DI Challenge - Statins in Rheumatoid Arthritis
Statins in Rheumatoid Arthritis
The ability to answer drug information (DI) questions is a critical skill for pharmacists in all practice areas. Student pharmacists are frequently asked to answer DI questions that may not have been covered in the standard pharmacy curriculum. Often, these responses require in-depth research and they always require good writing skills.
OPA’s first student Drug Information Challenge was initiated in 2013 to highlight high quality DI responses by publishing them in the Ohio Pharmacist journal and on OPA’s website. Students from four of the seven colleges submitted questions from physicians, educators, patients and preceptors. Submissions were blinded to name, school, and graduation year before grading. Judges scored submissions on grammar and punctuation, completeness of response, strength of references and clarity of recommendation.
This year’s winner was Joy Hoffman, PharmD candidate 2016, from Ohio Northern University. Her article, Effervescent Alendronate Bioavailability, was published in the April 2013 issue of Ohio Pharmacist.
The following article, Statins in Rheumatoid Arthritis, was submitted by Leandro Llambi, PharmD candidate 2014 from University of Cincinnati and received honorable mention.
AC, a long-time patient of your pharmacy presents to your pharmacy with a prescription for Crestor 10mg. You notice that the prescription was written by his rheumatologist. Upon further questioning, AC tells you that his rheumatologist has prescribed this medication to help with his rheumatoid arthritis. AC fills all of his medications with your pharmacy, including his methotrexate for rheumatoid arthritis, and you know that his arthritis is fairly well controlled with only the occasional, mild flare-up of pain and swelling. Before you call his doctor, you wonder if there is any evidence for the use of statins in rheumatoid arthritis.
Response. The American College of Rheumatology published clinical practice guidelines for the treatment of Rheumatoid Arthritis (RA) in 2008 with a more recent update in 2012. The guidelines focus on the use of Disease Modifying AntiRheumatic Drugs (DMARD) and biologic agents. These guidelines have a well-defined algorithm that uses the Disease Activity Score (DAS) to determine the course of therapy. The DAS is a scoring system that takes into consideration joint tenderness and redness in 28 joints, erythrocyte sedimentation rate, and patient assessed global scores. Despite the most recent update, statins do not have a place in the RA guidelines1,2. However, there are several studies that demonstrate the usefulness of statins in patients with RA.
In one randomized control, double-blind study, 50 RA patients with a stable DAS (≤5.1 for up to 3 months prior to enrollment) were enrolled to study rosuvastatin’s effects upon joint stiffness and carotid atherosclerosis. Patients were divided between an intervention group (n=24) that received rosuvastatin 5mg daily, then stepped up to rosuvastatin 10mg daily; and a placebo group (n=26) that was also stepped up from 5mg daily to 10 mg daily. Patients were followed for 12 months, and were assessed for the DAS at baseline and every 3 months by a group of three rheumatologists. While there was no statistically significant improvement in the DAS between groups throughout the duration of the study, there was a statistically significant improvement (p<0.05) in DAS in the intervention group compared to baseline (2.7±0.8) at 6 months (2.5±0.9), and 12 months (2.4±1.0)3.
In another study, investigators studied the effects of atorvastatin on the DAS of patients suffering from RA. 30 patients were randomly assigned into two groups, and were assessed for their DAS at baseline and 6 months. Group 1 (n=15, baseline DAS=6.19±0.82) received Methotrexate 15.5mg±1.3 qweek and prednisone 10mg qday. Group 2 (n=15, baseline DAS=6.09±0.88) received the same medications as Group 1 with the addition of atorvastatin 40mg qday. Patients in Group 2 had a statistically significant lower DAS after 6 months (3.9±0.45) than patients in Group 1 (5.27±0.66) with a p-value of <0.0014.
Another double-blind, randomized placebo control trial studied the effects of atorvastatin on DAS in RA patients who had been initiated on DMARD therapy for at least three months. The intervention group (n=58) was given 40mg of atorvastatin daily, and the control group (n=58) was given a 40mg placebo. Patients were assessed for DAS at baseline, 3 months, and 6 months. The study found that the intervention group (baseline DAS=5.75±1.10) experienced a 0.50 decrease in DAS (p=0.004) after 6 months of treatment. The placebo group (baseline DAS=5.88±0.97) showed a 0.03 increase in DAS (p=0.004) after 6 months of treatment5.
While the use of statins is not officially recognized by the American College of Rheumatologists, there are a growing number of studies showing their benefit in decreasing joint inflammation in RA patients suffering with a low to moderate DAS. Additionally, it has previously been shown that even patients with good lipid profiles and no significant cardiovascular history can benefit from the use of statins without significant side effects6. Taking all of this into consideration, along with the fact that AC’s medication profile indicates a low to moderate DAS, I believe there is no problem with AC taking atorvastatin with his other RA medications. We simply need to counsel AC on the medication, and ensure he is being appropriately monitored for statin use by his physician.
- Saag KG, Teng GG, Patkar NM, et alias. American college of rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis and Rheumatism. 2008; 59(6):762-84.
- Singh JA, Furst DE, Bharat A, et alias. 2012 update of the 2008 american college of rheumatology recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Care and Research. 2012; 64(5): 625-39.
- Tam LS, Li EK, Shang Q, et alias. Effects of rosuvastatin on subclinical atherosclerosis and arterial stiffness in rheumatoid arthritis: a randomized controlled pilot trial. Scand J Rheumatol. 2011;40: 411-21.
- El-Barbary AM, Hussein MS, Rageh EM, et alias. Effect of atorvastatin on inflammation and modification of vascular risk factors in rheumatoid arthritis. J Rheumatol. 2011; 38: 229-35.
- McCarey DW, McInnes IB, Madhok R, et alias. Trial of atorvastatin in rheumatoid arthritis (tara): double-blind, randomized placebo-controlled trial. Lancet. 2004; 363(9426): 2015-21.
- Ridker PM, Danielson E, Fonseca FAH, et alias. Rosuvastatin to prevent vascular events in men and women with elevated c-reactive protein. N Engl J Med. 2008; 359: 2195-207.