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New research evaluates RA patients’ cardiovascular risks
Rheumatologists also mull advances, complications of drug therapy

From the January ACP Internist, copyright © 2008 by the American College of Physicians.

By Stacey Butterfield

BOSTON—Reflecting a growing awareness that arthritis affects more than just a patient’s joints, much of the research presented at the 71st annual meeting of the American College of Rheumatology (ACR) focused on cardiovascular and other non-rheumatological consequences of the disease.

The opening ceremony welcomes attendees to the 71st annual meeting of the American College of Rheumatology.


The opening ceremony welcomes attendees to the 71st annual meeting of the American College of Rheumatology.



Among the 2,300 abstracts presented at the meeting were two studies evaluating the increased cardiovascular risks affecting patients with rheumatoid arthritis (RA). Using a British government database that included 33,000 patients with RA, researchers found that the patients with RA had 65% increased risk of stroke when compared to controls, while a new risk prediction model from the Mayo Clinic determined that newly diagnosed patients in their 60s had about double the cardiovascular risk of patients without RA.

“Not only do [patients with RA] have inflammation in the joints, but it appears that the same inflammation probably also occurs in the lining of the blood vessels, especially the blood vessels supplying blood to the heart,” said Gurkipal Singh, MD, a rheumatology researcher from Stanford University who spoke at the ACR meeting.

Dr. Singh did offer some hope for RA patients with high cardiovascular risks in a study which found that aggressive combination treatment of RA can reduce the risk of heart attack. Using the California Medicaid database, researchers compared the number of heart attacks in patients who took methotrexate alone or in combination with TNF-inhibitors and found that patients on combined therapy had an 80% reduced risk compared to those on methotrexate alone.

Treatment with glucocorticoids, on the other hand, does increase patients’ cardiovascular risk, another study found, although the researchers noted that the impact on survival could be minimized by keeping doses to 10 mg or lower per day.

Anti-TNF drugs can be helpful in efforts to lower doses of steroids, some German researchers found. In their study presented at the meeting, anti-TNF agents enabled the majority of studied patients to eliminate or lower their doses of glucocorticoids.

The need for drug treatment can also be reduced by early intervention, according to the authors of another study. Canadian researchers found that among patients who began taking high doses of disease-modifying antirheumatic drugs (DMARDs) within six weeks to 12 months of symptom onset, about half had achieved remission within a year, and only about a quarter of patients had initiated biologic therapy.

“This study highlights the benefits of early DMARD therapy, ideally in combination, using a higher dose of methotrexate,” said study author Vivian Bykerk, MD. “I look at this as a glass half-empty or half-full situation. This is terrific that 50% of our patients can meet remission, but 50% of our patients are not meeting remission.”

Despite the good news on medication, treatment of arthritis entails some potential consequences of its own, according to another study. Using the California Medicaid database again, researchers determined that recent decreases in use of COX-2 inhibitors may be associated with an increase in the number of serious ulcer complications in elderly users of non-steroidal anti-inflammatory drugs (NSAIDs).

According to their data, the percentage of elderly patients taking NSAIDs without some form of gastroprotective medication (proton pump inhibitors or misoprostol) more than doubled between 2004 and 2005, during which time there was also a 21% increase in serious ulcer complications.

“This would mean that when we reacted to the mass hysteria [about COX-2 inhibitors], that was not good for our patients,” said Dr. Singh, who also authored this study. “We really threw the baby out with the bath water.” Based on the study results, he urged physicians to ensure that patients who take NSAIDs also receive gastroprotective medication.

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