Does Treatment of Psoriasis Reduce the Risk of Cardiovascular Disease?

The potential impact of systemic anti-inflammatory therapies in psoriasis on major adverse cardiovascular events: a Korean nationwide cohort study

This nationwide population-based cohort study aimed to investigate the impact of systemic anti-inflammatory treatment on the major adverse cardiovascular events (MACE) risk in patients with psoriasis from January 2006 to December 2018, using a database provided by the Korean National Health Insurance Service. Patients were grouped based on the following treatment modalities: biologics, phototherapy, methotrexate, cyclosporine, and mixed conventional systemic agents. Patients who had not received any systemic treatment were assigned to the control cohort. The incidence of MACE per 1000 person-year was 3.5, 9.3, 12.1, 28.4, 39.5, and 14.5 in the biologic, phototherapy, methotrexate, cyclosporine, mixed conventional systemic agents, and control cohorts, respectively. During the 36-month follow-up, the cumulative incidence of MACE in the phototherapy and biologic cohorts remained lower than that of other treatment modalities. Cyclosporine (hazard ratio (HR) = 2.11, 95% confidence interval (CI) = 1.64–2.71) and mixed conventional systemic agents (HR = 2.57, 95% CI = 2.05–3.22) treatments were associated with increased MACE risk. Methotrexate treatment was not associated with MACE. Our finding demonstrates that treatment modalities may affect cardiovascular comorbidities in patients with psoriasis. Thus, an appropriate combination of anti-psoriatic therapies should be considered to manage patients with high cardiovascular risk.

IRB approval status: Waiver decision was obtained by the institutional review board, Konkuk University Hospital, Seoul, Republic of Korea (KUH1120107).

Cutaneous lupus erythematosus and cardiovascular disease: current knowledge and insights into pathogenesis

Multiple autoinflammatory diseases, including psoriasis, psoriatic arthritis, and systemic lupus erythematosus, have been linked to increased risk of cardiovascular disease. Inflammation is known to play a key role in the pathogenesis of atherosclerosis, thus the contribution of systemic immune dysregulation, which characterizes such inflammatory conditions, towards the development of cardiovascular disease has garnered considerable interest. Cutaneous lupus erythematosus (CLE) is a chronic inflammatory skin disease, but risk of cardiovascular disease amongst patients with cutaneous lupus is less well known. Observational studies, including those of large nationwide cohorts, have been conducted to examine cardiovascular disease risk in CLE, with varying findings. As with other inflammatory diseases, immunologic mechanisms may provide plausible causal links between CLE and cardiovascular risk. On a macrolevel, several disease-related characteristics may also contribute to cardiovascular risk amongst CLE patients. This represents an area of research that should be prioritized, as understanding cardiovascular disease risk has important clinical implications for CLE patients.

Effectiveness of methotrexate in moderate to severe psoriasis patients: real-world registry data from the Swiss Dermatology Network for Targeted Therapies (SDNTT)

Methotrexate (MTX) is a frequently used anti-psoriatic drug that is commonly recommended in international psoriasis guidelines. It is effective in treating skin lesions, nail changes and psoriatic arthritis. In 2017 a prospective, multicenter, randomized, double-blind, placebo-controlled, phase 3 trial, commonly known as the METOP trial, was published assessing the effectiveness and safety of subcutaneous administration of methotrexate. Because trial data do not always relate to real-life data with unselected patient populations, we wanted to determine whether the data obtained in the METOP-trial correspond to real-life registry data from our Swiss Dermatology Network for Targeted Therapies (SDNTT). Data of 449 patients with moderate to severe psoriasis who participated in the SDNTT registry between 2011 and 1st of July 2017 were analyzed. Only patients receiving methotrexate s.c. were included. 66 patients under MTX were included into this study. Baseline PASI was 6.3 ± 3.8 (SDNTT) compared to 15.9 ± 5.9 in the METOP trial. In our cohort, only 18% of all patients reached PASI 75 after 12 weeks, 6% showed a complete remission (PASI 100) compared to 41% and 4% in the METOP trial after 16 weeks. 22.7% of all patients showed increased liver enzymes in either study and nausea was seen in 15% (SDNTT) versus 22% (METOP) of patients. No severe adverse events were observed in our cohort. Compared to the METOP-trial, the response rates seen our real-world cohort were distinctly lower.

The risk of cardiovascular events in psoriasis patients treated with tumor necrosis factor-α inhibitors versus phototherapy: An observational cohort study

BACKGROUND

Psoriasis is a risk factor for cardiovascular events.

OBJECTIVE

To assess the risk of major cardiovascular events and the effect of cumulative treatment exposure on cardiovascular event risk in patients with psoriasis treated with tumor necrosis factor-α inhibitors (TNFis) versus phototherapy.

METHODS

Adult patients with psoriasis were selected from a large US administrative claims database (from the first quarter of 2000 through the third quarter of 2014) and classified in 2 mutually exclusive cohorts based on whether they were treated with TNFis or phototherapy. Cardiovascular event risk was compared between cohorts using multivariate Cox proportional hazards models. Cumulative exposure was defined based on treatment persistence.

RESULTS

A total of 11,410 TNFi and 12,433 phototherapy patients (psoralen plus ultraviolet A light phototherapy, n = 1117; ultraviolet B light phototherapy, n = 11,316) were included in this study. TNFi patients had a lower risk of cardiovascular events compared to phototherapy patients (adjusted hazard ratio 0.77, P < .05). The risk reduction associated with 6 months of cumulative exposure was 11.2% larger for patients treated with TNFis compared to phototherapy (P < .05).

LIMITATIONS

Information on psoriasis severity and mortality was limited/not available.

CONCLUSIONS

Patients with psoriasis who were treated with TNFis exhibited a lower cardiovascular event risk than patients treated with phototherapy. Cumulative exposure to TNFis was associated with an incremental cardiovascular risk reduction compared to phototherapy.

The effect of tumor necrosis factor inhibitor therapy on the incidence of myocardial infarction in patients with psoriasis: a retrospective study

BACKGROUND

Psoriasis has been shown to be associated with increased incidence of myocardial infarction (MI). The data on the effect of tumor necrosis factor (TNF) inhibitors on MI in psoriasis are scarce.

OBJECTIVE

To evaluate the effect of TNF inhibitors on the risk of MI in psoriasis patients compared with methotrexate (MTX) and topical agents.

METHODS

Data were obtained from the Electronic Health Records database of Farwaniya Hospital from psoriasis patients seen from January 2008 to December 2014. Patients were categorized into TNF inhibitor, MTX and topical cohorts.

RESULTS

The study included 4762 psoriasis patients. Both TNF inhibitor and MTX cohorts showed a statistically lower rate of MI compared with topical cohort. However, there was no statistically significant difference in MI rate between TNF inhibitor and MTX cohorts (P = .32). The probability of MI was lower in TNF inhibitor responders compared with non-responders (p = .001).

CONCLUSIONS

The use of TNF inhibitors in psoriasis showed a significant reduction in the risk of MI compared with topical agents and a non-significant reduction compared with MTX. Responders to TNF inhibitor therapy showed a reduction in MI rate compared with non-responders.

Psoriasis and Cardiovascular Comorbidities: Focusing on Severe Vascular Events, Cardiovascular Risk Factors and Implications for Treatment

Psoriasis is a common and chronic inflammatory disease of the skin. It may impair the physical and psychosocial function of patients and lead to decreased quality of life. Traditionally, psoriasis has been regarded as a disease affecting only the skin and joints. More recently, studies have shown that psoriasis is a systemic inflammatory disorder which can be associated with various comorbidities. In particular, psoriasis is associated with an increased risk of developing severe vascular events such as myocardial infarction and stroke. In addition, the prevalence rates of cardiovascular risk factors are increased, including hypertension, diabetes mellitus, dyslipidemia, obesity, and metabolic syndrome. Consequently, mortality rates have been found to be increased and life expectancy decreased in patients with psoriasis, as compared to the general population. Various studies have also shown that systemic treatments for psoriasis, including methotrexate and tumor necrosis factor-α inhibitors, may significantly decrease cardiovascular risk. Mechanistically, the presence of common inflammatory pathways, secretion of adipokines, insulin resistance, angiogenesis, oxidative stress, microparticles, and hypercoagulability may explain the association between psoriasis and cardiometabolic disorders. In this article, we review the evidence regarding the association between psoriasis and cardiovascular comorbidities, focusing on severe vascular events, cardiovascular risk factors and implications for treatment.

Carotid intima-media thickness in patients with mild or moderate psoriasis

Introduction

Psoriasis is a chronic inflammatory disease associated with a significantly higher morbidity and various comorbidities (obesity, metabolic syndrome, diabetes). Previous studies focused mainly on patients with severe psoriasis who were found to have increased markers of early atherosclerosis, higher intima-media thickness (IMT) values.

Aim

To evaluate the association between the severity or duration of psoriasis and carotid IMT in patients with mild and moderate psoriasis.

Material and methods

We studied seventy four patients with mild and moderate psoriasis. Clinical assessment and common carotid artery (CCA) IMT measurements were performed in all patients.

Results

The mean CCA IMT value was 1.03 ±0.37 mm, mean PASI score (psoriasis area severity index) was 18.6 ±10.5. There was a significant association between PASI score and IMT values (r = 0.33; p = 0.007) adjusted for age, psoriasis duration, blood pressure and smoking. However, we found no correlations between carotid IMT and disease duration or other clinical variables.

Conclusions

The severity of psoriasis is associated with carotid IMT even in patients with mild and moderate psoriasis.

Impact of Elevated Serum Uric Acid Levels on Systemic Inflammation in Patients With Psoriasis

Patients with psoriasis have increased systemic inflammation and serum uric acid (SUA) levels compared with the general population. However, the role of SUA in modulating inflammation in these patients is not known. We evaluated the associations of SUA with inflammation and psoriasis severity; 199 patients with psoriasis and 54 healthy volunteers were included in the study. Demographic features, Psoriasis Area and Severity Index (PASI) scores, and laboratory data including SUA, C-reactive protein (CRP), and neutrophil to lymphocyte ratio (NLR) were collected. Patients with psoriasis had higher fasting blood glucose, body mass index (BMI), CRP, SUA, white blood cell (WBC) count, neutrophil count, and NLR compared with controls. The PASI score positively correlated only with CRP ( r = .185, P = .012) and NLR ( r = .313, P < .001). The BMI, WBC count, PASI score, and CRP, but not SUA, appeared as independent associates of NLR in patients with psoriasis in linear regression analysis. Neutrophil to lymphocyte ratio and SUA were significantly increased in patients with psoriasis compared with controls. Neutrophil to lymphocyte ratio and CRP were independent predictors of PASI score, whereas SUA was not. Serum uric acid seemed not to modulate the inflammation seen in patients with psoriasis in our cohort.

The Association between Psoriasis Area and Severity Index and Cardiovascular Risk Factor in Korean Psoriasis Patients

Background

Psoriasis is associated with increased risk of cardiovascular morbidities, especially in severe cases. Severity of the disease has been known to be associated with higher prevalence of these risk factors. However, in the absence of robust measurements, studies to date relied mostly on treatment spectrum as a proxy for the severity.

Objective

To evaluate the relationship between psoriasis area and severity index (PASI) and cardiovascular risk factors in Korean patients.

Methods

Presence of diabetes mellitus (DM), hypertension, smoking history was surveyed through questionnaires and serum lipid profile analysis were done after fasting overnight. The severity of psoriasis was assessed using PASI scores: mild, <10; moderate to severe, ≥10. Cardiovascular risk factors such as smoking, hypertension, diabetes and dyslipidemia were compared between the mild group and moderate to severe group. The prevalence of diabetes and hypertension was compared among these two groups of psoriasis patients and the general population based control; age and gender were matched among three groups accordingly prior to analysis.

Results

A total of 256 patients with plaque type psoriasis were included. Between mild group and moderate to severe group, significant differences of cardiovascular risk factors including lipid profile were not discovered except in triglyceride level. Comparing to general population, prevalence of diabetes was found significantly higher in psoriasis patients while that of hypertension was similar.

Conclusion

Our results suggest that among cardiovascular risks, presence of DM and triglyceride level seem to be associated with the presence of psoriasis in Korean psoriasis patients, while other factors may not contribute meaningfully.

[New populations at increased cardiovascular risk: Cardiovascular disease in dermatological diseases]

The increased cardiovascular risk in some dermatological diseases has been demonstrated in recent decades. Diseases such as psoriasis and systemic lupus erythematosus are currently included in the guidelines for prevention of cardiovascular disease. Other diseases such as androgenic alopecia, polycystic ovary syndrome, hidradenitis suppurativa or lichen planus have numerous studies that point to an increased risk, however, they have not been included in these guidelines. In this article we review the evidence supporting this association, in order to alert the clinician to the need for greater control in cardiovascular risk factors in these patients.

Antipsoriatic treatment extends beyond the skin: recovering of high-density lipoprotein function

Epidemiological and clinical studies have shown a consistent association of psoriasis with systemic metabolic disorders including an increased prevalence of diabetes, obesity and cardiovascular disease. Psoriasis is accompanied by systemic inflammation and low levels of high-density lipoprotein (HDL) cholesterol. Recent studies provided clear evidence that psoriasis affects HDL composition and function. HDL isolated from patients with psoriasis showed a significantly impaired capability to mobilize cholesterol from macrophages, a crucial step in reverse cholesterol transport and markedly lower paraoxonase activity, a protein that co-transports with HDL in serum with well-known anti-atherogenic properties. Of particular interest, successful antipsoriatic therapy significantly improved HDL composition and function independently of serum HDL cholesterol levels. These novel findings suggest that the conventional approaches of evaluating cardiovascular risk in psoriasis may be in need of refinement. As these data argue for a loss of beneficial activities of HDL in patients with psoriasis, altered HDL functionality should be considered when evaluating the lipid status of patients.