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Aktuelle Rheumatologie 2014; 39(03): 186-190
DOI: 10.1055/s-0034-1372602
Übersichtsarbeit
© Georg Thieme Verlag KG Stuttgart · New York

Innovative Therapieoptionen in der Rheumatologie: Die Büchse der Pandora aus kardiologischer Sicht

Innovative Therapy Options in Rheumatic Diseases: Pandora’s Box from the Cardiological Point of View
B. Markus
1   Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Philipps Universität Marburg, Marburg
,
B. Schieffer
1   Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Philipps Universität Marburg, Marburg
,
U. Lüsebrink
1   Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Philipps Universität Marburg, Marburg
› Author Affiliations
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Publication History

Publication Date:
17 June 2014 (online)

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Zusammenfassung

Rheumatologische Erkrankungen sind durch chronisch aktivierte Entzündungskaskaden charakterisiert, die neben Gelenkdestruktionen parallel die atherosklerotische Plaque Entwicklung antreiben und zu vermehrtem Herzinfarkt, Schlaganfall oder plötzlichem Herztod bei Rheuma-Patienten führen. Ziel dieser Übersichtsarbeit ist es die pharmakologische Therapie rheumatologischer Erkrankungen unter Berücksichtigung des kardiovaskulären Risikos zu analysieren. Als First-line-Therapy finden u. a. NSAR, Coxibe und Glucocorticoide Verwendung. Hinsichtlich des kardiovaskulären Risikos zeigt die Gruppe der sog. „Basistherapeutika“ (disease-modifying anti-rheumatic drugs; DMARDs) sehr gegensätzliche Studienergebnisse. Einerseits erhöhen NSAR, Coxibe und Glucocorticoide in hohen Dosen das kardiovaskuläre Risiko, wohingegen Methotrexat das kardiovaskuläre Risiko zu reduzieren scheint. Aus Sicht des Kardiologen wurde die Büchse der Pandora geöffnet mit dem breiten Einsatz der Gruppe der Biologika, die spezifische Schlüsselenzyme von Inflammationskaskaden blockieren. Wirkt sich die TNF-alpha Hemmung eher positiv auf das kardiovaskuläre Risiko von Patienten aus, so ist dessen Abschätzung bei Interleukin 6-Inhibition aktuell noch unklar aufgrund der ausgeprägten Hyperlipoproteinämie. Komplett unklar wird eine Risikostratifizierung kardiovaskulär und teilweise auch infektiologisch beim Einsatz von IL-1 Inhibitoren (Anakinra) oder CD20-Antikörpern (Rituximab). Hier setzen die standardisierten Therapie- und Kontrollmechanismen der EULAR Empfehlungen an, die nicht nur Parameter vorgeben, um den Erfolg einer rheumatologische Therapie zu bewerten, sondern auch das Monitoring kardiovaskulärer Parameter empfehlen um somit das kardiovaskuläre Risiko therapieadaptiert abschätzen und ggf. reduzieren zu können. Die Unabwägbarkeiten, die sich aus dem Öffnen der Büchse der Pandora ergaben, können damit reduziert werden, wobei eine conditio-sine-qua-non die Forderung nach prospektiven Studien mit den einzelnen Substanzen unter Berücksichtigung kardiovaskulärer Endpunkte sein muss.

Abstract

Rheumatologic diseases are characterised by chronic inflammation and activated cascades that simultaneously enhance the development of atherosclerotic plaque and lead to heart attack, stroke or sudden cardiac death, the leading cause of death worldwide. The aim of this review is to analyse the pharmacological therapy of rheumatic diseases in the light of cardiovascular risks. As first-line therapy analgetics and non-steroidal antirheumatic drugs were used commonly, but concerning cardiovascular morbidity the group of disease-modifying anti-rheumatic drugs (DMARDs) shows conflicting study results. On the one hand NSAR, coxibs and glucocorticoids in high doses increase cardiovascular risk, whereas on the other hand methotrexate appears to reduce cardiovascular risk. From the cardiologist’s point of view Pandora’s Box has been opened with the wide use of biologicals, blocking specific key enzymes of the inflammation cascade. While blocking TNF alpha seems to have a positive effect on the cardiovascular risk of patients, inhibiting interleukin-6 seems less satisfactory and promising due to the pronounced hyperlipoproteinemia. Complete uncertainty remains looking at the cardiovascular – and partly infectiological – risk for the use of IL-1 inhibitors (anakinra) or CD20 antibodies (rituximab). This is where the standardised treatment and control of EULAR recommendations appear, that will not only define the success of a rheumatological therapy, but also help monitoring the cardiovascular parameters and risk by taking the actual antirheumatic therapy into account. The uncertainties that resulted from the opening of Pandora's Box can thus be reduced, but as a conditio-sine-qua-non the need for prospective studies including cardiovascular endpoints remains.

Schlüsselwörter

rheumatologische Erkrankungen - medikamentöse Therapie - Biologika - kardiovaskuläres Risiko

Key words

rheumatoid diseases - drug therapy - biologicals - cardiovascular risk
 

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