Then, Dr. Charles-Schoeman spoke to blood sugar. “We know that glucose control is important. Attaining a hemoglobin A1c of less than 7% can reduce CVD risk by 37% over 11 years.8 These are numbers that you can discuss with your patients,” she said.
RA Medications
RA medications have a spectrum of effects on CV risks, some positive and some negative. All RA medications decrease inflammation, which has anti-atherogenic effects. However, non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, Janus kinase (JAK) inhibitors and other drugs have possible pro-atherogenic effects, too.
After data from the ORAL Surveillance study were published in 2022, the FDA issued a black box warning for all JAK inhibitors, noting an increased risk of serious heart-related events, cancer, blood clots and death.9 However, Dr. Charles-Schoeman and her colleagues recently published a post hoc analysis of the ORAL Surveillance study that provides data useful in the clinic.10 Data show that there’s a differential risk between tofacitinib and TNF inhibitors, primarily observed for those with a prior history of atherosclerotic CVD (ASCVD).
“In ORAL, 80% of the patients didn’t have a history of ASCVD,” she said, “and there was absolutely no difference in major adverse cardiac events (MACE) between tofacitinib and TNF inhibitors in these patients.”
What’s more, there was an inadequate use of statins in the ORAL trial, with only 23.4% of the total high-risk population using statins, and only 53% with a history of ASCVD treated with statins at baseline. This begs us to ask the question, “Does statin use make a difference on the occurrence of MACE in patients using tofacitinib?”
An abstract presented at ACR Convergence 2024 showed that it does. There was no difference in MACE between the tofacitinib and TNFi groups in patients treated with statins at baseline, regardless of whether they had ASCVD at baseline or not.11
Conclusion
So how can we best care for our patients from a joint and CV perspective? “At the end of the day, it’s a balance of factors driving adverse CV outcomes,” concluded Dr. Charles-Schoeman. “We need to look at RA disease control and CV risk factors, and treat both. The good news is that atherosclerosis takes time to develop. You have time to intervene. So that blood pressure of 150/90? You [may] not have time to mention it at this visit, but at the next, mention it. It can make a difference.”
