients using high-concentration AGIs had a significantly lower TB infection risk compared with those using low-concentration AGIs (IRR 0.918, 95% CI: 0.854-0.987). We noted a dose-response relationship in the effects of DM medications on TB risk. Accordingly, we suggest that DM patients use AGIs to benefit from their protective effect on TB infection risk.
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Affiliation(s)
- Kai-Huang Lin
- Division of Critical Care Medicine, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
- Division of Chest Medicine, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Ci-Wen Luo
- Department of Pharmacology, School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Pharmacy, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Shih-Pin Chen
- Department of Internal Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Dom-Gene Tu
- Department of Nuclear Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan
- Department of Biomedical Science, National Chung Cheng University, Chiayi, Taiwan
| | - Ming-Shian Lin
- Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Yu-Hsiang Kuan
- Department of Pharmacology, School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Pharmacy, Chung Shan Medical University Hospital, Taichung, Taiwan
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16
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Liew JW, Ramiro S, Gensler LS. Cardiovascular morbidity and mortality in ankylosing spondylitis and psoriatic arthritis. Best Pract Res Clin Rheumatol 2019; 32:369-389. [PMID: 31171309 DOI: 10.1016/j.berh.2019.01.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 12/13/2018] [Accepted: 12/21/2018] [Indexed: 12/11/2022]
Abstract
The cardiovascular burden in inflammatory rheumatic diseases is well recognized. Recently, this burden has been highlighted in ankylosing spondylitis (also known as radiographic axial spondyloarthritis) and psoriatic arthritis. We review the cardiovascular morbidity and mortality in these diseases, as well as the prevalence and incidence of traditional cardiovascular risk factors. We examine the contribution of anti-inflammatory therapy with nonsteroidal anti-inflammatory drugs, disease-modifying anti-rheumatic drugs, and TNF inhibitors on the cardiovascular risk profile. Finally, we examine the available recommendations for the management of cardiovascular comorbidity, as they apply to the spondyloarthritis population.
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Affiliation(s)
- Jean W Liew
- University of Washington, 1959 NE Pacific St, BB561, Seattle, 98195, WA, USA.
| | - Sofia Ramiro
- Leiden University Medical Center, Leiden, 2333 ZA, the Netherlands.
| | - Lianne S Gensler
- University of California, San Francisco, 400 Parnassus Ave, Box 0326, San Francisco, 94143-0326, CA, USA.
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Martín Arias LH, Martín González A, Sanz Fadrique R, Vazquez ES. Cardiovascular Risk of Nonsteroidal Anti-inflammatory Drugs and Classical and Selective Cyclooxygenase-2 Inhibitors: A Meta-analysis of Observational Studies. J Clin Pharmacol 2018; 59:55-73. [PMID: 30204233 DOI: 10.1002/jcph.1302] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 07/23/2018] [Indexed: 01/09/2023]
Abstract
The purpose of this study was to review the published evidence on the clinical use of nonsteroidal anti-inflammatory drugs (NSAIDs) and to assess the cardiovascular risk (CVR) of cyclooxygenase-2 inhibitors (coxibs), excluding aspirin, by means of a meta-analytic procedure. A search was conducted on MEDLINE and EMBASE databases between October 1999 and June 2018. Cohort and case-control studies showing CVR as relative risk (RR), odds ratio, hazard ratio, or incidence rate ratio associated with NSAIDs versus no treatment were selected. We estimated the pooled RR and the 95% confidence interval (CI) for all NSAIDs as a whole and individually. Eighty-seven studies met the inclusion criteria. Overall, NSAIDs were found to be associated with a statistically significantly increased CVR (RR, 1.24 [95%CI, 1.19-1.28]). The risk was slightly higher for coxibs (RR, 1.22 [95%CI, 1.17-1.28]) as compared with nonselective NSAIDs (RR, 1.18 [95%CI, 1.12-1.24]). Data analysis by drug disclosed that rofecoxib (RR, 1.39 [95%CI, 1.31-1.47]), followed by diclofenac (RR, 1.34 [95%CI, 1.26-1.42]) and etoricoxib (RR, 1.27 [95%CI, 1.12-1.43]) were the NSAIDs associated with the highest CVR. Analysis by type of event showed that the highest risk corresponded to vascular events for both coxibs (RR, 2.18 [95%CI, 1.72-2.78]) and nonselective NSAIDs (RR, 2.46 [95%CI, 2.00-3.02]). The meta-analysis results suggest that the use of the marketed coxibs celecoxib and etoricoxib would be related to a statistically significant CVR increase. Etoricoxib CVR could be higher than that for celecoxib. This increment would be similar to classical NSAID CVR.
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Affiliation(s)
| | | | - Rosario Sanz Fadrique
- Centre for Drug Surveillance (CESME), School of Medicine, Valladolid University, Valladolid, Spain
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Celecoxib exerts protective effects in the vascular endothelium via COX-2-independent activation of AMPK-CREB-Nrf2 signalling. Sci Rep 2018; 8:6271. [PMID: 29674687 PMCID: PMC5908847 DOI: 10.1038/s41598-018-24548-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 04/05/2018] [Indexed: 01/13/2023] Open
Abstract
Although concern remains about the athero-thrombotic risk posed by cyclo-oxygenase (COX)-2-selective inhibitors, recent data implicates rofecoxib, while celecoxib appears equivalent to NSAIDs naproxen and ibuprofen. We investigated the hypothesis that celecoxib activates AMP kinase (AMPK) signalling to enhance vascular endothelial protection. In human arterial and venous endothelial cells (EC), and in contrast to ibuprofen and naproxen, celecoxib induced the protective protein heme oxygenase-1 (HO-1). Celecoxib derivative 2,5-dimethyl-celecoxib (DMC) which lacks COX-2 inhibition also upregulated HO-1, implicating a COX-2-independent mechanism. Celecoxib activated AMPKα(Thr172) and CREB-1(Ser133) phosphorylation leading to Nrf2 nuclear translocation. Importantly, these responses were not reproduced by ibuprofen or naproxen, while AMPKα silencing abrogated celecoxib-mediated CREB and Nrf2 activation. Moreover, celecoxib induced H-ferritin via the same pathway, and increased HO-1 and H-ferritin in the aortic endothelium of mice fed celecoxib (1000 ppm) or control chow. Functionally, celecoxib inhibited TNF-α-induced NF-κB p65(Ser536) phosphorylation by activating AMPK. This attenuated VCAM-1 upregulation via induction of HO-1, a response reproduced by DMC but not ibuprofen or naproxen. Similarly, celecoxib prevented IL-1β-mediated induction of IL-6. Celecoxib enhances vascular protection via AMPK-CREB-Nrf2 signalling, a mechanism which may mitigate cardiovascular risk in patients prescribed celecoxib. Understanding NSAID heterogeneity and COX-2-independent signalling will ultimately lead to safer anti-inflammatory drugs.
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Verhoeven F, Totoson P, Marie C, Prigent-Tessier A, Wendling D, Tournier-Nappey M, Prati C, Demougeot C. Diclofenac but not celecoxib improves endothelial function in rheumatoid arthritis: A study in adjuvant-induced arthritis. Atherosclerosis 2017; 266:136-144. [PMID: 29024866 DOI: 10.1016/j.atherosclerosis.2017.09.033] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 09/03/2017] [Accepted: 09/28/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIMS We aimed at investigating the effect of celecoxib (COX-2 selective inhibitor) and diclofenac (non-selective COX inhibitor) on endothelial function, and at identifying the underlying mechanisms in adjuvant-induced arthritis (AIA). METHODS At the first signs of AIA, diclofenac (5 mg/kg twice a day, i.p), celecoxib (3 mg/kg/day, i.p) or saline (Vehicle) was administered for 3 weeks. Endothelial function was studied in aortic rings relaxed with acetylcholine (Ach) with or without inhibitors of NOS, arginase, EDHF and superoxide anions (O2-°) production. Aortic expression of eNOS, Ser1177-phospho-eNOS, COX-2, arginase-2, p22phox and p47phox was evaluated by Western blotting analysis. Arthritis scores, blood pressure, glycaemia and serum ADMA levels were measured. RESULTS Diclofenac and celecoxib significantly reduced arthritis score to the same extent (p<0.05). As compared to vehicle-treated AIA, celecoxib did not change whereas diclofenac improved endothelial function (p<0.05) through increased EDHF production, decreased arginase activity and expression, decreased superoxide anions production and expression of p22phox and p47phox. Diclofenac but not celecoxib significantly enhanced blood pressure and serum ADMA levels. Glycaemia was unchanged by both treatments. CONCLUSIONS Our study reveals that the effect of NSAIDs on endothelial function cannot be extrapolated from their impact on arthritis severity and suggest that changes in blood pressure and plasma ADMA levels may not be useful to predict CV risk of NSAIDs in RA.
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Affiliation(s)
- Frank Verhoeven
- PEPITE EA4267, FHU INCREASE, Univ. Bourgogne Franche-Comté, F-25030, Besançon, France; Service de Rhumatologie, CHRU Besançon, 25000 Besançon, France
| | - Perle Totoson
- PEPITE EA4267, FHU INCREASE, Univ. Bourgogne Franche-Comté, F-25030, Besançon, France
| | - Christine Marie
- INSERM U1093, Univ. Bourgogne Franche-Comté, F-21000, Dijon, France
| | | | - Daniel Wendling
- Service de Rhumatologie, CHRU Besançon, 25000 Besançon, France; EA4266, Univ. Bourgogne Franche-Comté, F-25030, Besançon, France
| | - Maude Tournier-Nappey
- PEPITE EA4267, FHU INCREASE, Univ. Bourgogne Franche-Comté, F-25030, Besançon, France
| | - Clément Prati
- PEPITE EA4267, FHU INCREASE, Univ. Bourgogne Franche-Comté, F-25030, Besançon, France; Service de Rhumatologie, CHRU Besançon, 25000 Besançon, France
| | - Céline Demougeot
- PEPITE EA4267, FHU INCREASE, Univ. Bourgogne Franche-Comté, F-25030, Besançon, France.
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Hung YM, Lin L, Chen CM, Chiou JY, Wang YH, Wang PYP, Wei JCC. The effect of anti-rheumatic medications for coronary artery diseases risk in patients with rheumatoid arthritis might be changed over time: A nationwide population-based cohort study. PLoS One 2017; 12:e0179081. [PMID: 28658301 PMCID: PMC5489160 DOI: 10.1371/journal.pone.0179081] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 05/23/2017] [Indexed: 01/14/2023] Open
Abstract
Objectives To determine whether anti-rheumatic drug usage is associated with risk of coronary artery diseases (CAD) in incident Rheumatoid Arthritis (RA) patients. Methods Data were obtained from the Taiwan National Health Insurance Research Database. The study cohort comprised 6260 patients who were newly diagnosed with RA between 2001–2010. The study endpoint was occurrence of CAD according to the ICD-9-CM codes. We used the WHO Defined Daily Dose (DDD) as a tool to assess the drugs exposure. The Cox proportional hazards regression model was used to estimate the hazard ratio (HR) of disease after controlling for demographic and other co-morbidities. When the proportionality assumption is violated, a spline curve of the Scaled Schoenfeld residuals is fitted to demonstrate the estimated effect on CAD over time for drug usage. Results Among RA patients, use of celecoxib, and etoricoxib was associated with significantly decreased incidence of CAD. The adjusted HR(95% CI) of CAD for low-dose celecoxib (DDD≦1) and high-dose user were 0.47(0.34, 0.65) and 0.37(0.24, 0.58) during the 4 year follow-up time; however, it became 0.98(0.70, 1.37) and1.29(0.85, 1.95). Adjusted HR(95% CI) of CAD for etoricoxib users remained 0.47(0.26, 0.84). Conclusions This study revealed association of decreased CAD risk in RA patients taking 2 different kinds of COX-2i in comparison with nonusers. The effect might be changed over time, after about 4 years.
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Affiliation(s)
- Yao-Min Hung
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Institute of Public Health, School of Medicine, National Yang Ming University, Taipei, Taiwan
- Yuhing Junior College of Health Care and Management, Kaohsiung, Taiwan
| | - Lichi Lin
- Department of Statistics, Oklahoma state University, Stillwater, OK, United States of America
- Division of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital, and Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Chyong-Mei Chen
- Institute of Public Health, School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Jeng-Yuan Chiou
- School of Health Policy and Management, Chung Shan Medical University, Taichung, Taiwan
- * E-mail: (JC-CW); (J-YC)
| | - Yu-Hsun Wang
- Department of Medical Research, Chung Shan Medical University, Taichung, Taiwan
| | - Paul Yung-Pou Wang
- Division of Nephrology, Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, CA, United States of America
| | - James Cheng-Chung Wei
- Division of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital, and Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
- * E-mail: (JC-CW); (J-YC)
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Keat A, Bennett AN, Gaffney K, Marzo-Ortega H, Sengupta R, Everiss T. Should axial spondyloarthritis without radiographic changes be treated with anti-TNF agents? Rheumatol Int 2016; 37:327-336. [DOI: 10.1007/s00296-016-3635-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 12/19/2016] [Indexed: 12/17/2022]
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