Who should screen for hyperlipidaemia in RA patients? Rheumatologists or primary care physicians?

Risk factors for cardiovascular disease such as hyperlidipaemia are not being picked up and managed in patients with rheumatology arthritis because it often falls through the gap between rheumatology and primary care provision.

Understanding why this is happening is key to improving cardiovascular management and outcomes for these patients, who have a high risk of cardiovascular disease, so US researchers held a series of structured focus groups with rheumatologists and primary care doctors from across the country to investigate.

Three focus groups were conducted with 27 rheumatologists and three with 20 primary care doctors (general internists or family medicine physicians); the focus groups were held online in October and December 2017 and each had between 4 and 11 participants.

The findings, published in the journal BMC Rheumatology,  show that rheumatologists are “conflicted” over whether screening and treatment for hyperlipidemia falls within their remit. Primary care physicians, on the other hand, believe that reducing cardiovascular risk of patients is part of their role, but they feel that they do not know enough about how lipid lowering treatment could influence symptoms of rheumatoid arthritis (for example, the risk of myalgia from statins) or how inflammation from rheumatoid disease and treatment may influence lipid profiles to manage risk confidently.

Just over one third (36%) of the rheumatologists considered management of cardiovascular risk to be their responsibility, 48% believed that it was not their responsibility and 16% were uncertain. Lack of time was the factor most frequently mentioned by rheumatologists as a barrier to managing cardiovascular risk, followed by lack of training and familiarity with hyperlipidaemia guidelines.

While all primary care physicians considered management of cardiovascular risk to be part of their role, they showed a lack of confidence in doing so among patients with rheumatoid arthritis with lack of training and familiarity with guidelines the most frequently mentioned barrier. They felt that they did not know enough about the interplay between rheumatoid arthritis and its treatment and that of hyperlipidaemia and statins. They were also concerned that patients would be worried about taking statins because of their potential side-effects and potential to interact with their treatment for rheumatoid arthritis, and overall they believed that patients would want to prioritise management of their RA symptoms over statin prophylaxis.

Both groups of doctors also said that challenges in coordinating care between them also acted as a barrier to screening for and managing hyperlipidaemia.

The researchers conclude: “There is a need for interventions that improve care coordination among physicians, educate patients with rheumatoid arthritis about the need to directly address cardiovascular disease risk screening with their rheumatologist, and be prepared to see a primary care physician regularly for follow up treatment and management of cardiovascular risk.”
Engaging primary care physicians might be the best approach for trying to drive up lipid screening of rheumatoid arthritis patients “as primary care physicians thought of this process as lying within their scope of practice,” suggest the researchers, who were led by Iris Navarro-Millán, assistant professor of medicine, Weill Cornell Medicine Hospital for Special Surgery in New York.

While patients with rheumatoid arthritis may want to discuss lipid testing with their rheumatologist as they visit frequently  to have their rheumatoid arthritis medication monitored, the researchers say, few rheumatologists may agree to manage cardiovascular disease risk by prescribing statins, which “underscores the need for primary care among patients with rheumatoid arthritis.”

“Our results and that of others support the need for patients with rheumatoid arthritis to have a primary care physician, which might not only increase the likelihood of cardiovascular disease screening itself but also enable the implementation of interventions that can increase cardiovascular disease risk screening and reduction,” they said.