PREVALENCE OF DYSLIPIDEMIA AND ITS ASSOCIATION WITH DISEASE ACTIVITY IN PATIENTS WITH RHEUMATOID ARTHRITIS IN SULAIMANI GOVERNORATE

Objectives: Rheumatoid arthritis is a systemic inflammatory disease characterized by chronic and erosive polyarthritis it is the most common inflammatory arthritis, affecting from 0.5-1% of the general population. Dyslipidemia is a quite important problem in Rheumatoid arthritis (RA) patient, which causes morbidity and mortality. Objectives are to measure prevalence of dyslipidemia in patients with Rheumatoid Arthritis compared with healthy control peoples and to find out correlations between dyslipidemia and disease activity in patients with Rheumatoid Arthritis. Methods: A total of one hundred patients with RA (80 female and 20 male) were included in the study, they were attending consultation clinic and division of rheumatology in the General Medical Teaching Hospital in Slemani city from (October 2015 to September 2016) who fulfilling the 2010 American College of Rheumatology/European league against Rheumatism classification criteria for RA and one hundred healthy age and sex-matched controls. Fasting lipid profiles of cases and control were estimated after an overnight fast of 12 hours. Results: RA patients showed a higher prevalence of associated dyslipidemia (48%) in comparison to control (4%) pvalue less than 0.001. Results showed a significant reduction in serum high density lipoproteins (HDL) p-value less than 0.001, with significant elevation of serum total cholesterol, triglyceride, low density lipoprotein and very low density lipoprotein p-value 0.001, 0.007, 0.01and 0.5 respectively in comparison to controls. There is a significant association between dyslipidemia and high DAS 28 score (p=0.02). Conclusion: There is a significant association between high ESR of RA patients and dyslipidemia (p=0.001). A significant association was observed between high CRP level and RA patients with no dyslipidemia (p<0.001). Dyslipidemia are frequent among the patients with rheumatoid arthritis and highly associated with active RA. Serum HDL significantly reduced while other parameters of lipid profiles significantly increased in comparisons to control.


INTRODUCTION
Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease characterized by chronic and erosive polyarthritis 1 , associated with persistent inflammatory synovitis, progressive joint destruction , and an excess mortality when compared to the general population 2,3 . It is characterized by symmetric erosive synovitis 3 . Female are 2.5 times more likely to be affected than male 4 . The onset of disease can occur at any age but peak incidence occurs within fourth and fifth decade of life 5 . Its clinical diagnosis made on the basis of symptoms, physical examinations, X-ray and laboratory investigations 6 . Patients with RA have an increased mortality when compared with age-matched controls, primarily due to cardiovascular disease. This is most marked in those with severe disease, with reduction in expected life span by 8-15 years 7 . Dyslipidemia are being increasingly recognized as an important contributory factor toward the development of cardiovascular disease 8 . Premature cardiovascular disease (CVD) is very common in RA patients 9, 10 . RA is associated with 50% increase in incidence of myocardial infarction (MI) and cardiovascular diseases as compared to general population 10 . It has been observed that increased inflammation and active disease has an impact on lipid patterns in blood 11 . Atherosclerosis is now considered as an inflammatory disease as it is a result of inflammation and

Exclusion criteria
History of smoking or patients suffering from condition that affect the lipid profile such as diabetes mellitus, hypertension, ischemic heart disease, renal impairment, liver and thyroid functional abnormalities, cushing syndrome and obesity (BMI >30) were excluded. Also any patients received medications affecting lipid metabolism such as beta blocker, diuretics, cyclosporine, oral contraceptive pills (OCP), patients who received oral or intra-articular steroid till one month before study and pregnant women were excluded.

The study protocol
The study protocol includes :- ( Questionnaire, clinical

RESULTS
A total 100 rheumatoid arthritis (RA) patients were included in present study with mean age of as 57±8.6 years, 36% of them were 50-59 years age. Females were more than males with female to male ratio as 4:1. Disease duration distribution of RA patients RA disease duration of studied patients, 52% of them had disease duration of more than 5 years.

DISCUSSION
Several pieces of evidence indicate that rheumatoid arthritis (RA) is a proatherogenic disease associated with increased cardiovascular (CV) mortality 23 which account for about half of all deaths in these patients 24 .

Figure 4: DAS 28 scores distribution of RA patients
Besides genetic and traditional CV risk factors chronic 25 inflammation has effect in the development of this process 26 . Results showed that RA occurs in all age groups between 20-70 years, which showed that 36% of them between 50 to 59 years and 26% were between 40 to 49 years of age; this is in accordance with other study which mentioned that RA affects usually people above 40 years old 27   Patients with rheumatoid arthritis (RA) have higher rates of morbidity and mortality than the general population, which is highly attributed to an increased risk of cardiovascular disease (CVD) among RA patients 32 . The increased risk of CVD appears to be linked to coronary atherosclerosis 33 and may be directly caused by chronic inflammation or secondarily caused by physical inactivity and drugs used to treat RA 34 . In this study we found that patients diagnosed with RA had significantly reduced levels of HDLcholesterol in comparison to control groups and this was matched with many other study done in all of Pakistan by Nisar A et al., 35

CONCLUSION
The prevalence of dyslipidemia among rheumatoid arthritis patients in Sulaimani is high. The blood levels of total cholesterol, triglycerides and LDL cholesterols were higher among RA patients. HDL cholesterol level was lower among RA patients. Dyslipidemia may be a risk factor for rheumatoid arthritis severity and cardiovascular diseases. Obesity is a risk factor for rheumatoid arthritis incidence.

RECOMMENDATIONS
Dyslipidemia among RA patients are common and this increase risk of cardiovascular disease and mortality among RA patients, lipid management including greater use of statin therapy may be appropriate to reduce this. Screening programs for RA patients on lipid profile to predict activity and severity of disease, Cardiovascular screening should be recommended every 6 months to once yearly in Sulaimani city. Encouraging the diet restriction programs and physical activities in schools to prevent the obesity. Further national large sized studies on prevalence and effect of hyperlipidemia on RA patients must be supported.