Inflammation in RA is also a risk factor for which we have effective treatments. Would a target for “inflammation” be beneficial in decreasing CVD risk in RA? Should the target be remission, a low CRP level, or lack of swollen joints? Is targeting specific inflammatory pathways more beneficial for CV risk reduction than another? Pursuing answers to these questions is a topic of active research. A recent genetic study suggests that tocilizumab could potentially target a causal pathway for CVD.8 Would this be a better drug to use than a tumor necrosis factor (TNF) inhibitor in RA patients at high risk for CVD, even if the TNF inhibitor controlled their RA? Sometimes it feels as if we have more questions than answers.
I believe an important first step beyond aggressively treating RA is to be cognizant of the status of CV risk factors in our patients and to assess whether they are adequately treated, as per national guidelines. I find that I often see my patients more frequently than their primary care physician (PCP) because of their RA. In a perfect world, patients regularly follow up with their PCPs and these risk factors would be well controlled. In reality, very few people visit their PCPs on a regular basis, and some of my patients do not even have a PCP, despite my strong recommendation to establish care with one. We already routinely check blood pressures in our practice. What I have started doing on a regular basis is screening lipids, since I am often ordering monitoring labs for their disease-modifying antirheumatic drug therapy. As a result, I have started a few patients on statins in conjunction with their PCPs.
Deciding on targets for therapy still requires applying some component of the “art” of medicine. As an example, my 55-year-old patient by Framingham Risk Score and Adult Treatment Panel III guidelines had a recommended LDL goal of 130 mg/dL, but none of the risk factor calculations take into account that he has RA. In our practice, we work closely with a group of cardiologists who provide their expert opinion on patients, some of whom, according to guidelines, would not require more aggressive therapy but, by our estimation, seem to require it. As there are no formal guidelines for RA, we use our expert opinion to guide treatment decisions for each individual patient. I also work with the patient’s PCP (if they have one) to help reinforce lifestyle modifications such as smoking cessation and the treatments already prescribed to treat CV risk factors.
