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      Case Control Study

      Samira Rostom; Mariam Mengat; Racha Lahlou; Asmaa Hari; Rachid Bahiri; Najia Hajjaj-Hassouni

      Disclosures

      BMC Musculoskelet Disord. 2013;14(147) 

      Arthritis Curehow to Arthritis Cure for In This Article

      Background

      Rheumatoid arthritis (RA) is a chronic inflammatory disease associated with increased disability, morbidity and mortality.[1,2] CVD has turned out to be one of the most important causes of death in RA patients.[3] Therefore, the European League Against Rheumatism (EULAR) guidelines recommend that cardiovascular risk screening and management to be urgently done in patients with RA.[4]

      Metabolic syndrome and Inflammation are intimately linked. Inflammatory biomarkers are frequently elevated in people with Met S and conversely, the prevalence of Met S is higher in patients with chronic inflammatory rheumatic diseases.[5]

      Arthritis Curehow to Arthritis Cure for Metabolic syndrome main components are dyslipidemia (elevated triglycerides and apolipoprotein B (apoB)-containing lipoproteins, and low high-density lipoproteins (HDL)), elevation of arterial blood pressure (BP) and dysregulated glucose homeostasis, while abdominal obesity and/or insulin resistance (IR) have gained increasing attention as the core manifestations of the syndrome.[6] Recently, other abnormalities such as prothrombotic states, non-alcoholic fatty liver disease and sleep apnea have been added to the entity of the syndrome, making its definition even more complex.[6] Besides the many components and clinical implications of metabolic syndrome, there are still no clearly defined diagnostic criteria. Several studies have examined the prevalence of Met S in RA subjects and whether it is increased compared to subjects without RA, but the results have been inconsistent, maybe due to the differences in metabolic syndrome definitions and in study populations.[7,8] The frequency of metabolic syndrome in RA patients is influenced not only by traditional factors such as race, age, and dietary habits, but also by disease-specific factors.

      Morocco is one of the countries of North Africa with unmet need of sustainable healthcare delivery systems. North Africa is a region with challenging political, climatic and geographical conditions. Data from small studies in the region showed that RA is frequently diagnosed late and many patients present with active disease and severe disability. Despite this, only a small proportion of patients receive DMARDs particularly biologic DMARDS, and the scarcity of medical and social resources is a barrier to appropriate treatment in many countries.[9–14] Morocco had also participated in two international studies: QUEST RA study,[15] which is a successful example of quantitative clinical measuring of RA as part of routine clinical care in a large number of centers across more than 30 countries including countries from Europe (France, Germany, Netherlands….), USA, Argentina, Brazil, Morocco, and United Arab Emirates. This study has suggested high disease activity in our country. The second study is COMORA study: comorbidities in RA (data not yet published), these two studies suggest a high disease activity in our country (300 patients from 10 centers of the country), the use of high-dose of corticoids, and a more frequent association with hyeprtension pressure, dyslipidemia, overweight and less frequent exposure to tobacco and alcohol. Solomon A et al.[16] have assessed the risk factor profiles for atherosclerotic cardiovascular disease in black and other Africans with established rheumatoid arthritis and found that proportions of individual metabolic syndrome components differed between black and other patients but their total numbers of metabolic risk factors and metabolic syndrome frequencies were similar. From these data from cross-sectional studies in Africa, we can assume that the activity profile and Severity of RA in Africa is quite different from Western countries. Furthermore, metabolic syndrome and activity are intimately linked. Hence, we aimed to assess the frequency of metabolic syndrome and its components and evaluate the supposed association with disease activity and severity of RA.

      BMC Musculoskelet Disord. 2013;14(147) © 2013  BioMed Central, Ltd.

      © 1999-2006 BioMed Central Ltd

      Tables
      Table 1.  A summary of the definitions of the metabolic syndrome[20–27]
      JC 2009 IDF (2005) NCEP ATP III 2004 NCEP ATP III (2001) EGIR 1999 WHO 1998
      Number of criteria Three or more of: And two or more of †: Three or more of: Three or more of: And two or more of †: And two or more of †:
      Obesity Population- and country-specific definitions * WC ≥ 94 cm men, WC ≥ 80 cm women WC ≥ 102 cm (men), WC ≥ 88 cm (women) WC ≥ 102 cm (men), WC ≥ 88 cm (women) WC ≥ 94 cm (men, WC ≥ 80 cm (women) BMI > 30 and/or WHR > 0.9 (men), WHR > 0.85 (women)
      Blood Pressure mmhg ≥ 130/85 or treatmen ≥130/≥85 or treatment ≥ 130/85 or treatment ≥ 130/85 or treatment ≥ 140/90 ≥ 140/90
      Dyslipidaemia:HDL-C ≥ 40 mg/dL (1.03 mol/L) in men, ≥ 50 mg/dL (1.29 mmol/L) in women, or treatment ≥ 40 mg/dL (1.03 mol/L) in men, ≥ 50 mg/dL (1.29 mmol/L) in women, or treatment ≥ 40 mg/dL (1.03 mol/L) in men, ≥ 50 mg/dL (1.29 mmol/L) in women, or treatment ≥ 40 mg/dL (1.03 mmol/L) in men or ≥ 50 mg/dL (1.29 mmol/L) in women ≥ 39 mg/dL (1.0 mmol/L) or treatment ≥ 35 mg/dL (0.9 mmol/L) in men or ≥ 39 mg/dL (≥ 1.0 mmol/L) in women
      Triglycerides ≥150 mg/dL (1.7 mmol/L) or treatment ≥150 mg/dL (1.7 mmol/L) or treatment ≥150 mg/dL (1.7 mmol/L) or treatment ≥150 mg/dL (1.7 mmol/L) ≥150 mg/dL (1.7 mmol/L) ≥178 mg/dL (2.0 mmol/L) or treatment
      Glucose intolerance or fasting plasma glucose ≥100 mg/dL (5.6 mmol/L) or T2D ≥100 mg/dL (5.6 mmol/L) or T2D ≥100 mg/dL (5.6 mmol/L) or T2D ≥110 mg/dL (6.1 mmol/L) ≥110 mg/dL (6.1 mmol/L) ≥110 mg/dL (6.1 mmol/l), DM, IGT, IR

      * cut-off values differ according to ethnic origin , for Mediterranean for 1 last update 2020/05/25 and sub Saharian people, the threshold of obesity defined by WC corres pond to the IDF definition;
      BMI = body mass index; JC= Joint Consensus; DM = diabetes mellitus; EGIR = European Group against Insulin Resistance; HDL-C = high-density lipoproteincholesterol; IDF = International Diabetes Federation; IGT = impaired glucose tolerance; IR = insulin resistance;NCEP ATPIII = National Cholesterol Education Programme Adult Treatment Panel; T2 D, type II diabetes mellitus; WC = waist circumference; WHO = World Health Organization; WHR = waist hip ratio.
      For IDF 2005, EGIR 1999 and WHO 1998. The definition of metabolic syndrome focus on the presence of diabetes, glucose intolerance or insulin resistance together with the presence of at least two other components from a list of five components. * cut-off values differ according to ethnic origin , for Mediterranean and sub Saharian people, the threshold of obesity defined by WC corres pond to the IDF definition;
      BMI = body mass index; JC= Joint Consensus; DM = diabetes mellitus; EGIR = European Group against Insulin Resistance; HDL-C = high-density lipoproteincholesterol; IDF = International Diabetes Federation; IGT = impaired glucose tolerance; IR = insulin resistance;NCEP ATPIII = National Cholesterol Education Programme Adult Treatment Panel; T2 D, type II diabetes mellitus; WC = waist circumference; WHO = World Health Organization; WHR = waist hip ratio.
      For IDF 2005, EGIR 1999 and WHO 1998. The definition of metabolic syndrome focus on the presence of diabetes, glucose intolerance or insulin resistance together with the presence of at least two other components from a list of five components.

      Tables
      Table 2.  Demographic and anthropometric characteristics of patients with RA and healthy controls
      Variables RA patients (N=120) Controls (N=100) p-value
      Age (years)1 49 ± 12 48.5 ± 13 0.78
      female Sex2 110 (91.7) 90 (90) 0.88
      Menopause2 63(51.1) 61(61) 0.97
      Body mass index3 28.1 (22.4 to 30.8) 24.5 (22.4 to 26.4) 0.23
      Waist circumference3 91.4 (83.8 to 93.4) 80.4 (77.2 to 82.8) 0.001
      Systolic blood pressure (mmHg)3 132.3 (126.1 to 130.5) 117.6 (115.5 to 119.7) 0.01
      Diastolic blood pressure (mmHg)3 79.1 (77.9 to 80.3) 71.4 (70.3 to 74.5) 0.12
      Total cholesterol, (mmol/l)3 5.4 (5.2 to 5.6) 5.2 (5.1 to 5.3) 0.32
      HDL-cholesterol, (mmol/l)3 1.32 (1.25 to 1.37) 1.64 (1.60 to 1.70) 0.02
      LDL-cholesterol, (mmol/l)3 3.3 (2.8 to 3.4) 2.4 (2.3 to 2.68) 0.04
      Triglycerides, (mmol/l)3 2.09 (2.06 to 2.14) 1.97 (1.94 to 1.99) 0.23
      Fasting plasma glucoce, (mmol/l)3 5.4 (5.3 to 5.5) 5.2 (5.1 to 5.4) 0.34

      1: mean and standard deviation, 2: number and percentage, 3: median and quartiles.

      Tables
      Table 3.  Prevalence of metabolic syndrome according to definition used
      Definitions JC 2009 IDF 2005 NCEP 2004 NCEP 2001 EGIR 1999 WHO 1998
      Controls 18 23 18 16 12 14
      Rheumatoid arthritis 32.3* 48.6* 32.4* 24.6* 18* 20*

      * For all definitions p<0.05.

      Tables
      Table 4.  Main characteristics of patients with rheumatoid arthritis included in this study according to the presence or absence of metabolic syndrome
      Characteristics Total (n=120) Mets absent (n=83) Mets present (n=37) P value
      Mean Age (years)1 49± 12 47±12 52±10 0.03
      Female Sex n (%)2 110 (91.7) 74(89.2) 36(97.3) 0.13
      Menopause n(%)2 63(51.1) 38(45.8) 25(67.6) 0.02
      RF positive n (%)2 93(76) 65(78.3) 28(75.7) 0.74
      ACPA positive n (%)2 104(85) 73(88) 31(83) 0.53
      Disease duration (yrs)1 7.8 ± 5.3 7.5±5.4 8.5± 4.9 0.31
      CRP (mg/L)1 17(1à 112) 17±21 19±19 0.59
      ESR (mm 1erhour)1 33± 23 24± 23 37± 24 0.04
      DAS281 5 ± 1.4 4.9±1.3 5.2± 1.5 0.32
      Global pain (VAS : 0-100 mm)1 54 ± 21 57±17 53±20 0.36
      HAQ1 1.4± 0.7 1.1±0.7 1.5±0.7 0.04
      Methotrexate n (%)2 117(96) 80(96) 37(100) 0.24
      glucocorticoids mean daily dose (mg/j)1 7.3±3.05 7.5±2.3 8±2.4 0.44

      1: Mean ± standard deviation, 2: number (percentage). ACPA = anti-cyclic citrullinated peptide; BP = blood pressure; CRP = C-reactive protein; DAS =Disease Activity Score; ESR = erythrocyte sedimentation rate; HAQ = Health Assessment Questionnaire; HDL =high-density lipoprotein; MetS = metabolic syndrome; RA = rheumatoid arthritis; RF = rheumatoid facto; BMI= Body mass index; VAS= visual analogic scale.

      Tables
      Table 5.  Odds ratios for having the metabolic syndrome in patients with RA
      Univariate analysis Multivariate analysis
      OR IC95% P OR 95% CI P
      Age (years) 1.33 1.19-2.35 0.03 1.13 1.18-1.76 0.07
      Disease duration (years) 1.03 0.96-1.11 0.32
      DAS28 1.16 0.87-1.55 0.28
      HAQ 1.45 1.12-2.5 0.03 1. 13 0.90-2.13 0.16
      MTX 0.01 0.03-1.7 0.76
      Glucocorticoids use 1.93 1.34-3.92 0.003 1.45 1.12-2.14 0.04
      CRP 1.01 0.88-1.02 0.60
      ESR 2.21 1.99-2.62 0.002 1.36 1.18-2.12 0.03

      DAS =Disease Activity Score; ESR = erythrocyte sedimentation rate; HAQ = Health Assessment Questionnaire; CRP = C-reactive protein; MTX =methotrexate. The factors included in the multivariate analysis were age, HAQ, glucorticoids use, and ESR.

      References
      Authors and Disclosures

      Authors and Disclosures

      Samira Rostom*, Mariam Mengat, Racha Lahlou, Asmaa Hari, Rachid Bahiri and Najia Hajjaj-Hassouni

      Department of Rheumatology, University Mohammed V Souissi. Faculty of Medicine and Pharmacy. El Ayachi hospital, University Hospital of Rabat-Sale, PO Box: 10000, Sale, Morocco

      Competing interests
      The authors declare that they have no competing interests.

      *Corresponding author
      [email protected]

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