Diabetes & Metabolic Syndrome: Clinical Research & Reviews 11S (2017) S425–S427
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Original Article
Prevalence of metabolic syndrome in Algerian rheumatoid arthritis patients. Correlation with disease activity and functional status Samy Slimania,* , Abdelmalek Abbasb , Amina Ben Ammarc , Fadia Rahald , Imene Khiderd , Khireddine Khelife , Aicha Ladjouze-Rezigd a
Department of Medicine, Hadj Lakhdar University, Batna, Algeria Medical Office, M’sila, Algeria Department of Medicine, EPH El Berrouaghia, Medea, Algeria d Department of Rheumatology, EHS Ben Aknoun, Algiers, Algeria e Department of Medicine, EPH Ain El Fakroun, Oum El Bouaghi, Algeria b c
A R T I C L E I N F O
Keywords: Rheumatoid arthritis Algeria Metabolic syndrome Disease activity
A B S T R A C T
Background: There is evidence that rheumatoid arthritis (RA) patients have an over-risk of cardiovascular disease. This may be mainly due to an increase in the prevalence of metabolic syndrome (MetS). The prevalence of MetS among adults in Algeria is 19.1%. Objectives: The aim of the study was to evaluate the prevalence of MetS among RA patients in Algeria. Another aim was to evaluate the relationship between MetS, inflammation biomarkers and disease scores. Methods: The study was performed on a cohort of 249 patients meeting the ACR/EULAR criteria for RA, followed in 11 Algerian centers. The diagnosis of MetS was based on the NCEP/ATP III (MetS+ if 3/5) definition. Prevalence of MetS was calculated, and patients were divided in two groups (MetS+ and MetS). Comparison between the groups was performed using a t-test. Results: Among the 249 RA patients, 213 were females and 36 males of a mean age of 50.1 14.5 years and a mean disease duration of 8.4 7.8 years. The overall prevalence of MetS was 13.9% (CI95%: 9.5-20.1%); it was 14.3% in males and 13.8% in females. The ESR level was significantly higher in MetS+ patients than in MetS- patients (p = 0.036). Conclusion: In this multicenter study, unlike most studies on RA patients, the prevalence of MetS was as not higher in Algerian RA patients (13.9%) than in the Algerian general population (19.1%). Only ESR levels correlate with the presence of MetS, this may be due to the modest cohort size and needs to be confirmed. © 2017 Diabetes India. Published by Elsevier Ltd. All rights reserved.
1. Introduction Rheumatoid arthritis (RA) is a common inflammatory joint disease that often leads to significant disability and is associated with increased morbidity and mortality [1]. There is evidence that rheumatoid arthritis patients have an over-risk of cardiovascular disease [2]. This may be due to an increase in the prevalence of metabolic syndrome (MetS). The prevalence of MetS among adults in Algeria is 19.1% [3]. There is no report evaluating MetS in Algerian RA patients. We have created a national cohort of Algerian RA patients to describe demographic, clinical and laboratory features and to evaluate their current therapies; some of the
* Corresponding author at: Department of Medicine, University of Batna 2, Batna, Algeria. E-mail address:
[email protected] (S. Slimani). http://dx.doi.org/10.1016/j.dsx.2017.03.029 1871-4021/© 2017 Diabetes India. Published by Elsevier Ltd. All rights reserved.
important results have been previously published [4]. The aim of this analysis was to calculate the prevalence of MetS among RA patients in Algeria. Another aim was to evaluate the relationship between MetS, inflammation biomarkers and disease scores (DAS28 and HAQ). 2. Patients and methods 2.1. Patients The study was performed on a cohort of 249 patients meeting the ACR/EULAR criteria for RA, followed in 11 Algerian centers. A detailed description of methods has been published in a previous paper [4]. It was an observational, multicenter, population-based survey on patients with RA from December 2010 to April 2011. Patients were aged 18 years old or over and have given their
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S. Slimani et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 11S (2017) S425–S427
Table 1 The 2001 NCEP ATP III definition of MetS. MetS is defined by the presence of 3 parameters or more. BMI 30 kg/m2 TG 150 mg/dl C-HDL < 40 mg/dl in men C-HDL < 50 mg/dl in women Blood pressure 130/85 mmHg or previous hypertension diagnosis Fasting glucose 110 mg/dl or previous type 2 DM
3. Results
Abbreviations: NCEP ATP III, National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) definition; BMI, body mass index; C-HDL, highdensity lipoprotein-cholesterol; DM, diabetes mellitus; TG, triglycerides.
Table 2 Comparison between RA patients with MetS (MetS + ) and without MetS (MetS-). Variable
MetS + N = 35
MetS
Tender joints Swollen joints DAS28 HAQ Morning stiffness (min) ESR (mm) CRP (mg/L) RF (%) ACPA (%) Erosions (%)
4.4 3.9 1.4 1.8 4.1 1.3 0.7 0.7 32 26 53 17 9.3 9.0 75 44 67 50 74 45
3.3 3.0 1.8 2.4 4.2 1.4 0.9 0.8 34 42 38 15 10.3 10.4 79 41 76 43 68 47
N = 214
MetS was calculated, and patients were divided in two groups, as having (MetS + ) or not having (MetS-) a metabolic syndrome. Comparisons between the 2 groups were performed using a t-test. Statistical tests were two-sided and the significance level was set at 0.05. Statistical analyses were performed using the SPSS software, version 17.0.
p 0.201 0.407 0.973 0.457 0.833 0.036 0.691 0.712 0.561 0.550
Abbreviations: ACPA, anticitrullinated peptide antibody; CRP, C-Reactive Protein; DAS28, Disease activity Score on 28 joints; ESR, erythrocyte sedimentation rate; HAQ, Health Assessment Questionnaire; MetS, metabolic syndrome; RF, rheumatoid factor. Text in bold signifies significant result.
consent for inclusion in the study. The study was approved by the scientific committee of Ben Aknoun University Hospital, Algeria. 2.1.1. Patients’ evaluation A standard clinical evaluation was performed. The investigating rheumatologist recorded demographic data, as well as clinical data. Evaluation of pain, disease activity and physician global assessments were performed at inclusion. The existence of comorbidities has been noted. Were also noted at inclusion height, weight and blood pressure measurements. Blood samples were taken to measure biochemical and inflammatory parameters including fasting glucose, cholesterol and triglycerides, along with acute phase reactants (Erythrocyte sedimentation rate, C-reactive protein). 2.2. Methods Body mass index (BMI) has been calculated as weight (kg)/ height2 (m2). Hypertension was defined by a systolic > 130 mmHg or a diastolic > 85 mmHg. The diagnosis of MetS was based on the NCEP/ATP III definition (MetS+ if 3/5) (Table 1) [5]. Prevalence of
Among the 249 RA patients, 213 were females and 36 males of a mean age 50.1 14.5 years, a mean disease duration 8.4 7.8 years, DAS28 3.9 4.8, CRP 11 16 mg/L, ESR 41 26 mm, and HAQ 0.81 0.82. Rheumatoid factor was positive in 78.5% of cases, mean BMI was 25.3 5.1 kg/m2. More details about clinical status, disease activity, gender differences and calcium intake in this population are detailed in a previous paper. Among the 249 patients, 35 satisfied to the NCEP/ATP III definition of MetS, giving an overall prevalence of MetS of 13.9% (95%CI: 9.5-20.1%); it was 14.3% in males and 13.8% in females. Comparing patients with (n = 35) and without (n = 214) MetS found no association between the presence of MetS and levels of CRP, DAS28, HAQ scores, morning stiffness, RF, ACPA and presence of erosions. However, The ESR level was significantly higher in MetS+ patients than in MetS- patients (p = 0.036) (Table 2). 4. Discussion We aimed through our study to detail the clinical and laboratory characteristics of patients with RA in Algeria, focusing in this analyses on how much prevalent is metS in a representative population of Algerian RA patients, because the participating centers were different geographically and included tertiary research hospitals, general hospitals and private practice clinics. In this multicenter study, unlike most western studies on RA patients, the prevalence of MetS was not higher in Algerian RA patients (13.9%) than in the Algerian general population (19.1%). Moreover, we were not able to bring out a strong association between the RA activity and the presence of metS. ESR levels correlate with the presence of MetS and thus go with the conclusions drawn on western cohorts [6,7]; However, CRP does not, this may be due to the modest cohort size and needs to be confirmed. Unlike many studies from the developing world, we did not find any association between the presence of MetS and disease activity, measured using DAS28. We found very few studies evaluating the prevalence of MetS in RA and its relationship with disease activity from the developing world [8–13]. We cannot directly compare these studies because of the use of different definitions of the MetS, different inclusion methods and different sample sizes. Table 3 gives a comparison between findings of studies from the developing world.
Table 3 Comparison between MetS prevalence and association with disease parameters in the developing world. Study
Country
Study design
Sample size (n,/controls)
MetS Definition
MetS prevalence (%)
Associating factors
Cunha et al. [8] Karimi et al. [9] Parra-Salcedo et al. [10] Rostom et al. [11] Karakoc et al. [12] Dao et al. [13] Abourazzak et al. [14] Our study
Brazil Iran Mexico Morocco Turkey Viet Nam Morocco Algeria
Case-control Case-control Observational Case-control Case-control Case-control Observational Observational
283/226 92/96 160 120 54/52 105/105 179 249
NCEPT NCEPT NCEPT NCEPT AHA NCEPT NCEPT NCEPT
39.2 27.2 24 24.6 42.6 26 24.6 13.9
DAS28 Duration of RA BMI, DAS28 GC DAS28 ESR, DAS28, HAQ Severity, less MTX use ESR
Abbreviations: AHA, American heart association; BMI, body mass index; CRP, C-Reactive Protein; DAS28, Disease activity Score on 28 joints; ESR, erythrocyte sedimentation rate; GC, glucocorticoids intake; HAQ, health assessment questionnaire; MetS, metabolic syndrome; MTX, methotrexate; NCEPT, National Cholesterol Education Program Adult Treatment Panel III.
S. Slimani et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 11S (2017) S425–S427
Our study has some limitations. Firstly, the sample size and the number of patients with MetS (35 among 249) may be small and insufficiently powerful to draw solid conclusions on the association between RA features and the presence of MetS. The second limitation is the absence of a control group. In conclusion, this study gives, for the first time, an idea on the prevalence of MetS among Algerian RA patients, and its relationship with disease parameters. There is no evidence that this prevalence of 13.9% of MetS is greater than in the general adult population. Author contributions: Slimani S contributed to the study conception, design, analysis and data acquisition. Abbas A contributed to data acquisition and final approval of article. Ben Ammar A contributed to data acquisition and final approval of article. Rahal F contributed to data acquisition and final approval of article. Khider I contributed to data acquisition and final approval of article. KHelif K contributed to data acquisition and final approval of article. Ladjouze-Rezig A contributed to editing and final approval of article. Sources of funding None Institutional review board statement Approved by the scientific committee of Ben Aknoun Hospital, Algiers, Algeria. Informed consent statement All patients have provided an informed consent. Conflicts of interest All the authors declare no conflict of interest with regard to this study Acknowledgement We would like to thank all the patients for participation in this study.
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