Obesity and cardiovascular risk factors in rheumatoid arthritis

Sir, We read with interest the review of Hall and Dalbeth [1] on the influence of disease-modifying drugs (DMARDs) on cardiovascular risk. The article covers the effect of pharmaceutical interventions, such as corticosteroids, TNF-α blockade and statins, and the influence of lifestyle variables, such as the Mediterranean diet. We believe that direct interventions on body mass index (BMI) might also have an important role to play. We recently assessed a range of cardiovascular risk factors including BMI, and measures of disease activity and impact in 100 rheumatoid arthritis (RA) patients [20 male, 80 female, median age 60 yrs (95% CI 57.0–62.0), median disease duration 12 yrs (95% CI 9.0–17.0)] attending an out-patient clinic, and demonstrated strong associations between BMI and both hypercholesterolaemia and diastolic blood pressure. Median BMI was 27.0 (95% CI 26.0–28.0). Of the patients, 68% were overweight (BMI > 25) and 31% obese (BMI > 30). There was a positive correlation between BMI and diastolic blood pressure (R = 0.37, P < 0.01), a positive correlation between BMI and cholesterol:HDL ratio (R = 0.36, P < 0.01), and a negative correlation between BMI and HDL (R = 0.31, P < 0.01). There was no association between BMI and daily exercise or current steroid use. Overall, 40% of the patients had a diastolic blood pressure >80 mmHg, and 18% had >90 mmHg. We, established that 54% of the patients had a fasting cholesterol >5.2 mmol/l, and the median fasting cholesterol was 5.27 (95% CI 5.05–5.50). It has been shown that even modest reductions in BMI can have positive implications for cardiovascular health [2]. Moreover, in addition to dietary advice, a range of pharmaceutical interventions is now available for the treatment of obesity. We agree with the authors that RA ought to be treated as an additional risk factor when calculating 10-yr risk of a CHD-related event; if this is the case, then should it, for example, qualify as a comorbidity as defined by the NICE guidelines [3] for the use of the weight-reducing drug orlistat? Rheumatologists should be instrumental in leading intervention on cardiovascular risk factors in RA, as discussed by Hall and Dalbeth [1]. We believe that direct intervention on obesity, which is common in our RA population, offers further opportunities to modify associated risk factors, such as hypertension and hypercholesterolaemia. 1Musgrave Park Hospital and 2Royal Victoria Hospital, Department of Rheumatology, Belfast, UK