The Autoimmune Connection: Essential Information for Women on Diagnosis, Treatment, and Getting On With Your Life (10 page)

The risk of cardiovascular disease (CVD) is two to three times greater among women with rheumatoid arthritis. There are several reasons for this.

While RA principally affects your joints, systemic inflammation can affect other organs—including the heart and blood vessels—and the risk may rise with more severe disease. Inflammation is reflected in blood markers such as C-reactive protein (CRP), considered an independent risk factor for CVD. Inflammation even in early RA may accelerate
atherosclerosis
, narrowing of the arteries by fatty plaques.
⁴¹

People with RA also have a greater prevalence of traditional CVD risk factors, notably smoking, high blood pressure, obesity, insulin resistance, and elevated cholesterol. And heart risk can be impacted by medications used to treat RA, such as corticosteroids, NSAIDs, and some DMARDs. There’s also the issue of physical inactivity due to disability.

Among traditional risk factors are higher levels of harmful blood fats like
low-density lipoprotein (LDL)
cholesterol, which is more prone to accumulate in plaques. One recent study showed that thickening of the inside of the arteries with cholesterol-laden plaques was worse in people with rheumatoid arthritis and that their cholesterol levels were higher, compared to people the same age without the disease.
⁴²

The risk of CVD increases for all women after menopause, and women with RA are no exception. An update from the Women’s Health Initiative found that the risk was 1.5 to 2.5 times higher among postmenopausal women. While traditional cardiovascular risk factors played a strong role, inflammation and joint pain severity were also associated with increased risk.
⁴³

However, younger women with RA still face heart risks, notes Susan Manzi, MD, MPH, professor of medicine at Temple University and chair of the Department of Medicine of the West Penn Allegheny Health System.

Dr. Manzi notes that mortality ratios for women with RA aged 15 to 49 show an increased risk of death from heart attack and congestive heart failure as high as three times that of healthy women. According to Dr. Manzi, inflammation in RA (as measured by CRP) not only speeds up the development of plaque, “but it also makes the plaque more vulnerable to rupture, leading to clot formation and blockage of the blood vessel.”

Recent research suggests that biologic therapy may lower the risk of CVD while reducing overall disease activity.
²⁹
Indeed, improvements in managing cardiovascular disease have contributed to the decline in deaths from RA.

The ACR and EULAR recommended that people with RA be screened regularly and treated for cardiovascular risk factors like high blood pressure and elevated cholesterol.
⁴⁴

Current U.S. federal guidelines recommend keeping LDL at an “optimal” level of 100 milligrams per deciliter of blood (mg/dl) or below, and recommend lifestyle changes and drug therapy when LDL tops 130 mg/dl in people at higher risk for coronary heart disease. Low levels of high-density lipoprotein (HDL) cholesterol are also a risk factor, since HDL helps remove LDL from the bloodstream. Under the guidelines, low HDL for women is under 40 mg/dl.
⁴⁵
However, treatment of elevated cholesterol is no longer based on hitting specific numbers but on reducing an individual’s risk.
⁴⁶
Just having RA or other inflammatory conditions is considered a risk factor for coronary heart disease.

As for blood pressure, stay below the normal level of 120 millimeters of mercury (mm Hg) for systolic pressure (the higher number, measured while the heart is beating) and 80 mm Hg diastolic (blood pressure between beats). According to the National Heart, Lung, and Blood Institute and the American Heart Association, your risk rises when pressure is between 120/80 and 139/89 mm Hg. High blood pressure (hypertension) is any reading above 140/90 mm Hg.

So make sure your doctor—whether it’s your internist or rheumatologist—assesses your blood pressure at every visit. Each year your doctor should order blood tests to measure levels of LDL and HDL cholesterol,
triglycerides
(another harmful blood fat), and blood glucose (if it’s elevated, that’s a sign your body isn’t using insulin properly—a red flag for type 2 diabetes, an independent risk factor for coronary disease). A thorough physical exam should include an electrocardiogram (ECG).

Making lifestyle changes can also help. These include avoiding obesity, getting 30 to 60 minutes of moderate exercise most (if not all) days of the week, eating a diet rich in fruits, vegetables, whole grains, healthy oils, and low-fat dairy products, while limiting calories from saturated fat, and avoiding trans fats. You may need advice from a nutritionist to help you work out a heart-healthy diet that you can follow.

Your RA medications may even help lower your risk of cardiovascular disease.

A recent review found that biologic therapies reduced CVD risk for RA patients, presumably by lowering inflammation.
⁴⁷
In one study of more than 200 patients, biologic therapies moved women from the high and moderate heart risk categories to low risk within 24 months, lowering total cholesterol and LDL and increasing HDL.
⁴⁸

Bone loss is a threat for any woman with RA, indeed any woman with an autoimmune disease who takes corticosteroids or other drugs that thin the bones. Postmenopausal women are already at increased risk for osteoporosis, and steroid treatment increases the risk even further; bone loss can begin as early as six months after starting steroids. Osteoporosis risk is doubled among women with RA, and it may not all be related to corticosteroids.

One study from Norway measured bone mineral density (BMD) in the hip and spine of almost 400 women with RA aged 50 to 70 and compared them with healthy women in the same age groups from the United States and Europe. The researchers found that over 31 percent of the RA patients had reduced BMD in the hip, and 19 percent had bone loss in the upper spine. Current use of steroids was one factor predicting lower BMD, but rheumatoid factor predicted lower bone mass in the top of the thigh bone in the hip (which may reflect bone erosion in that joint).

Corticosteroids cause bone loss because they interfere with calcium absorption. Even low-dose prednisone (10 milligrams a day) taken long term can cause significant bone thinning, so rheumatologists look for ways to minimize these effects (such as giving other drugs with corticosteroids that allow lower doses to be used, or steroid-sparing drugs). Often the only way to stave off osteoporosis is with drugs that reduce bone loss.

According to the ACR guidelines for preventing steroid-induced osteoporosis, bisphosphonates should be given to premenopausal women on long-term (over three months) corticosteroid treatment and to postmenopausal women when they begin steroid therapy. Bisphosphonates slow the resorption of bone and have been shown to reduce both hip and spinal fractures. For
women on long-term therapy, bone mineral density (BMD) scans should be done every one to two years.
⁴⁹

The bisphosphonates approved for treating osteoporosis are
alendronate (Fosamax)
and
risedronate (Actonel)
, available in daily and weekly oral preparations;
ibandronate (Boniva)
given in monthly or quarterly injections;
zoledronic acid (Reclast)
, and
parathyroid hormone (Teriparatide)
, both given as a yearly injection.

In addition, ACR guidelines recommend that women take 1,500 milligrams a day of elemental calcium (in diet and supplements), plus 400 to 800 IU of vitamin D (which aids calcium absorption). Women who can’t take bisphosphonates should be given calcitonin (
Miacalcin
,
Fortical
), an antiresorptive agent in nasal spray form.

I’ve always had this sense from doctors and other people that because this is not life threatening, because you’re not going to necessarily die from this disease, it’s not important. It’s just some kind of inconvenience, just creaky joints. But it’s lifestyle threatening . . . your sex life, your parenting, your work. Everything is affected by this disease. The most important thing is to know you can fight it—that you can fight it and you can pretty much beat it. There’s so much that can be done to alleviate this disease and to fight it and to feel that you’re not this victim, that you’re not helpless in the face of this disease.

K
ATHLEEN
T
URNER

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