Rheumatoid Arthritis and Cholesterol: What to Know

Medically Reviewed by James Beckerman, MD, FACC on March 30, 2022
3 min read

Rheumatoid arthritis is a disease that inflames tissues of the body. It often causes stiffness and pain in the joints, especially the hands, wrists, and feet.

Scientists know it’s because the body’s immune system gets confused and attacks your joints and other healthy tissue. But, they don’t know why this happens.

Cholesterol is a measure of the fats, or “lipids,” that circulate in your blood. Unhealthy cholesterol levels typically mean your LDL, or “bad” cholesterol, is too high and/or your triglycerides – a type of fat – are too high. It may also mean you have unusually low levels of HDL, or “good” cholesterol.

Unhealthy cholesterol levels are a risk factor for a number of health conditions. The relationship between cholesterol levels and RA is complex and involves something scientists call the “lipid paradox.”

But in order to understand the lipid paradox, you first have to understand the relationship between RA and cardiovascular disease.

Cardiovascular disease, also known as heart and blood vessel disease, or just “heart disease,” happens when your blood vessels narrow because of plaque buildup. This can lead to a number of problems like heart attack, stroke, heart failure, and heart rhythm problems.

If you have RA you have almost double the chance of developing cardiovascular disease compared with people without RA. There are two main reasons for this.

First, the tiny proteins called cytokines that inflame your joints in RA can also fuel blood vessel damage and plaque buildup in heart disease.

Second, RA and heart disease share many of the same risk factors. Risk factors are simply conditions or activities that raise your chances of getting a certain condition. These shared risk factors include high blood pressure, obesity, smoking, metabolic syndrome (a collection of signs and symptoms) and – most importantly for our purposes here – unhealthy cholesterol levels.

In fact, heart disease is the primary risk associated with unhealthy cholesterol levels – sometimes called “high cholesterol.”

The lipid paradox is this: Though people with RA have a higher risk of heart disease, they often have lower total cholesterol (TC) and LDL levels than the general population. These numbers should lower your risk of heart disease, not raise it. And yet – here’s the paradox – in those with RA, as total cholesterol and LDL levels go up, the risk of heart disease goes down.

One theory is that in those with RA, inflammation is the main driver behind increased heart disease risk. Lower the inflammation, and you lower the risk of heart disease. So even though certain RA medications can raise your TC and LDL levels, they lower your heart disease risk by getting rid of some of that inflammation.

For example, one such medication, tumor necrosis factor inhibitor (TNFi), raised TC and LDL as much as 30% while at the same time lowering risk of heart disease.

It also may be that more complex measures of cholesterol, including something called HDL cholesterol efflux capacity, could be more helpful in predicting heart disease in people with RA.

Much more study is needed to be sure.

The use of statins, lipid lowering meds, in people with RA or at risk for RA is complicated. Some research shows that statins can help lessen RA symptoms and heart disease risk in those who already have RA. But not always. Sometimes it can do the opposite.

Other studies show that statins can speed up the onset of RA in people at risk for the disease, especially in the first year. On the other hand, high cholesterol may be a risk factor for developing RA in the first place – at least in women, but not in men.

And then there is the risk of heart disease from high cholesterol. At what point does your need for statins because of high cholesterol trump any possible negative effects on your RA?

There are simply too many unknown factors in each individual case to know for sure. That’s why it’s important to discuss all of your health history and risk factors with your doctor so that together you can make the best decision about statin use in your case.