How can I effectively manage comorbidities in patients with rheumatoid arthritis, particularly cardiovascular risk factors?

Effectively managing comorbidities, particularly cardiovascular risk factors, in patients with rheumatoid arthritis (RA) is a crucial aspect of their care in General Practice, often coordinated as part of a multidisciplinary team approach NICE CKS.

• Annual Review and Comorbidity Screening: All adults with RA, including those who have achieved treatment targets, should be offered an annual review to check for the development of comorbidities such as hypertension, ischaemic heart disease, osteoporosis, and depression NICE CKS,NICE NG100. This review is essential for identifying and addressing cardiovascular risks early NICE CKS,NICE NG100.
• Cardiovascular Risk Assessment: Given that patients with chronic inflammatory joint disorders like RA have an increased risk of atherosclerotic cardiovascular disease (Agca et al. 2016), it is important to consider formal cardiovascular risk assessment. For severe inflammatory conditions like psoriasis, which shares some inflammatory pathways, a cardiovascular risk assessment at presentation and every five years thereafter (or more frequently if indicated) is recommended NICE CG153. This principle can be extended to RA patients to proactively manage their risk.
• Lifestyle Modifications: Advise patients about the significant benefits of lifestyle changes to reduce cardiovascular disease risk NICE CKS,NICE NG100. This includes encouraging a Mediterranean diet, which is rich in fruit, vegetables, and fish, with less meat and butter NICE CKS,NICE NG100. Patients should also be advised to stop smoking and to drink only sensible amounts of alcohol NICE CKS,NICE NG100.
• Lipid Management: Specific attention should be paid to lipid management in patients with RA, as highlighted by position papers from expert bodies like the European Society of Cardiology's Working Group on Cardiovascular Pharmacotherapy (Hollan et al. 2020). This indicates that standard lipid management strategies may need tailored consideration in this patient group.
• Medication Review and Monitoring: Primary care plays a vital role in ongoing drug monitoring and regular medication reviews to check concordance, assess adverse effects, and manage them appropriately NICE CKS. When considering glucocorticoids, be aware that low-dose steroids (7.5mg prednisone daily or less) used in RA have been associated with a weight gain of 1kg over two years, but no increase in blood pressure NICE CKS.
• Vaccinations: As part of overall comorbidity management and to reduce infection-related risks that can impact cardiovascular health, offer pneumococcal and yearly influenza vaccinations to RA patients if necessary NICE CKS.