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One-third of patients switch, end DMARDs after cardiovascular event
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More than 30% of patients with rheumatoid arthritis, psoriatic arthritis or psoriasis either switched or discontinued their diseasemodifying antirheumatic drug treatment following a cardiovascular event, according to findings published in Arthritis Care and Research.
“After a [cardiovascular] event in patients with RA, PsA, or [psoriasis], adverse events may be more likely to occur and to have serious clinical consequences, or DMARDs may be contraindicated because of organ dysfunction resulting from the [cardiovascular] event,” Jeffrey A. Sparks, MD, MMSc, of Brigham and Women’s Hospital, Harvard Medical School, and colleagues wrote. “However, DMARD therapy may be required for underlying rheumatic disease control. Moreover, recent data support the potential benefit of immunomodulators in patients who have experienced a [cardiovascular] event.”
To analyze DMARD therapies — including conventional synthetic and biologic variations of the treatment — and determine the risk for subsequent cardiovascular events among patients with RA, PsA and psoriasis following an initial event, the researchers conducted a retrospective cohort study of information in the MarketScan claims databases. Focusing on the nationwide Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits databases, the researchers identified 10,254 patients with either RA, PsA or psoriasis.
Each patient had experienced an initial cardiovascular event — defined as acute myocardial infarction, stroke or coronary revascularization — while receiving either TNF inhibitor biologic DMARDs, non-TNF inhibitor biologic DMARDs or conventional synthetic DMARDs. From Jan. 1, 2006, through June 30, 2015, Sparks and colleagues evaluated DMARD treatment patterns follow the initial cardiovascular event, and the rates of subsequent events. In addition, they studied the predictors of DMARD discontinuation and risk factors for future events using Cox regression.
According to the researchers, among the 10,254 patients included in the study, 15.3% discontinued and 15.5% switched their DMARD treatment following their initial cardiovascular event. Independent predictors of DMARD discontinuation included a diagnosis of psoriasis, renal disease, hypertension, heart failure, diabetes mellitus, older age and baseline treatment with conventional synthetic DMARDs or non-TNF inhibitor biologic DMARDs. Incidence rates for subsequent cardiovascular events were 75.2 per 1,000 patient years for those receiving TNF-inhibitor biologic DMARDs, 83.6 for conventional synthetic DMARDs and 122.4 for non-TNF-inhibitor biologic DMARDs. The researchers also noted that baseline RA and heart failure were independently associated with increased risk for future cardiovascular events.
“Patients with RA, PsA, or [psoriasis] remain at high risk for a subsequent [cardiovascular] event following an initial [cardiovascular] event,” Sparks and colleagues wrote. “Our study suggests that DMARD therapy for the underlying RA, PsA, or [psoriasis] does not appear to affect the risk for subsequent [cardiovascular] events, and clinicians should carefully consider continuing DMARD therapy as well as appropriate therapies for [cardiovascular] disease.” – by Jason Laday
Disclosure: Sparks reports research grants from the NIH, the Rheumatology Research Foundation and Amgen, as well as consulting fees from Optum. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Charles Pritchard, MD
We know that patients with inflammatory diseases like RA, PsA and psoriasis are at an increased risk of cardiovascular diseases. Patients with chronic inflammatory diseases have an excess of traditional risk factors and an additional risk associated with chronic inflammation. A recent population-based cohort study reported an adjusted hazard ratio factor of 1.58 (1.46-1.7) for patients with RA compared to a matched cohort.
These patients have an increased prevalence of hypertension, diabetes, hyperlipidemia and obesity. The high inflammatory burden mediated by proinflammatory cytokines is linked to accelerated atherosclerosis. RA, PsA and psoriasis are treated with similar classes of medications including conventional synthetic and biologic DMARDs, some of which may have a cardioprotective effect; for example, methotrexate is associated with reduced cardiovascular risk. However, we have no clear guidance on further management of these inflammatory illnesses in patients who have had a cardiovascular event like myocardial infarction or cerebrovascular accident, or coronary bypass.
The study from Sparks and colleagues looked at a large database of over ten thousand inflammatory disease patients who had had an initial cardiovascular event and followed their claim databases for subsequent cardiovascular events, as well as changes to DMARDs subsequent to the event. The study used MarketScan claims database from January 2006 to June 2015.
Approximately 15% of patients switched and 15% discontinued DMARDs; however, the baseline rate of these changes in patients who did not have an event was not reported, nor was cardiovascular data specifically on the patients who changed medications. The study was subject to the inherent limitations of claims databases and observational studies. No pattern of DMARD use was associated with a subsequent cardiovascular event. There were no significant differences between classes of DMARDs and subsequent MI, CVA or coronary bypass. The only risk factors for subsequent events were the presence of an RA diagnosis and baseline heart failure.
The importance of this study is that there is now data to suggest continuing a DMARD subsequent to a cardiovascular event does not seem to increase the risk of further events. No specific DMARD class seems to increase cardiovascular events after an MI, CVA or coronary bypass.
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