Treatment options for rheumatic diseases and their cardiovascular effects
| Group | Examples | Disease | CV effects | Interactions with commonly used CV medications |
|---|---|---|---|---|
| NSAIDs | Diclofenac Ibuprofen Naproxen Meloxicam Nabumetone Celecoxib Etoricoxib | RA, ASp, PsA | Increased blood pressure, contraindicated after MI, CVA and peripheral arterial disease, has an antiplatelet clotting effect like aspirin, ticagrelor and clopidogrel | Renal dysfunction, increased risk of (GI) bleeding in combination with anticoagulants, possible decrease of cardioprotective effect of aspirin and increase in thrombo-embolic complications, due to competitive COX inhibition, may decrease effect of antihypertensive agents and diuretics |
| Conventional synthetic DMARDs | Methotrexate Hydroxychloroquine Sulfasalazine Leflunomide | RA, PsA | Improvement of lipid profile, insulin resistance and physical activity | Renal dysfunction with MTX, leflunomide can increase serum levels of furosemide, hydroxychloroquine and sulfasalazine can alter plasma levels of digoxin |
| Tumour necrosis factor-α inhibitors* | Infliximab (intravenously) Etanercept Adalimumab Golimumab Certolizumab pegol | RA, ASp, PsA | Improvement of lipid profile, insulin resistance and physical activity | Acute heart failure in patients with pre-existing CHF classes 3 and 4 |
| T cell costimulation inhibitor* | Abatacept | RA | ? | ? |
| Anti-B cell agent* | Rituximab (intravenously) | RA | Heart failure has been reported, caution warranted in patients with known CV disease | Caution warranted with cardiotoxic chemotherapy |
| Interleukin-6-receptor blocking monoclonal antibody | Tocilizumab intravenously or subcutaneously | RA | Increases lipids due to IL-6 inhibition | May influence metabolization of atorvastatin and calcium antagonists |
| Interleukin-1 inhibitor | Anakinra | RA | ? | ? |
| Targeted synthetic DMARDs | Tofacitinib | RA, PsA | Increases lipid levels due to IL-6 inhibition | ? |
| Oral/intra-articular glucocorticosteroids | Prednis(ol)one Methylprednisolone Triamcinolone Dexamethasone | RA, ASp, PsA | Increase in insulin resistance, increase in blood pressure, heart failure, weight gain | Risk of hypokalaemia with diuretics, change in response to anticoagulants, faster elimination of salicylates |
*bDMARDs.
ASp, ankylosing spondylitis; CHF, congestive heart failure; COX, cyclooxygenase; CV, cardiovascular; CVA, cerebrovascular accident; DMARDs, disease-modifying antirheumatic drugs; GI, gastrointestinal; MI, myocardial infarction; MTX, methotrexate; NSAIDs, non-steroidal anti-inflammatory drugs; PsA, psoriatic arthritis; RA, rheumatoid arthritis.