Body Mass Index and Disease Activity in Chronic Inflammatory Rheumatic Diseases: Results of the Cardiovascular in Rheumatology (Carma) Project

Weight loss affects disease activity and treatment response in inflammatory rheumatic diseases

The quantity and quality of the adipose tissue is altered in obesity: hypertrophy of adipocytes, decrease in expandability, fibrosis, production of pro-inflammatory cytokines and adipokines, inflammatory infiltration by pro-inflammatory M1 macrophages and T lymphocytes. Excess adipose tissue and obesity are associated with low-grade inflammation that can aggravate chronic inflammatory diseases, decrease treatment efficacy, contribute to the development of comorbidities, and of the disease in its preclinical phase. Obesity increases the incidence of rheumatoid arthritis (RA), psoriasis, psoriatic arthritis with a weight-dose effect. It is also a predictor of worse response to treatment, in particular TNF inhibitors. Weight loss induced by bariatric surgery decreases the risk of psoriasis and psoriatic arthritis and improves disease activity and remission in RA. A 5% weight loss through a low-calorie diet improves the response to TNF inhibitors in psoriatic arthritis, losing even more weight improves the response even more. In RA, the beneficial effect of weight loss from a low-calorie diet on disease activity has been reported in a few observational studies but has not been demonstrated in a randomized controlled trial. Screening and management of obesity are part of the dietary recommendations of the French Society for Rheumatology in patients with chronic inflammatory rheumatic diseases. Of course, this should be combined with other lifestyle modifications such as smoking cessation, higher food quality, increased physical activity and reduced sedentary behavior.

Relationship between onset of psoriasis and spondyloarthritis symptoms with clinical phenotype and diagnosis: data from REGISPONSER registry

Background

The relationship of psoriasis and spondyloarthritis (SpA) is well-known, and the age of appearance of different manifestations has been described as a determinant of SpA phenotype. However, differences between Spa with psoriasis and psoriatic arthritis (PsA) are still controversial.

Objectives

To evaluate whether the time of onset of psoriasis relative to the appearance of rheumatic symptoms in patients with SpA is associated with a clinical phenotype, a rheumatologist's diagnosis and the evolution of the disease.

Design

This was a cross-sectional study with data extracted from the REGISPONSER (Spondyloarthritis Registry of the Spanish Rheumatology Society) registry.

Methods

All patients had data available for both psoriasis and SpA dates of onset. Patients were classified into two groups depending on the time of appearance of psoriasis: psoriasis before or after rheumatic symptoms. The clinical characteristics, disease activity, radiographic damage, functional ability and received treatments were compared between the two groups. Moreover, the rheumatologists' diagnoses were compared between the two groups. Univariate and multivariate logistic regressions were conducted to evaluate the factors associated with each group.

Results

A total of 433/2367 (18.3%) patients included in the REGISPONSER database had psoriasis: 330 (76.2%) patients had psoriasis before rheumatic symptoms, and 103 (23.8%) had psoriasis after rheumatic symptoms. Patients with psoriasis before rheumatic symptoms had a shorter disease duration and a lower body mass index, a lower prevalence of both HLA-B27 antigens and anterior uveitis, a higher prevalence of dactylitis and an increase in levels of the erythrocyte sedimentation rate (ESR). Furthermore, a higher prevalence of PsA diagnoses (78.1% versus 56.4%) and a more frequent fulfilment of the CASPAR criteria (57.5% versus 42.2%) were found in these patients. The use of DMARDs was not significantly different between the two groups.

Conclusion

The time of appearance of psoriasis is associated with the clinical phenotype of SpA and could determine a diagnosis of PsA by rheumatologists.

The correlation of plasma atherogenic index and obesity in patients with familial Mediterranean fever

BACKGROUND

The plasma atherogenic index (PAI) is associated with cardiovascular diseases. This study evaluated the relationship between PAI and obesity in patients with familial Mediterranean fever (FMF) and its advantage over conventional lipid components in predicting obesity.

METHODS

The cross-sectional study included 164 FMF patients in the attack-free period and a control group of 160 healthy individuals. Serum lipid components were measured, including triglycerides (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C). PAI was calculated as log 10 (TG/HDL-C). The relationship between PAI, four conventional lipid profiles, and obesity was evaluated.

RESULTS

The mean PAI values (p = 0.003), frequency of obesity (p = 0.005), TC (p = 0.008), TG (p = 0.000), and LDL-C (p = 0.005) values were determined to be statistically significantly higher in the FMF patients than in the control group. The FMF patients with a higher PAI value had a higher risk of obesity, systolic and diastolic blood pressure, TC, and LDL-C, and lower HDL-C (p < 0.001). The Pearson coefficient for PAI (r = 0.854; p < 0.001) was calculated as an explanatory percentage on the variable of obesity of r² = 0.730. There was a stronger relationship between obesity and PAI than conventional lipid components (p < 0.001).

CONCLUSION

We have found that the PAI, BMI, TC, TG, and LDL-C values of the FMF patients were determined to be higher. The higher PAI was strongly correlated to obesity in FMF patients. The first time in FMF patients, PAI showed increased sensitivity to predict obesity, higher than conventional lipid components. It can be a promising biomarker for obesity compared to other lipid components. A low-cost and readily available index derived from routine (TG and HDL-C) tests are advantages in identifying obesity in FMF patients. Key Points • The PAI is valuable for atherosclerotic CVD risk management in patients with rheumatismal diseases. • A correlation is found between PAI level and obesity, and it is used as a biomarker for obesity in the healthy population. • The PAI revealed increased sensitivity to predict obesity, higher than conventional lipid components in FMF patients.

Factors associated with high cardiovascular risk in psoriatic arthritis and non-psoriatic spondyloarthritis

To identify the association between traditional cardiovascular risk factors, diseases related factors, body composition and adipokines with high cardiovascular risk (HCVR) in psoriatic arthritis and non-psoriatic spondyloarthritis. This was a cross-sectional study involving age and BMI matched adults with psoriatic arthritis (PsA) (n = 56) and non-psoriatic spondyloarthritis (nPsA-SpA) (n = 58). Body composition using whole-body dual energy X-ray absorptiometry, adipokines and disease characteristics along with cardiovascular risk scoring QRISK3 and carotid intimal medial thickness (CIMT) was collected. Individuals with a QRISK3 ≥ 10% or CIMT of ≥ 75 percentile of the general population were categorised as HCVR. Predictors of HCVR were determined by logistic regression. HCVR was detected in 39 (34.2%) of the patients. After adjusting for all the factors, sarcopenia (aOR-15.83; 95% CI 1.16-215.48; p = 0.038) and presence of any traditional CV comorbidity (aOR: 18.97; 95% CI 1.63-221.29; p = 0.019) were associated with HCVR. nPsA-SpA had a 97% lesser chance of having HCVR as compared to PsA. The ROC curve analysis for the multiple logistic regression model which estimated the AUC as 0.787 (95% CI 0.701-0.874) and a P value < 0.001. Adipokine levels correlated well with body composition, but not with HCVR. PsA has a higher CV risk and the mechanisms for the same are poorly understood. Sarcopenia is an important determinant of HCVR and may be due to ectopic adipose tissue deposition in skeletal muscles. Focused physical therapy to prevent sarcopenia, optimum treatment of traditional CV risk factors and adequate disease control may help in preventing atherosclerosis in SpA.

The Effect of Ketogenic Diet on Inflammatory Arthritis and Cardiovascular Health in Rheumatic Conditions: A Mini Review

The principle of ketogenic diet (KD) is restriction of carbohydrates to a maximum of 5-10% of the total daily caloric intake, aiming at shifting body metabolism toward ketone bodies. Different studies suggested promising results of KD to help patients to lose weight, to reduce insulin requirements in diabetes, to supplement cancer protocols, to treat neurological conditions and to optimize control of metabolic and cardiovascular diseases. However, literature about the anti-inflammatory properties of KD in rheumatic diseases is still limited. The beneficial effects of weight loss in patients with inflammatory arthritis can be explained by biomechanical and biochemical factors. Obesity is associated with macrophage activation and production of pro-inflammatory cytokines including TNF-α, IL-1b, and IL-6. The clinical effect of KD may be primarily attributed to improvement of insulin sensitivity. Insulin resistance is associated with an increase of TNF-α, IL-1α, IL-1β, IL-6, and leptin. Moreover, reduction of body's adipose tissue and weight loss account for part of the anti-inflammatory effects and for the impact of KD on cardiovascular health. In rheumatoid arthritis, fasting was shown to be effective in reducing disease symptoms, possibly through the production of β-hydroxybutyrate (BHB), the main ketone body. BHB may exert inhibitory effects also on IL-17 and intermittent fasting improved the clinical manifestations of psoriatic arthritis. In ankylosing spondylitis, current literature doesn't allow to draw conclusion about the effects of KD. Future prospective studies will be needed to elucidate the potential beneficial effects of KD on specific domains and clinical outcomes in patients with inflammatory arthritis.

Rheumatoid Arthritis and Cardiovascular Risk: Retrospective Matched-Cohort Analysis Based on the RECORD Study of the Italian Society for Rheumatology

Background: Rheumatoid arthritis (RA) is associated with an increase in cardiovascular (CV) risk. This issue maybe not only explained by a genetic component, as well as by the traditional CV risk factors, but also by an underestimation and undertreatment of concomitant CV comorbidities.

Method: This was a retrospective matched-cohort analysis in the Italian RA real-world population based on the healthcare-administrative databases to assess the CV risk factors and incidence of CV events in comparison with the general population. Persistence and adherence to the CV therapy were also evaluated in both groups.

Results: In a RA cohort (N = 21,201), there was a greater prevalence of hypertension and diabetes with respect to the non-RA subjects (N = 249,156) (36.9 vs. 33.4% and 10.2 vs. 9.6%, respectively), while dyslipidemia was more frequent in the non-RA group (15.4 vs. 16.5%). Compared with a non-RA cohort, the patients with RA had a higher incidence of atrial fibrillation (incidence rate ratio, IRR 1.28), heart failure (IRR 1.53), stroke (IRR 1.19), and myocardial infarction (IRR 1.48). The patients with RA presented a significantly lower persistence rate to glucose-lowering and lipid-lowering therapies than the controls (odds ratio, OR 0.73 [95% CI 0.6–0.8] and OR 0.82 [0.8–0.9], respectively). The difference in the adherence to glucose-lowering therapy was significant (OR 0.7 [0.6–0.8]), conversely no statistically significant differences emerged regarding the adherence to lipid-lowering therapy (OR 0.89 [95% CI 0.8–1.0]) and anti-hypertensive therapy (OR 0.96 [95% CI 0.9–1.0]).

Conclusion: The patients with RA have a higher risk of developing CV events compared with the general population, partially explained by the excess and undertreatment of CV risk factors.