Statin therapy now more common than steroids in clinical practice.

Dear Editor, In the recent article from Ozen et al, the authors found increased risk of diabetes mellitus (DM) in patients with rheumatoid arthritis (RA) compared with normal US adult population. The authors have also reported increased risk of DM in patients with RA who took glucocorticoids (GCs) and statin therapy. Surprisingly, the HR of diabetes has been found to be higher in the statin group than in the steroid group. It is important to know the duration of exposure to steroids in patients with RA . Not all patients may be exposed to steroids for prolonged period. The authors may comment on the duration of steroids in various patients. While the concomitant use of GC did not alter DM risk reduction with HCQ, the authors have also reported DM risk reduction with concomitant use of HCQ and statin therapy. The authors have mentioned the risk of incident diabetes by steroid dose, HCQ dose, and duration and concomitant GC use in a tabular form (table 4, page no. 5) but similar information is missing for concomitant use of statin and HCQ. We request the authors to throw more light on this. In our study, ‘Efficacy and safety of fixed dose combination of atorvastatin and hydroxychloroquine: a randomized, doubleblind comparison with atorvastatin alone among Indian patients with dyslipidemia’, we compared the efficacy and safety of atorvastatin (10 mg)+hydroxychloroquine (200 mg) fixed-dose combination tablets in comparison with atorvastatin (10 mg) alone in treatment of dyslipidaemia for 6 months and found in exploratory analysis that 15% patients with prediabetic dyslipidaemia from the monotherapy group and 2% from the combination group developed diabetes. Other observational studies have also suggested the potential benefit of hydroxychloroquine in attenuating the risk of diabetes in patients with RA. A population-based cohort study in patients with systemic lupus erythematosus 4 demonstrated an increased risk of DM with high dose of GC which was decreased by concomitant use of HCQ in a dose-dependent manner. It is important to note that in comparison with GC, which may often be used intermittently for short period, statin therapy is used for long term to reduce cardiovascular risk. Hence, it is important to know the risk of diabetes due to statin exposure in patients with RA and the preventive role of HCQ in the same.