When people with rheumatoid arthritis, or RA, stop taking cholesterol-lowering drugs known as statins, they greatly increase their risk of dying within a few years, according to a new study published online March 29, 2012, in Arthritis Care & Research.

The study found a 60 percent increased risk of death from heart disease among RA patients who stopped their statin therapy and a 79 percent increased risk of death from all causes, compared with RA patients who continued taking statins.

The death rate among people with RA is 1.5 times greater than the general population, with cardiovascular disease, or CVD, as the leading cause of death. So managing risk factors for CVD – such as keeping cholesterol at recommended levels – is especially important for RA patients, and statin drugs, such as atorvastatin, or Lipitor, and simvastatin, or Zocor, are commonly prescribed to control cholesterol.

When RA patients quit taking statins, it may literally be a life-and-death decision, says lead study author Mary De Vera, PhD, who at the time was a doctoral student at the University of British Columbia School of Population and Public Health and Arthritis Research Centre of Canada.

“If you have RA and your doctor prescribes statin therapy for cardiovascular risks, it’s important to stay on the therapy,” De Vera says. “Even quitting intermittently, for just three months, then going back on, can increase death risk.”

Previous reports by the same researchers have shown that 38 percent of RA patients permanently discontinue statin use, increasing their heart attack risk by 67 percent. Other studies have found that in the general population, statin discontinuation rates can be more than 50 percent. Part of the reason for the high levels of discontinuation, the researchers note in the study, is that “statin therapy represents ‘chronic’ or long-term treatment in which therapeutic effects are not readily observed.”

“A lot of studies have shown that, in the general population, patients tend to discontinue or not take these drugs properly,” says De Vera. “We wanted to investigate the impact on RA patients, because there is such a high risk of cardiovascular disease in this patient group.”
 

Using data from 37,151 RA patients who received health services in British Columbia from 1996 to 2006, De Vera and her team identified 4,102 who were prescribed statin drugs. Data came from the British Columbia Ministry of Health records.

Among this group of RA patients taking statins:

• 45 percent discontinued therapy at least once during the four-year follow-up period.
• There were 467 deaths overall, with 198 deaths from heart disease.
• Of the heart disease-related deaths, 31 percent were from heart attacks and 15 percent from strokes.

De Vera’s team reports that stopping statin therapy resulted in:

• 60 percent higher risk of heart disease-related death, and
• 79 percent higher risk of death from all causes.

De Vera defined “discontinued” as quitting for three months or longer. “Stopping for one or two months was not considered stopping,” she says. “Sometimes people have trouble getting to the pharmacy on time to refill. We wanted to give them the benefit of the doubt.”

How long the patients had been taking statins before they quit – or if they were intermittent, quitting for several months, then going back on the drugs – didn’t matter, she explains. “Anyone who discontinued the statin medication increased their death risk during the four-year follow-up period.”

While De Vera did not have access to data on patients’ cholesterol levels, she says, “People generally are prescribed statins because they have elevated lipids [cholesterol] as well as signs of cardiovascular disease.”

Jeffrey Curtis, MD, director of the Arthritis Clinical Intervention Program at the University of Alabama at Birmingham (UAB), is not surprised by the findings. “This study confirms what medical specialists have known – that statins work among people who take them,” he says. “But should all RA patients take statins? That’s not yet clear. Right now, we prescribe statins according to the general guidelines – if LDL cholesterol is 160 or greater, and at lower thresholds, depending on what other cardiovascular risk factors the patient has.”

Whether RA should be considered one of those risk factors has not yet been determined, he adds. “We don’t have complete knowledge to accurately estimate cardiovascular risk for RA patients.”

Another fact that RA patients should understand is that their risk of heart disease develops about five to 10 years earlier than in the general population, Dr. Curtis adds. 

“As a practical matter, it’s helpful if patients are aware of their cholesterol, blood pressure and cardiovascular risk factors, and act as their own advocate, making sure those risks are managed,” he says. “There are many effective medications to treat those conditions, and they are traditionally managed by the primary care physician. It’s usually best for patients to see a primary care doctor in addition to a rheumatologist.”