As earlier diagnosis and improved therapies have greatly increased the life expectancy associated with systemic lupus erythematosus (lupus), people with lupus now must face a longer-term problem: an increased risk of cardiovascular disease.
Studies suggest that for a premenopausal woman with lupus, the risk of a heart attack or stroke is increased, says Laura Schanberg, M.D., a researcher supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). That risk, she says, is due to the premature development of atherosclerosis, or hardening of the arteries, which can occur as a result of the disease or its treatment.
Dr. Schanberg, professor of pediatrics at Duke University School of Medicine, and Dr. Christy Sandborg, M.D., of Standford University have questioned whether treating preemptively with statin drugs, which have been proven to reduce heart attacks and strokes in people with, or at risk for, atherosclerosis, might help protect children and adolescents with lupus years down the road. New findings of the Atherosclerosis Prevention in Pediatric Lupus Erythematosus (APPLE) study provide important insights.
The 36-month study, which was also supported by the Childhood Arthritis and Rheumatology Research Alliance (CARRA), enrolled 221 pediatric lupus patients at 21 sites across the United States, and compared outcomes of children given the statin drug atorvastatin to those given placebo. Because children usually don’t have myocardial infarctions or strokes – the ultimate indicator of whether the drugs were effective — the researchers instead measured carotid intima-media thickness (CIMT) to assess outcomes. CIMT — a test that uses ultrasound to determine the thickness of the intimal and medial layers of the carotid artery walls – can help doctors predict the risk of heart attack and stroke. Thicker walls mean an increased risk of cardiovascular events. For every unit that they thicken, the risk of a cardiovascular event goes up. In children, the rate of progression ideally should be zero, says Dr. Schanberg.
For children with lupus, however, the scientists found that the rate of progression was not zero. Children with lupus have a significantly increased rate of progression even in childhood, and treatment with statins made no statistically significant change in that progression, the study showed. The researchers suggest that further analyses may identify subgroups of children who may benefit from targeted statin therapy.
While the study failed to show a significant benefit of statins overall, that’s not necessarily bad news, because it lets doctors know they don’t need to prescribe statins for every child with lupus from the time they are diagnosed, says Dr. Schanberg. This finding will spare children the cost and potential side effects of a drug that’s not proven beneficial. At the same time, it suggests that for certain children the drugs may, in fact, be helpful.
Schanberg LE, et al. Use of atorvastatin in systemic lupus erythematosus in children and adolescents. Arthritis Rheum. 2012 Jan;64(1):285-96. doi: 10.1002/art.30645. [PubMed - indexed for MEDLINE] PMID: 22031171
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