Fluctuating Weight in RA Can Heighten CVD Risk

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Rheumatologists should be alert for fluctuations in the weight of patients with rheumatoid arthritis because weight fluctuation may be a warning of an impending cardiovascular event, particularly in patients who have a normal BMI or are underweight, suggests a study published in the journal Arthritis Care and Research.

Fluctuations in weight have been shown to be associated with a greater risk of cardiovascular events and death in patients with coronary artery disease, and also linked to adverse outcomes in patients with cancer.

Weight loss can be a predictor of disability and death in patients with rheumatoid arthritis, and cardiovascular events are a key cause of death in this group of patients. However, while rheumatoid arthritis patients may experience weight changes related to disease, treatments, and comorbidities, until now no research has investigated whether such fluctuating weight might herald a forthcoming cardiovascular event.

Dr. Joshua Baker, University of Pennsylvania

Using the Corrona registry, set up in 2001 and the largest independent database in North America collecting data from both rheumatologists and patients at the time of a clinical encounter, researchers identified 31,180 rheumatoid arthritis patients for which data were available for at least three clinic visits. At each visit data were collected on medication use, rheumatoid arthritis disease activity, patient’s level of function, comorbid illnesses, and acute events, such as cardiovascular incidents, infections and cancer.

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After the baseline encounter, patients attended for follow-up appointments every three to six months, and the researchers categorized patients according to how their weight had changed between the initial and second follow up visit. Over this time, weight had remained stable in 16,791 (54%) of patients, 3,139 (10%) lost weight at a per-year rate of 10% or more per year and 3972 (13%) gained weight at a rate of 10% or more per year.

Patients who had lost or gained at least 10% of their weight per year tended to have significantly higher disease activity and worse physical function, were more likely to smoke, have diabetes, use prednisone and be disabled but less likely to drink alcohol. Those that gained at least 10% in weight tended to be younger and have had rheumatoid arthritis for a shorter length of time.

Cardiovascular events that occurred during a median 3.4 years were included in the analysis which showed that those patients who had experienced a 10% weight loss or 10% weight gain were 18% and 20% more likely respectively to have experienced a cardiovascular event. Larger fluctuations in weight were associated with even higher risk of cardiovascular events. The association between weight fluctuations and cardiovascular events was strongest in patients who were not overweight and had a BMI of less than 25 kg/m2.

“Perhaps the most important message is that weight fluctuations, when observed in a thin patient with rheumatoid arthritis, should be of concern. Among this group, recent changes in weight were fairly strongly associated with the risk of cardiovascular events” said Dr. Joshua Baker, assistant professor in rheumatology and epidemiology at the University of Pennsylvania and Philadelphia VA Medical Center in Pennsylvania.

In patients with a BMI of less than 25 kg/m2, a 10% weight loss was associated with a 34% greater risk of a cardiovascular event while a 10% weight gain was associated with a 74% greater risk of a cardiovascular event.

The researchers said that weight fluctuations had also been shown to have a greater impact on risk of cardiovascular events in patients with normal or below normal weights who had other disease and speculated that weight fluctuations were a sign of adverse metabolic changes that might be associated with more long-term weight loss.

“We hypothesize that weight fluctuations are a sign of adverse metabolic health, findings that are often observed with aging, smoking, greater disease activity, and different comorbidities,” said Baker. “These things are commonly observed in thin patients. While controversial, weight fluctuation may itself be bad, by promoting visceral fat accumulation and promoting adverse metabolic health and inflammation.”

The main takeaway for rheumatologists was that if weight is unstable, there may be a reason why, he added. “Fluctuating weight should perhaps ring alarm bells and warn us to look for active disease, new medical problems, and perhaps even factor this into aggressive preventative measures to prevent cardiovascular disease events. Whether crash diets with re-gain cause long-term problems remains unclear.”

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REFERENCE

Baker JF, Reed G, Kremer J. "Weight Fluctuation and the Risk of Cardiovascular Events in Patients with Rheumatoid Arthritis." Arthritis Care Res (Hoboken). 2020 Oct 1. doi: 10.1002/acr.24469. Epub ahead of print. PMID: 33002323.