Several investigators[14, 15, 34, 35] have studied the use of biologics, such as anti-TNF and rituximab, for treating

endothelial function in patients with RA. Gonzalez-Juanatey et al. demonstrated that Sirolimus improved%FMD is associated with significantly decreased CRP as well as the active effect of rituximab on endothelial function in RA patients, refractory to TNF blockers.[15] Other investigator have shown that short-term TNF blockade reduces disease activity and CRP levels and significantly improves endothelial function in patients with RA.[12] Although our study included various anti-TNF biologics such as infliximab, etanercept and adalimumab, our results are concordant with those of previous studies. A recent epidemiologic study emphasizes the importance of inflammation and the role of baseline CRP levels in particular, as predictors

of all causes of mortality, specifically cardiovascular mortality, in patients with inflammatory polyarthritis in a 10-year period after the onset of the RA.[36] CRP is postulated to promote atherosclerotic processes and endothelial cell activation. We hypothesize that the strong anti-inflammatory effects elicited by anti-TNF biologic therapy may explain the improved of endothelial function manifesting as improved%FMD. Since patients have better disease control with biologics they may be more physically active, which could result in improved FMD. Several previous studies also report that increased carotid IMT is correlated with CVD risk factors.[37, 38] Gonzalez-Juanatey et al. reported that carotid IMT is strongly associated BCKDHB with CVD events In

patients with RA, carotid GSI-IX cell line IMT had high predictive power for the development of CVD events over a 5-year follow-up period.[9] Furthermore, previous studies in patients with CVD indicate an inverse correlation between carotid IMT and brachial FMD.[39-41] Some researchers state that patients with acute RA, treated with anti-TNF therapy, exhibit significant carotid IMT reduction preceded by a significant decrease in disease activity.[14] Although reductions in carotid IMT have been observed following the administration of anti-TNF drugs,[14] some researchers report the progression of carotid IMT in long-standing RA patients refractory to conventional therapy who underwent infliximab therapy because of severe disease.[34] Gonzalez-Juanatey et al. found no relationship between FMD and IMT in patients, regardless of disease duration.[42] In the current preliminary study, although the change in max IMT appeared to be related to the dosing period of anti-TNF therapy, there was no significant progression following anti-TNF therapy. This is probably due to alleviation of the disease with a reduction of the inflammatory burden, because persistent chronic inflammation is associated with carotid IMT progression.[43] The main limitations of our study are the relatively small number of subjects and the cross-sectional design.