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  • Review Article
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Cardiometabolic comorbidities in RA and PsA: lessons learned and future directions

Nature Reviews Rheumatology volume 15, pages 461–474 (2019)Cite this article

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Abstract

Cardiometabolic comorbidities present a considerable burden for patients with rheumatoid arthritis (RA) or psoriatic arthritis (PsA). Both RA and PsA are associated with an increased risk of cardiovascular disease (CVD). PsA more often exhibits an increased risk of metabolically linked comorbidities such as obesity, insulin resistance, type 2 diabetes mellitus and non-alcoholic fatty liver disease. Although both RA and PsA are characterized by a state of chronic inflammation, the mechanisms that contribute to CVD risk in these conditions might not be identical. In RA, systemic inflammation is thought to directly contribute to CVD risk, whereas in PsA, adiposity is thought to contribute to a notable metabolic phenotype that, in turn, contributes to CVD risk. Hence, appropriate management strategies that consider the increased risk of cardiometabolic comorbidities in patients with inflammatory arthropathy are important. In RA, such strategies should focus on the prediction of CVD risk and its management through targeting chronic inflammation and traditional CVD risk factors. In PsA, management strategies should additionally focus on targeting metabolic components, including weight management, which might not only help improve disease activity in the joints, entheses and skin, but also reduce the risk of metabolic comorbidities and improve the quality of life of patients.

Key points

  • Cardiometabolic comorbidities represent a notable morbidity and mortality burden in patients with rheumatoid arthritis (RA) or psoriatic arthritis (PsA).

  • Patients with RA have a higher risk of cardiovascular disease than individuals of the general population; however, some of this increased risk might be driven by steroid use.

  • PsA is more strongly linked to metabolic comorbidities, including obesity, non-alcoholic fatty liver disease and type 2 diabetes mellitus.

  • Dampening inflammation with methotrexate or TNF inhibitors might lower the cardiovascular risk of patients with RA, but formal randomized controlled trials are currently sparse.

  • In PsA, weight loss might reduce disease severity and/or risk of PsA development, but future prospective studies are needed to assess the effects of lifestyle interventions and/or pharmacologically induced weight loss.

  • Clinical trials assessing the long-term effects of new drugs for the treatment of RA or PsA on cardiovascular outcomes are warranted, including the safety and benefits of  these treatments.

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Fig. 1: Potential relationship between systemic inflammation in RA and PsA and cardiovascular risk.
Fig. 2: Potential relationship between cardiovascular and metabolic comorbidities in RA and PsA.

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Acknowledgements

The work by L.D.F. is supported by a clinical research fellowship fund from the British Heart Foundation (BHF) Centre of Research Excellence (grant number, RE/13/5/30177).

Review criteria

A search for studies published up to January 2019 and focusing on cardiometabolic comorbidities in rheumatoid and psoriatic arthritis was performed in PubMed. The search terms used were “rheumatoid arthritis” or “psoriatic arthritis”, with either “cardiometabolic”, “cardiovascular”, “dyslipidaemia”, “adiposity”, “diabetes”, “NAFLD”, “blood pressure”, “hypertension”, “DMARDs”, “TNF inhibitors”, “corticosteroids”, or “NSAIDs”. All articles identified were English language, full-text papers. We also searched the reference lists of identified articles for further relevant papers.

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  1. Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK

    Lyn D. Ferguson & Naveed Sattar

  2. Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK

    Lyn D. Ferguson, Stefan Siebert & Iain B. McInnes

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  1. Lyn D. Ferguson
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  2. Stefan Siebert
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The authors contributed equally to all aspects of the article.

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Nature Reviews Rheumatology thanks A. Ogdie, M. Nurmohamed and the other, anonymous, reviewer for their contribution to the peer review of this work.

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Ferguson, L.D., Siebert, S., McInnes, I.B. et al. Cardiometabolic comorbidities in RA and PsA: lessons learned and future directions. Nat Rev Rheumatol 15, 461–474 (2019). https://doi.org/10.1038/s41584-019-0256-0

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