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• Corrected version of the e-letter "Selection bias may have blunted the effect of atorvastatin on the progression of atherosclerosis in systemic lupus erythematosus patients: Commentary on the Lupus Prevention Atherosclerosis Study (LAPS) "
  Markus Bredemeier
  Published on: 13 April 2016
• About Lupus Atherosclerosis Prevention Study (LAPS)
  JM Sabio
  Published on: 13 April 2016

• Published on: 13 April 2016

  Corrected version of the e-letter "Selection bias may have blunted the effect of atorvastatin on the progression of atherosclerosis in systemic lupus erythematosus patients: Commentary on the Lupus Prevention Atherosclerosis Study (LAPS) "

  • Markus Bredemeier, Rheumatologist

  Dear editor,

  We read with interest the study by Petri et al. (1), which showed absence of effect of atorvastatin on the change in coronary artery calcium and carotideal intima media thickness in lupus patients treated for 2 years. Lupus was been considered a coronary heart disease (CHD) equivalent by some authors given the major increase of cardiovascular risk in this disease (2).

  The authors reported that patie...

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  Dear editor,

  We read with interest the study by Petri et al. (1), which showed absence of effect of atorvastatin on the change in coronary artery calcium and carotideal intima media thickness in lupus patients treated for 2 years. Lupus was been considered a coronary heart disease (CHD) equivalent by some authors given the major increase of cardiovascular risk in this disease (2).

  The authors reported that patients with atherosclerotic disease or LDL > 190 mg/dl were excluded from the sample. Observing the baseline characteristics of the patients, more than 50% had from the start LDL cholesterol <= 100 mg/dl, which is considered the desirable level for patients with CHD and equivalents (3). HDL cholesterol >= 60 mg/dl, which has protective effect for atherosclerotic disease, was present in 44% percent of the sample. On the other hand, patients with diabetes mellitus (DM) were allowed, but these patients should have been excluded given that DM is a CHD equivalent. However, the number of these patients was small.

  Considering the evidence, it is possible that the broad criteria used for selection of patients and the inclusion of many patients with low cardiovascular risk profile may have precluded a positive effect of atorvastatin on the reduction of progression of atherosclerosis in this study.

  References

  1. Petri MA, Kiani AN, Post W, et al. Lupus Atherosclerosis Prevention Study (LAPS). Ann Rheum Dis 2011;70:760-5.

  2. Bruce IN. Cardiovascular disease in lupus patients: should all patients be treated with statins and aspirin? Best Pract Res Clin Rheumatol 2005;19:823-38.

  3. Grundy SM, Cleeman JI, Merz CN, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004;110:227-39.

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  Conflict of Interest:
  None declared.

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• Published on: 13 April 2016

  About Lupus Atherosclerosis Prevention Study (LAPS)

  • JM Sabio, MD, PhD
  • Other Contributors:
    • N.Navarrete-Navarrete

  Dear Editor,

  We read with great interest the article of Petri et al [1] addressing the effect of atorvastatin 40 mg daily on subclinical atherosclerosis (ATS), systemic inflammation and disease activity in patients with systemic lupus erythematosus (SLE). Contrary to expectations, atorvastain had no effect on any of these parameters after 2 years of follup-up. Although these findings are clinically relevant, some issues...

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  Dear Editor,

  We read with great interest the article of Petri et al [1] addressing the effect of atorvastatin 40 mg daily on subclinical atherosclerosis (ATS), systemic inflammation and disease activity in patients with systemic lupus erythematosus (SLE). Contrary to expectations, atorvastain had no effect on any of these parameters after 2 years of follup-up. Although these findings are clinically relevant, some issues should be considered in order to better interpret the results.
  First, the authors provide no information about the treatments received by patients during the 2 years of follow up, especially in regard to the use of prednisone, inmmunosupresive agents and hydroxychloroquine. All these drugs have a direct effect on inflammation and disease activity and potentially on subclinical ATS. Thus, the negative results found in this clinical trial could be due to an imbalance in the use of these drugs in both arms, rather than the lack of effect of atorvastatin on these parameters.
  Second, the mean SELENA SLEDAI value for all patients at baseline was ~2 (range 0-24), indicating that most patients had inactive or moderately active disease status and consequently a low-moderate grade of systemic inflammation [2]. Moreover, 87% of patients had an intima-media thickness < 0.7 mm, and only 20% of them had plaque at baseline. Therefore, perhaps the ability of atorvastatin to improve these parameters in this context is limited, and it is likely that the results would have been better if patients had had a higher lupus activity, inflammation and a higher ATS burden at baseline.
  This concept emphasizes the desirability of stratifying SLE patients according to cardiovascular (CV) risk in order to adjust the measures to prevent the development of CV diseases rather than applying them indiscriminately in all SLE patients. Perhaps one of the most important lessons from this clinical trial is that statins should not be used in the prevention of CV disease in SLE patients with normal lipid levels, inactive or low active disease and low ATS burden.

  References

  1. Petri MA, Kiani AN, Post W, et al. Lupus Atherosclerosis Prevention Study (LAPS). Ann Rheum Dis 2010 Dec 21:[Epub ahead of print].

  2. Petri M, Kim MY, Kalunian KC, et al. Combined oral contraceptives in women with systemic lupus erythematosus. N Engl J Med 2005;353:2550-8.

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  Conflict of Interest:
  None declared.

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