Economic burden of comorbidities in patients with psoriasis is substantial

Psoriasis and Cardiovascular Disease

Psoriasis is a systemic inflammatory disease that confers significant risk of metabolic derangements and adverse cardiovascular outcomes. Early detection and treatment of modifiable risk factors and modulation of the systemic inflammatory response are important treatment goals. Studies have shown that there is a significant lack of awareness of the relationship between psoriasis and cardiovascular disease, so future considerations should focus on education of and collaboration with health care providers, especially those in primary care, and development of updated, rigorous screening guidelines. In addition, targeted biologic therapies such as TNF-a inhibitors have shown immense promise in targeting the systemic inflammation associated with psoriatic disease, but whether they will impact long-term cardiovascular outcomes remains to be seen.

Economic and Comorbidity Burden Among Patients with Moderate-to-Severe Psoriasis

BACKGROUND

Previous studies demonstrated substantial economic and comorbidity burden associated with psoriasis (PsO) before biologics were available. Biologics have changed PsO treatment paradigms and potentially improved patient outcomes. There is a need to reassess the economic and comorbidity burden of PsO in the biologic era.

OBJECTIVE

To compare the prevalence of comorbidities, health care resource utilization, and costs between moderate-to-severe PsO patients and demographically matched controls. 

METHODS

Adults aged 18-64 years with at least 2 PsO diagnoses (ICD-9-CM code 696.1) were identified in the OptumHealth Reporting and Insights claims database from January 2007 to March 2012. Moderate-to-severe PsO patients were identified as those receiving ≥ 1 systemic therapy or phototherapy during the 12-month study period following the index date (randomly selected date after the first PsO diagnosis). Controls were free of PsO and psoriatic arthritis (PsA) and were matched 1:1 with PsO patients on age, gender, and geographic region. All patients had at least 12 months of continuous enrollment after the index date. Selected comorbidities, medication use, all-cause health care utilization, and costs were compared between PsO patients and controls. Multivariate regression models were performed to examine the association between PsO and selected comorbidities, medication use, and health care costs and utilization, adjusting for demographics, index year, insurance type, and other comorbidities. Odds ratios (ORs) were reported for any medication use, hospitalization, emergency room visit, and outpatient visit, and incidence rate ratios (IRRs) were reported for the number of medications filled. Adjusted cost differences between PsO patient and controls were also estimated. 

RESULTS

A total of 5,492 matched pairs of moderate-to-severe PsO patients and controls were selected, with a mean age of 47.6 years and 55.5% of patients being male. PsO patients were significantly more likely to have most of the comorbidities examined, with the top 3 most common in both groups being hyperlipidemia (33.3% vs. 27.3%), hypertension (32.8% vs. 23.5%), and diabetes (15.8% vs. 9.7%). Compared with controls, PsO patients were more likely to have any medication filled (OR = 27.5) and had more distinct number of prescription medications (IRR = 2.1; both P  less than  0.01). PsO patients were more likely to have any inpatient admission (OR = 1.3), emergency room visit (OR = 1.3), and outpatient visit (OR = 29.3; all P  less than  0.01). PsO patients also incurred significantly higher total, pharmacy, and medical costs (adjusted annual costs differences: $18,960, $13,990, and $3,895 per patient, respectively; all P  less than  0.01) than controls. 

CONCLUSIONS

Compared with PsO- and PsA-free controls, moderate-to-severe PsO patients were more likely to have selected comorbidities and higher health care utilization and costs.

Risk of depression in women with psoriasis: a cohort study

BACKGROUND

Psoriasis is a common, chronic and inflammatory disease of the skin, which has been associated with depression in cross-sectional studies with limited adjustment for confounders.

OBJECTIVES

In this prospective cohort study, we investigated the risk of incident depression among individuals with psoriasis and psoriatic arthritis (PsA).

METHODS

We included 50 750 US female nurses from the Nurses' Health Study who were free of depression at baseline in 2000. Those participants who had ever self-reported clinician-diagnosed depression or regular use of antidepressants, or had a Mental Health Inventory score of ≤ 52 were excluded. In 2008, we retrospectively asked participants if they had ever received a physician's diagnosis of psoriasis or PsA. We defined depression as self-report of clinician-diagnosed depression or regular use of antidepressant medication. Time-dependent Cox proportional hazard models were used to estimate age and multivariate-adjusted relative risks (RRs) of clinical depression.

RESULTS

After adjusting for covariates including body mass index, physical activity, smoking and the presence of major chronic conditions, the multivariate-adjusted RRs of clinical depression were 1·29 [95% confidence interval (CI) 1·10-1·52] for women with psoriasis and 1·52 (95% CI 1·06-2·19) for women with psoriasis and concomitant PsA, compared with women without psoriasis.

CONCLUSIONS

We found an increased risk of depression in US women with psoriasis compared with those without psoriasis. This risk was higher in those who reported concomitant PsA. Future studies are needed to confirm these findings in other populations and to identify pathophysiological mechanisms linking psoriasis to depression.

TUR-PSO: A cross-sectional, study investigating quality of life and treatment status of psoriasis patients in Turkey

Psoriasis is a common inflammatory disease that has a severe impact on quality of life. There is lack of data regarding epidemiological and clinical features of psoriasis patients in Turkey, a country with a population of 76 million. The aim of this study was to define the demographic and clinical characteristics, quality of life and treatment patterns of psoriasis patients in Turkey. A cross-sectional observational study was conducted at 40 centers, chosen from geographically diverse locations in Turkey. Patients diagnosed with psoriasis were assessed by investigators who were specialists of dermatology using standardized study questionnaire forms. Dermatology Life Quality Index (DLQI) and EuroQol-5 dimension (EQ-5D) forms were also filled out by each patient. 3971 psoriasis patients were included in this study. 24.2% of plaque psoriasis patients had moderate to severe psoriasis (Psoriasis Area and Severity Index, ≥10). Mean DLQI was 7.03 ± 6.02; quality of life was moderately, severely or very severely affected in 49.2% of patients. The most severely affected component of EQ-5D was anxiety/depression. Among all patients, 22.9% were not receiving any treatment, 39.8% were receiving only topical treatment, 11.5% were on phototherapy, 26.1%, were taking conventional systemic agents and 4.1% were on a biologic treatment. 31.3% of psoriasis patients with moderate to severe disease were treated with only topical agents and only 30.5% of moderate to severe psoriasis patients were receiving systemic therapy. Moderate to severe psoriasis has a considerable impact on quality of life. Treatment in Turkey of patients with moderate to severe psoriasis is insufficient.

Evidence-based Recommendations for the Management of Comorbidities in Rheumatoid Arthritis, Psoriasis, and Psoriatic Arthritis: Expert Opinion of the Canadian Dermatology-Rheumatology Comorbidity Initiative

Objective.

Comorbidities such as cardiovascular diseases (CVD), cancer, osteoporosis, and depression are often underrecognized in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), or psoriasis (PsO). Recommendations may improve identification and treatment of comorbidities. The Canadian Dermatology-Rheumatology Comorbidity Initiative reviewed the literature to develop practical evidence-based recommendations for management of comorbidities in patients with RA, PsA, and PsO.

Methods.

Eight main topics regarding comorbidities in RA, PsA, and PsO were developed. MEDLINE, EMBASE, and the Cochrane Library (1960–12/2012), together with abstracts from major rheumatology and dermatology congresses (2010–2012), were searched for relevant publications. Selected articles were analyzed and metaanalyses performed whenever possible. A meeting including rheumatologists, dermatologists, trainees/fellows, and invited experts was held to develop consensus-based recommendations using a Delphi process with prespecified cutoff agreement. Level of agreement was measured using a 10-point Likert scale (1 = no agreement, 10 = full agreement) and the potential effect of recommendations on daily clinical practice was considered. Grade of recommendation (ranging from A to D) was determined according to the Oxford Centre for Evidence-Based Medicine evidence levels.

Results.

A total of 17,575 articles were identified, of which 407 were reviewed. Recommendations were synthesized into 19 final recommendations ranging mainly from grade C to D, and relating to a large spectrum of comorbidities observed in clinical practice: CVD, obesity, osteoporosis, depression, infections, and cancer. Level of agreement ranged from 80.9% to 95.8%.

Conclusion.

These practical evidence-based recommendations can guide management of comorbidities in patients with RA, PsA, and PsO and optimize outcomes.

Economic and comorbidity burden among moderate-to-severe psoriasis patients with comorbid psoriatic arthritis

OBJECTIVE

To compare the prevalence of comorbidities, health care utilization, and costs between moderate-to-severe psoriasis (PsO) patients with comorbid psoriatic arthritis (PsA) and matched controls.

METHODS

Adults ages 18-64 years with concomitant diagnoses of PsO and PsA (PsO+PsA) were identified in the OptumHealth Reporting and Insights claims database between January 2007 and March 2012. Moderate-to-severe PsO was defined based on the use of at least one systemic or phototherapy during the 12-month study period after the index date (randomly selected date after the first PsO diagnosis). Control patients without PsO and PsA were demographically matched 1:1 with PsO+PsA patients. Multivariate regressions were employed to examine PsO/PsA-related comorbidities, medications, health care utilization, and costs between PsO+PsA patients and controls, adjusting for demographics, index year, insurance type, and non-PsO/PsA-related comorbidities.

RESULTS

Among 1,230 matched pairs of PsO+PsA patients and controls, PsO+PsA patients had significantly more PsO/PsA-related comorbidities, with the top 3 most common in both groups being hypertension (35.8% versus 23.5%), hyperlipidemia (34.6% versus 28.5%), and diabetes mellitus (15.9% versus 10.0%). Compared with controls, PsO+PsA patients had a higher number of distinct prescriptions filled (incidence rate ratio 2.3, P < 0.05); were more likely to have inpatient admissions (odds ratio [OR] 1.6), emergency room visits (OR 1.3), and outpatient visits (OR 62.7) (all P < 0.05); and incurred significantly higher total, pharmacy, and medical costs (adjusted annual cost differences per patient $23,160, $17,696, and $5,077, respectively; all P < 0.01).

CONCLUSION

Compared with matched PsO- and PsA-free controls, moderate-to-severe PsO patients with comorbid PsA had higher comorbidity and health care utilization and costs.

The International Dermatology Outcome Measures Group: Update from the GRAPPA 2014 Annual Meeting

The International Dermatology Outcome Measures (IDEOM) group was formed to enhance outcomes and facilitate access to dermatologic care by creating standardized measures of disease progression and treatment efficacy that emphasize the perspectives of patients and the others involved. With these goals in mind, IDEOM enabled patients, physicians, health economists from participating pharmaceutical industries, payers, and regulatory agencies to create validated measures for use in both clinical trials and clinical practice.

Clinical symptoms and self-reported disease severity among patients with psoriasis - Implications for psoriasis management

BACKGROUND

Pain, itching, burning and irritation are common symptoms of psoriasis but have not been well characterized by overall psoriasis severity.

METHODS

Using 2012 syndicated psoriasis patient survey data, 1050 subjects were classified into mild (n = 610) and moderate-to-severe (n = 440) psoriasis severity groups based on self-reporting. Demographics, comorbid medical conditions and patient-reported key symptoms (i.e. flare-up frequency, psoriasis-related pain, itching, burning, hurting, irritation) were compared between groups. Multiple regressions were employed to examine the impact of overall psoriasis severity on each key symptom, controlling for demographics and comorbidities.

RESULTS

Mild patients were older; more than 20% in both groups had joint pain and depression. Over 35 and 68% of the moderate-to-severe patients reported severe pain between or during flare-ups, respectively, and over 79% reported frequent bothersome itching. Controlling for between-group differences, moderate-to-severe patients had worse pain, were more likely to have continual flare-ups (odds ratio = 3.0) and flare-ups more than once monthly (odds ratio = 3.0), and reported more bothersome symptoms than patients with mild disease (all p < 0.05).

CONCLUSION

The presence and level of particular symptoms increase with self-reported disease severity in patients with psoriasis. Careful investigation of symptoms in tandem with clinical observation is important for effective psoriasis management.

Time Spent per delta PASI (TSdP) among psoriasis patients undergoing UVB-therapy - A pilot study

BACKGROUND

Psoriasis often poses a significant challenge to treat. Ultraviolet light band (UVB) treatment is widely used and well recognized. However, the frequent visits to the dermatologist may indirectly present an impediment to many of the patients' careers and every day life due to the vast time burden with subsequent lost work earnings. We investigated the cost-effectiveness of the psoriasis UVB treatment from a patient's point of view using time as a surrogate measure.

METHOD

Twenty-five patients participated (17 males and 8 females) in the study. We registered the number of UVB treatments per patient as well as the patients PASI (psoriasis area and severity index) score at each treatment session. The time spent in relation to each treatment session was reported in a questionnaire given to the patient. Time Spent per delta PASI (TSdP) was defined as number of minutes to reduce the PASI score by one.

RESULTS

Seventeen (68%) of the participants needed less than 300 min to lower the PASI with one score. The rest (n = 7 (32%)) used more than 300 min to lower the PASI score by one. Thus, the TSdP distribution displayed two peaks; ><300 min/dPASI. Log-transformed linear regression model showed that the expected TSdP would decrease with 42% for each time the start PASI was doubled, i.e. the higher the PASI level at the beginning of the treatment, the lower the TSdP.

CONCLUSION

The level of reduction in psoriasis severity compared with the amount of lost work time/earnings may pose a much higher impact for patients and society than what is currently recognized.

[Disease burden of psoriasis associated with psoriatic arthritis in Hungary]

INTRODUCTION

Psoriasis is a frequent, chronic, systemic immune-mediated disease mainly affecting the skin and joints.

AIM

To assess health related quality of life and cost-of-illness in moderate to severe psoriasis associated with psoriatic arthritis.

METHOD

A cross-sectional questionnaire survey was conducted at two academic dermatology clinics in Hungary.

RESULTS

Fifty-seven patients (65% males) completed the survey with a mean age of 54.3±11.6 years and mean EQ-5D score of 0.48±0.4. Mean annual total cost was €8,977 per patient, of which 71% occurred due to biological therapy and 21% were indirect costs, respectively. Permanent work disability due to psoriasis accounted for €1,775 (95% of the indirect costs). Per patient costs of subgroups not receiving systemic therapy (21%), traditional systemic therapy (32%), and biological systemic therapy (47%) amounted to the sum of €1,729, €1,799, and €16,983, respectively.

CONCLUSIONS

Patients on biological therapy showed significantly better health related quality of life. As for health economics, the efficacy of systemic treatments is appropriate to be assessed together in patients with moderate to severe psoriasis associated with psoriatic arthritis, since actual health gain might exceed that reported in psoriasis or psoriatic arthritis separately.

Patterns of medication utilization and costs associated with the use of etanercept, adalimumab, and ustekinumab in the management of moderate-to-severe psoriasis

BACKGROUND

Dose escalations of biologic agents may be attempted in the management of moderate-to-severe psoriasis. This has implications for the real-world cost of treatment.

OBJECTIVE

To examine the utilization patterns and costs associated with the use of etanercept, adalimumab, and ustekinumab among patients with moderate-to-severe psoriasis.

METHODS

This was a retrospective cross-sectional study. Patients with 2 or more medical claims with a diagnosis of psoriasis (excluding psoriatic arthritis) who were enrolled in large employer-sponsored health plans (including a pharmacy benefit) in the United States from January 2007 to March 2012 were identified and extracted from the MarketScan Commercial Encounters Database. Patients aged at least 18 years were required to have 2 or more pharmacy claims for etanercept, adalimumab, or ustekinumab; the index date was the first biologic fill date. Demographics and comorbidities were identified during the 1-year pre-index period, and medication utilization and costs were evaluated in the 1-year post-index period after a titration period according to the product prescribing information (2 weeks to 12 weeks). Medication utilization parameters such as dose escalation, dose reduction, persistence, switching, discontinuation, and restarts were assessed at 6, 9, and 12 months from the end of the dose titration window.

RESULTS

A total of 4,309 patients were included with a mean average age of 46 years, and 55% were male. Fifty-seven percent of the patients were started on etanercept, 39% on adalimumab, and 5% on ustekinumab. Patients had substantial dose escalation rates (etanercept: 41%; adalim-umab: 37%; ustekinumab: 36%, P  less than  0.05) and discontinuation rates (etanercept: 35%; adalimumab: 27%; ustekinumab: 16%, P  less than  0.05) over the 12-month post-titration period. Many patients also restarted the same biologic (etanercept: 37%; adalimumab: 10%; ustekinumab: 6%, P  less than  0.05) or switched to another biologic (etanercept: 15%; adalimumab: 10%; ustekinumab: 5%, P  less than  0.05) over the 12-month post-titration period. The persistence rates over 12 months were 19%, 53%, and 71% for etanercept, adalimumab, and ustekinumab, respectively (P  less than  0.05). Close to one-third of the patients at 6 months and 39% at 12 months postdose titration experienced a dose escalation. Approximately half of the patients who experienced a dose escalation also had a discontinuation or a dose reduction over the 12-month post-titration period.

CONCLUSIONS

Over one-third of psoriasis patients experienced a dose escalation of their biologic agents, and most of the dose escalation occurred during the first 6 months. Restarting, switching, and discontinuing index biologics were also common.

Use of health care services by patients with psoriasis: a population-based study

BACKGROUND

Although psoriasis is seldom life threatening, very few studies have compared differences in health care service use between patients with and without psoriasis.

OBJECTIVES

To investigate differences in health care service use between patients with and without psoriasis.

METHODS

Patient details and data on their use of health services were retrieved from the Taiwan Longitudinal Health Insurance Database 2000. We included 3649 patients with psoriasis and 3649 without it. Each patient was followed for a 1-year period to estimate their utilization of health care resources. Student t-tests were used to compare differences in health care services use between patients with and without psoriasis.

RESULTS

For dermatology services, patients with psoriasis had significantly more outpatient visits (3·5 vs. 0·9), and higher outpatient and total costs (US$148·00 vs. US$12·20 and US$581·60 vs. US$347·20, respectively) than those without psoriasis. For nondermatology services, patients with psoriasis had more outpatient visits (21·3 vs. 17·6), and higher outpatient and total costs (US$904·60 vs. US$663·50 and US$1335·50 vs. US$998·30, respectively) than those without psoriasis. For overall health care service use, patients with psoriasis had significantly more outpatient visits (24·8 vs. 18·5; P < 0·01) and greater total costs (US$1917·10 vs. US$1345·60; P < 0·01) than those without psoriasis. This indicates that the total cost was about 1·4-fold greater for patients with psoriasis than those without it.

CONCLUSIONS

Patients with psoriasis used health care services significantly more often than those without psoriasis.

Annual biologic treatment cost for new and existing patients with moderate to severe plaque psoriasis in Greece

Aim

The aim of the present study was to estimate the annual per-patient cost of treatment with adalimumab, etanercept, infliximab, and ustekinumab by response status for new and existing patients with moderate to severe psoriasis in Greece.

Methods

An economic analysis was developed from a national health care perspective to estimate the direct cost of treatment alternatives for new and existing patients within a 1-year time horizon. The model included drug acquisition and administration costs for responders and nonresponders. Real-world treatment pattern and resource use data were extracted through nationwide field research using telephone-based interviews with a representative sample of dermatologists. Unit costs were collected from official sources in the public domain.

Results

The mean annual cost of treatment for new patients who responded (or did not respond) to treatment was as follows: adalimumab €10,686 (€3,821), etanercept €10,415 (€3,224), infliximab €14,738 (€7,582), and ustekinumab €17,155 (€9,806). For existing patients the mean annual cost was €9,916, €9,462, €12,949, and €17,149, respectively. Results did not change significantly under several one-way sensitivity and scenario analyses.

Conclusion

Under the base-case scenario, the cost of treatment with etanercept is lower than that of the other biological agents licensed for moderate to severe plaque psoriasis in Greece, for both new and existing patients, irrespective of response status.

Efficacy of a fixed combination of calcipotriol/betamethasone dipropionate topical gel in adult patients with mild to moderate psoriasis: blinded interim analysis of a phase IV, multicenter, randomized, controlled, prospective study

BACKGROUND

Psoriasis is a common, chronic, inflammatory skin disease with the majority of individuals having limited disease, treated with topical medication. However, special attributes of topical treatments like galenic/cosmetic properties or an inconvenient treatment schedule may result in low preference for topical treatments. Hence, there is strong medical need for a topical medication, which is highly efficacious, easy-to-use and preferred by both physicians and patients.

OBJECTIVE

Blinded interim analysis with the purpose to assess efficacy of (both from the physician's and patient's perspective) and the patients' preference with a highly efficacious and easy-to-use fixed combination of calcipotriol/betamethasone dipropionate topical gel after 8 weeks of once daily treatment in a large patient population.

METHODS

In this phase IV, international, multicentre, randomized, controlled, prospective, parallel group study, adult patients with active, mild to moderate psoriasis despite previous topical psoriasis treatment, i.e. unsuccessful in the 8 weeks preceding study participation, are followed over 64 weeks. During the first 8 weeks the patients apply their medication once a day followed by a 56-weeks maintenance period according to SmPC. Blinded interim analysis of all patients included demographics, Physician's Global Assessment, the novel Patient's self Global Assessment (PsGA) and Patient Preference Questionnaire (PPQ).

RESULTS

1795 patients were analysed. At week 8, 36.5% of the physicians rated the patients' psoriasis as clear/almost clear. Similarly, based on the patients' self-assessment, 34.2% had a clear/almost clear score of PsGA in week 8. Analysis of the PPQ showed that the vast majority of the patients judged their 8-week treatment to be preferable compared with their previous treatments.

CONCLUSION

Results of this blinded interim analysis indicate that the fixed combination of calcipotriol/betamethasone dipropionate gel is highly efficacious and preferred by the majority of analysed patients.

Validity of diagnostic codes and prevalence of physician-diagnosed psoriasis and psoriatic arthritis in southern Sweden--a population-based register study

Objective

To validate diagnostic codes for psoriasis and psoriatic arthritis (PsA) and estimate physician-diagnosed prevalence of psoriasis and PsA in the Skåne region, Sweden.

Methods

In the Skåne Healthcare Register (SHR), all healthcare consultations are continuously collected for all inhabitants in the Skåne region (population 1.2 million). During 2005–2010 we identified individuals with ≥1 physician-consultations consistent with psoriasis (ICD-10). Within this group we also identified those diagnosed with PsA. We performed a validation by reviewing medical records in 100 randomly selected cases for psoriasis and psoriasis with PsA, respectively. Further, we estimated the pre- and post-validation point prevalence by December 31, 2010.

Results

We identified 16 171 individuals (psoriasis alone: n = 13 185, psoriasis with PsA n = 2 986). The proportion of ICD-10 codes that could be confirmed by review of medical records was 81% for psoriasis and 63% for psoriasis with PsA with highest percentage of confirmed codes for cases diagnosed ≥2 occasions in specialized care. For 19% and 29% of the cases respectively it was not possible to determine diagnosis due to insufficient information. Thus, the positive predicted value (PPV) of one ICD-10 code for psoriasis and psoriasis with PsA ranged between 81–100% and 63–92%, respectively. Assuming the most conservative PPV, the post-validation prevalence was 1.23% (95% CI: 1.21–1.25) for psoriasis (with or without PsA), 1.02% (95% CI: 1.00–1.03) for psoriasis alone and 0.21% (95% CI: 0.20–0.22) for psoriasis with PsA. The post-validation prevalence of PsA in the psoriasis cohort was 17.3% (95% CI: 16.65–17.96).

Conclusions

The proportion of diagnostic codes in SHR that could be verified varied with frequency of diagnostic codes and level of care highlighting the importance of sensitivity analyses using different case ascertainment criteria. The prevalence of physician-diagnosed psoriasis and PsA confirm other population-based studies, also after adjustment due to misclassification of disease.

Cost-of-illness in patients with moderate to severe psoriasis: a cross-sectional survey in Hungarian dermatological centres

BACKGROUND

Despite the widespread availability of biological drugs in psoriasis, there is a shortage of disease burden studies.

OBJECTIVES

To assess the cost-of-illness and quality of life of patients with moderate to severe psoriasis in Hungary.

METHODS

Consecutive patients with Psoriasis Area and Severity Index (PASI) > 10 and Dermatology Life Quality Index (DLQI) > 10, or treated with traditional systemic (TST) or biological systemic treatment (BST) were included. Demographic data, clinical characteristics, psoriasis related medication, health care utilizations and employment status in the previous 12 months were recorded. Costing was performed from the societal perspective applying the human capital approach. Quality of life was assessed using DLQI and EQ-5D measures.

RESULTS

Two-hundred patients were involved (females 32%) with a mean age of 51 (SD 13) years, 103 (52%) patients were on BST. Mean PASI, DLQI and EQ-5D scores were 8 (SD 10), 6 (SD 7) and 0.69 (SD 0.3), respectively. The mean total cost was €9,254/patient/year (SD 8,502) with direct costs accounting for 86%. The main cost driver was BST (mean €7,339/patient/year). Total costs differed significantly across treatment subgroups, mean (SD): no systemic therapy €2,186 (4,165), TST €2,388 (4,106) and BST €15,790 (6,016) (p < 0,001). Patients with BST had better PASI and DLQI scores (p < 0.01) than the other two subgroups.

CONCLUSIONS

Patients with biological treatment have a significantly better quality of life and higher total costs than patients with or without traditional systemic treatment. Our study is the largest in Europe and the first in the CEE region that provides cost-of-illness data in psoriasis involving patients with BST.

Limited evidence of the effects of patient education and self-management interventions in psoriasis patients: a systematic review

OBJECTIVE

To describe the contents of educational and self-management programmes for patients with psoriasis, and to evaluate their effects.

METHODS

A systematic review of randomized controlled trials (RCTs), quasi-randomized trials and controlled clinical trials identified by a systematic literature search. Risk of bias was assessed by two independent reviewers and interventional effects were summarized descriptively and by meta-analysis.

RESULTS

Nine studies were included, which ranged from single brief interventions to long complex multidisciplinary programmes. Four RCTs with adequate sequence allocation were included to analyze interventional effects. One RCT compared two different educational programmes and found no differences between groups. The results of three trials that focused on combinations of education and self-management were heterogeneous. One RCT based on a 12-week comprehensive programme reported statistically significant effects (p<0.05) on disease severity and health-related quality of life. Two RCTs with less comprehensive programmes reported no effects on HRQoL.

CONCLUSION

This review showed that little evidence is available to support the effects of educational and self-management interventions in patients with psoriasis that are studied in RCTs. There is a significant lack of focused self-management and, compared with other chronic conditions, there appear to be few effective disease-specific tailored educational programmes for psoriasis.

Psoriasis prevalence among adults in the United States

BACKGROUND

Psoriasis is a chronic inflammatory disorder associated with significant morbidity and mortality. Up-to-date prevalence data on psoriasis provide the foundation for informing population research, education, and health policy.

OBJECTIVE

We sought to determine the prevalence of psoriasis among US adults.

METHODS

We performed a cross-sectional study using National Health and Nutrition Examination Survey 2009 through 2010 data to determine psoriasis prevalence rates.

RESULTS

From 6218 participants older than 20 years of age, 6216 respondents provided complete information regarding a psoriasis diagnosis. The prevalence of psoriasis among US adults ages 20 years and older is 3.2% (95% confidence interval [CI] 2.6%-3.7%). A total of 7.2 million US adults had psoriasis in 2010; an estimated 7.4 million US adults were affected in 2013. When stratifying the sample by race among those between ages 20 and 59 years, the psoriasis prevalence was highest in Caucasians at 3.6% (95% CI 2.7%-4.4%), followed by African Americans (1.9%; 95% CI 1.0%-2.8%), Hispanics (1.6%; 95% CI 0.5%-2.8%), and others (1.4%; 95% CI 0.3%-2.6%). The prevalence of psoriasis among US adults has not changed significantly since 2003 to 2004 (P > .05).

LIMITATIONS

Dermatologist evaluation and skin photographs were unavailable for the 2009 through 2010 surveys.

CONCLUSIONS

In the United States, psoriasis remains a common, immune-mediated disease, affecting 7.4 million adults. Its prevalence has remained stable since the mid-2000s.

Psoriasis beyond the skin: an expert group consensus on the management of psoriatic arthritis and common co-morbidities in patients with moderate-to-severe psoriasis

BACKGROUND

Psoriatic arthritis (PsA) and co-morbidities of psoriasis represent a significant clinical and economic burden for patients with moderate-to-severe psoriasis. Often these co-morbidities may go unrecognized or undertreated. While published data are available on the incidence and impact of some of them, practical guidance for dermatologists on detection and management of these co-morbidities is lacking.

OBJECTIVE

To prepare expert recommendations to improve the detection and management of common co-morbidities in patients with moderate-to-severe psoriasis.

METHODS

A systematic literature review was conducted on some common co-morbidities of psoriasis-cardiovascular (CV) diseases (including obesity, hypertension, hyperglycaemia and dyslipidaemia), psychological co-morbidities (including depression, alcohol abuse and smoking) and PsA-to establish the incidence and impact of each. Data gaps were identified and a Delphi survey was carried out to obtain consensus on the detection and management of each co-morbidity. The expert panel members for the Delphi survey comprised 10 dermatologists with substantial clinical expertise in managing moderate-to-severe psoriasis patients, as well as a cardiologist and a psychologist (see appendix) with an interest in dermatology. Agreement was defined using a Likert scale of 1-7. Consensus regarding agreement for each statement was defined as ≥75% of respondents scoring either 1 (strongly agree) or 2 (agree).

RESULTS

The expert panel members addressed several topics including screening, intervention, monitoring frequency, and the effects of anti-psoriatic treatment on each co-morbidity. Consensus was achieved on 12 statements out of 22 (3 relating to PsA, 4 relating to psychological factors, 5 relating to CV factors). The panel members felt that dermatologists have an important role in screening their psoriasis patients for PsA and in assessing them for psychological and CV co-morbidities. In most cases, however, patients should be referred for specialist management if other co-morbidities are detected.

CONCLUSION

This article provides useful and practical guidance for the detection and management of common co-morbidities in patients with moderate-to-severe psoriasis.

Cost-of-illness in psoriasis: comparing inpatient and outpatient therapy

Treatment modalities of chronic plaque psoriasis have dramatically changed over the past ten years with a still continuing shift from inpatient to outpatient treatment. This development is mainly caused by outpatient availability of highly efficient and relatively well-tolerated systemic treatments, in particular BioLogicals. In addition, inpatient treatment is time- and cost-intense, conflicting with the actual burst of health expenses and with patient preferences. Nevertheless, inpatient treatment with dithranol and UV light still is a major mainstay of psoriasis treatment in Germany. The current study aims at comparing the total costs of inpatient treatment and outpatient follow-up to mere outpatient therapy with different modalities (topical treatment, phototherapy, classic systemic therapy or BioLogicals) over a period of 12 months. To this end, a retrospective cost-of-illness study was conducted on 120 patients treated at the University Medical Centre Mannheim between 2005 and 2006. Inpatient therapy caused significantly higher direct medical, indirect and total annual costs than outpatient treatment (13,042 € versus 2,984 €). Its strong influence on cost levels was confirmed by regression analysis, with total costs rising by 104.3% in case of inpatient treatment. Patients receiving BioLogicals produced the overall highest costs, whereas outpatient treatment with classic systemic antipsoriatic medications was less cost-intense than other alternatives.

Burden of disease: psoriasis and psoriatic arthritis

Psoriatic arthritis (PsA) increases the disease burden associated with psoriasis by further diminishing quality of life, increasing health care costs and cardiovascular risk, and potentially causing progressive joint damage. The presence of PsA influences psoriasis treatment by increasing overall disease complexity and, within the framework of current guidelines and recommendations, requiring the use of conventional disease-modifying anti-rheumatic drugs or tumor necrosis factor-α inhibitors in order to prevent progressive joint damage. Despite its important impact, PsA is still under-diagnosed in dermatology practice. Dermatologists are well positioned to recognize and treat PsA, given that it characteristically presents, on average, 10 years subsequent to the appearance of skin symptoms. Regular screening of psoriasis patients for early evident joint symptoms should be incorporated into daily dermatologic practice. Although drugs effective in PsA are available, not all patients may respond to treatment, and others may lose their initial response over time. New investigational therapies, such as inhibitors of interleukin-17A, interleukin-12/23, Janus kinase 3, or phosphodiesterase-4, may address unmet needs in psoriatic disease, with further research needed to determine the role of these agents in reducing joint damage and other comorbidities.

Cost effectiveness of moderate to severe psoriasis therapy with etanercept and ustekinumab in the United States

BACKGROUND

Limited information is available on the cost effectiveness of ustekinumab and alternative biologic treatments in a United States (US) setting. Given the recent head-to-head clinical trial study of ustekinumab and etanercept, an economic model comparing the two treatments can be constructed. Etanercept and ustekinumab are indicated for the treatment of chronic moderate to severe plaque psoriasis in adult patients who are candidates for phototherapy or systemic therapy.

OBJECTIVE

Clinical trials have evaluated the efficacy of ustekinumab, an anti-cytokine biologic, for the treatment of moderate to severe psoriasis. This study evaluated the cost effectiveness of ustekinumab compared with etanercept from a US societal perspective.

METHODS

A Markov model was constructed to simulate the incremental cost per quality-adjusted life-year (QALY) gained every 12 weeks over a base-case 3-year time horizon. A hypothetical patient cohort was based on the characteristics of the phase III Active Comparator Psoriasis Trial (ACCEPT). The main outcome measures were costs and QALYs, which were estimated from the US societal perspective. Costs, utilities, treatment strategy, and resource use estimates were obtained from relevant literature. All costs were adjusted to 2011 US dollars. A 3 % annual discount rate was applied to costs and QALYs. Incremental cost-effectiveness ratios were in US dollars per QALY gained.

RESULTS

For the base-case 3-year time horizon, the incremental cost-effectiveness ratio comparing ustekinumab 90 mg with etanercept 50 mg was US$384,401 per QALY gained. Ustekinumab 45 mg dominates etanercept 50 mg for the same time horizon. These results were robust to sensitivity analyses involving treatment strategy, transition probabilities, valuing outcomes, and resource use and costs. The probabilistic sensitivity analysis suggests ustekinumab 90 mg has a minimal (4 %) chance of being cost effective compared with etanercept 50 mg at a willingness-to-pay threshold of US$150,000 per QALY improvement. For the same threshold, ustekinumab 45 mg has a high (88 %) chance of being cost effective compared with etanercept 50 mg.

CONCLUSION

Under typical US willingness-to-pay cutoffs, ustekinumab 90 mg is not cost effective compared with etanercept 50 mg therapy in moderate to severe psoriasis patients for the base-case 3-year time horizon. Ustekinumab 45 mg dominates etanercept 50 mg therapy for an equivalent patient psoriasis severity and time horizon.

Psoriasis Outcome Measures: A Report from the GRAPPA 2012 Annual Meeting

Psoriasis is a multisystem disease. The cutaneous and musculoskeletal manifestations (psoriatic arthritis) are well recognized. However, the other manifestations of psoriatic disease including metabolic syndrome, atherosclerotic cardiovascular disease, depression, poor self-esteem, and self-destructive habits including obesity, smoking and excess alcohol consumption are underappreciated. At the 2012 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), members addressed the need to develop uniform, validated, standardized outcome measures for psoriatic disease, measures that are useful to all stakeholders including patients, physicians, regulators, and payers.

Psoriatic disease and tuberculosis nowadays

Psoriasis is a chronic, relapsing and remitting inflammatory skin and joint disease that has a prevalence of 2-3% in the world's population, whereas of 1-2% in Europe. The traditional concept of psoriasis as the "healthy people's" disease has been recently revised because of ever-increasing reports of associations with various pathological conditions (hypertension, Crohn's disease, type II diabetes mellitus, obesity, dyslipidemia, metabolic syndrome, infectious conditions). Particularly, advances in psoriasis therapies have introduced biologic agents. All the tumor necrosis factor-alpha inhibitors are associated with an increased risk of developing active disease in patients with latent tuberculosis infection, because of TNF-α key role against Mycobacterium tuberculosis. For this reason, exclusion of active tuberculosis and treatment of latent tuberculosis infection are clinical imperatives prior to starting this therapy. Moreover active surveillance for a history of untreated or partially treated tuberculosis or latent form has already been shown to be effective in reducing the number of incident tuberculosis cases.

Impact of ustekinumab on health-related quality of life in Japanese patients with moderate-to-severe plaque psoriasis: results from a randomized, double-blind, placebo-controlled phase 2 / 3 trial

This study evaluates the effect of ustekinumab on health-related quality of life (HRQoL) in Japanese patients with moderate-to-severe plaque psoriasis through 64 weeks. A total of 158 patients were randomized to receive subcutaneous injections of ustekinumab 45 mg (n = 64) or 90 mg (n = 62) at weeks 0, 4, and every-12-weeks, or placebo (n = 32) with crossover to ustekinumab at week 12. Secondary study endpoints included change in Dermatology Life Quality Index (DLQI) at week 12. Other assessments included the 36-item Short Form health survey to assess Physical Component Summary (PCS) and Mental Component Summary (MCS) scores, and Psoriasis Disability Index (PDI), a psoriasis-specific instrument to assess HRQoL. Baseline demographic and disease characteristics were similar across randomized treatment groups. Ustekinumab-treated patients had significantly greater mean improvements in DLQI from baseline to week 12 (45 mg: 8.0 ± 6.5; 90 mg: 7.4 ± 6.5) than placebo-treated patients (0.3 ± 5.3; P < 0.0001 for each), and these improvements were maintained through week 64. Also at week 12, significant improvements from baseline in PDI scores were observed in ustekinumab-treated patients (45 mg: 8.6 ± 9.6; 90 mg: 12.0 ± 11.8) compared with placebo-treated patients (-0.1 ± 4.2). Improvements in the PCS (45 mg: 7.8 ± 14.5; 90 mg: 5.1 ± 12.0) and MCS (45 mg: 5.3 ± 9.8; 90 mg: 5.8 ± 10.5) scores were also observed in ustekinumab-treated patients at week 12. Placebo-treated patients who crossed-over to ustekinumab achieved improvements in HRQoL comparable to those observed in patients originally randomized to ustekinumab. Ustekinumab significantly improves HRQoL in Japanese patients with moderate-to-severe plaque psoriasis through week 64.

The Path Forward to Biomarker Discovery in Psoriatic Disease: A Report from the GRAPPA 2010 Annual Meeting

At the 2010 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), wide-ranging discussions were held regarding biomarker research in psoriatic disease. Consensus was reached on 2 areas of priority: (1) the study of soluble biomarkers of radiographic progression in psoriatic arthritis (PsA); and (2) the analysis of comorbidity biomarkers, specifically cardiovascular and articular, in a psoriasis inception cohort. For each of these areas, rigorous definition of the clinical phenotype of PsA will be essential. To date, 2 instruments have been identified to define the phenotype: the ClASsification of Psoriatic ARthritis criteria and various screening questionnaires. In this overview, we discuss the challenges of the clinical phenotype of PsA and review GRAPPA plans for developing a research program for biomarker discovery.

Medical comorbidity associated with psoriasis in adults: a population-based study

BACKGROUND

Most publications to date on comorbidities associated with psoriasis have focused on cardiovascular and metabolic diseases. Few comprehensive investigations of medical comorbidities in a cohort of patients with psoriasis appear in the literature.

OBJECTIVES

To examine the prevalence of comorbidities in adult patients with psoriasis, including a comparison of comorbid prevalence vs. that in controls without psoriasis, in a nationally representative dataset in Taiwan.

METHODS

There were 1685 adult patients with psoriasis in the study group and 5055 randomly selected subjects in the comparison group. We used conditional logistic regression analyses to examine the risk of 29 comorbidities for these two groups after adjusting for monthly income, geographical region of residence and the level of urbanization of each patient's community of residence.

RESULTS

After adjusting for several potential confounders, patients with psoriasis had higher odds of comorbid congestive heart failure [odds ratio (OR) 1·63], ischaemic heart disease (OR 1·51), renal failure (OR 1·45), uncomplicated diabetes (OR 1·37), liver diseases (OR 1·34), hepatitis B or C (OR 1·34), complicated diabetes (OR 1·32), hyperlipidaemia (OR 1·28), hypertension (OR 1·24) and peptic ulcer (OR 1·22) than did patients without psoriasis. However, patients with mild psoriasis had higher odds of comorbidity only with uncomplicated diabetes (OR 1·55), asthma (OR 1·30), liver diseases (OR 1·30) and peptic ulcer (OR 1·26) than patients without psoriasis.

CONCLUSIONS

We conclude that psoriasis is associated with a variety of medical comorbidities including cardiovascular diseases, metabolic diseases, renal failure, liver diseases, viral hepatitis B or C, asthma and peptic ulcers.