Bariatric Surgery and the Incidence of Psoriasis and Psoriatic Arthritis in the Swedish Obese Subjects Study

Metabolic syndrome and psoriatic arthritis: the role of weight loss as a disease-modifying therapy

Psoriatic arthritis (PsA) is an inflammatory joint and entheseal disease associated with significant personal and public health burden. PsA has a prevalence of up to 1%, affecting ~20% of people suffering with psoriasis. PsA is frequently accompanied by metabolic syndrome (MetS), and both conditions are characterised by a chronic pro-inflammatory state, with several key cytokines in PsA (interleukin (IL)-17 and IL-23) also elevated in those with MetS. This narrative review aims to provide an update on MetS in PsA, focusing on its prevalence, pathogenesis, prognosis, treatment interactions and future therapeutic options. MetS is particularly prevalent in PsA compared to other inflammatory arthritides. Cohort studies indicate a higher risk of PsA in individuals with obesity, while Mendelian randomization studies link childhood obesity, insulin resistance, and dyslipidaemia to PsA. Weight loss interventions have been shown to reduce disease activity in PsA. Additionally, MetS negatively impacts the efficacy of tumour necrosis factor inhibitor (TNFi) drugs in treating PsA. Drugs given for PsA may also affect the conditions constituting MetS. Leflunomide has been shown to reduce body weight but also increase blood pressure. TNFi drugs lead to weight gain but reduce cardiovascular risk. Janus kinase inhibitors increase lipid levels and cardiovascular risk among high-risk groups. Anti-IL-17 and anti-IL-12/IL-23 drugs may cause a short-term increase in cardiovascular risk, although the long-term effects have yet to be established. Weight loss represents an unexplored avenue for disease modification in PsA, alongside a plethora of general health benefits. Dietary and exercise modifications are the cornerstone of weight management but vary substantially across individuals. Novel therapies to treat weight loss, such as glucagon-like peptide 1 agonists and sodium-glucose cotransporter 2 inhibitors, may prove useful alongside disease-modifying therapies for those with PsA and MetS and should be investigated as potential therapeutic adjuncts.

Nutritional Status in Pediatric Psoriasis: A Case-Control Study in a Tertiary Care Referral Centre

BACKGROUND

Psoriasis and obesity are chronic, inflammatory diseases, sharing certain pathophysiological factors. Psoriasis, increasingly viewed as a systemic inflammatory condition, may have various symptoms beyond the skin manifestations.

METHODS

This research aimed to explore the connection between body mass index (BMI) and pediatric psoriasis, through a case-control study on 100 psoriasis cases and 100 controls who were matched in terms of age and sex. The percentiles of the BMI by age and sex determined the nutritional status of each patient and control. The severity of psoriasis was evaluated based on the psoriasis area and severity index (PASI), nail involvement based on the nail psoriasis severity index (NAPSI), and quality of life impairment with the dermatology life quality index (DLQI).

RESULTS

While no statistically significant relationship was identified between increased BMI and PASI (p = 0.074), the risk of being overweight and obesity was significantly higher in the psoriasis group (OR 6.93, p = 0.003; OR 12.6, p < 0.001, respectively). The BMI increased with the PASI for psoriasis vulgaris but not for psoriasis inverse. No connections were found between disease duration and BMI (p = 0.56) or between BMI and PASI based on sex (p = 0.26). The NAPSI increased significantly with increased BMI (p = 0.000015).

CONCLUSIONS

This study highlights the association between elevated BMI, psoriasis diagnosis, and severity of psoriatic onychopathy in pediatric patients, advocating for further large-scale studies to confirm these explorations and increasing awareness for better screening and management of such cases for overweight/obese patients.

Psoriasis as a Systemic Disease

BACKGROUND

Psoriasis was long regarded as an inflammatory disease limited to the skin. Data from dermatologic, rheumatologic and cardiologic research now show it to be a systemic disease, for which the term psoriatic disease is used.

METHODS

This paper is based on a selective literature search with special attention to the findings of clinical trials and other current publications, as well as the recommendations of international guidelines.

RESULTS

Immunologically mediated inflammation of the skin, arteries, bones, and joints is a central feature of psoriatic disease. Other diseases that are known to be associated with psoriatic disease include hypertension, metabolic syndrome, and depression. The main risk factor for the development of psoriatic disease is obesity, which also increases the likelihood of psoriatic arthritis. The main known trigger factors are stress, infection, and, less commonly, medication. Psoriatic disease is characterized by complex genetics and by a characteristic pattern of inflammation that involves elements of both innate and acquired immunity and, in particular, the cytokines interleukin 17 and 23. The inflammatory processes underlying psoriatic disease can now be targeted with modern biologic and other therapies.

CONCLUSION

In view of the complexity of psoriatic disease, structured management is now recommended so that physicians and patients can work together to determine the optimal treatment strategy.

Weight loss affects disease activity and treatment response in inflammatory rheumatic diseases

The quantity and quality of the adipose tissue is altered in obesity: hypertrophy of adipocytes, decrease in expandability, fibrosis, production of pro-inflammatory cytokines and adipokines, inflammatory infiltration by pro-inflammatory M1 macrophages and T lymphocytes. Excess adipose tissue and obesity are associated with low-grade inflammation that can aggravate chronic inflammatory diseases, decrease treatment efficacy, contribute to the development of comorbidities, and of the disease in its preclinical phase. Obesity increases the incidence of rheumatoid arthritis (RA), psoriasis, psoriatic arthritis with a weight-dose effect. It is also a predictor of worse response to treatment, in particular TNF inhibitors. Weight loss induced by bariatric surgery decreases the risk of psoriasis and psoriatic arthritis and improves disease activity and remission in RA. A 5% weight loss through a low-calorie diet improves the response to TNF inhibitors in psoriatic arthritis, losing even more weight improves the response even more. In RA, the beneficial effect of weight loss from a low-calorie diet on disease activity has been reported in a few observational studies but has not been demonstrated in a randomized controlled trial. Screening and management of obesity are part of the dietary recommendations of the French Society for Rheumatology in patients with chronic inflammatory rheumatic diseases. Of course, this should be combined with other lifestyle modifications such as smoking cessation, higher food quality, increased physical activity and reduced sedentary behavior.

The management of cardiovascular risk in psoriatic disease: A bridge over troubled water

Evidence that psoriatic disease is burdened by an excess cardiovascular (CV) risk has accrued, however many questions remain unanswered. Although an interplay between traditional risk factors inflammation, disease activity and pharmacological therapies, as observed in rheumatoid arthritis (RA), may account for this increased risk, metabolic comorbidities rather than inflammation seem to have a leading role in psoriatic disease. Therefore, specific approaches, risk factors targeting and the importance of traditional risk factors and inflammation management need to be considered. The purpose of this review article is to discuss current data on CV risk in psoriatic disease, and to outline similarities and differences with RA in the light of international recommendations. Arguments in favour of developing specific guidance for CV prevention in psoriatic disease are discussed.

Depression, a major comorbidity of psoriatic disease, is caused by metabolic inflammation

Psoriatic disease is a chronic, systemic immune-mediated inflammatory disorder comprising three major domains, skin, vascular and bone/joint inflammation. It is known for a long time that psoriatic disease is associated with a number of conditions such as hypertension, dyslipidemia, diabetes (metabolic syndrome) and depression. Up to one out of five people with psoriasis show concomitant depression. In the past, this was attributed to psychological stress of suffering from a chronic condition that is often visible and itchy, leading to stigmatization and adding to a significant burden of disease. Recent data provide evidence that depression associated with psoriatic disease is linked to the specific inflammatory pattern with IL-23, IL-17 family cytokines, TNF, IL-6 and IL-8 causing neuroinflammation and subsequently depression or depressive behaviour and/or anxiety. Psoriatic disease shows a distinct pattern of immune cells (e.g. dendritic cells, Th17 cells, neutrophils), mediators (e.g. IL-17A/F, IL-23, TNF) and tissue-related factors in all major domains that is different from other inflammatory dermatoses. There is a striking similarity between the inflammatory pattern in psoriatic disease and neuroinflammation that leads to depression. A number of risk factors have been identified in psoriatic disease, the most important of which are obesity and tobacco smoking. Obesity is known as a major risk factor for depression and anxiety due to its inflammatory signature. Apart from psychotherapy and anti-depressive medication, targeted treatments for psoriasis, including TNF, IL-17 and IL-23 inhibitors, can improve depression/depressive symptoms. The review summarizes the current knowledge about depression as a comorbidity in psoriatic disease.

[Impact of surgical treatment of morbid obesity on joint diseases]

The prevalence of obesity in the modern world is increasing. Obesity is an independent risk factor for some rheumatic diseases and also worsens their course. The presence of chronic joint disease can make it difficult for obesity to reduce activity, creating a vicious circle where joint pain makes exercise difficult and being overweight exacerbates joint pain. At the same time, there is a conditionally radical method of treating obesity - bariatric surgery (BS), which is currently used when conservative methods are ineffective. The purpose of this review is to analyze the data presented in the world literature on the impact of BS on the course of the most common rheumatic diseases. The available data show the possibility of a positive effect of BS not only on weight loss, but also on the course of a number of rheumatic diseases.

Horizon scan: State-of-the-art therapeutics for psoriatic arthritis

Psoriatic arthritis (PsA) is a common immune-mediated inflammatory disease (IMID) that can present with a heterogenous clinical phenotype. The advent of advanced therapies has substantially improved patient outcomes, but many patients still have suboptimal or unsustained response, resulting in morbidity, structural damage and functional impairment. There remains a need for better therapeutic options and precision medicine approaches to improve outcomes for patients with PsA. This review synthesises recently approved the state-of-the-art therapeutics for PsA, including inhibitors of IL-23, Janus kinase (JAK), tyrosine kinase 2 (TYK2) and dual-target IL-17A/F. The evidence base for emerging therapeutics, including MK-2 inhibitors, nano-IL-17 inhibitors, nanobodies and other dual-target therapies for PsA is also reviewed. Potential future therapeutic strategies and unmet research needs are discussed.

Separating the effects of childhood and adult body size on inflammatory arthritis: a Mendelian randomisation study

OBJECTIVES

Using Mendelian randomisation (MR), we examined whether childhood body size affects risk of rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), gout and systemic lupus erythematosus (SLE) after accounting for the effect of adult body size.

METHODS

Genetic instruments for childhood (age 10 years) and adult body size were derived using data from 453 169 individuals from the UK Biobank study (313 and 580 variants respectively), which have been previously validated using body mass index data from three independent populations. Genome-wide association data comprised 22 350 RA, 9069 AS, 3609 PsA, 13 179 gout and 5201 SLE cases. For each outcome, we conducted univariable MR to estimate the total effects of childhood and adult body size, and multivariable MR to examine the independent effect of childhood body size after accounting for adult body size.

RESULTS

Genetically predicted childhood body size had a total effect on risk of PsA (OR 2.18 per change in body size category; 95% CI 1.43 to 3.31), gout (OR 2.18; 95% CI 1.43 to 3.31) and SLE (OR 2.44; 95% CI 1.14 to 5.22), but not RA (OR 0.95; 95% CI 0.70 to 1.29) or AS (OR 0.96; 95% CI 0.61 to 1.52). After accounting for adult body size, the direct effect of childhood body size was little changed for PsA (OR 1.92; 1.14 to 3.25) and SLE (OR 2.69; 1.24 to 5.87) but was attenuated for gout (OR 1.40; 95% CI 0.94 to 2.09).

CONCLUSIONS

Our findings suggest that, for PsA and SLE, the risk conferred from having a larger body size during childhood may not be fully reversable even when a healthy size is achieved in adulthood.

Exploring the Links between Obesity and Psoriasis: A Comprehensive Review

Obesity is a major public health issue worldwide since it is associated with the development of chronic comorbidities such as type 2 diabetes, dyslipidemias, atherosclerosis, some cancer forms and skin diseases, including psoriasis. Scientific evidence has indicated that the possible link between obesity and psoriasis may be multifactorial, highlighting dietary habits, lifestyle, certain genetic factors and the microbiome as leading factors in the progress of both pathologies because they are associated with a chronic pro-inflammatory state. Thus, inflammation management in obesity is a plausible target for psoriasis, not only because of the sick adipose tissue secretome profile but also due to the relationship of obesity with the rest of the immune derangements associated with psoriasis initiation and maintenance. Hence, this review will provide a general and molecular overview of the relationship between both pathologies and present recent therapeutic advances in treating this problem.

Does weight loss lead to improvement of dermatological conditions: What is the evidence?

Obese and overweight individuals may have a wide gamut of cutaneous features and can have more severe manifestations of multiple dermatological conditions. There have been multiple expert opinions on the favorable effects of weight reduction in improving skin conditions. Over the past decade, there have been few studies evaluating the response of exercise and other modes of weight loss on various dermatoses such as psoriasis, acne, hidradenitis suppurativa, acanthosis nigricans. In this review, we have attempted to provide a summary of the benefits of reduction of body weight on various skin aliments.

Nutrition and psoriasis

Nutrition and dietary supplements are commonly used in the management of psoriasis; however, evidence of their efficacy is inconsistent. Although some dietary interventions have been shown to improve psoriasis consistently, others have little evidence supporting their use. We review common dietary interventions for the management of psoriasis and the evidence behind them. Caloric restriction, especially in overweight and obese individuals, has been shown to consistently diminish psoriatic activity. Evidence about other supplements and dietary interventions is inconsistent. Given the cost and side effects of pharmaceutical treatments for psoriasis, larger, long-term studies on the use of nutrition for the management of psoriasis are necessary.

Psoriatic Arthritis and Metabolic Syndrome: Is There a Role for Disease Modifying Anti-Rheumatic Drugs?

Although psoriatic arthritis (PsA) primarily leads to joint and skin damage, it is associated with higher prevalence of metabolic syndrome (MetS) and its components, namely hypertension, dyslipidemia, obesity, and type II diabetes. Additionally, chronic inflammation is known to aggravate these cardiometabolic factors, thus explaining the enhanced cardiovascular (CV) morbidity and mortality in RA. Furthermore, emerging evidence suggest that some risk factors can fuel inflammation, thus pointing to a bidirectional crosstalk between inflammation and cardiometabolic factors. Therefore, dampening inflammation by disease-modifying anti-rheumatic drugs (DMARDs) may be thought to ameliorate MetS burden and thus, CV risk and disease severity. In fact, recommendations for PsA management emphasize the need of considering comorbidities to guide the treatment decision process. However, the existing evidence on the impact of approved DMARDs in PsA on MetS and MetS components is far from being optimal, thus representing a major challenge for the clinical setting. Although a beneficial effect of some DMARDs such as methotrexate, TNF inhibitors and some small molecules is clear, no head-to-head studies are published and no evidence is available for other therapeutic approaches such as IL-23 or IL-17 inhibitors. This narrative review summarizes the main evidence related to the effect of DMARDs on MetS outcomes in PsA patients and identify the main limitations, research needs and future perspectives in this scenario.

ActiPso: definition of activity types for psoriatic disease: A novel marker for an advanced disease classification

BACKGROUND

Assessment of psoriasis is exclusively done measuring severity using somatic scores such as the psoriasis area and severity index or patient-reported outcomes such as the dermatology life quality index. There is no established tool to measure a patient's individual psoriasis activity over time.

OBJECTIVES

Development of a new tool to classify psoriasis activity types.

METHODS

Open patient interviews were performed and adapted in several steps and by using different groups of patients. Wording of the tool's axis and description how to use it was optimized with the input of patients. The final ActiPso tool was used in a prospective study in psoriasis patients.

RESULTS

Four activity types could be identified describing psoriasis intensity (e.g. severity, itch, pain) over one typical year and an event/trigger type describing flares. In the study in 586 psoriasis patients of the 536 patients eligible for analysis 40.9% self-classified as type 1 ('stable'), 22.6% as type 2 ('unstable'), 30.6% as type 3 ('winter type') and 6.0% as type 4 ('summer type'), respectively. Flares of psoriasis as identified by the event/trigger type were reported in 36.1% of patients with activity type 1, 67.8% with type 2, 73.8% of type 3 and 59.4% of type 4, respectively.

CONCLUSIONS

Interviewed patients were able to describe their course of psoriatic disease and to name potential triggering factors. By doing so, activity types of psoriasis were defined for the first time and the importance of events/triggers for flares described and integrated into ActiPso types as a basis for advanced patient-centric management. A limitation of ActiPso is that in regions with no seasonal variations types 3 and 4 may not apply.

[Obesity - A Risk Factor for Psoriasis and COVID-19]

Obesity is a major health problem whose well-known association with psoriasis has been amply described. The importance of obesity as a risk factor for poor prognosis in the coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 infection has recently been demonstrated. This review examines a possible relationship between obesity, psoriasis, and COVID-19, analyzing the pathophysiological links and their practical implications. On the one hand, a higher body mass index increases the risk of psoriasis and is also a factor in metabolic syndrome, which is common in patients with psoriasis and has been implicated in reducing the effectiveness of psoriasis treatments. On the other hand, obesity is a risk factor for severe COVID-19 and mortality. Obesity also promotes a proinflammatory state in the lung, where it compromises respiratory mechanics.

Psoriasis in Patients with Metabolic Syndrome or Type 2 Diabetes Mellitus: Treatment Challenges

Psoriasis is a chronic inflammatory disease that affects 2-3% of the population worldwide. It is associated with plaques, psoriatic arthritis, and metabolic syndrome and its components, including obesity, diabetes, dyslipidemia, nonalcoholic fatty liver disease, and cardiovascular disease. In this review, we highlight the shared pathogenic pathways leading to the comorbid existence of both diseases and the impact of drugs used for psoriasis on metabolic syndrome and vice versa. Persistent inflammation is common to both diseases. They share increased inflammatory cytokines such as tumor necrosis factor (TNF)-α and interleukin-6. Biologics have revolutionized the treatment of plaque psoriasis and also have a positive impact on metabolic syndrome. There is some evidence that TNFα inhibitors decrease insulin resistance and improve glycemic indices. Some psoriasis treatments may result in decreased body weight. Lifestyle measures used in the management of metabolic syndrome, such as weight loss, exercise, and healthy diet, are beneficial in patients with psoriasis. Considering the association between metabolic syndrome and psoriasis, we recommend screening patients with psoriasis for metabolic syndrome with clinical examinations and laboratory tests. Patients with a co-diagnosis of these diseases deserve special attention for optimal treatment.

Obesity - A Risk Factor for Psoriasis and COVID-19

Obesity is a major health problem whose well-known association with psoriasis has been amply described. The importance of obesity as a risk factor for poor prognosis in the coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 infection has recently been demonstrated. This review examines a possible relationship between obesity, psoriasis, and COVID-19, analyzing the pathophysiological links and their practical implications. On the one hand, a higher body mass index increases the risk of psoriasis and is also a factor in metabolic syndrome, which is common in patients with psoriasis and has been implicated in reducing the effectiveness of psoriasis treatments. On the other hand, obesity is a risk factor for severe COVID-19 and mortality. Obesity also promotes a proinflammatory state in the lung, where it compromises respiratory mechanics.

Psoriatic arthritis and the association with cardiometabolic disease: a narrative review

Psoriatic arthritis (PsA) is associated with a higher burden of cardiometabolic disorders, such as hypertension, dyslipidemia, diabetes, obesity, and cardiovascular disease (CVD), compared with the general population. These comorbidities are associated with the severity of disease, and adversely affect treatment outcomes in PsA. Comorbidities lead to increased physician visits and medications for patients and make the selection and maintenance of therapies challenging for physicians. Moreover, CVD is a leading cause of mortality in PsA. Therefore, optimal management of PsA should include not only treating the skin and joint disease, but also identifying comorbidities early, and managing them to improve long-term outcomes. Further studies are needed to understand the complex mechanisms, interactions, and trajectories of cardiometabolic comorbidities in psoriatic disease.

Weight loss is associated with sustained improvement of disease activity and cardiovascular risk factors in patients with psoriatic arthritis and obesity: a prospective intervention study with two years of follow-up

Background

Obesity is overrepresented in patients with psoriatic arthritis (PsA) and associated with increased disease activity. We have previously shown in 41 patients with PsA (Caspar criteria) and obesity (body mass index; BMI ≥33 kg/m²) that weight loss treatment with Very Low Energy Liquid Diet (VLED), 640 kcal/day during 12–16 weeks, followed by a structured reintroduction of an energy restricted diet resulted in a median weight loss of 18.6% and concomitantly a significant improvement of the disease activity in joints, entheses and skin.

The objectives of this follow-up were to study the effects of the weight loss treatment on disease activity in longer term (12 and 24 months) and to study the effects on cardiovascular risk factors.

Methods

The patients were assessed with 66/68 joints count, Leeds enthesitis index (LEI), body surface area, blood pressure, BMI, questionnaires and fasting blood samples at the 12- and 24-month visits.

Results

In total, 39 and 35 PsA patients attended the 12- and the 24-month visits, respectively. Median weight loss since baseline was 16.0% (IQR 10.5–22.4) and 7.4% (IQR 5.1–14.0) at the 12- and 24-months follow-up. The 66/68 swollen/tender joints score, LEI, CRP and HAQ score were still significantly reduced at the 12- and 24-month visits compared to baseline. The number of patients with Minimal Disease Activity increased from 28.2% (11/39) at baseline, to 38.5% (15/39; p = 0.008) and 45.7% (16/35; p = 0.016) at the 12- and 24-month visits.

The weight loss was also associated with improved levels of serum lipids, glucose and urate and the antihypertensive treatment was reduced or stopped in five patients during the follow-up.

Conclusions

Weight loss treatment, with VLED included in the program, was associated with long-term improvement of measures of disease activity, self-reported function and markers of the metabolic syndrome after 24-months follow-up.

Trial registration

ClinicalTrials.gov identifier: NCT02917434, Registered September 28, 2016- Retrospectively registered.

Obesity and Psoriatic Arthritis: A Narrative Review

Patients with psoriatic arthritis (PsA) have a higher burden of cardio-metabolic comorbidities like obesity, hypertension, diabetes, and cardiovascular disease compared to the general population. Adipose tissue is thought to promote a chronic low grade inflammatory state through inflammatory mediators like tumor necrosis factor alpha (TNFα), interleukin-6 (IL-6), leptin, and adiponectin. A higher body mass index (BMI) is a risk factor for development of PsA and affects disease activity and response to therapy including both disease-modifying anti-rheumatic drugs (DMARDs) and tumor necrosis factor inhibitors (TNFi). Obesity has an impact on the morbidity in PsA, particularly cardiovascular and/or metabolic. Patients with PsA have a higher cardiovascular risk and obesity may have an additive impact on morbidity and mortality. This review explores the relationship between obesity and PsA.

Characterization of the inflammatory-metabolic phenotype of heart failure with a preserved ejection fraction: a hypothesis to explain influence of sex on the evolution and potential treatment of the disease

Accumulating evidence points to the existence of an inflammatory-metabolic phenotype of heart failure with a preserved ejection fraction (HFpEF), which is characterized by biomarkers of inflammation, an expanded epicardial adipose tissue mass, microvascular endothelial dysfunction, normal-to-mildly increased left ventricular volumes and systolic blood pressures, and possibly, altered activity of adipocyte-associated inflammatory mediators. A broad range of adipogenic metabolic and systemic inflammatory disorders - e.g. obesity, diabetes and metabolic syndrome as well as rheumatoid arthritis and psoriasis - can cause this phenotype, independent of the presence of large vessel coronary artery disease. Interestingly, when compared with men, women are both at greater risk of and may suffer greater cardiac consequences from these systemic inflammatory and metabolic disorders. Women show disproportionate increases in left ventricular filling pressures following increases in central blood volume and have greater arterial stiffness than men. Additionally, they are particularly predisposed to epicardial and intramyocardial fat expansion and imbalances in adipocyte-associated proinflammatory mediators. The hormonal interrelationships seen in inflammatory-metabolic phenotype may explain why mineralocorticoid receptor antagonists and neprilysin inhibitors may be more effective in women than in men with HFpEF. Recognition of the inflammatory-metabolic phenotype may improve an understanding of the pathogenesis of HFpEF and enhance the ability to design clinical trials of interventions in this heterogeneous syndrome.

The Impact of Obesity on Disease Activity and Treatment Response in Rheumatoid Arthritis

PURPOSE OF THE REVIEW

A growing number of studies have suggested that disease outcomes and response to therapy may be different in patients with rheumatoid arthritis (RA) who are obese. The goal of this review is to examine the most recent literature, with a focus on the impact of obesity on the assessment of disease activity and treatment outcomes in RA.

RECENT FINDINGS

Obesity is common in patients with RA and can have a substantial impact on patient symptoms and outcomes. Obesity is associated with higher rates of chronic pain and opiate use, elevated inflammatory markers, and less reliable physical exam findings, making assessment of disease activity and treatment response more challenging. Despite seemingly worse clinical disease activity, evidence has accumulated demonstrating that obese patients with RA have less inflammation by imaging and lower rates of radiographic progression over time. Whether obesity influences the effectiveness of specific therapies remains controversial. Obesity is very common and is associated with more severe symptoms and higher rates of disability among RA patients. While clinical disease activity is frequently observed to be higher in obese patients with RA, it remains unclear whether poorer treatment response rates in this setting are related to reduced efficacy of therapies or are an artifact of biases in the accurate assessment of the disease.

Targeting perivascular and epicardial adipose tissue inflammation: therapeutic opportunities for cardiovascular disease

Major shifts in human lifestyle and dietary habits toward sedentary behavior and refined food intake triggered steep increase in the incidence of metabolic disorders including obesity and Type 2 diabetes. Patients with metabolic disease are at a high risk of cardiovascular complications ranging from microvascular dysfunction to cardiometabolic syndromes including heart failure. Despite significant advances in the standards of care for obese and diabetic patients, current therapeutic approaches are not always successful in averting the accompanying cardiovascular deterioration. There is a strong relationship between adipose inflammation seen in metabolic disorders and detrimental changes in cardiovascular structure and function. The particular importance of epicardial and perivascular adipose pools emerged as main modulators of the physiology or pathology of heart and blood vessels. Here, we review the peculiarities of these two fat depots in terms of their origin, function, and pathological changes during metabolic deterioration. We highlight the rationale for pharmacological targeting of the perivascular and epicardial adipose tissue or associated signaling pathways as potential disease modifying approaches in cardiometabolic syndromes.

Bariatric surgery and the incidence of rheumatoid arthritis - a Swedish Obese Subjects study

Objective

The aim of this study was to determine the effect of bariatric surgery on the incidence of RA in participants of the Swedish Obese Subjects (SOS) study.

Methods

The SOS is a longitudinal study aiming to assess the effect of bariatric surgery on mortality and obesity-related diseases. This report includes 2002 subjects with obesity who underwent bariatric surgery and 2034 matched controls; none of them had RA at baseline. Cases of incident RA were identified through the Swedish National Patient Register by searching for International Classification of Diseases codes. Both intention-to-treat analyses and per-protocol analyses are reported. In the per-protocol analysis, participants from the control group who underwent bariatric surgery later on during follow-up were censored at the time of surgery.

Results

During follow-up, 92 study participants developed RA. The median follow-up was 21 years (range 0–29). Bariatric surgery was neither associated with the incidence of RA in the intention-to-treat analysis [hazard ratio (HR) 0.92 (95% CI 0.59, 1.46), P = 0.74], nor in the per-protocol analysis [HR 0.86 (95% CI 0.54, 1.38), P = 0.53]. Weight change at the 2 year follow-up, expressed as the change in BMI compared with baseline, did not associate with the development of RA. Higher serum CRP levels and smoking associated with the future development of RA independent of other factors.

Conclusions

We did not detect any association between bariatric surgery and the incidence of RA in subjects affected by obesity followed up for up to 29 years.

ClinicalTrials.gov

(http://clinicaltrials.gov): NCT01479452.

Research Techniques Made Simple: Using Genetic Variants for Randomization

Observational epidemiological studies have identified associations between a number of modifiable exposures and outcomes, including in dermatology, such as between smoking and psoriasis. However, it is challenging to determine if such relationships are causal because of the potential of confounding and reverse causation. Mendelian randomization (MR) is a statistical method that can be used to investigate the causal relationships between an exposure and outcome by using a genetic instrument that proxies the exposure. The resulting estimate (under certain assumptions) can be interpreted as the causal estimate, free of confounding and reverse causation. In this review, we provide an overview of how to undertake an MR analysis, with examples from the dermatology literature. We also discuss the challenges and future directions of this method.

Link Between Synovial and Myocardial Inflammation: Conceptual Framework to Explain the Pathogenesis of Heart Failure with Preserved Ejection Fraction in Patients with Systemic Rheumatic Diseases

Patients with a broad range of systemic rheumatic diseases are at increased risk of heart failure (HF), an event that is not related to traditional cardiovascular risk factors or underlying ischaemic heart disease. The magnitude of risk is linked to the severity of arthritic activity, and HF is typically accompanied by a preserved ejection fraction. Subclinical evidence for myocardial fibrosis, microcirculatory dysfunction and elevated cardiac filling pressures is present in a large proportion of patients with rheumatic diseases, particularly those with meaningful systemic inflammation. Drugs that act to attenuate pro-inflammatory pathways (methotrexate and antagonists of tumour necrosis factor and interleukin-1) may ameliorate myocardial inflammation and cardiac structural abnormalities and reduce the risk of HF events.

Cardiovascular risk in psoriatic arthritis, a narrative review

INTRODUCTION

Psoriatic arthritis (PsA) is a chronic inflammatory rheumatism characterized for a long time by a high degree of cardiovascular risk. Chronic inflammation is one of the mechanisms that explain this cardiovascular excess of risk through direct and indirect pathways. In recent years, epidemiological data have changed somewhat since the increasing use of bio-drugs that are effective in reducing this inflammation. The purpose of this review is to assess the current state of cardiovascular morbidity and mortality in PsA and thus to assess the cardiovascular risk in case of PsA.

METHOD

We conducted a literature review using Pubmed and Medline databases with the following keywords "Psoriatic Arthritis" AND "cardiovascular" including articles from the last three years.

RESULTS

It appears that in case of PsA, there is an increased prevalence of high blood pressure, diabetes, obesity and dyslipidemia, and therefore of metabolic syndrome. Insulin resistance is closely linked to PsA. On the other hand, the data are more contrasted for active smoking. There is also arterial inflammation specific to PsA. Finally, at the therapeutic level, the impact of NSAIDs remains controversial, while methotrexate and bio-drugs are beneficial at the cardiovascular level.

CONCLUSION

PsA is characterized by an increase in cardiovascular morbidity in relation with insulin resistance. Current treatments seem to improve this risk with a decrease in cardiovascular mortality in comparison with patients with plaque psoriasis but this requires confirmation in larger prospective studies.

Obesity in psoriatic arthritis: Comparative prevalence and associated factors

Obesity is a common cardiovascular risk factor in psoriatic disease. Although the prevalence of obesity is high, the factors associated with it in patients with psoriatic arthritis (PsA) are poorly understood. We aimed to analyze the frequency and obesity-associated factors in a cohort of PsA.This retrospective cross-sectional study included 290 consecutive patients with PsA according to CASPAR criteria. Three-hundred ten psoriatic patients without arthritis and 600 outpatients without inflammatory conditions were used as comparison populations. The factors associated with obesity were analyzed first using conditional logistic regression. The significant factors in this first model were introduced in a multivariate model using a backward step approach.This series included 159 men (54.8%) and 131 women (45.2%), with an average age of 54 ± 12 years. Obesity was more common both in psoriasis (36.5% vs 22%, OR 2.1 [95%CI: 1.5-2.8), P < .01]) and PsA (27.6% vs 22%, OR 1.4 [95%CI: 1.0-1.9], P < .05) than in the non-inflammatory population. Obesity was more frequent in psoriasis (36.5%) than in PsA (27.6%), OR 1.5 95% CI: 1.1 to 2.1, P < .05. After correcting for age, sex, disease duration, and other confounders, independent associations with obesity (P < .05) were: PsA family history (OR 3.6, 95%CI: 1.1-12.4), evolution as axial disease (OR 4.4, 95%CI: 1.0-15.4), and dyslipidemia (OR 3.5, 95%CI: 1.5-8.6).Obesity is common in psoriatic disease, but much more frequent among patients with cutaneous than joint disease. Patients who present with spondylitis during evolution are more prone to this comorbidity, and therefore, should be closely monitored to correct this eventuality in a timely manner.

Does weight loss reduce the severity and incidence of psoriasis or psoriatic arthritis? A Critically Appraised Topic

CLINICAL QUESTION

Does weight loss reduce the severity and incidence of psoriasis or psoriatic arthritis (PsA) in obese individuals?

BACKGROUND

Obesity presents a rising public health challenge and is more prevalent among individuals with psoriasis or PsA than in the general population. Longitudinal population-based studies suggest a causal role for obesity in psoriasis and PsA onset and that obesity drives greater disease severity.

METHODS

We systematically reviewed evidence within the MEDLINE, Embase and CENTRAL databases and clinical trials registries examining lifestyle, pharmacological and surgical weight loss interventions in the treatment and prevention of psoriasis and PsA in obese individuals. Meta-analysis was conducted using random-effects models, followed by sensitivity analyses.

RESULTS

Of 176 full-text articles reviewed, 14 met the inclusion criteria. Meta-analysis of six randomized control trials (RCTs) confirmed that weight loss following lifestyle interventions (diet or physical activity) improves psoriasis compared with control [mean change in Psoriasis Area and Severity Index -2·59, 95% confidence interval (CI) -4·09 to -1·09; P < 0·001]. One RCT demonstrated a greater likelihood of achieving minimal PsA activity following diet-induced weight loss (odds ratio 4·20, 95% CI 1·82-9·66; P < 0·001). Three studies of pharmacological treatments reported conflicting results, and no RCTs of bariatric surgery were identified. Two cohort studies suggested that bariatric surgery, particularly gastric bypass, reduces the risk of developing psoriasis (hazard ratio 0·52, 95% CI 0·33-0·81; P < 0·01).

CONCLUSIONS

These limited data indicate that weight loss can improve pre-existing psoriasis and PsA, and prevent the onset of psoriasis in obese individuals. Together with the National Institute for Health and Care Excellence obesity guidance, this informed a local obesity screening and management pathway, providing multidisciplinary weight loss interventions alongside conventional skin-focused care for patients with psoriasis.

Evidence of a causal relationship between body mass index and psoriasis: A mendelian randomization study

BACKGROUND

Psoriasis is a common inflammatory skin disease that has been reported to be associated with obesity. We aimed to investigate a possible causal relationship between body mass index (BMI) and psoriasis.

METHODS AND FINDINGS

Following a review of published epidemiological evidence of the association between obesity and psoriasis, mendelian randomization (MR) was used to test for a causal relationship with BMI. We used a genetic instrument comprising 97 single-nucleotide polymorphisms (SNPs) associated with BMI as a proxy for BMI (expected to be much less confounded than measured BMI). One-sample MR was conducted using individual-level data (396,495 individuals) from the UK Biobank and the Nord-Trøndelag Health Study (HUNT), Norway. Two-sample MR was performed with summary-level data (356,926 individuals) from published BMI and psoriasis genome-wide association studies (GWASs). The one-sample and two-sample MR estimates were meta-analysed using a fixed-effect model. To test for a potential reverse causal effect, MR analysis with genetic instruments comprising variants from recent genome-wide analyses for psoriasis were used to test whether genetic risk for this skin disease has a causal effect on BMI. Published observational data showed an association of higher BMI with psoriasis. A mean difference in BMI of 1.26 kg/m2 (95% CI 1.02-1.51) between psoriasis cases and controls was observed in adults, while a 1.55 kg/m2 mean difference (95% CI 1.13-1.98) was observed in children. The observational association was confirmed in UK Biobank and HUNT data sets. Overall, a 1 kg/m2 increase in BMI was associated with 4% higher odds of psoriasis (meta-analysis odds ratio [OR] = 1.04; 95% CI 1.03-1.04; P = 1.73 × 10(-60)). MR analyses provided evidence that higher BMI causally increases the odds of psoriasis (by 9% per 1 unit increase in BMI; OR = 1.09 (1.06-1.12) per 1 kg/m2; P = 4.67 × 10(-9)). In contrast, MR estimates gave little support to a possible causal effect of psoriasis genetic risk on BMI (0.004 kg/m2 change in BMI per doubling odds of psoriasis (-0.003 to 0.011). Limitations of our study include possible misreporting of psoriasis by patients, as well as potential misdiagnosis by clinicians. In addition, there is also limited ethnic variation in the cohorts studied.

CONCLUSIONS

Our study, using genetic variants as instrumental variables for BMI, provides evidence that higher BMI leads to a higher risk of psoriasis. This supports the prioritization of therapies and lifestyle interventions aimed at controlling weight for the prevention or treatment of this common skin disease. Mechanistic studies are required to improve understanding of this relationship.

Impact of obesity on autoimmune arthritis and its cardiovascular complications

Obesity can instigate and sustain a systemic low-grade inflammatory environment that can amplify autoimmune disorders and their associated comorbidities. Metabolic changes and inflammatory factors produced by the adipose tissue have been reported to aggravate autoimmunity and predispose the patient to cardiovascular disease (CVD) and metabolic comorbidities. Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) are autoimmune arthritic diseases, often linked with altered body mass index (BMI). Severe joint inflammation and bone destruction have a debilitating impact on the patient's life; there is also a staggering risk of cardiovascular morbidity and mortality. Furthermore, these patients are at risk of developing metabolic symptoms, including insulin resistance resulting in type 2 diabetes mellitus (T2DM). In addition, arthritis severity, progression and response to therapy can be markedly affected by the patient's BMI. Hence, a complex integrative pathogenesis interconnects autoimmunity with metabolic and cardiovascular disorders. This review aims to shed light on the network that connects obesity with RA, PsA, systemic lupus erythematosus and Sjӧgren's syndrome. We have focused on clarifying the mechanism by which obesity affects different cell types, inflammatory factors and traditional therapies in these autoimmune disorders. We conclude that to further optimize arthritis therapy and to prevent CVD, it is imperative to uncover the intricate relation between obesity and arthritis pathology.

Epicardial Adipose Tissue May Mediate Deleterious Effects of Obesity and Inflammation on the Myocardium

Epicardial adipose tissue has unique properties that distinguish it from other depots of visceral fat. Rather than having distinct boundaries, the epicardium shares an unobstructed microcirculation with the underlying myocardium, and in healthy conditions, produces cytokines that nourish the heart. However, in chronic inflammatory disorders (especially those leading to heart failure with preserved ejection fraction), the epicardium becomes a site of deranged adipogenesis, leading to the secretion of proinflammatory adipokines that can cause atrial and ventricular fibrosis. Accordingly, in patients at risk of heart failure with preserved ejection fraction, drugs that promote the accumulation or inflammation of epicardial adipocytes may lead to heart failure, whereas treatments that ameliorate the proinflammatory characteristics of epicardial fat may reduce the risk of heart failure. These observations suggest that epicardial adipose tissue is a transducer of the adverse effects of systemic inflammation and metabolic disorders on the heart, and thus, represents an important target for therapeutic interventions.