Guidelines for prevention of CVD in lupus patients

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Rheumawire

Jan 30, 2004

Guidelines for prevention of CVD in lupus patients

Manchester, UK - British researchers have, for the first time,

formulated guidelines to help prevent the development of cardiovascular

disease (CVD) in patients with systemic lupus erythematosus (SLE).

In their paper in the January 2004 issue of Rheumatology [1], Dr J Wajed

(Manchester Royal Infirmary Lupus and Connective Tissue Disease Clinic,

UK) and colleagues say there is plenty of evidence that patients with

SLE have a much greater risk of coronary heart disease (CHD) than the

general population, but " there is no clear guidance on how

cardiovascular risk in SLE should be managed. "

Hence, they have reviewed current guidelines for use in the general

population and adapted them for use in lupus, proposing targets for CHD

risk factors and a management plan for dealing with these patients. One

of the key points to emphasize, they say, is the increased scope to

modify CHD risk by adjustment of therapy - for example, by reducing

steroid use.

Depending on the exact definition used, hypercholesterolemia is found in

34% to 51% of lupus patients, Wajed et al say. Lipid alterations seen

include low high-density lipoprotein (HDL) as well as raised

triglycerides, which can occur as a consequence of inflammatory disease

activity and/or steroid therapy.

As SLE can be viewed as a CHD-equivalent condition, " It is therefore our

view that ... the targets for LDL cholesterol should be derived from

those used in diabetes mellitus, " Wajed et al say. " The overall aim of

management is to achieve a reduction in LDL cholesterol to <2.6 mmol/L. "

They suggest:

Annual screening should measure a fasting lipid profile - namely

total, HDL, and LDL cholesterol as well as triglycerides

For LDL <2.6 mmol/L, no action should be taken, but the lipid

profile should be reviewed annually

For LDL 2.6 to 3.4 mmol/L, therapeutic lifestyle changes (dietary

modification, weight reduction, and increased physical activity) should

be introduced, and the patient's progress on achieving the ideal target

reviewed every 3 to 6 months

Statins should be considered when LDL is >3.4 mmol/L with or

without other risk factors or when LDL is persistently >2.6 mmol/L even

after therapeutic lifestyle changes

Moving on to discuss body weight, the researchers say that truncal

obesity ( " apple " shape) in particular is a risk factor for CHD events

and that this type of obesity is frequently seen in SLE patients. They

suggest:

Screening for obesity should take place every year, involving

weight measurement and calculation of target body mass index (BMI). If a

patient is found to be overweight (BMI >25 kg/m2), then secondary causes

need to be considered, especially steroid treatment, which can cause

truncal obesity and a cushingoid appearance. Initial therapy should

involve therapeutic lifestyle changes and adjustment of steroid

treatment, if applicable.

If the patient still remains obese despite serious efforts to lose

weight, then drug treatment with antiobesity agents should be

considered, they say. " Given the high-risk nature of SLE, we suggest the

use of drug therapy to control weight if the following 3 criteria are

met: " (a) BMI 27 kg/m2 or greater, ( loss of less than 2.5 kg through

diet and exercise in the month before treatment, © age 18 to 75 years.

However, they stress that since there are no studies reporting the use

of antiobesity drugs in SLE, " such a therapy should be instituted under

the guidance of a dietician and specialist in weight management. "

With regard to smoking, it is important to advise smoking cessation in

SLE, not only because of the strong risk associated with CVD in the

general population, but also because smoking may be a risk factor in the

progression of SLE.

Patients with SLE are more likely to be hypertensive than population

controls, Wajed et al note, adding that high blood pressure (BP) is

associated with renal impairment, steroid therapy, and a sedentary

lifestyle. Interventions to control blood pressure in those with SLE

should include:

Regular BP measurements at every clinic visit and at least

annually

As recommended for patients with diabetes, the ideal target is to

maintain BP at 130/80 mm Hg

In patients with >140 mm Hg systolic or >90 mm Hg diastolic, BP

should be reviewed closely and lifestyle advice offered. In the context

of SLE, renal function should also be assessed and steroid therapy

closely reviewed

If, despite these measures, BP is persistently >140 mm Hg systolic

or >90 mm Hg diastolic, antihypertensive medication should be

considered. BP should then be reviewed every 3 months, ideally aiming to

keep levels below 130/80 mm Hg

The antihypertensive drug of choice will be determined by the patient's

additional comorbidities, Wajed and colleagues say. While low-dose

thiazide diuretics seem an effective first-line treatment, a second

agent is likely to be necessary in many to achieve a target BP. An ACE

inhibitor would be a preferred agent " since there is evidence that ACE

inhibitors may improve survival in at-risk patients. " They caution also

that beta blockers " may precipitate Raynaud's phenomenon in some

patients. " For those in whom a low-dose thiazide is not tolerated or

indicated as a first-line agent, a calcium channel blocker is an

acceptable alternative.

With regard to aspirin, Wajed et al say, " Given the risk of CHD

associated with SLE, all lupus patients may potentially benefit from

low-dose aspirin prophylaxis, the benefits being strongest in those who

have the lupus anticoagulant (LAC) or antiphospholipid (aPL) antibodies.

They go on to suggest a minimum standard - that patients with SLE should

receive aspirin if they have any of the following factors in the absence

of a clear contraindication to aspirin:

Previous history of myocardial infarction, angina, stroke, or

transient ischemic attack

Positive aPL or LAC

Hypertension

Diabetes mellitus

Hypercholesterolemia

Smokers

However, they note that patients who have aPL and are already on

warfarin may not need aspirin.

Finally, 5% to 7% of SLE patients also have diabetes mellitus, a higher

proportion than in the general population, the researchers say. They

recommend the following:

Testing for diabetes should be performed regularly in all patients

with SLE. Diabetes mellitus is diagnosed in the presence of fasting

blood glucose 7 mmol/L or greater or random blood glucose 11.1 mmol/L or

greater.

In those with a fasting glucose of 6.1 mmol/L or greater, a formal

glucose-tolerance test may be necessary and referral to a dietician for

advice regarding dietary modification.

A referral to a diabetes specialist is recommended for all

patients with frank diabetes and where there is concern regarding

impaired glucose tolerance.

Nainggolan

Source

1. Wajed J, Ahmad Y, Durrington PN, Bruce IN. Prevention of

cardiovascular disease in systemic lupus erythematosus--proposed

guidelines for risk factor management. Rheumatology (Oxford) 2004 Jan;

43(1):7-12.

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