EULAR 2009: Statins Achieve Similar Secondary Prevention Benefits in Patients With and Without Rheumatoid Arthritis

Alice Goodman

June 18, 2009

June 18, 2009 (Copenhagen, Denmark) — An exploratory study of aggressive lipid-lowering suggests that patients with rheumatoid arthritis (RA) who have coronary heart disease (CHD) derive the same cardiovascular benefits from statin therapy as patients without RA (non-RA). This finding adds to the growing body of evidence supporting the value of initiating statin therapy in RA patients, especially those with evidence of CHD, according to a presentation here at EULAR 2009: The Annual European Congress of Rheumatology.

"Patients with rheumatoid arthritis are at increased risk of coronary heart disease, compared with the general population. Their risk is as high as in people with diabetes, yet there have been no prospective randomized studies of prevention with statins in rheumatoid arthritis," said lead author Anne Grete Semb, MD, from DiakonhjemmetHospital in Oslo, Norway.

The exploratory post hoc analysis focused on 87 patients with RA embedded in the study population of 8888 patients enrolled in the IDEAL study. IDEAL compared atorvastatin 80 mg/day and simvastatin 20 to 40 mg/day as secondary prevention in patients who had a previous myocardial infarction. Overall, no significant difference in aggressive lipid-lowering was seen between atorvastatin and simvastatin for the primary end point of major coronary events (coronary death, nonfatal acute myocardial infarction, or cardiac arrest with resuscitation).

At baseline, the mean age of both RA and non-RA patients was about 63 years. The only significant differences between the 2 groups were that there were more women in the RA group (P < .001) and there was more warfarin use in the non-RA group (P < .05). At baseline, RA patients had significantly lower total cholesterol (P = .02), low-density-lipoprotein cholesterol (P = .03), and apolipoprotein B (P = .03) levels.

Despite having lower baseline lipid values, at a mean follow-up of 4.8 years, RA and non-RA patients on statin therapy had similar rates of cardiovascular events — hospitalization for angina and/or fatal or nonfatal myocardial infarction, heart failure, angioplasty, or coronary artery bypass graft surgery, stroke, or transient ischemic attack (26.4% of RA patients vs 28.7% of non-RA patients).

Cardiovascular events occurred in 14 (35.9%) of 39 RA patients taking atorvastatin and in 9 (18.8%) of 48 RA patients taking simvastatin. Both drugs achieved comparable lipid-lowering effects in RA and non-RA patients.

No significant differences were observed between the RA and non-RA groups for adverse and serious adverse events. RA patients experienced more myalgia and gastrointestinal adverse effects than non-RA patients. However, some differences in patterns of adverse events were seen in RA patients receiving the 2 different statins. More nausea and abdominal pain was reported with atorvastatin, whereas more myalgia and worsening of RA was seen with simvastatin.

"This study shows us that RA patients with CHD have similar overall cardioprotective benefits and comparable lipid-lowering with statin treatment as those without RA," Dr. Semb stated.

Growing Interest in Cardiovascular Risk

"The arthritis community is witnessing a growing appreciation and understanding of the morbidity and mortality from cardiovascular disease that has been best studied in rheumatoid arthritis, and we are now seeing the same biological message in psoriatic arthritis and ankylosing spondylitis," said Philip Mease, MD, from the Swedish Medical Center and Seattle Rheumatology Associates in Washington.

Dr. Mease mentioned a recent editorial in Arthritis & Rheumatism by Paul Ridker on whether all RA patients should get statins (Arthritis Rheum. 2009;60:1205-1209). "This editorial by the lead investigator of the JUPITER trial should open rheumatologists' eyes to the potential value of statins in patients with rheumatoid arthritis," Dr. Mease pointed out.

Cardiovascular risk factors in RA patients should be addressed by a team of primary-care physicians, cardiologists, and rheumatologists, according to Dr. Mease. "The primary-care physician may not think about cardiovascular disease in a patient with rheumatoid arthritis," Dr. Mease continued.

"RA patients may be undertreated for cardiovascular risk," Dr. Mease said. "Now that we appreciate the very important need to adequately treat all aspects of cardiovascular risk in patients with arthritis, prospective randomized controlled trials are needed."

The study did not receive commercial support. Dr. Semb has disclosed no relevant financial relationships. Dr. Mease has received financial support from Abbott, Amgen, Biogen-IDEC, Bristol-Myers Squibb, Centocor, Genentech, Wyeth, Roche, Sanofi-Aventis, and UCB.

EULAR 2009: The Annual European Congress of Rheumatology: Abstract FRI1060. Presented June 13, 2009.

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