Updated EULAR Guidelines for RA CVD Risk Management

TOPIC SERIES: CVD PREVENTION IN RHEUMATIC DISEASE	TOPIC SERIES: CVD PREVENTION IN RHEUMATIC DISEASE
TOPIC SERIES: CVD PREVENTION IN RHEUMATIC DISEASE

The European League Against Rheumatism (EULAR) has released updated management guidelines to address cardiovascular disease (CVD) risk assessment in patients with rheumatoid arthritis (RA) and other inflammatory arthritides. A new EULAR task force, including 26 members from 13 European countries, was assembled to perform a literature review in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. A total of 264 articles were included in the final analysis after screening for study eligibility and scientific strength.

During a meeting in 2015, all task force members convened to present and discuss the concept recommendations. The task force agreed upon 3 general, overarching principles. Ten recommendations were created by consensus agreement, revising 6 of the recommendations from the 2009 guidelines and adding a new guideline not previously endorsed.

Overarching Principles of CVD Risk Management in Inflammatory Joint Disease

1. The increased risk of CVD development in patients with RA likely also extends to patients with ankylosing spondylitis (AS) and psoriatic arthritis (PsA).
2. The management of CVD risk in patients with IJD is the primary responsibility of the treating rheumatologist.
3. Treatment-specific recommendations released by EULAR and the Assessment of Spondyloarthritis International Society regarding the use of non-steroidal anti-inflammatory drugs (NSAIDs) should be followed.

Updated EULAR 2015/2016 Guidelines  for CVD Risk Management in  Inflammatory Joint Disease

1. Early, tight control of disease activity and reduction of number of disease flares should be achieved to lower CVD risk in patients with RA, AS, and PsA.
2. Repeat assessment of CVD risk should be conducted at least once every 5 years or when major changes in disease-modifying antirheumatic drug (DMARD) therapies are instituted.
3. Validated risk scores such as the Systematic Coronary Risk Evaluation (SCORE) should be used when no national guidelines for CVD risk assessment are available.  The EULAR guidelines committee recognized that there is little evidence-based research into specific CVD risk calculators in patients with inflammatory joint disease (IJD) and therefore recommends evaluating CVD risk according to the general population.
4. Non-fasting total cholesterol and high-density lipoprotein (LDL) cholesterol should be measured and treated appropriately to further mitigate CVD risk.  Cholesterol profiles should be obtained when disease is stable or in remission.
5. When available, CVD risk scores should be modified to reflect increased CVD risk in patients with RA by multiplying by a factor of 1.5, unless IJD is already accounted for in the risk algorithm.
6. Carotid ultrasound screening of subclinical carotid artery plaques in patients with RA should be considered by rheumatologists to further mitigate any increased CVD risk imparted by the presence of carotid atherosclerosis 
7. Preventive medicine including the recommendation of adoption of healthy diet, daily exercise, and smoking cessation should be emphasized to patients with IJD.
8. Updated national guidelines regarding the medical management of hypertension and hypercholesterolemia with anti-hypertensives and statins should be followed in patients with RA, AS, or PsA. Older recommendations prioritizing the use of angiotensin II receptor blockers and angiotensin converting enzyme inhibitors in patients with RA have since been omitted.
9. NSAIDs should be used sparingly and with caution in patients with RA and PsA, especially those with known prior history of CVD or with risk factors for CVD. The new guidelines take into account recent research that suggests that both non-selective NSAIDs and COXIBs increase risk of adverse CV events in patients with RA and PsA. Diclofenac remains contraindicated in patients with congestive heart failure, ischemic heart disease, peripheral arterial disease, or cerebrovascular disease. No evidence was found supporting stricter NSAID treatment guidelines in patients with RA when compared with patients without RA. Individualized risk benefit analysis should be applied to patients with AS, in whom NSAIDs are still the recommended first-line drug treatment for axial pain and stiffness.
10. In cases where protracted treatment with corticosteroids are necessary for treatment, the new guidelines advise minimizing total dosage and trial of drug taper during times of disease remission and low disease activity.

Summary and Clinical Applicability

“The 2015/2016 update of the EULAR recommendations for CVD risk management in patients with RA and other forms of IJD confirms and further extends the evidence of an increased CVD risk in the whole spectrum of IJD and reinforces the need for proper CVD risk management in these patients,” the researchers concluded. 

Disclosures

Dr Agca has received personal remuneration from BMS, Pfizer, MSD.Dr McInnes  has received research funding or honoraria from AbbVie, BMS, Pfizer, Janssen, Novartis, Celgene, MSD, UCB and Roche. 

Dr Jacobsson has received consultancy fees or speaker honoraria from AbbVie, Actavis, Celgene, Novartis and Pfizer. 

Dr Kitas has received honoraria for lectures or advisory boards or hospitality from Pfizer, AbbVie, Novartis, UCB, Genesis, Roche, BMS, GSK, Eli Lilly and AstraZeneca. 

Dr Kvien has received fees for speaking and/or consulting from AbbVie, Biogen, BMS, Boehringer Ingelheim, Celgene, Celltrion, Eli Lilly, Epirus, Hospira, Merck-Serono, MSD, Novartis, Orion Pharma, Pfizer, Roche, Sandoz and UCB and received research funding to Diakonhjemmet Hospital from AbbVie, BMS, MSD, Pfizer, Roche and UCB. 

Dr Sattar has consulted for Roche, Amgen, Sanofi, AstraZeneca and received grant funding from Roche. 

Dr Jonsson has received speaker honoraria from MSD and Pfizer. 

Dr Nurmohamed has received research funding or speaking/consultancy honoraria from Abbvie, Pfizer, Merck, Roche, BMS, UCB, Eli Lilly and Janssen.

References

Agca R, Heslinga SC, Rollefstad S, et al. EULAR recommendations for cardiovascular disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update. Ann Rheum Dis 2016 Oct 3. doi:10.1136/annrheumdis-2016-209775 [Epub ahead of print].

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