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Rheumatologists consider cancer, cardiovascular disease

From the February ACP Internist, copyright 2009 by the American College of Physicians

By Stacey Butterfield

SAN FRANCISCO—It may have been the annual meeting of the American College of Rheumatology, but much of the research presented at this conference focused on body parts other than joints.

Researchers from Spain presented findings on the hot-button issue of whether the TNF-antagonists used to treat rheumatoid arthritis (RA) increase cancer risk. They said no.

“On the contrary, blocking the inflammation cascade may help diminish the overall risk of cancer in these patients,” said study author Loreto Carmona, MD, PhD.

Dr. Carmona's study used a drug registry established in 2001 to assess outcomes for 4,529 rheumatoid arthritis patients who had taken anti-TNF drugs. They then compared the cases of cancer that developed among those patients with cancer rates in a control group of RA patients who had not taken the medications and found very similar statistics.

The study was reassuring in light of previous research which had found an association between cancer and arthritis itself and led to concerns about what impact TNF-blockers might have on cancer risk.

Less reassuring was the research presented on cardiovascular disease and rheumatoid arthritis.

Patients with RA have about the same risk of developing cardiovascular disease as type 2 diabetics, according to an observational study of 335 RA patients. A second study, conducted in Sweden, confirmed that during the first 10 years after an arthritis diagnosis, patients' heart attack risk nearly doubles.

“Rheumatoid arthritis is an independent cardiovascular risk factor as important as type 2 diabetes,” said Michael T. Nurmohamed, MD, PhD, an author of the first study. “Cardiovascular risk management is really necessary for our patients. We should educate our patients; we should educate our rheumatology fellows.”

Physicians might also want to be on the lookout for diastolic dysfunction in their RA patients. A comparison of 149 arthritis patients to 1,405 controls found that 38.9% of RA patients had diastolic dysfunction vs. 28.8% of controls, and that the arthritis group had higher average pulmonary arterial pressure.

Those RA patients who do have a heart attack also fare worse afterwards than other patients. They are at higher risk of dying or developing heart failure after the heart attack, an analysis of 38 patients found.

“Of course, the next question is why?” said study author Hilal Maradit Kremers, MD.

Based on his research, rheumatologist Christopher J. Edwards, MD, believes that the increased cardiovascular risk seen in all these studies is due to the rheumatoid itself, rather than general inflammation or the drugs used to treat arthritis.

He offered some good news to RA patients, with a study finding that those who took hydroxycholoroquine, methotrexate or sulphasalazine were less likely to have heart attacks. Prednisolone slightly increased the risk, but lipid-lowering drugs reduced by about 25% the risk of heart attacks in studied patients with RA.

In addition to popping their statins, arthritis patients should be sure to brush their teeth, according to another study presented at the ACR meeting. The analysis of 153 patients with RA found an association between arthritis and periodontal disease. Of the studied patients, 82% reported gum problems and those with greater arthritis disease activity were more likely to have dental problems.

The study author suggested that good oral health care could improve outcomes for RA patients. Quitting smoking also improves RA symptoms, an analysis of 1,400 smokers with arthritis found.

Research presented at the conference offered some lifestyle advice for patients with osteoarthritis as well.

The less you weigh, the less likely it is that you will need an arthritis-induced hip or knee replacement, according to a Swedish study. The findings were most dramatic in the overweight and obese population, but carried through into normal weight groups.

“Overweight is one of the few factors leading to osteoarthritis that we can actually do something about,” said study author Stefan Lohmander, MD, PhD.

For patients who already have osteoarthritis, some alternative treatments were supported by evidence presented at the meeting.

Indian researchers found that traditional ayurvedic drugs were just as effective as glucosamine and celecoxib in reducing pain and improving function of arthritic knees. The randomized, double-blind study included 440 patients.

A modified version of tai chi also improved pain and function for a group of patients with severe knee osteoarthritis in another study. More details on this study and other data presented at the American College of Rheumatology meeting are available on ACP Internist's blog.

Abstracts of the studies presented at the meeting are available as press releases on the ACR's Web site at www.rheumatology.org.

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ACP and ACR join forces on rheumatoid arthritis

ACP will be working together with the American College of Rheumatology to improve rheumatoid arthritis care. At the ACR annual meeting, the group's board of directors agreed to collaborate with the College to develop recommendations to educate primary care physicians on diagnosis and screening for rheumatoid arthritis.

The groups will work together on an evidence review and then develop a guideline, likely to be released toward the end of 2009, according to Amir Qaseem, MD, senior associate in ACP's clinical programs and quality of care department.

Earlier this year, the ACP Foundation released a HEALTH TiP on rheumatoid arthritis. The HEALTH TiPs are index-card-size slips of paper with easy-to-understand information on common medical conditions. Physicians can order the TiPs for free to distribute to patients through the Foundation's Web site.

“We want to make sure that people know that there are ways of controlling rheumatoid arthritis today, both things they can do and things they can ask their physicians to do,” said Paul F. Howard, FACP, a rheumatologist who helped develop the arthritis HEALTH TiP.

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