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Fan W, Lei N, Zheng Y, Liu J, Cao X, Su T, Su Z, Lu Y. Oral microbiota diversity in moderate to severe plaque psoriasis, nail psoriasis and psoriatic arthritis. Sci Rep 2024; 14:18402. [PMID: 39117753 PMCID: PMC11310443 DOI: 10.1038/s41598-024-69132-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Accepted: 07/31/2024] [Indexed: 08/10/2024] Open
Abstract
Gaining a comprehensive understanding of the role played by the oral microbiome in moderate to severe plaque psoriasis and its potential implications for disease management and development holds significant importance. With the objective of exploring correlations between the oral microbiota and severe psoriasis, this study involved 72 severe psoriasis patients and 16 healthy individuals, whose clinical manifestations and living habits were carefully recorded. Cutting-edge techniques such as 16S rRNA gene sequencing and bioinformatics analysis were employed to compare the microbial flora, investigating dynamic changes among severe plaque psoriasis patients, psoriatic arthritis patients and healthy individuals. The findings revealed noteworthy patterns including increased levels of Aggregatibacter in the psoriatic arthritis group, accompanied by a decrease in the level of Prevotella. Moreover, the enrichment o Capnocytandophaga (P = 0.009), Campylobacter (P = 0.0022), and Acetobacter (P = 0.0292) was notably more substantial in the psoriasis group compared to the control group, whereas certain bacterial species such as Bacteroides (P = 0.0049), Muribaculaceae (P = 0.0048) demonstrated decreased enrichment. Additionally, the psoriatic arthritis group exhibited significantly higher levels of Ralstonia, Bifidobacterium and Micromonospora. Based on these findings, it can be inferred that individuals with lower levels of Prevotella and higher levels of Corynebacterium may be more susceptible to psoriasis exacerbation.
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Affiliation(s)
- Wen Fan
- Department of Dermatology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, Nanjing, People's Republic of China
- Department of Dermatology, Changzhou NO. 2 People's Hospital Affiliated to Nanjing Medical University, Changzhou, Jiangsu, People's Republic of China
| | - Na Lei
- Department of Dermatology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, Nanjing, People's Republic of China
| | - Yujie Zheng
- Department of Dermatology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, Nanjing, People's Republic of China
| | - Juan Liu
- Department of Bacteriological Laboratory, Changzhou NO. 2 People's Hospital Affiliated to Nanjing Medical University, Changzhou, Jiangsu, People's Republic of China
| | - Xuechen Cao
- Department of Dermatology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, Nanjing, People's Republic of China
| | - Ting Su
- Department of Dermatology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, Nanjing, People's Republic of China
| | - Zhonglan Su
- Department of Dermatology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, Nanjing, People's Republic of China
| | - Yan Lu
- Department of Dermatology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, Nanjing, People's Republic of China.
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Galajda NÁ, Meznerics FA, Mátrai P, Fehérvári P, Lengyel AS, Kolonics MV, Sipos Z, Kemény LV, Csupor D, Hegyi P, Bánvölgyi A, Holló P. Reducing cardiovascular risk in immune-mediated inflammatory diseases: Tumour necrosis factor inhibitors compared to conventional therapies-A systematic review and meta-analysis. J Eur Acad Dermatol Venereol 2024; 38:1070-1088. [PMID: 38433519 DOI: 10.1111/jdv.19900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/19/2024] [Indexed: 03/05/2024]
Abstract
Immune-mediated inflammatory disease (IMID) patients including psoriasis, inflammatory arthritides and bowel diseases have a higher risk of developing cardiovascular (CV) diseases compared to the general population. The increased CV risk may be promoted by tumour necrosis factor (TNF)-α-mediated immunological processes, which are present both in the pathomechanism of IMIDs and atherosclerosis. Our objective was to comprehensively investigate the effect of TNF inhibitors (TNFi) on CV risk compared with conventional therapies in IMIDs. The systematic literature search was conducted in three databases (MEDLINE, EMBASE, Cochrane Library) on 14 November 2022. Randomized controlled trials, cohort and case-control studies were eligible for inclusion. Outcomes consisted of the incidence of CV events, with major adverse cardiovascular events (MACE) as a main endpoint. A random-effects meta-analysis was performed by pooling fully adjusted multivariate hazard ratios (HR) and incidence rate ratios (IRR) with a 95% confidence interval (CI) comparing TNFis with conventional systemic non-biologicals (CSNBs). Of a total of 8724 search results, 56 studies were included overall, of which 29 articles were eligible for the meta-analysis, and 27 were involved in the systematic review. Including all IMIDs, the TNFi group showed a significantly reduced risk of MACE compared with the CSNB group (HR = 0.74, 95% confidence interval (CI) 0.58-0.95, p = 0.025; IRR = 0.77, 95% CI 0.67-0.88, p < 0.001). Subgroup analysis of Pso, PsA patients by pooling IRRs also confirmed the significantly decreased risk of MACE in TNFi-treated patients compared with CSNB groups (IRR = 0.79, 95% CI 0.64-0.98). The observational nature of most included studies leading to high heterogeneity represents a limitation. Based on the results, TNFis may reduce the risk of CV events compared to CSNBs. Therefore, earlier use of TNFis compared to conventional systemic agents in the therapeutic sequence may benefit CV risk in IMID patients.
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Affiliation(s)
- N Á Galajda
- Department of Dermatology, Venereology and Dermatooncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - F A Meznerics
- Department of Dermatology, Venereology and Dermatooncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - P Mátrai
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - P Fehérvári
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Biostatistics, University of Veterinary Medicine, Budapest, Hungary
| | - A S Lengyel
- Department of Dermatology, Venereology and Dermatooncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- HCEMM-SU Translational Dermatology Research Group, Department of Physiology, Semmelweis University, Budapest, Hungary
| | - M V Kolonics
- Department of Dermatology, Venereology and Dermatooncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Z Sipos
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - L V Kemény
- Department of Dermatology, Venereology and Dermatooncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- HCEMM-SU Translational Dermatology Research Group, Department of Physiology, Semmelweis University, Budapest, Hungary
| | - D Csupor
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, Szeged, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - P Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - A Bánvölgyi
- Department of Dermatology, Venereology and Dermatooncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - P Holló
- Department of Dermatology, Venereology and Dermatooncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
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Kaiser H, Näslund-Koch C, Kvist-Hansen A, Skov L. Does Systemic Anti-Psoriatic Treatment Impact the Risk of Cardiovascular Disease? A Review Over Cardiovascular Imaging Studies. Dermatol Ther (Heidelb) 2024; 14:303-321. [PMID: 38291285 PMCID: PMC10891014 DOI: 10.1007/s13555-024-01098-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 01/10/2024] [Indexed: 02/01/2024] Open
Abstract
Psoriasis is an immune-mediated inflammatory disease associated with an increased risk of cardiovascular disease (CVD). The risk of CVD increases with the severity of psoriasis, and exposure to systemic inflammation may partly explain the increased risk of CVD in these patients. This raises the question of whether anti-psoriatic treatment, in addition to treating the skin lesions, also lowers the risk of developing CVD. Different types of studies have examined the impact of systemic anti-psoriatic treatments on the risk of CVD in patients with psoriasis and epidemiological observational studies with, e.g., myocardial infarction and stroke as outcomes, and clinical studies investigating circulating inflammatory biomarkers in the blood indicate that anti-psoriatic therapy has a protective effect; however, no randomized controlled trial (RCT) has examined the impact of systemic anti-psoriatic treatment on future hard cardiovascular endpoints. This narrative review provides an overview of the clinical cardiovascular imaging studies examining the effect of systemic anti-psoriatic treatment on the risk of subclinical CVD in patients with psoriasis. We found a total of 24 clinical imaging studies, where 16 of these were observational cohort studies and eight were RCTs. The observational studies suggest an improvement in the risk of subclinical CVD based on different cardiovascular imaging biomarkers; however, the RCTs showed inconsistent results and mainly included vascular inflammation as the outcome. Future RCTs including other imaging biomarkers as surrogates for subclinical CVD, with longer follow-up and with hard cardiovascular endpoints are warranted to address whether systemic anti-psoriatic treatments reduce the risk of CVD.
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Affiliation(s)
- Hannah Kaiser
- Department of Dermatology and Allergy, University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark.
| | - Charlotte Näslund-Koch
- Department of Dermatology and Allergy, University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
| | - Amanda Kvist-Hansen
- Department of Dermatology and Allergy, University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
| | - Lone Skov
- Department of Dermatology and Allergy, University Hospital-Herlev and Gentofte, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Kleinrensink NJ, Spierings J, Vonkeman HE, Seddiqi N, Herman A, Suijkerbuijk KPM, Heijstek MW, Jansen MP, de Jong PA, Foppen W. Increased vascular inflammation on PET/CT in psoriatic arthritis patients in comparison with controls. RMD Open 2024; 10:e003547. [PMID: 38296307 PMCID: PMC10836343 DOI: 10.1136/rmdopen-2023-003547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 01/05/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Patients with psoriatic arthritis (PsA) have an increased risk of cardiovascular disease, possibly due to a chronic inflammatory state. OBJECTIVES The main objective of this study was to investigate the difference in vascular inflammation, measured with 18-fluorodeoxyglucose positron emission tomography/CT (PET/CT), in PsA patients and controls. We conducted a secondary analysis to assess the association between clinical parameters of disease activity with vascular inflammation in PsA. METHODS We included a total of 75 PsA patients with active peripheral arthritis (defined as ≥2 tender and swollen joints) from an ongoing clinical trial (EudraCT 2017-003900-28) and a retrospective group of 40 controls diagnosed with melanoma, without distant metastases and not receiving immunotherapy. The main outcome measure was aortic vascular inflammation which was measured on PET/CT scans using target-to-background ratios. Clinical disease activity in PsA was assessed with joint counts, body surface area and the Disease Activity index for PsA. Laboratory assessments included C reactive protein and erythrocyte sedimentation rate. RESULTS Vascular inflammation was increased in patients with PsA in comparison with controls (mean target-to-background ratio for entire aorta, respectively, 1.63±0.17 vs 1.49±0.16; p=<0.001). This association remained significant after correction for gender, age, body mass index, mean arterial pressure and aortic calcification (p=0.002). Vascular inflammation was not associated with disease-related parameters. CONCLUSIONS Aortic vascular inflammation was significantly increased in patients with active PsA compared with controls. This evidence supports the theory that inflammation in PsA is not limited to the skin and joints but also involves the vascular system.
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Affiliation(s)
- Nienke J Kleinrensink
- Department of Rheumatology & Clinical Immunology, UMC Utrecht, Utrecht, Netherlands
- Department of Radiology, UMC Utrecht, Utrecht, Netherlands
| | - Julia Spierings
- Department of Rheumatology & Clinical Immunology, UMC Utrecht, Utrecht, Netherlands
| | - Harald E Vonkeman
- Department of Rheumatology and Clinical Immunology, Medisch Spectrum Twente, Enschede, Netherlands
- Department of Psychology, Health & Technology, University of Twente, Enschede, Netherlands
| | - Negina Seddiqi
- Department of Radiology, UMC Utrecht, Utrecht, Netherlands
| | - Amin Herman
- Department of Rheumatology, Sint Antonius Hospital, Nieuwegein, Netherlands
| | | | - Marloes W Heijstek
- Department of Rheumatology & Clinical Immunology, UMC Utrecht, Utrecht, Netherlands
| | - Mylène P Jansen
- Department of Rheumatology & Clinical Immunology, UMC Utrecht, Utrecht, Netherlands
| | - Pim A de Jong
- Department of Radiology, UMC Utrecht, Utrecht, Netherlands
| | - Wouter Foppen
- Department of Radiology, UMC Utrecht, Utrecht, Netherlands
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Sbidian E, Chaimani A, Guelimi R, Garcia-Doval I, Hua C, Hughes C, Naldi L, Kinberger M, Afach S, Le Cleach L. Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis. Cochrane Database Syst Rev 2023; 7:CD011535. [PMID: 37436070 PMCID: PMC10337265 DOI: 10.1002/14651858.cd011535.pub6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
BACKGROUND Psoriasis is an immune-mediated disease with either skin or joints manifestations, or both, and it has a major impact on quality of life. Although there is currently no cure for psoriasis, various treatment strategies allow sustained control of disease signs and symptoms. The relative benefit of these treatments remains unclear due to the limited number of trials comparing them directly head-to-head, which is why we chose to conduct a network meta-analysis. OBJECTIVES To compare the benefits and harms of non-biological systemic agents, small molecules, and biologics for people with moderate-to-severe psoriasis using a network meta-analysis, and to provide a ranking of these treatments according to their benefits and harms. SEARCH METHODS For this update of the living systematic review, we updated our searches of the following databases monthly to October 2022: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase. SELECTION CRITERIA Randomised controlled trials (RCTs) of systemic treatments in adults over 18 years with moderate-to-severe plaque psoriasis, at any stage of treatment, compared to placebo or another active agent. The primary outcomes were: proportion of participants who achieved clear or almost clear skin, that is, at least Psoriasis Area and Severity Index (PASI) 90; proportion of participants with serious adverse events (SAEs) at induction phase (8 to 24 weeks after randomisation). DATA COLLECTION AND ANALYSIS We conducted duplicate study selection, data extraction, risk of bias assessment, and analyses. We synthesised data using pairwise and network meta-analysis (NMA) to compare treatments and rank them according to effectiveness (PASI 90 score) and acceptability (inverse of SAEs). We assessed the certainty of NMA evidence for the two primary outcomes and all comparisons using CINeMA, as very low, low, moderate, or high. We contacted study authors when data were unclear or missing. We used the surface under the cumulative ranking curve (SUCRA) to infer treatment hierarchy, from 0% (worst for effectiveness or safety) to 100% (best for effectiveness or safety). MAIN RESULTS This update includes an additional 12 studies, taking the total number of included studies to 179, and randomised participants to 62,339, 67.1% men, mainly recruited from hospitals. Average age was 44.6 years, mean PASI score at baseline was 20.4 (range: 9.5 to 39). Most studies were placebo-controlled (56%). We assessed a total of 20 treatments. Most (152) trials were multicentric (two to 231 centres). One-third of the studies (65/179) had high risk of bias, 24 unclear risk, and most (90) low risk. Most studies (138/179) declared funding by a pharmaceutical company, and 24 studies did not report a funding source. Network meta-analysis at class level showed that all interventions (non-biological systemic agents, small molecules, and biological treatments) showed a higher proportion of patients reaching PASI 90 than placebo. Anti-IL17 treatment showed a higher proportion of patients reaching PASI 90 compared to all the interventions. Biologic treatments anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha showed a higher proportion of patients reaching PASI 90 than the non-biological systemic agents. For reaching PASI 90, the most effective drugs when compared to placebo were (SUCRA rank order, all high-certainty evidence): infliximab (risk ratio (RR) 49.16, 95% CI 20.49 to 117.95), bimekizumab (RR 27.86, 95% CI 23.56 to 32.94), ixekizumab (RR 27.35, 95% CI 23.15 to 32.29), risankizumab (RR 26.16, 95% CI 22.03 to 31.07). Clinical effectiveness of these drugs was similar when compared against each other. Bimekizumab and ixekizumab were significantly more likely to reach PASI 90 than secukinumab. Bimekizumab, ixekizumab, and risankizumab were significantly more likely to reach PASI 90 than brodalumab and guselkumab. Infliximab, anti-IL17 drugs (bimekizumab, ixekizumab, secukinumab, and brodalumab), and anti-IL23 drugs except tildrakizumab were significantly more likely to reach PASI 90 than ustekinumab, three anti-TNF alpha agents, and deucravacitinib. Ustekinumab was superior to certolizumab. Adalimumab, tildrakizumab, and ustekinumab were superior to etanercept. No significant difference was shown between apremilast and two non-biological drugs: ciclosporin and methotrexate. We found no significant difference between any of the interventions and the placebo for the risk of SAEs. The risk of SAEs was significantly lower for participants on methotrexate compared with most of the interventions. Nevertheless, the SAE analyses were based on a very low number of events with very low- to moderate-certainty evidence for all the comparisons. The findings therefore have to be viewed with caution. For other efficacy outcomes (PASI 75 and Physician Global Assessment (PGA) 0/1), the results were similar to the results for PASI 90. Information on quality of life was often poorly reported and was absent for several of the interventions. AUTHORS' CONCLUSIONS Our review shows that, compared to placebo, the biologics infliximab, bimekizumab, ixekizumab, and risankizumab were the most effective treatments for achieving PASI 90 in people with moderate-to-severe psoriasis on the basis of high-certainty evidence. This NMA evidence is limited to induction therapy (outcomes measured from 8 to 24 weeks after randomisation), and is not sufficient for evaluating longer-term outcomes in this chronic disease. Moreover, we found low numbers of studies for some of the interventions, and the young age (mean 44.6 years) and high level of disease severity (PASI 20.4 at baseline) may not be typical of patients seen in daily clinical practice. We found no significant difference in the assessed interventions and placebo in terms of SAEs, and the safety evidence for most interventions was very low to moderate quality. More randomised trials directly comparing active agents are needed, and these should include systematic subgroup analyses (sex, age, ethnicity, comorbidities, psoriatic arthritis). To provide long-term information on the safety of treatments included in this review, an evaluation of non-randomised studies is needed. Editorial note: This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Emilie Sbidian
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Clinical Investigation Centre, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Anna Chaimani
- Université de Paris, Centre of Research in Epidemiology and Statistics (CRESS), INSERM, F-75004, Paris, France
- Cochrane France, Paris, France
| | - Robin Guelimi
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Ignacio Garcia-Doval
- Department of Dermatology, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Camille Hua
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Carolyn Hughes
- c/o Cochrane Skin Group, The University of Nottingham, Nottingham, UK
| | - Luigi Naldi
- Centro Studi GISED (Italian Group for Epidemiologic Research in Dermatology) - FROM (Research Foundation of Ospedale Maggiore Bergamo), Padiglione Mazzoleni - Presidio Ospedaliero Matteo Rota, Bergamo, Italy
| | - Maria Kinberger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sivem Afach
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Laurence Le Cleach
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
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Yeh CB, Yeh LT, Yang SF, Wang BY, Wang YH, Chan CH. Association between psoriasis and peripheral artery occlusive disease: a population-based retrospective cohort study. Front Cardiovasc Med 2023; 10:1136540. [PMID: 37378400 PMCID: PMC10291070 DOI: 10.3389/fcvm.2023.1136540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
Introduction Psoriasis (PSO) is a chronic skin condition that affects a variety of disorders, especially the cardiovascular system. This study investigated the association between PSO and peripheral arterial disease (PAOD). Methods A retrospective cohort study design was carried out between 2000 and 2018. The exposure subject was a newly diagnosed PSO. The diagnosis of PSO was never elaborated as a comparison subject. Balanced heterogeneity of the two groups was used by propensity score matching. The cumulative incidence of PAOD between the two groups was performed using Kaplan-Meier analysis. The Cox proportional hazard model was used to measure the risk of PAOD risk hazard ratio. Results After matching the 1: 1 propensity score, 15,696 subjects with PSO and the same number of subjects without the diagnosis of PSO were recruited. The PSO subject had a higher risk of PAOD than the non-PSO subject (adjusted HR = 1.25; 95% CI = 1.03-1.50). In the 40-64-year-old subgroup, the subject of PSO exhibited an increased risk of PAOD than the subject without PSO. Conclusion Psoriasis is associated with an increased risk of peripheral arterial disease and curative care is necessary to reduce the risk of PAOD..
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Affiliation(s)
- Chao-Bin Yeh
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Liang-Tsai Yeh
- Department of Anesthesiology, Changhua Christian Hospital, Changhua, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Bo-Yuan Wang
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Yu-Hsun Wang
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chi-Ho Chan
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
- Department of Microbiology and Immunology, Chung Shan Medical University, Taichung, Taiwan
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Rocha VZ, Rached FH, Miname MH. Insights into the Role of Inflammation in the Management of Atherosclerosis. J Inflamm Res 2023; 16:2223-2239. [PMID: 37250107 PMCID: PMC10225146 DOI: 10.2147/jir.s276982] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 03/28/2023] [Indexed: 05/31/2023] Open
Abstract
Atherosclerosis is the biological basis of ischemic heart disease and ischemic stroke, the leading causes of death in the world. After decades of studies, the understanding of atherosclerosis has evolved dramatically, and inflammation has been recognized as one of the most relevant pillars in all phases of atherosclerotic disease. Nevertheless, only recently, the trial CANTOS, and subsequent outcome studies with colchicine, finally provided proof-of-concept evidence that anti-inflammatory therapies were able to reduce cardiovascular events with no influence on lipid levels. These landmark studies inaugurated an era of clinical and pre-clinical studies of immunomodulatory strategies focused on reduction of cardiovascular risk. Although there are promising results in the field, selection of the most appropriate immunomodulatory therapy and identification of patients who could benefit the most, are still enormous challenges. Further research is imperative before we can finally advance towards regular use of anti-inflammatory agents to reduce atherosclerotic events in our clinical practice.
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Affiliation(s)
- Viviane Zorzanelli Rocha
- Cardiopneumology Department at the Heart Institute (InCor), University of São Paulo Medical School Hospital (FMUSP), Sao Paulo, Brazil
- Fleury Medicina e Saúde, Grupo Fleury, São Paulo, SP, Brazil
| | - Fabiana Hanna Rached
- Cardiopneumology Department at the Heart Institute (InCor), University of São Paulo Medical School Hospital (FMUSP), Sao Paulo, Brazil
- Department of Cardiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Marcio Hiroshi Miname
- Cardiopneumology Department at the Heart Institute (InCor), University of São Paulo Medical School Hospital (FMUSP), Sao Paulo, Brazil
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Kommoss KS, Enk A, Heikenwälder M, Waisman A, Karbach S, Wild J. Cardiovascular comorbidity in psoriasis - psoriatic inflammation is more than just skin deep. J Dtsch Dermatol Ges 2023. [PMID: 37186503 DOI: 10.1111/ddg.15071] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 02/24/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND There is a growing understanding of inflammation in psoriasis beyond its dermatological manifestation, towards systemic inflammation. Management of possible comorbidities encompassing psychological, metabolic and cardiovascular disease is recommended in national and international dermatology guidelines for treatment of psoriasis patients. Vice versa, psoriasis is being recognized as a new risk factor for cardiovascular inflammation within the cardiological community. METHODS A review of the literature was conducted. Key points regarding epidemiological, mechanistic and management aspects were summarized and put into context for physicians treating psoriasis patients. RESULTS Efforts are currently being made to better understand the mechanistic underpinnings of systemic inflammation within psoriatic inflammation. Studies looking to "hit two birds with one stone" regarding specifically cardiovascular comorbidities of psoriasis patients using established systemic dermatological therapies have so far provided heterogeneous data. The diagnosis of psoriasis entails preventive and therapeutic consequences regarding concomitant diseases for the individual patient. CONCLUSIONS The knowledge of comorbidities in psoriasis calls for pronounced interdisciplinary care of psoriasis patients, to which this article highlights efforts regarding vascular inflammation and cardiovascular disease.
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Affiliation(s)
- Katharina S Kommoss
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
- Division of Chronic Inflammation and Cancer, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Alexander Enk
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Mathias Heikenwälder
- Division of Chronic Inflammation and Cancer, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Ari Waisman
- Institute for Molecular Medicine, University Medical Center of Mainz, Mainz, Germany
- Research Center for Immunotherapy, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Susanne Karbach
- Center for Cardiology - Cardiology I, University Medical Center Mainz, Mainz, Germany
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK) - Partner site RheinMain, Germany
| | - Johannes Wild
- Center for Cardiology - Cardiology I, University Medical Center Mainz, Mainz, Germany
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK) - Partner site RheinMain, Germany
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9
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Senders ML, Calcagno C, Tawakol A, Nahrendorf M, Mulder WJM, Fayad ZA. PET/MR imaging of inflammation in atherosclerosis. Nat Biomed Eng 2023; 7:202-220. [PMID: 36522465 DOI: 10.1038/s41551-022-00970-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 10/25/2022] [Indexed: 12/23/2022]
Abstract
Myocardial infarction, stroke, mental disorders, neurodegenerative processes, autoimmune diseases, cancer and the human immunodeficiency virus impact the haematopoietic system, which through immunity and inflammation may aggravate pre-existing atherosclerosis. The interplay between the haematopoietic system and its modulation of atherosclerosis has been studied by imaging the cardiovascular system and the activation of haematopoietic organs via scanners integrating positron emission tomography and resonance imaging (PET/MRI). In this Perspective, we review the applicability of integrated whole-body PET/MRI for the study of immune-mediated phenomena associated with haematopoietic activity and cardiovascular disease, and discuss the translational opportunities and challenges of the technology.
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Affiliation(s)
- Max L Senders
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Claudia Calcagno
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ahmed Tawakol
- Cardiology Division and Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthias Nahrendorf
- Center for Systems Biology and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Willem J M Mulder
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
- Department of Internal Medicine, Radboud Institute of Molecular Life Sciences (RIMLS) and Radboud Center for Infectious Diseases (RCI), Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands.
- Laboratory of Chemical Biology, Department of Biochemical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands.
| | - Zahi A Fayad
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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10
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Huang S, Bai Y. Knowledge Mapping and Research Hotspots of Comorbidities in Psoriasis: A Bibliometric Analysis from 2004 to 2022. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020393. [PMID: 36837593 PMCID: PMC9961708 DOI: 10.3390/medicina59020393] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/02/2023] [Accepted: 02/14/2023] [Indexed: 02/19/2023]
Abstract
Background and Objectives: Psoriasis is a chronic inflammatory disease whose impact on health is not only limited to the skin, but is also associated with multiple comorbidities. Early screening for comorbidities along with appropriate treatment plans can provide a positive prognosis for patients. This study aimed to summarize the knowledge structure in the field of psoriasis comorbidities and further explore its research hotspots and trends through bibliometrics. Materials and Methods: A search was conducted in the core collection of the Web of Science for literature on comorbidities of psoriasis from 2004 to 2022. VOSviewer and CiteSpace software were used for collaborative network analysis, co-citation analysis of references, and keyword co-occurrence analysis on these publications. Results: A total of 1803 papers written by 6741 authors from 81 countries was included. The publications have shown a progressive increase since 2004. The United States and Europe were at the forefront of this field. The most prolific institution was the University of California, and the most productive author was A. Armstrong. Research has focused on "psoriatic arthritis", "metabolic syndrome", "cardiovascular disease", "psychosomatic disease", "inflammatory bowel disease", "prevalence", "quality of life", and "risk factor" in the past 18 years. Keywords such as "biologics" and "systemic inflammation", have been widely used recently, suggesting current research hotspots and trends. Conclusions: Over the past 18 years, tremendous progress has been made in research on psoriasis comorbidity. However, collaborations among countries, institutions, and investigators are inadequate, and the study of the mechanisms of interaction between psoriasis and comorbidities and management of comorbidities is insufficient. The treatment of comorbidities with biologic agents, screening of comorbidities, and multidisciplinary co-management are predicted to be the focus of future research.
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Affiliation(s)
- Shan Huang
- Graduate School, Beijing University of Chinese Medicine, Beijing 100105, China
| | - Yanping Bai
- Department of Dermatology, China-Japan Friendship Hospital, Beijing 100029, China
- Correspondence: ; Tel.: +86-13910758509
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11
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Tsiogka A, Gregoriou S, Stratigos A, Soulaidopoulos S, Rompoti N, Panagakis P, Papoutsaki M, Kostakis P, Kontochristopoulos G, Tsioufis K, Campanati A, Offidani A, Vlachopoulos C, Rigopoulos D. The Impact of Treatment with IL-17/IL-23 Inhibitors on Subclinical Atherosclerosis in Patients with Plaque Psoriasis and/or Psoriatic Arthritis: A Systematic Review. Biomedicines 2023; 11:biomedicines11020318. [PMID: 36830855 PMCID: PMC9953668 DOI: 10.3390/biomedicines11020318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/16/2023] [Accepted: 01/22/2023] [Indexed: 01/24/2023] Open
Abstract
Accumulating evidence considers psoriasis a systemic inflammatory disorder that is associated with comorbidities such as psoriatic arthritis, cardiovascular disease, and metabolic syndrome. Although the precise pathogenetic links between psoriasis and atherosclerosis warrants further investigation, it is believed that chronic systemic inflammation along with the T helper (Th)-1 and Th17 polarization are associated with endothelial dysfunction and subsequent acceleration of atherosclerosis. Considering the above, several studies have evaluated if optimal control of the inflammation in psoriasis by inhibiting interleukins targeting the Interleukin (IL)-23/Th17 axis could subsequently reduce the atherosclerotic process during anti-psoriatic treatment by using a variety of surrogate markers of subclinical atherosclerosis. This systematic review summarizes current knowledge on the pathogenetic mechanisms and diagnostic evaluation of atherosclerosis in the context of psoriasis and provides a systematic review of the literature on the impact of treatment with biologics targeting the IL-23/Th17 axis on subclinical atherosclerosis in patients with plaque psoriasis and/or psoriatic arthritis.
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Affiliation(s)
- Aikaterini Tsiogka
- First Department of Dermatology-Venereology, Faculty of Medicine, “A. Sygros” Hospital for Skin and Venereal Diseases, National and Kapodistrian University of Athens, 16121 Athens, Greece
- Correspondence: ; Tel.: +30-210-9337315; Fax: +30-2107211122
| | - Stamatios Gregoriou
- First Department of Dermatology-Venereology, Faculty of Medicine, “A. Sygros” Hospital for Skin and Venereal Diseases, National and Kapodistrian University of Athens, 16121 Athens, Greece
| | - Alexander Stratigos
- First Department of Dermatology-Venereology, Faculty of Medicine, “A. Sygros” Hospital for Skin and Venereal Diseases, National and Kapodistrian University of Athens, 16121 Athens, Greece
| | - Stergios Soulaidopoulos
- First Cardiology Department, Hippokration General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Natalia Rompoti
- First Department of Dermatology-Venereology, Faculty of Medicine, “A. Sygros” Hospital for Skin and Venereal Diseases, National and Kapodistrian University of Athens, 16121 Athens, Greece
| | - Pantelis Panagakis
- First Department of Dermatology-Venereology, Faculty of Medicine, “A. Sygros” Hospital for Skin and Venereal Diseases, National and Kapodistrian University of Athens, 16121 Athens, Greece
| | - Marina Papoutsaki
- First Department of Dermatology-Venereology, Faculty of Medicine, “A. Sygros” Hospital for Skin and Venereal Diseases, National and Kapodistrian University of Athens, 16121 Athens, Greece
| | - Panagiotis Kostakis
- First Department of Dermatology-Venereology, Faculty of Medicine, “A. Sygros” Hospital for Skin and Venereal Diseases, National and Kapodistrian University of Athens, 16121 Athens, Greece
| | - George Kontochristopoulos
- First Department of Dermatology-Venereology, Faculty of Medicine, “A. Sygros” Hospital for Skin and Venereal Diseases, National and Kapodistrian University of Athens, 16121 Athens, Greece
| | - Konstantinos Tsioufis
- First Cardiology Department, Hippokration General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Anna Campanati
- Department of Clinical and Molecular Sciences, Dermatology Clinic, Polytechnic Marche University, 60121 Ancona, Italy
| | - Annamaria Offidani
- Department of Clinical and Molecular Sciences, Dermatology Clinic, Polytechnic Marche University, 60121 Ancona, Italy
| | - Charalambos Vlachopoulos
- First Cardiology Department, Hippokration General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Dimitrios Rigopoulos
- First Department of Dermatology-Venereology, Faculty of Medicine, “A. Sygros” Hospital for Skin and Venereal Diseases, National and Kapodistrian University of Athens, 16121 Athens, Greece
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12
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Gelfand JM, Shin DB, Armstrong AW, Tyring SK, Blauvelt A, Gottlieb S, Lockshin BN, Kalb RE, Fitzsimmons R, Rodante J, Parel P, Manyak GA, Mendelsohn L, Noe MH, Papadopoulos M, Syed MN, Werner TJ, Wan J, Playford MP, Alavi A, Mehta NN. Association of Apremilast With Vascular Inflammation and Cardiometabolic Function in Patients With Psoriasis: The VIP-A Phase 4, Open-label, Nonrandomized Clinical Trial. JAMA Dermatol 2022; 158:1394-1403. [PMID: 36129688 PMCID: PMC9494263 DOI: 10.1001/jamadermatol.2022.3862] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/24/2022] [Indexed: 01/13/2023]
Abstract
Importance Psoriasis is an inflammatory condition associated with metabolic and cardiovascular disease. Apremilast, a phosphodiesterase 4 inhibitor, is commonly used for psoriasis and can cause weight loss. Objective To determine the association between apremilast and aortic vascular inflammation as assessed by 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT), cardiometabolic markers (primary outcomes at week 16), and abdominal fat composition. Design, Setting, and Participants A single-arm, open-label, interventional, nonrandomized clinical trial in which the imaging and laboratory outcomes were measured by an investigator who was blinded to time was conducted between April 11, 2017, and August 17, 2021, at 7 dermatology sites in the United States. A total of 101 patients with moderate to severe psoriasis were screened, 70 enrolled, 60 completed week 16, and 39 completed week 52. Intervention Apremilast, 30 mg, twice daily. Main Outcomes and Measures Aortic vascular inflammation (measured by FDG-PET/CT), 68 cardiometabolic biomarkers, and abdominal fat composition (measured by CT) at week 16 and week 52 compared with baseline. Results The mean (SD) age of the 70 patients was 47.5 (14.6) years, 54 were male (77.1%), 4 were Black (5.7%), and 58 were White (82.9%). There was no change in aortic vascular inflammation at week 16 (target to background ratio, -0.02; 95% CI, -0.08 to 0.05; P = .61) or week 52 (target to background ratio, -0.07; 95% CI, -0.15 to 0.01; P = .09) compared with baseline. At week 16, potentially beneficial decreases in interleukin 1b, valine, leucine, isoleucine, fetuin A, and branched-chain amino acids were observed. At week 52 compared with baseline, potentially beneficial decreases in ferritin, β-hydroxybutyrate, acetone, and ketone bodies, with an increase in apolipoprotein A-1, were observed, but there was a reduction in cholesterol efflux. There was an approximately 5% to 6% reduction in subcutaneous and visceral adiposity at week 16 that was maintained at week 52. Conclusions and Relevance The findings of this nonrandomized clinical trial suggest that apremilast has a neutral association with aortic vascular inflammation, variable but generally beneficial associations with a subset of cardiometabolic biomarkers, and associations with reductions in visceral and subcutaneous fat, indicating that the drug may have an overall benefit for patients with cardiometabolic disease and psoriasis. Trial Registration ClinicalTrials.gov Identifier: NCT03082729.
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Affiliation(s)
- Joel M. Gelfand
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Daniel B. Shin
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - April W. Armstrong
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles
| | - Stephen K. Tyring
- Department of Dermatology, University of Texas Health Science Center at Houston, Houston
| | | | - Scott Gottlieb
- Dermatology and Skin Surgery Center, Exton, Pennsylvania
| | | | - Robert E. Kalb
- SUNY at Buffalo School of Medicine and Biomedical Sciences, Department of Dermatology, Buffalo Medical Group, Buffalo, New York
| | - Robert Fitzsimmons
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Justin Rodante
- Section of Inflammation and Cardiometabolic Diseases, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Philip Parel
- Section of Inflammation and Cardiometabolic Diseases, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Grigory A. Manyak
- Section of Inflammation and Cardiometabolic Diseases, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Laurel Mendelsohn
- Section of Inflammation and Cardiometabolic Diseases, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Megan H. Noe
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maryte Papadopoulos
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Maha N. Syed
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Thomas J. Werner
- Department of Radiology (Nuclear Medicine), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Joy Wan
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Martin P. Playford
- Section of Inflammation and Cardiometabolic Diseases, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Abass Alavi
- Department of Radiology (Nuclear Medicine), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nehal N. Mehta
- Section of Inflammation and Cardiometabolic Diseases, National Heart, Lung, and Blood Institute, Bethesda, Maryland
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13
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Felix PAO, Sampaio AL, Silva BL, Viana ALP. Early intervention in psoriasis: Where do we go from here? Front Med (Lausanne) 2022; 9:1027347. [PMID: 36530901 PMCID: PMC9751903 DOI: 10.3389/fmed.2022.1027347] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/16/2022] [Indexed: 04/16/2024] Open
Abstract
Patients with psoriasis often have comorbidities and are at increased risk of developing several complications compared with the general population. Knowledge on the role of immune mediators and systemic inflammation in psoriasis has led to the hypothesis that early intervention with systemic therapy has the potential to modify the course of the disease and reduce the risk of long-term adverse outcomes. In this article, we address some potential issues that need to be considered before early intervention can be implemented routinely. The first is determining what constitutes "early" intervention for psoriasis. A second point is whether the intervention should be considered for patients with early disease or for selected subsets based on risk stratification. A third important consideration is defining success for early intervention. Finally, adoption of early and effective intervention should be based on high-level evidence. Ideally, randomized trials would be the best strategy to compare early vs. late systemic treatment in patients with psoriasis, probably using the frequency of long-term outcomes as primary endpoint, with cutaneous and pharmacoeconomic outcomes assessed secondarily.
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Affiliation(s)
| | - Ana Luisa Sampaio
- Dermatology Department, Hospital Universitário Pedro Ernesto, Rio de Janeiro State University, Rio de Janeiro, Brazil
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14
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Looking beyond the Skin: Pathophysiology of Cardiovascular Comorbidity in Psoriasis and the Protective Role of Biologics. Pharmaceuticals (Basel) 2022; 15:ph15091101. [PMID: 36145322 PMCID: PMC9503011 DOI: 10.3390/ph15091101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 08/23/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
Psoriasis is a chronic systemic inflammatory disease associated with a higher incidence of cardiovascular disease, especially in patients with moderate to severe psoriasis. It has been estimated that severe psoriasis confers a 25% increase in relative risk of cardiovascular disease, regardless of traditional risk factors. Although the underlying pathogenic mechanisms relating psoriasis to increased cardiovascular risk are not clear, atherosclerosis is emerging as a possible link between skin and vascular affection. The hypothesis that the inflammatory cascade activated in psoriasis contributes to the atherosclerotic process provides the underlying basis to suggest that an anti-inflammatory therapy that improved atherosclerosis would also reduce the risk of MACEs. In this sense, the introduction of biological drugs which specifically target cytokines implicated in the inflammatory cascade have increased the expectations of control over the cardiovascular comorbidity present in psoriasis patients, however, their role in vascular damage processes remains controversial. The aim of this paper is to review the mechanistic link between psoriasis and cardiovascular disease development, as well as analyzing which of the biological treatments could also reduce the cardiovascular risk in these patients, fueling a growing debate on the modification of the general algorithm of treatment.
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15
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Daugaard C, Iversen L, Hjuler KF. Comorbidity in Adult Psoriasis: Considerations for the Clinician. PSORIASIS (AUCKLAND, N.Z.) 2022; 12:139-150. [PMID: 35712227 PMCID: PMC9196664 DOI: 10.2147/ptt.s328572] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/24/2022] [Indexed: 01/19/2023]
Abstract
Psoriasis is associated with several comorbidities ranging from cardiovascular comorbidity and mental disorders to other immune mediated inflammatory diseases. However, most of these co-morbidities are often overlooked or diagnosed late. Furthermore, evidence suggests that comorbidities are undertreated. Here, we provide an overview of comorbidities in psoriasis and present a simple rundown of considerations of relevance to the clinician. We hope that this review may raise clinicians' awareness of comorbidities in psoriasis and provide simple guidance regarding screening tools and treatment decisions in psoriasis with comorbidities.
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Affiliation(s)
- Christine Daugaard
- Department of Dermatology and Venereology, Aarhus University Hospital, Aarhus, Denmark
| | - Lars Iversen
- Department of Dermatology and Venereology, Aarhus University Hospital, Aarhus, Denmark
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16
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Sbidian E, Chaimani A, Garcia-Doval I, Doney L, Dressler C, Hua C, Hughes C, Naldi L, Afach S, Le Cleach L. Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis. Cochrane Database Syst Rev 2022; 5:CD011535. [PMID: 35603936 PMCID: PMC9125768 DOI: 10.1002/14651858.cd011535.pub5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Psoriasis is an immune-mediated disease with either skin or joints manifestations, or both, and it has a major impact on quality of life. Although there is currently no cure for psoriasis, various treatment strategies allow sustained control of disease signs and symptoms. The relative benefit of these treatments remains unclear due to the limited number of trials comparing them directly head-to-head, which is why we chose to conduct a network meta-analysis. OBJECTIVES To compare the efficacy and safety of non-biological systemic agents, small molecules, and biologics for people with moderate-to-severe psoriasis using a network meta-analysis, and to provide a ranking of these treatments according to their efficacy and safety. SEARCH METHODS For this update of the living systematic review, we updated our searches of the following databases monthly to October 2021: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase. SELECTION CRITERIA Randomised controlled trials (RCTs) of systemic treatments in adults over 18 years with moderate-to-severe plaque psoriasis, at any stage of treatment, compared to placebo or another active agent. The primary outcomes were: proportion of participants who achieved clear or almost clear skin, that is, at least Psoriasis Area and Severity Index (PASI) 90; proportion of participants with serious adverse events (SAEs) at induction phase (8 to 24 weeks after randomisation). DATA COLLECTION AND ANALYSIS We conducted duplicate study selection, data extraction, risk of bias assessment and analyses. We synthesised data using pairwise and network meta-analysis (NMA) to compare treatments and rank them according to effectiveness (PASI 90 score) and acceptability (inverse of SAEs). We assessed the certainty of NMA evidence for the two primary outcomes and all comparisons using CINeMA, as very low, low, moderate, or high. We contacted study authors when data were unclear or missing. We used the surface under the cumulative ranking curve (SUCRA) to infer treatment hierarchy, from 0% (worst for effectiveness or safety) to 100% (best for effectiveness or safety). MAIN RESULTS This update includes an additional 19 studies, taking the total number of included studies to 167, and randomised participants to 58,912, 67.2% men, mainly recruited from hospitals. Average age was 44.5 years, mean PASI score at baseline was 20.4 (range: 9.5 to 39). Most studies were placebo-controlled (57%). We assessed a total of 20 treatments. Most (140) trials were multicentric (two to 231 centres). One-third of the studies (57/167) had high risk of bias; 23 unclear risk, and most (87) low risk. Most studies (127/167) declared funding by a pharmaceutical company, and 24 studies did not report a funding source. Network meta-analysis at class level showed that all interventions (non-biological systemic agents, small molecules, and biological treatments) showed a higher proportion of patients reaching PASI 90 than placebo. Anti-IL17 treatment showed a higher proportion of patients reaching PASI 90 compared to all the interventions, except anti-IL23. Biologic treatments anti-IL17, anti-IL12/23, anti-IL23 and anti-TNF alpha showed a higher proportion of patients reaching PASI 90 than the non-biological systemic agents. For reaching PASI 90, the most effective drugs when compared to placebo were (SUCRA rank order, all high-certainty evidence): infliximab (risk ratio (RR) 50.19, 95% CI 20.92 to 120.45), bimekizumab (RR 30.27, 95% CI 25.45 to 36.01), ixekizumab (RR 30.19, 95% CI 25.38 to 35.93), risankizumab (RR 28.75, 95% CI 24.03 to 34.39). Clinical effectiveness of these drugs was similar when compared against each other. Bimekizumab, ixekizumab and risankizumab showed a higher proportion of patients reaching PASI 90 than other anti-IL17 drugs (secukinumab and brodalumab) and guselkumab. Infliximab, anti-IL17 drugs (bimekizumab, ixekizumab, secukinumab and brodalumab) and anti-IL23 drugs (risankizumab and guselkumab) except tildrakizumab showed a higher proportion of patients reaching PASI 90 than ustekinumab and three anti-TNF alpha agents (adalimumab, certolizumab and etanercept). Ustekinumab was superior to certolizumab; adalimumab and ustekinumab were superior to etanercept. No significant difference was shown between apremilast and two non-biological drugs: ciclosporin and methotrexate. We found no significant difference between any of the interventions and the placebo for the risk of SAEs. The risk of SAEs was significantly lower for participants on methotrexate compared with most of the interventions. Nevertheless, the SAE analyses were based on a very low number of events with low- to moderate-certainty for all the comparisons (except methotrexate versus placebo, which was high-certainty). The findings therefore have to be viewed with caution. For other efficacy outcomes (PASI 75 and Physician Global Assessment (PGA) 0/1), the results were similar to the results for PASI 90. Information on quality of life was often poorly reported and was absent for several of the interventions. AUTHORS' CONCLUSIONS Our review shows that, compared to placebo, the biologics infliximab, bimekizumab, ixekizumab, and risankizumab were the most effective treatments for achieving PASI 90 in people with moderate-to-severe psoriasis on the basis of high-certainty evidence. This NMA evidence is limited to induction therapy (outcomes measured from 8 to 24 weeks after randomisation), and is not sufficient for evaluating longer-term outcomes in this chronic disease. Moreover, we found low numbers of studies for some of the interventions, and the young age (mean 44.5 years) and high level of disease severity (PASI 20.4 at baseline) may not be typical of patients seen in daily clinical practice. We found no significant difference in the assessed interventions and placebo in terms of SAEs, and the safety evidence for most interventions was low to moderate quality. More randomised trials directly comparing active agents are needed, and these should include systematic subgroup analyses (sex, age, ethnicity, comorbidities, psoriatic arthritis). To provide long-term information on the safety of treatments included in this review, an evaluation of non-randomised studies and postmarketing reports from regulatory agencies is needed. Editorial note: This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Emilie Sbidian
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Clinical Investigation Centre, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Anna Chaimani
- Université de Paris, Centre of Research in Epidemiology and Statistics (CRESS), INSERM, F-75004, Paris, France
- Cochrane France, Paris, France
| | - Ignacio Garcia-Doval
- Department of Dermatology, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Liz Doney
- Cochrane Skin, Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Corinna Dressler
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Camille Hua
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Carolyn Hughes
- c/o Cochrane Skin Group, The University of Nottingham, Nottingham, UK
| | - Luigi Naldi
- Centro Studi GISED (Italian Group for Epidemiologic Research in Dermatology) - FROM (Research Foundation of Ospedale Maggiore Bergamo), Padiglione Mazzoleni - Presidio Ospedaliero Matteo Rota, Bergamo, Italy
| | - Sivem Afach
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Laurence Le Cleach
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
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17
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Wu JJ, Kavanaugh A, Lebwohl MG, Gniadecki R, Merola JF. Psoriasis and metabolic syndrome: implications for the management and treatment of psoriasis. J Eur Acad Dermatol Venereol 2022; 36:797-806. [PMID: 35238067 PMCID: PMC9313585 DOI: 10.1111/jdv.18044] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 02/11/2022] [Indexed: 11/28/2022]
Abstract
Psoriasis is a chronic systemic inflammatory disorder associated with several comorbidities in addition to the characteristic skin lesions. Metabolic syndrome (MetS) is the most frequent comorbidity in psoriasis and a risk factor for cardiovascular disease, a major cause of death among patients with psoriasis. Although the exact causal relationship between these two disorders is not fully established, the underlying pathophysiology linking psoriasis and MetS seems to involve overlapping genetic predispositions and inflammatory pathways. Dysregulation of the IL‐23/Th‐17 immune signalling pathway is central to both pathologies and may be key to promoting susceptibility to metabolic and cardiovascular diseases in individuals with and without psoriasis. Thus, biological treatments for psoriasis that interrupt these signals could both reduce the psoriatic inflammatory burden and also lessen the risk of developing atherosclerosis and cardiometabolic diseases. In support of this hypothesis, improvement of skin lesions was associated with improvement in vascular inflammation in recent imaging studies, demonstrating that the beneficial effect of biological agents goes beyond the skin and could help to prevent cardiovascular disease. This review will summarize current knowledge on underlying inflammatory mechanisms shared between psoriasis and MetS and discuss the most recent clinical evidence for the potential for psoriasis treatment to reduce cardiovascular risk.
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Affiliation(s)
- J J Wu
- Dermatology Research and Education Foundation, Irvine, CA, USA
| | - A Kavanaugh
- University of California San Diego, San Diego, CA, USA
| | - M G Lebwohl
- Department of Dermatology, Icahn School of Medicine at Mt. Sinai, New York, NY, USA
| | - R Gniadecki
- Division of Dermatology, University of Alberta, Edmonton, AB, Canada
| | - J F Merola
- Department of Medicine, Division of Rheumatology and Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Kleinrensink NJ, Pouw JN, Leijten EFA, Takx RAP, Welsing PMJ, de Keizer B, de Jong PA, Foppen W. Increased vascular inflammation on PET/CT in psoriasis and the effects of biologic treatment: systematic review and meta-analyses. Clin Transl Imaging 2022. [DOI: 10.1007/s40336-021-00476-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Wang X, Kaiser H, Kvist-Hansen A, McCauley BD, Skov L, Hansen PR, Becker C. IL-17 Pathway Members as Potential Biomarkers of Effective Systemic Treatment and Cardiovascular Disease in Patients with Moderate-to-Severe Psoriasis. Int J Mol Sci 2022; 23:ijms23010555. [PMID: 35008981 PMCID: PMC8745093 DOI: 10.3390/ijms23010555] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 12/30/2021] [Accepted: 12/30/2021] [Indexed: 02/01/2023] Open
Abstract
Psoriasis is a chronic inflammatory condition associated with atherosclerotic cardiovascular disease (CVD). Systemic anti-psoriatic treatments mainly include methotrexate and biological therapies targeting TNF, IL-12/23 and IL-17A. We profiled plasma proteins from patients with moderate-to-severe psoriasis to explore potential biomarkers of effective systemic treatment and their relationship to CVD. We found that systemically well-treated patients (PASI < 3.0, n = 36) had lower circulating levels of IL-17 pathway proteins compared to untreated patients (PASI > 10, n = 23). Notably, IL-17C and PI3 were decreased with all four examined systemic treatment types. Furthermore, in patients without CVD, we observed strong correlations among IL-17C/PI3/PASI (r ≥ 0.82, p ≤ 1.5 × 10−12) pairs or between IL-17A/PASI (r = 0.72, p = 9.3 × 10−8). In patients with CVD, the IL-17A/PASI correlation was abolished (r = 0.2, p = 0.24) and the other correlations were decreased, e.g., IL-17C/PI3 (r = 0.61, p = 4.5 × 10−5). Patients with moderate-to-severe psoriasis and CVD had lower levels of IL-17A compared to those without CVD (normalized protein expression [NPX] 2.02 vs. 2.55, p = 0.013), and lower IL-17A levels (NPX < 2.3) were associated with higher incidence of CVD (OR = 24.5, p = 0.0028, 95% CI 2.1–1425.1). As a result, in patients with moderate-to-severe psoriasis, we propose circulating IL-17C and PI3 as potential biomarkers of effective systemic anti-psoriatic treatment, and IL-17A as potential marker of CVD.
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Affiliation(s)
- Xing Wang
- Department of Medicine, Division of Clinical Immunology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (X.W.); (B.D.M.)
| | - Hannah Kaiser
- Department of Cardiology, University Hospital—Herlev and Gentofte, 2900 Hellerup, Denmark; (H.K.); (A.K.-H.); (P.R.H.)
- Department of Dermatology and Allergy, University Hospital—Herlev and Gentofte, 2900 Hellerup, Denmark;
- Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Amanda Kvist-Hansen
- Department of Cardiology, University Hospital—Herlev and Gentofte, 2900 Hellerup, Denmark; (H.K.); (A.K.-H.); (P.R.H.)
- Department of Dermatology and Allergy, University Hospital—Herlev and Gentofte, 2900 Hellerup, Denmark;
| | - Benjamin D. McCauley
- Department of Medicine, Division of Clinical Immunology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (X.W.); (B.D.M.)
| | - Lone Skov
- Department of Dermatology and Allergy, University Hospital—Herlev and Gentofte, 2900 Hellerup, Denmark;
- Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Peter Riis Hansen
- Department of Cardiology, University Hospital—Herlev and Gentofte, 2900 Hellerup, Denmark; (H.K.); (A.K.-H.); (P.R.H.)
- Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Christine Becker
- Department of Medicine, Division of Clinical Immunology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (X.W.); (B.D.M.)
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Correspondence:
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20
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Lee TL, Tsai TF. Non-immune functions of inflammatory cytokines targeted by anti-psoriatic biologics: a review. Inflamm Res 2022; 71:157-168. [PMID: 34981130 DOI: 10.1007/s00011-021-01528-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 11/25/2021] [Accepted: 11/25/2021] [Indexed: 12/01/2022] Open
Abstract
PURPOSE Psoriasis is an inflammatory disease characterized by skin thickening with silvery white desquamation due to dysregulated inflammatory pathways and elevated levels of inflammatory cytokines. Biologic agents targeting these inflammatory cytokines have brought about significant improvement in clearing psoriatic lesions in patients with moderate-to-severe psoriasis. Moreover, biologics exert both beneficial and detrimental effects on comorbidities in psoriasis, which include increased risk of cardiovascular events, metabolic syndrome, among other conditions. However, non-immune functions of cytokines targeted by biologics, and, hence, the potential risks and benefits of biologics for psoriasis to different organs/systems and comorbidities, have not been well elucidated. RESULTS This review summarizes current understanding of the pathogenesis of psoriasis-related comorbidities and emerging discoveries of roles of cytokines targeted in psoriasis treatment, including tumor necrosis factor α and interleukins 12, 23, and 17, aiming to complete the safety profile of each biologics and provide therapeutic implications on psoriasis-related comorbidities, and on diseases involving other organs or systems.
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Affiliation(s)
- Tung-Lin Lee
- Department of Medical Education, National Taiwan University Hospital, Taipei, Taiwan
| | - Tsen-Fang Tsai
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, 7 Chung-Shan S. Rd., Taipei, 100, Taiwan.
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21
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Cai J, Cui L, Wang Y, Li Y, Zhang X, Shi Y. Cardiometabolic Comorbidities in Patients With Psoriasis: Focusing on Risk, Biological Therapy, and Pathogenesis. Front Pharmacol 2021; 12:774808. [PMID: 34803716 PMCID: PMC8600112 DOI: 10.3389/fphar.2021.774808] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/14/2021] [Indexed: 12/23/2022] Open
Abstract
Psoriasis is a chronic inflammatory disease characterized by erythematous scaly plaques, accompanied by systemic damage that leads to the development of multiple comorbidities. In particular, the association between psoriasis and cardiometabolic comorbidities, including cardiovascular diseases (CVDs), obesity, diabetes mellitus, and metabolic syndrome, has been verified in a considerable number of clinical trials. Moreover, the increased risk of cardiometabolic comorbidities positively correlates with psoriasis severity. Biologic therapy targeting inflammatory pathways or cytokines substantially improves the life quality of psoriasis patients and may affect cardiometabolic comorbidities by reducing their incidences. In this review, we focus on exploring the association between cardiometabolic comorbidities and psoriasis, and emphasize the benefits and precautions of biologic therapy in the management of psoriasis with cardiometabolic comorbidities. The pathogenic mechanisms of cardiometabolic comorbidities in psoriasis patients involve common genetic factors, lipid metabolism, insulin resistance, and shared inflammatory pathways such as tumor necrosis factor-α and interleukin-23/Th-17 pathways.
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Affiliation(s)
- Jiangluyi Cai
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China.,Institute of Psoriasis, Tongji University School of Medicine, Shanghai, China
| | - Lian Cui
- Institute of Psoriasis, Tongji University School of Medicine, Shanghai, China.,Department of Dermatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yu Wang
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China.,Institute of Psoriasis, Tongji University School of Medicine, Shanghai, China
| | - Ying Li
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China.,Institute of Psoriasis, Tongji University School of Medicine, Shanghai, China
| | - Xilin Zhang
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China.,Institute of Psoriasis, Tongji University School of Medicine, Shanghai, China
| | - Yuling Shi
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, China.,Institute of Psoriasis, Tongji University School of Medicine, Shanghai, China
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22
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Villani AP, Pavel AB, Wu J, Fernandes M, Maari C, Saint‐Cyr Proulx E, Jack C, Glickman J, Choi S, He H, Ungar B, Estrada Y, Kameyama N, Zhang N, Gonzales J, Tardif J, Krueger JG, Bissonnette R, Guttman‐Yassky E. Vascular inflammation in moderate-to-severe atopic dermatitis is associated with enhanced Th2 response. Allergy 2021; 76:3107-3121. [PMID: 33866573 DOI: 10.1111/all.14859] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/15/2021] [Accepted: 03/04/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND In atopic dermatitis (AD), some studies have shown an association with increased cardiovascular disease in certain populations. However, other investigations found modest or no association. Despite conflicting results, molecular profiling studies in both AD skin and blood have demonstrated upregulation of atherosclerosis and cardiovascular risk-related markers. However, the underlying mechanisms connecting AD to vascular inflammation/atherosclerosis are unknown. In this study, we aim to determine factors associated with vascular inflammation/atherosclerosis in AD patients. METHODS We used 18-FDG PET-CT to characterize vascular inflammation in AD patients and healthy subjects. In parallel, we assessed their skin and blood immune profiles to determine AD-related immune biomarkers associated with vascular inflammation. We also assessed levels of circulating microparticles, which are known to be associated with increased cardiovascular risk. RESULTS We found significant correlations between vascular inflammation and Th2-related products in skin and blood of AD patients as well as atherosclerosis-related markers that were modulated by dupilumab. Circulating levels of endothelial microparticles were significantly higher in severe AD patients and tended to correlate with vascular inflammation assessed by PET-CT. CONCLUSION Vascular inflammation in AD is associated with enhanced Th2 response and clinical severity, which may explain cardiovascular comorbidities observed in select AD populations. Larger prospective studies are needed to further evaluate vascular inflammation and cardiovascular events and mortality in AD patients. Finally, as dupilumab treatment demonstrated significant modulation of atherosclerosis-related genes in AD patients compared to placebo, these data suggest that modulation of vascular inflammation with systemic treatment should be explored in patients with AD.
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Affiliation(s)
- Axel P. Villani
- Department of Dermatology and the Immunology Institute Icahn School of Medicine at Mount Sinai New York NY USA
| | - Ana B. Pavel
- Department of Dermatology and the Immunology Institute Icahn School of Medicine at Mount Sinai New York NY USA
- Department of Biomedical Engineering University of Mississippi University MS USA
| | - Jianni Wu
- Department of Dermatology and the Immunology Institute Icahn School of Medicine at Mount Sinai New York NY USA
- College of Medicine State University of New York Downstate Medical Center Brooklyn New York USA
| | - Marie Fernandes
- Department of Dermatology and the Immunology Institute Icahn School of Medicine at Mount Sinai New York NY USA
| | | | | | | | - Jacob Glickman
- Department of Dermatology and the Immunology Institute Icahn School of Medicine at Mount Sinai New York NY USA
| | - Seulah Choi
- Department of Dermatology and the Immunology Institute Icahn School of Medicine at Mount Sinai New York NY USA
| | - Helen He
- Department of Dermatology and the Immunology Institute Icahn School of Medicine at Mount Sinai New York NY USA
| | - Benjamin Ungar
- Department of Dermatology and the Immunology Institute Icahn School of Medicine at Mount Sinai New York NY USA
| | - Yeriel Estrada
- Department of Dermatology and the Immunology Institute Icahn School of Medicine at Mount Sinai New York NY USA
| | - Naoya Kameyama
- Department of Dermatology and the Immunology Institute Icahn School of Medicine at Mount Sinai New York NY USA
| | - Ning Zhang
- Department of Dermatology and the Immunology Institute Icahn School of Medicine at Mount Sinai New York NY USA
| | - Juana Gonzales
- Department of Dermatology and the Immunology Institute Icahn School of Medicine at Mount Sinai New York NY USA
| | - Jean‐Claude Tardif
- Montreal Heart Institute Faculty of Medicine Université de Montréal Montreal QC Canada
| | - James G. Krueger
- Laboratory for Investigative Dermatology The Rockefeller University New York NY USA
| | | | - Emma Guttman‐Yassky
- Department of Dermatology and the Immunology Institute Icahn School of Medicine at Mount Sinai New York NY USA
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23
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Yan D, Blauvelt A, Dey AK, Golpanian RS, Hwang ST, Mehta NN, Myers B, Shi ZR, Yosipovitch G, Bell S, Liao W. New Frontiers in Psoriatic Disease Research, Part II: Comorbidities and Targeted Therapies. J Invest Dermatol 2021; 141:2328-2337. [PMID: 33888321 PMCID: PMC8464483 DOI: 10.1016/j.jid.2021.02.743] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 01/27/2021] [Accepted: 02/09/2021] [Indexed: 12/12/2022]
Abstract
Although psoriasis and psoriatic arthritis (PsA) have been classically considered to be diseases of the skin and joints, respectively, emerging evidence suggests that a combination of innate and environmental factors creates widespread immune dysfunction, affecting multiple organ systems. A greater understanding of the pathogenesis of psoriasis and the systemic effects of psoriatic inflammation has allowed for the development of new, more effective treatments. The second portion of this two-part review series examines the comorbidities associated with psoriasis and PsA as well as the most recent advances in targeted systemic therapies for these conditions.
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Affiliation(s)
- Di Yan
- The Ronald O. Perelman Department of Dermatology, NYU Langone Medical Center, New York, New York, USA
| | | | - Amit K Dey
- Cardiopulmonary Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Rachel S Golpanian
- Itch Center, Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Samuel T Hwang
- Department of Dermatology, UC Davis Medical Center, Sacramento, California
| | - Nehal N Mehta
- Cardiopulmonary Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Bridget Myers
- Department of Dermatology, University of California San Francisco, San Francisco, California
| | - Zhen-Rui Shi
- Department of Dermatology, UC Davis Medical Center, Sacramento, California
| | - Gil Yosipovitch
- Itch Center, Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Stacie Bell
- National Psoriasis Foundation, Portland, Oregon, USA
| | - Wilson Liao
- Department of Dermatology, University of California San Francisco, San Francisco, California.
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The Biological Disease-Modifying Antirheumatic Drugs and the Risk of Cardiovascular Events: A Systematic Review and Meta-Analysis. Mediators Inflamm 2021; 2021:7712587. [PMID: 34504395 PMCID: PMC8423578 DOI: 10.1155/2021/7712587] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/18/2021] [Indexed: 12/14/2022] Open
Abstract
Objective To assess the association between the use of biological disease-modifying antirheumatic drugs (bDMARDs) and the risk of cardiovascular events in patients with systemic inflammatory conditions. Methods Eligible cohort studies or randomized controlled trials (RCTs) from inception to January 2021 were included. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) for cardiovascular outcomes were calculated in the fixed- and random-effects model accordingly. Associated factors with risks of cardiovascular events were also studied in sensitivity analyses and metaregression analyses. Results Compared with non-bDMARD users, the risks of myocardial infarction (MI) (OR = 0.74, 95% CI, 0.63 to 0.87), heart failure (OR = 0.84, 95% CI, 0.74 to 0.95), cardiovascular (CV) death (OR = 0.62, 95% CI, 0.40 to 0.95), all-cause mortality (OR = 0.64, 95% CI, 0.58 to 0.70), and 3P-MACE (composite endpoint of MI, stroke, and CV death) (OR = 0.69, 95% CI, 0.53 to 0.89) were significantly reduced in bDMARD users, which were mainly driven by the risk reduction in patients with rheumatoid arthritis (RA). TNF-α inhibitors exhibited consistent benefits in reducing the risks of MI, heart failure, CV death, all-cause mortality, and 3P-MACE. Moreover, the risks of heart failure, CV death, all-cause mortality, and 3P-MACE were significantly reduced in bDMARD users with follow-up over one year. Conclusions The use of bDMARDs might be associated with the reduced risks of CV events, especially in patients with RA. The CV events might be less frequent in bDMARD users with TNF-α inhibitors or follow-up over one year. More investigations are needed to validate conclusions.
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25
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Mosca M, Hong J, Hadeler E, Hakimi M, Brownstone N, Liao W, Bhutani T. Psoriasis and Cardiometabolic Comorbidities: An Evaluation of the Impact of Systemic Treatments in Randomized Clinical Trials. Dermatol Ther (Heidelb) 2021; 11:1497-1520. [PMID: 34505985 PMCID: PMC8484473 DOI: 10.1007/s13555-021-00590-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/06/2021] [Indexed: 02/07/2023] Open
Abstract
The association between psoriasis, metabolic syndrome, and cardiovascular disease is well established. The shared pathways between psoriasis, metabolic syndrome, and atherosclerosis suggest that treatments targeting the inflammatory pathways of psoriasis may also be beneficial in the treatment of associated cardiometabolic comorbidities. This paper reviews the most recent data regarding the impact of systemic psoriasis treatments on comorbid cardiovascular and metabolic disease. Data from randomized clinical trials with systemic and biologic agents are presented. Overall, studies demonstrate beneficial effects on several cardiometabolic markers and risk factors in psoriasis patients; however, longer randomized controlled trials to characterize the direct benefit for cardiovascular outcomes are needed.
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Affiliation(s)
- Megan Mosca
- Department of Dermatology, University of California San Francisco, Psoriasis and Skin Treatment Center, 515 Spruce Street, San Francisco, CA, 94118, USA.
| | - Julie Hong
- Department of Dermatology, University of California San Francisco, Psoriasis and Skin Treatment Center, 515 Spruce Street, San Francisco, CA, 94118, USA
| | - Edward Hadeler
- Department of Dermatology, University of California San Francisco, Psoriasis and Skin Treatment Center, 515 Spruce Street, San Francisco, CA, 94118, USA
| | - Marwa Hakimi
- Department of Dermatology, University of California San Francisco, Psoriasis and Skin Treatment Center, 515 Spruce Street, San Francisco, CA, 94118, USA
| | - Nicholas Brownstone
- Department of Dermatology, University of California San Francisco, Psoriasis and Skin Treatment Center, 515 Spruce Street, San Francisco, CA, 94118, USA
| | - Wilson Liao
- Department of Dermatology, University of California San Francisco, Psoriasis and Skin Treatment Center, 515 Spruce Street, San Francisco, CA, 94118, USA
| | - Tina Bhutani
- Department of Dermatology, University of California San Francisco, Psoriasis and Skin Treatment Center, 515 Spruce Street, San Francisco, CA, 94118, USA
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Impact of Interleukin-17 Inhibitor Therapy on Arterial Intima-media Thickness among Severe Psoriatic Patients. Life (Basel) 2021; 11:life11090919. [PMID: 34575068 PMCID: PMC8471871 DOI: 10.3390/life11090919] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 08/30/2021] [Accepted: 09/03/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Psoriasis is frequently accompanied by cardiovascular diseases based on the shared immunopathogenic pathway. Authors determined the effect of interleukin (IL)-17 inhibitor therapy on arterial intima-media thickness (IMT) among severe psoriatic patients. METHODS Thirty-one severe psoriatic patients were enrolled. Twenty received secukinumab and 11 received ixekizumab. Before treatment initiation and after 6 months, the carotid-brachial-femoral IMT, the Psoriasis Area Severity Index (PASI), the Dermatology Life Quality of Index (DLQI) and the EuroQol Visual Analogue Scale (EQ VAS) were evaluated. RESULTS After 6 months, significant ameliorations were observed in PASI (p < 0.001) from 18 to 0, in DLQI (p < 0.001) from 17 to 0, in EQ VAS (p < 0.001) from 60 to 90, in right carotid IMT (p < 0.001) from 1.1 mm to 0.8 mm, in left carotid IMT (p < 0.001) from 1.1 mm to 0.7 mm, in right brachial IMT (p < 0.001) from 0.75 mm to 0.6 mm, in left brachial IMT (p < 0.001) from 0.8 mm to 0.5 mm, in right femoral IMT (p < 0.001) from 0.9 mm to 0.7 mm and in left femoral IMT (p < 0.001) from 0.8 mm to 0.7 mm. CONCLUSIONS By reducing the inflammation of the vascular wall, anti-IL-17 therapy may have a beneficial long-term effect on cardiovascular complications of systemic inflammation.
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Deroissart J, Porsch F, Koller T, Binder CJ. Anti-inflammatory and Immunomodulatory Therapies in Atherosclerosis. Handb Exp Pharmacol 2021; 270:359-404. [PMID: 34251531 DOI: 10.1007/164_2021_505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hypercholesterolemia is a major risk factor in atherosclerosis development and lipid-lowering drugs (i.e., statins) remain the treatment of choice. Despite effective reduction of LDL cholesterol in patients, a residual cardiovascular risk persists in some individuals, highlighting the need for further therapeutic intervention. Recently, the CANTOS trial paved the way toward the development of specific therapies targeting inflammation, a key feature in atherosclerosis progression. The pre-existence of multiple drugs modulating both innate and adaptive immune responses has significantly accelerated the number of translational studies applying these drugs to atherosclerosis. Additional preclinical research has led to the discovery of new therapeutic targets, offering promising perspectives for the treatment and prevention of atherosclerosis. Currently, both drugs with selective targeting and broad unspecific anti-inflammatory effects have been tested. In this chapter, we aim to give an overview of current advances in immunomodulatory treatment approaches for atherosclerotic cardiovascular diseases.
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Affiliation(s)
- Justine Deroissart
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Florentina Porsch
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Thomas Koller
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Christoph J Binder
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria.
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28
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Trakaki A, Wolf P, Weger W, Eichmann TO, Scharnagl H, Stadler JT, Salmhofer W, Knuplez E, Holzer M, Marsche G. Biological anti-psoriatic therapy profoundly affects high-density lipoprotein function. Biochim Biophys Acta Mol Cell Biol Lipids 2021; 1866:158943. [PMID: 33862237 DOI: 10.1016/j.bbalip.2021.158943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/24/2021] [Accepted: 04/07/2021] [Indexed: 12/13/2022]
Abstract
Psoriasis is a common chronic inflammatory skin disease linked to increased cardiovascular risk. Functional impairment of high-density lipoprotein (HDL) may contribute to excessive cardiovascular mortality in psoriasis patients. Anti-cytokine therapies with biologics have been efficiently used for the management of psoriasis, however little data is available on the effects of biologic anti-psoriatic therapies on the composition and functionality of HDL. Blood samples were taken from 17 healthy volunteers and from 27 real-world psoriasis patients at baseline (no therapy with biologics) and after short-term (3 to 6 months) and intermediate-term (1 to 2 years) therapy. The biologics used included anti-interleukin (IL)-12/23p40 (ustekinumab), anti-IL17A (secukinumab) or anti-tumor necrosis factor-α (etanercept or adalimumab) antibodies. We observed that in psoriasis patients at baseline, metrics of HDL function including cholesterol efflux capacity of apolipoprotein B-depleted serum (p = 0.021), paraoxonase (p < 0.001) and lecithin-cholesterol acyltransferase (p < 0.001) activities were impaired, when compared to controls. Unexpectedly, we observed that short- and especially intermediate-term therapy with biologics markedly reduced HDL cholesterol efflux capacity (p < 0.001) and rendered HDL pro-inflammatory (p < 0.001), but increased paraoxonase (p = 0.009) and lecithin-cholesterol acyltransferase (p = 0.019) activities. All biologics caused similar changes in HDL composition, subclass distribution and cholesterol efflux capacity. Our results provide evidence that anti-psoriatic therapy with biologic agents is associated with changes in HDL functionality, particle composition and subclass distribution.
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Affiliation(s)
- Athina Trakaki
- Division of Pharmacology, Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Medical University of Graz, Universitätsplatz 4, 8010 Graz, Austria
| | - Peter Wolf
- Department of Dermatology and Venereology, Auenbruggerplatz 8, 8036 Graz, Austria.
| | - Wolfgang Weger
- Department of Dermatology and Venereology, Auenbruggerplatz 8, 8036 Graz, Austria
| | - Thomas O Eichmann
- Institute of Molecular Biosciences, University of Graz, Graz, Austria; Center for Explorative Lipidomics, BioTechMed-Graz, Graz, Austria
| | - Hubert Scharnagl
- Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria
| | - Julia T Stadler
- Division of Pharmacology, Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Medical University of Graz, Universitätsplatz 4, 8010 Graz, Austria
| | - Wolfgang Salmhofer
- Department of Dermatology and Venereology, Auenbruggerplatz 8, 8036 Graz, Austria
| | - Eva Knuplez
- Division of Pharmacology, Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Medical University of Graz, Universitätsplatz 4, 8010 Graz, Austria
| | - Michael Holzer
- Division of Pharmacology, Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Medical University of Graz, Universitätsplatz 4, 8010 Graz, Austria
| | - Gunther Marsche
- Division of Pharmacology, Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Medical University of Graz, Universitätsplatz 4, 8010 Graz, Austria; BioTechMed Graz, Mozartgasse 12/II, 8010 Graz, Austria.
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Chen L, Li J, Yao Y, Wang S, Zheng S, Ju X, Zhang B. Circulating microRNA profile unveils mechanisms of action of acitretin for psoriasis vulgaris. Bioengineered 2021; 12:1838-1850. [PMID: 33975513 PMCID: PMC8806620 DOI: 10.1080/21655979.2021.1925205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Psoriasis vulgaris is a common chronic and recurrent inflammatory skin disease. In clinical practice, acitretin is the first-line treatment drug for psoriasis vulgaris. MicroRNAs (miRNAs) play a vital role in the initiation and development of psoriasis vulgaris. However few studies focused on the mechanisms of acitretin in the treatment of psoriasis vulgaris from the perspective of miRNAs. Here, the expression profiles of circulating miRNAs in the plasma of 12 patients with psoriasis vulgaris before and after acitretin treatment were sequenced. Three miRNAs (miR-146a-5p, miR-122-5p and miR-21-5p) were identified using expression pattern analysis, and the levels were significantly decreased after acitretin treatment (P< 0.001). Receiver operating characteristic (ROC) analyses indicated that the three miRNAs have the potential to be utilized as molecular markers to evaluate the therapeutic effect of acitretin, and the values of the area under the curve (AUC) were 0.825, 0.831, and 0.796, respectively. In addition, we predicted target genes of the three miRNAs and performed signaling pathway enrichment analyses. The results demonstrated that the target genes were mainly involved in the MAPK, JAK-STAT, and NF-κB signaling pathways, which were further validated through in vitro experiments. In conclusion, acitretin can suppress miRNA-mediated MAPK, JAK-STAT, and NF-κB signaling pathways by decreasing miRNAs expression, thereby inhibiting the proliferation and inflammatory response of keratinocytes.
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Affiliation(s)
- Lin Chen
- Department of Dermatology, The Second Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan Province, China
| | - Jie Li
- Department of Dermatology, The Second Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan Province, China
| | - Ying Yao
- Department of Dermatology, The Second Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan Province, China
| | - Shanlong Wang
- Department of Dermatology, The Second Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan Province, China
| | - Shuangjin Zheng
- Department of Dermatology, The Second Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan Province, China
| | - Xinggang Ju
- Department of Dermatology, The Second Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan Province, China
| | - Bin Zhang
- Department of Dermatology, The Second Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan Province, China
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González-Cantero A, Ortega-Quijano D, Álvarez-Díaz N, Ballester MA, Jimenez-Gomez N, Jaen P, González-Cantero J, González-Calvin JL, Barderas MG, Shin DB, Mehta NN, Gelfand JM. Impact of Biological Agents on Imaging and Biomarkers of Cardiovascular Disease in Patients with Psoriasis: A Systematic Review and Meta-Analysis of Randomized Placebo-Controlled Trials. J Invest Dermatol 2021; 141:2402-2411. [PMID: 33891953 DOI: 10.1016/j.jid.2021.03.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/02/2021] [Accepted: 03/04/2021] [Indexed: 01/23/2023]
Abstract
BACKGROUND The effect of biologics on the risk for cardiovascular disease in patients with psoriasis is still unclear despite their widespread use. OBJECTIVE The objective of this study was to examine the impact of licensed biological therapies on imaging and biomarkers of cardiovascular disease risk in patients with psoriasis by a systematic review and meta-analysis of placebo-controlled trials. METHODS A comprehensive search of studies published before 1 June 2020 was performed in Medline-Ovid, EMBASE, and CENTRAL using a predefined strategy to identify relevant articles. RESULTS Five studies were included for the final examination, and two studies were included in the meta-analysis. We did not find a significant reduction in aortic vascular inflammation in patients treated with adalimumab compared with those who received placebo at weeks 12-16. There was no beneficial effect on imaging biomarkers (aortic vascular inflammation or flow-mediated dilatation) of cardiovascular disease risk in patients exposed to biological therapies (adalimumab and secukinumab) compared with those exposed to placebo, except for ustekinumab showing a reduction in aortic vascular inflammation at week 12 but not at week 52 after the open-label extension period. The strongest reduction in blood-based cardiometabolic risk biomarkers was observed with adalimumab (CRP, TNF-α, IL-6, and GlycA) and phototherapy (CRP and IL-6) compared with that observed with placebo. CONCLUSIONS Randomized controlled trials show that ustekinumab reduces aortic vascular inflammation and that TNF-α inhibitors and phototherapy reduce CRP and IL-6. These surrogate marker findings require randomized controlled trials evaluating cardiovascular events to inform clinical practice.
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Affiliation(s)
| | | | | | | | | | - Pedro Jaen
- Department of Dermatology, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | | | | | - Maria G Barderas
- Department of Vascular Physiopathology, Hospital Nacional de Parapléjicos, SESCAM, Toledo, Spain
| | - Daniel B Shin
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nehal N Mehta
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Joel M Gelfand
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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31
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Sbidian E, Chaimani A, Garcia-Doval I, Doney L, Dressler C, Hua C, Hughes C, Naldi L, Afach S, Le Cleach L. Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis. Cochrane Database Syst Rev 2021; 4:CD011535. [PMID: 33871055 PMCID: PMC8408312 DOI: 10.1002/14651858.cd011535.pub4] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Psoriasis is an immune-mediated disease for which some people have a genetic predisposition. The condition manifests in inflammatory effects on either the skin or joints, or both, and it has a major impact on quality of life. Although there is currently no cure for psoriasis, various treatment strategies allow sustained control of disease signs and symptoms. Several randomised controlled trials (RCTs) have compared the efficacy of the different systemic treatments in psoriasis against placebo. However, the relative benefit of these treatments remains unclear due to the limited number of trials comparing them directly head-to-head, which is why we chose to conduct a network meta-analysis. OBJECTIVES To compare the efficacy and safety of non-biological systemic agents, small molecules, and biologics for people with moderate-to-severe psoriasis using a network meta-analysis, and to provide a ranking of these treatments according to their efficacy and safety. SEARCH METHODS For this living systematic review we updated our searches of the following databases monthly to September 2020: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase. We searched two trials registers to the same date. We checked the reference lists of included studies and relevant systematic reviews for further references to eligible RCTs. SELECTION CRITERIA Randomised controlled trials (RCTs) of systemic treatments in adults (over 18 years of age) with moderate-to-severe plaque psoriasis or psoriatic arthritis whose skin had been clinically diagnosed with moderate-to-severe psoriasis, at any stage of treatment, in comparison to placebo or another active agent. The primary outcomes of this review were: the proportion of participants who achieved clear or almost clear skin, that is, at least Psoriasis Area and Severity Index (PASI) 90 at induction phase (from 8 to 24 weeks after the randomisation), and the proportion of participants with serious adverse events (SAEs) at induction phase. We did not evaluate differences in specific adverse events. DATA COLLECTION AND ANALYSIS Several groups of two review authors independently undertook study selection, data extraction, 'Risk of bias' assessment, and analyses. We synthesised the data using pair-wise and network meta-analysis (NMA) to compare the treatments of interest and rank them according to their effectiveness (as measured by the PASI 90 score) and acceptability (the inverse of serious adverse events). We assessed the certainty of the body of evidence from the NMA for the two primary outcomes and all comparisons, according to CINeMA, as either very low, low, moderate, or high. We contacted study authors when data were unclear or missing. We used the surface under the cumulative ranking curve (SUCRA) to infer on treatment hierarchy: 0% (treatment is the worst for effectiveness or safety) to 100% (treatment is the best for effectiveness or safety). MAIN RESULTS We included 158 studies (18 new studies for the update) in our review (57,831 randomised participants, 67.2% men, mainly recruited from hospitals). The overall average age was 45 years; the overall mean PASI score at baseline was 20 (range: 9.5 to 39). Most of these studies were placebo-controlled (58%), 30% were head-to-head studies, and 11% were multi-armed studies with both an active comparator and a placebo. We have assessed a total of 20 treatments. In all, 133 trials were multicentric (two to 231 centres). All but two of the outcomes included in this review were limited to the induction phase (assessment from 8 to 24 weeks after randomisation). We assessed many studies (53/158) as being at high risk of bias; 25 were at an unclear risk, and 80 at low risk. Most studies (123/158) declared funding by a pharmaceutical company, and 22 studies did not report their source of funding. Network meta-analysis at class level showed that all of the interventions (non-biological systemic agents, small molecules, and biological treatments) were significantly more effective than placebo in reaching PASI 90. At class level, in reaching PASI 90, the biologic treatments anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha were significantly more effective than the small molecules and the non-biological systemic agents. At drug level, infliximab, ixekizumab, secukinumab, brodalumab, risankizumab and guselkumab were significantly more effective in reaching PASI 90 than ustekinumab and three anti-TNF alpha agents: adalimumab, certolizumab, and etanercept. Ustekinumab and adalimumab were significantly more effective in reaching PASI 90 than etanercept; ustekinumab was more effective than certolizumab, and the clinical effectiveness of ustekinumab and adalimumab was similar. There was no significant difference between tofacitinib or apremilast and three non-biological drugs: fumaric acid esters (FAEs), ciclosporin and methotrexate. Network meta-analysis also showed that infliximab, ixekizumab, risankizumab, bimekizumab, secukinumab, guselkumab, and brodalumab outperformed other drugs when compared to placebo in reaching PASI 90. The clinical effectiveness of these drugs was similar, except for ixekizumab which had a better chance of reaching PASI 90 compared with secukinumab, guselkumab and brodalumab. The clinical effectiveness of these seven drugs was: infliximab (versus placebo): risk ratio (RR) 50.29, 95% confidence interval (CI) 20.96 to 120.67, SUCRA = 93.6; high-certainty evidence; ixekizumab (versus placebo): RR 32.48, 95% CI 27.13 to 38.87; SUCRA = 90.5; high-certainty evidence; risankizumab (versus placebo): RR 28.76, 95% CI 23.96 to 34.54; SUCRA = 84.6; high-certainty evidence; bimekizumab (versus placebo): RR 58.64, 95% CI 3.72 to 923.86; SUCRA = 81.4; high-certainty evidence; secukinumab (versus placebo): RR 25.79, 95% CI 21.61 to 30.78; SUCRA = 76.2; high-certainty evidence; guselkumab (versus placebo): RR 25.52, 95% CI 21.25 to 30.64; SUCRA = 75; high-certainty evidence; and brodalumab (versus placebo): RR 23.55, 95% CI 19.48 to 28.48; SUCRA = 68.4; moderate-certainty evidence. Conservative interpretation is warranted for the results for bimekizumab (as well as mirikizumab, tyrosine kinase 2 inhibitor, acitretin, ciclosporin, fumaric acid esters, and methotrexate), as these drugs, in the NMA, have been evaluated in few trials. We found no significant difference between any of the interventions and the placebo for the risk of SAEs. Nevertheless, the SAE analyses were based on a very low number of events with low to moderate certainty for all the comparisons. Thus, the results have to be viewed with caution and we cannot be sure of the ranking. For other efficacy outcomes (PASI 75 and Physician Global Assessment (PGA) 0/1) the results were similar to the results for PASI 90. Information on quality of life was often poorly reported and was absent for several of the interventions. AUTHORS' CONCLUSIONS Our review shows that compared to placebo, the biologics infliximab, ixekizumab, risankizumab, bimekizumab, secukinumab, guselkumab and brodalumab were the most effective treatments for achieving PASI 90 in people with moderate-to-severe psoriasis on the basis of moderate- to high-certainty evidence. This NMA evidence is limited to induction therapy (outcomes were measured from 8 to 24 weeks after randomisation) and is not sufficient for evaluation of longer-term outcomes in this chronic disease. Moreover, we found low numbers of studies for some of the interventions, and the young age (mean age of 45 years) and high level of disease severity (PASI 20 at baseline) may not be typical of patients seen in daily clinical practice. Another major concern is that short-term trials provide scanty and sometimes poorly-reported safety data and thus do not provide useful evidence to create a reliable risk profile of treatments. We found no significant difference in the assessed interventions and placebo in terms of SAEs, and the evidence for all the interventions was of low to moderate quality. In order to provide long-term information on the safety of the treatments included in this review, it will also be necessary to evaluate non-randomised studies and postmarketing reports released from regulatory agencies. In terms of future research, randomised trials directly comparing active agents are necessary once high-quality evidence of benefit against placebo is established, including head-to-head trials amongst and between non-biological systemic agents and small molecules, and between biological agents (anti-IL17 versus anti-IL23, anti-IL23 versus anti-IL12/23, anti-TNF alpha versus anti-IL12/23). Future trials should also undertake systematic subgroup analyses (e.g. assessing biological-naïve participants, baseline psoriasis severity, presence of psoriatic arthritis, etc.). Finally, outcome measure harmonisation is needed in psoriasis trials, and researchers should look at the medium- and long-term benefit and safety of the interventions and the comparative safety of different agents. Editorial note: This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Emilie Sbidian
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Clinical Investigation Centre, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Anna Chaimani
- Université de Paris, Centre of Research in Epidemiology and Statistics (CRESS), INSERM, F-75004, Paris, France
- Cochrane France, Paris, France
| | - Ignacio Garcia-Doval
- Department of Dermatology, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Liz Doney
- Centre of Evidence Based Dermatology, Cochrane Skin Group, The University of Nottingham, Nottingham, UK
| | - Corinna Dressler
- Division of Evidence Based Medicine, Department of Dermatology, Venerology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Camille Hua
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Carolyn Hughes
- c/o Cochrane Skin Group, The University of Nottingham, Nottingham, UK
| | - Luigi Naldi
- Centro Studi GISED (Italian Group for Epidemiologic Research in Dermatology) - FROM (Research Foundation of Ospedale Maggiore Bergamo), Padiglione Mazzoleni - Presidio Ospedaliero Matteo Rota, Bergamo, Italy
| | - Sivem Afach
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Laurence Le Cleach
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
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Mehta NN. Epicardial Assessment of Coronary Artery Disease in Inflammatory Diseases: Is it Enough? JACC Cardiovasc Imaging 2021; 14:2221-2225. [PMID: 33865786 DOI: 10.1016/j.jcmg.2021.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/02/2021] [Accepted: 02/04/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Nehal N Mehta
- Lab of Inflammation and Cardiometabolic Diseases, National Heart, Lung and Blood Institute, Bethesda, Maryland, USA.
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How current biologic therapies affect the risk of major adverse cardiovascular events in patients with plaque psoriasis? A systematic review and meta-analysis of randomized controlled trials. Postepy Dermatol Alergol 2021; 37:986-994. [PMID: 33603620 PMCID: PMC7874875 DOI: 10.5114/ada.2020.102121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 11/29/2020] [Indexed: 02/07/2023] Open
Abstract
Introduction Concerns have been raised about an increased risk of major adverse cardiovascular events (MACEs) – stroke, myocardial infarction and sudden cardiac death – in patients with plaque psoriasis receiving biologic therapies. Aim This review and meta-analysis of randomized controlled trials (RCTs) was to evaluate the risk difference of MACEs between experimental and comparator interventions. Material and methods We searched MEDLINE database for suitable trials. Prior to that we identified the search strategy and eligibility criteria. Each RCT was double-blind, placebo controlled and scored five points in Jadad scale. We calculated risk difference (RD) with use of the Mantel-Haenszel fixed-effect method with 95% confidence intervals (CIs) and calculated i2 statistic to assess heterogeneity. A total of 43 RCTs were included, involving 19,161 patients. Overall, the risk of MACEs in the included studies was 0.1% (n = 21). Results There were no statistically significant risk differences in patients treated with biologic therapy vs. placebo (RD = 0.0; Z = 1.09; 95% CI: 0.0–0.0; p = 0.28); tumour necrosis inhibitors vs. placebo (RD = 0.0; Z = 0.47; 95% CI: –0.0–0.0; p = 0.64); anti-IL-17A agents vs. placebo (RD = 0.0; Z = 1.25; 95% CI: –0.0–0.01; p = 0.21); anti-IL-23 agents vs. placebo (RD = 0; Z = 0.36; 95% CI: –0.0–0.01; p = 0.72); anti-IL-12/23 agents vs. placebo (RD = 0.0; Z = 0.73; 95% CI: –0.0–0.0; p = 0.46). Conclusions Further trials are needed, including longer follow-up and patients with an increased cardiovascular risk, to assess the risk of MACEs.
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Piros ÉA, Szilveszter B, Vattay B, Maurovich-Horvat P, Szalai K, Dósa E, Merkely B, Holló P. Novel anti-inflammatory therapies to reduce cardiovascular burden of psoriasis. Dermatol Ther 2021; 34:e14721. [PMID: 33373079 PMCID: PMC8244030 DOI: 10.1111/dth.14721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 12/21/2020] [Indexed: 12/16/2022]
Abstract
Psoriasis mainly affects the skin and joints and has serious impacts on the physical, emotional, and financial life of patients. Recent studies have demonstrated that other comorbidities are frequently detected in psoriatic patients. A strong association with the development of cardiovascular diseases, such as hypertension, myocardial infarction, and stroke is responsible for the shortened (by 4.5‐5 years) life expectancy of severe psoriatic patients. Systemic inflammation plays an important role in the interrelationship between psoriasis and atherosclerotic plaque formation, which is a common immunopathogenic pathway that explains the multiorgan involvement in psoriasis. As far life‐threatening cardiovascular diseases are very often symptom‐free, the treating dermatologist's responsibility is to initiate interdisciplinary holistic patient care, which may lead to directly saved patients' lives. Holistic care of severe psoriatic patients should include regular cardiac monitoring using cardiovascular imaging modalities and functional testing to detect even subclinical coronary artery disease. Effective anti‐inflammatory treatment with biologic therapies may have beneficial effects on the cardiovascular state and may reduce the incidence of cardiac events. The authors review the latest findings on the shared immunopathogenic background of psoriasis and cardiovascular diseases and discuss the available data about the cardiovascular responses to the currently used biologic treatments.
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Affiliation(s)
- Éva Anna Piros
- Department of Dermatology, Venereology, and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - Bálint Szilveszter
- MTA-SE Cardiovascular Imaging Research Group, Semmelweis University, Heart and Vascular Center, Budapest, Hungary
| | - Borbála Vattay
- MTA-SE Cardiovascular Imaging Research Group, Semmelweis University, Heart and Vascular Center, Budapest, Hungary
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Semmelweis University, Heart and Vascular Center, Budapest, Hungary.,Department of Radiology, Semmelweis University, Medical Imaging Center, Budapest, Hungary
| | - Klára Szalai
- Department of Dermatology, Venereology, and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - Edit Dósa
- Department of Interventional Radiology, Semmelweis University, Heart and Vascular Center, Budapest, Hungary.,Hungarian Vascular Radiology Research Group, Budapest, Hungary
| | - Béla Merkely
- MTA-SE Cardiovascular Imaging Research Group, Semmelweis University, Heart and Vascular Center, Budapest, Hungary
| | - Péter Holló
- Department of Dermatology, Venereology, and Dermatooncology, Semmelweis University, Budapest, Hungary
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Aksentijevich M, Lateef SS, Anzenberg P, Dey AK, Mehta NN. Chronic inflammation, cardiometabolic diseases and effects of treatment: Psoriasis as a human model. Trends Cardiovasc Med 2020; 30:472-478. [PMID: 31837960 PMCID: PMC7428846 DOI: 10.1016/j.tcm.2019.11.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/22/2019] [Accepted: 11/02/2019] [Indexed: 01/25/2023]
Abstract
Chronic inflammation in humans is associated with accelerated development of cardiometabolic diseases such as myocardial infarction, stroke, and diabetes. Strong evidence from animal models and human interventional trials including CANTOS (The Canakinumab Anti-inflammatory Thrombosis Outcome Study) suggests that targeting residual systemic inflammation in humans may impart a benefit in reducing cardiometabolic diseases. Diseases associated with heightened immune-activation and systemic inflammation including psoriasis, rheumatoid arthritis, systemic lupus erythematosus, and human immunodeficiency virus infection are associated with upwards of two to seven-fold risk of future adverse cardiac events even when adjusted for traditional risk factors. Over the past decade, psoriasis has been utilized as a human model to study inflammatory-induced cardiometabolic dysfunction and to better understand residual risk due to inflammation. The high prevalence and early onset of cardiovascular disease in psoriasis enhances the likelihood of discovering novel pathways in vascular disease progression when followed over time. Furthermore, the United States Food and Drug Administration approved treatments for psoriasis include cytokine inhibitors (anti-tumor necrosis factor, anti-interleukin 17, anti-interleukin 12/23) which while treating the skin disease provide a unique opportunity to characterize how treating the inflammatory pathways may impact atherosclerosis. Herein, we provide a review of chronic inflammation, cardiometabolic disease associations, and treatment effects with a focus on psoriasis as a human model of study.
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Affiliation(s)
- Milena Aksentijevich
- National Heart, Lung, Blood Institute, National Institutes of Health, 10 Center Drive, Clinical Research Center, Room 5-5140 Bethesda, MD 20892, USA
| | - Sundus S Lateef
- National Heart, Lung, Blood Institute, National Institutes of Health, 10 Center Drive, Clinical Research Center, Room 5-5140 Bethesda, MD 20892, USA
| | - Paula Anzenberg
- National Heart, Lung, Blood Institute, National Institutes of Health, 10 Center Drive, Clinical Research Center, Room 5-5140 Bethesda, MD 20892, USA
| | - Amit K Dey
- National Heart, Lung, Blood Institute, National Institutes of Health, 10 Center Drive, Clinical Research Center, Room 5-5140 Bethesda, MD 20892, USA
| | - Nehal N Mehta
- National Heart, Lung, Blood Institute, National Institutes of Health, 10 Center Drive, Clinical Research Center, Room 5-5140 Bethesda, MD 20892, USA.
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Gelfand JM, Shin DB, Duffin KC, Armstrong AW, Blauvelt A, Tyring SK, Menter A, Gottlieb S, Lockshin BN, Simpson EL, Kianifard F, Sarkar RP, Muscianisi E, Steadman J, Ahlman MA, Playford MP, Joshi AA, Dey AK, Werner TJ, Alavi A, Mehta NN. A Randomized Placebo-Controlled Trial of Secukinumab on Aortic Vascular Inflammation in Moderate-to-Severe Plaque Psoriasis (VIP-S). J Invest Dermatol 2020; 140:1784-1793.e2. [PMID: 32088207 PMCID: PMC7434644 DOI: 10.1016/j.jid.2020.01.025] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/24/2020] [Accepted: 01/28/2020] [Indexed: 02/08/2023]
Abstract
Psoriasis, a chronic immune-mediated disease, is associated with an increased risk of cardiovascular events and mortality. Secukinumab selectively neutralizes IL-17A and has reported high efficacy with a favorable safety profile in various psoriatic disease manifestations. Subsequent to the 12-week randomized, placebo-controlled, double-blind treatment period, patients with moderate-to-severe psoriasis received secukinumab for 40 weeks. Vascular inflammation using 18F-2-fluorodeoxyglucose-positron emission tomography/computed tomography imaging and blood-based cardiometabolic was assessed at week 0, 12, and 52. The difference in change in aortic inflammation from baseline to week 12 for secukinumab (n = 46) versus placebo (n = 45) was -0.053 (95% confidence interval = -0.169 to 0.064; P= 0.37). Small increases in total cholesterol, low-density lipoprotein, and low-density lipoprotein particles, but no changes in markers of inflammation, adiposity, insulin resistance, or predictors of diabetes, were observed with secukinumab treatment compared with placebo. At week 52, reductions in TNF-α (P= 0.0063) and ferritin (P= 0.0354), and an increase in fetuin-A (P= 0.0024), were observed with secukinumab treatment compared with baseline. No significant changes in aortic inflammation or markers of advanced lipoprotein characterization, adiposity, or insulin resistance were observed with secukinumab treatment compared with baseline. Secukinumab exhibited a neutral impact on aortic vascular inflammation and biomarkers of cardiometabolic disease after 52 weeks of treatment.
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Affiliation(s)
- Joel M Gelfand
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Daniel B Shin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - April W Armstrong
- Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA
| | | | - Stephen K Tyring
- Department of Dermatology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Alan Menter
- Division of Dermatology, Baylor Scott &White, Dallas, Texas, USA
| | - Scott Gottlieb
- Dermatology and Skin Surgery Center, Exton, Pennsylvania, USA
| | | | - Eric L Simpson
- OSHU Dermatology Clinic, South Waterfront, Portland, Oregon, USA
| | - Farid Kianifard
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | | | - Elisa Muscianisi
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | | | - Mark A Ahlman
- Radiology and Imaging Sciences, National Institutes of Health, Bethesda, Maryland, USA
| | - Martin P Playford
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Aditya A Joshi
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Amit K Dey
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Thomas J Werner
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Abass Alavi
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nehal N Mehta
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
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Billi AC, Gudjonsson JE, Voorhees JJ. Psoriasis: Past, Present, and Future. J Invest Dermatol 2020; 139:e133-e142. [PMID: 31648690 DOI: 10.1016/j.jid.2019.08.437] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 08/09/2019] [Indexed: 01/02/2023]
Affiliation(s)
- Allison C Billi
- Department of Dermatology, University of Michigan, Ann Arbor, Michigan
| | | | - John J Voorhees
- Department of Dermatology, University of Michigan, Ann Arbor, Michigan
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Gisondi P, Geat D, Conti A, Dapavo P, Piaserico S, De Simone C, Bianchi L, Costanzo A, Malagoli P, Malara G, Micali G, Naldi L, Offidani A, Patrizi A, Prignano F, Parodi A, Rongioletti F, Calzavara-Pinton P, Girolomoni G. TNF-α inhibitors biosimilars as first line systemic treatment for moderate-to-severe chronic plaque psoriasis. Expert Rev Clin Immunol 2020; 16:591-598. [DOI: 10.1080/1744666x.2020.1771182] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Paolo Gisondi
- Department of Medicine, Section of Dermatology and Venereology, University of Verona, Verona, Italy
| | - Davide Geat
- Department of Medicine, Section of Dermatology and Venereology, University of Verona, Verona, Italy
| | - Andrea Conti
- Department of Surgical, Medical, Dental and Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, Dermatology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Paolo Dapavo
- Department of Biomedical Science and Human Oncology, Second Dermatologic Clinic, University of Turin, Turin, Italy
| | - Stefano Piaserico
- Section of Dermatology, Department of Medicine, University of Padua, Padova, Italy
| | - Clara De Simone
- Dermatology, Institute of Dermatology, Catholic University, Rome, Italy
| | - Luca Bianchi
- Dermatologic Unit, University of Rome Tor Vergata, Rome, Italy
| | | | - Piergiorgio Malagoli
- Department of Dermatology, Dermatology Unit Azienda Ospedaliera San Donato Milanese, Milan, Italy
| | - Giovanna Malara
- Dermatology Unit, Grande Ospedale Metropolitano, Bianchi Melacrino Morelli, Reggio, Italy
| | | | - Luigi Naldi
- Unit of Dermatology, San Bortolo Hospital, Vicenza, Italy
| | - Annamaria Offidani
- Department of Clinical and Molecular Sciences, Dermatological Clinic, Polytechnic Marche University, Ancona, Italy
| | - Annalisa Patrizi
- Department of Experimental, Diagnostic and Specialty Medicine, Division of Dermatology, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - F. Prignano
- Unit of Dermatology, Department of Dermatological Sciences, University of Florence, Florence, Italy
| | - Aurora Parodi
- Section of Dermatology, Department of Health Sciences, San Martino University Hospital IRCCS, University of Genoa, Genoa, Italy
| | - Franco Rongioletti
- Department of Medical Sciences and Public Health, Section of Dermatology, University of Cagliari, Cagliari, Italy
| | | | - Giampiero Girolomoni
- Department of Medicine, Section of Dermatology and Venereology, University of Verona, Verona, Italy
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Kovitwanichkanont T, Chong AH, Foley P. Beyond skin deep: addressing comorbidities in psoriasis. Med J Aust 2020; 212:528-534. [PMID: 32388913 DOI: 10.5694/mja2.50591] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Psoriasis is a chronic inflammatory disease that is commonly encountered in primary care and is associated with significant morbidity that extends beyond the skin manifestations. Psoriasis is associated with an elevated risk of psoriatic arthritis, cardiovascular disease, obesity, insulin resistance, mental health disorders, certain types of malignancy, inflammatory bowel disease and other immune-related disorders, and hepatic and renal disease. Enhanced recognition of these comorbidities may lead to earlier diagnosis and potentially better overall health outcomes. Psoriatic nail involvement, severe skin disease and obesity are associated with a greater risk of psoriatic arthritis. Individuals with psoriasis should be routinely screened for psoriatic arthritis to allow for early intervention to improve long term prognosis. Life expectancy is reduced in people with psoriasis due to a variety of causes, with cardiovascular disease and malignancy being the most common aetiologies. Psoriasis affects several factors that contribute to worsened quality of life and increased risk of depression and anxiety. Effective therapies are now available that have been shown to concurrently improve skin disease, quality of life and psychiatric symptoms. As the concordance between psychosocial impact and objective disease severity does not always correlate, it is essential to tailor management strategies specifically to the needs of each individual. Cigarette smoking and excess alcohol consumption are among the most important modifiable risk factors that increase the likelihood of psoriasis development and severity of skin disease. This provides a compelling rationale for smoking cessation and limiting alcohol intake in people with psoriasis beyond their traditional harmful health consequences.
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Affiliation(s)
| | - Alvin H Chong
- Skin Health Institute, Melbourne, VIC.,St Vincent's Hospital, Melbourne, VIC
| | - Peter Foley
- Skin Health Institute, Melbourne, VIC.,St Vincent's Hospital, Melbourne, VIC
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Kridin K, Cohen AD. Anti-psoriatic therapies and cardiovascular risk: is there a difference between different systemic agents? J Eur Acad Dermatol Venereol 2020; 34:668-669. [PMID: 32227423 DOI: 10.1111/jdv.16345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/03/2020] [Indexed: 11/28/2022]
Affiliation(s)
- K Kridin
- Clalit Health Services, Tel-Aviv, Israel
| | - A D Cohen
- Clalit Health Services, Tel-Aviv, Israel.,Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Abrahão-Machado ECF, Mendonça JA, Arruda ACBB, Nucci LB, Santos MASD. Analysis of cardiovascular risk and carotid intima-media thickness in patients with psoriasis. An Bras Dermatol 2020; 95:150-157. [PMID: 32122693 PMCID: PMC7175101 DOI: 10.1016/j.abd.2019.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 07/11/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Psoriasis is associated with atherosclerosis and increased cardiovascular risk. Currently, an automated ultrasound, called quantitative intima media thickness, has proven to be a useful method to evaluate subclinical atherosclerosis. OBJECTIVES To compare increased cardiovascular risk in psoriasis patients receiving two types of treatments: Methotrexate and tumor necrosis factor inhibitor and to evaluate the correlation between the Framingham score and quantitative intima media thickness. METHODS Fifty patients with plaque psoriasis were selected from June 2017 to July 2018, divided into two groups, receiving methotrexate and tumor necrosis factor inhibitor. Measurement of abdominal circumference, blood pressure, body mass index and presence of metabolic syndrome were performed. Afterwards, the patients were evaluated for increased cardiovascular risk with the Framingham score and for the quantitative intima media thickness of the carotid arteries. RESULTS The mean age was 54.8 (±12.5) with a slight male predominance (58%). Overall, 84% of the patients had elevated waist circumference, 82% had a body mass index above ideal, and 50% had a metabolic syndrome. For the correlation between quantitative intima media thickness and Framingham Score, Pearson's linear correlation coefficient was 0.617 (p<0.001), indicating a moderate to strong positive association. STUDY LIMITATIONS The protective effect of the therapies cited in relation to the increased cardiovascular risk was not evaluated. CONCLUSIONS A moderate to strong positive association was found correlating the Framingham Score values with the quantitative intima media thickness measurement and it is not possible to state which drug has the highest increased cardiovascular risk.
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Affiliation(s)
| | - José Alexandre Mendonça
- Rheumatology Outpatient Clinic, Pontifícia Universidade Católica de Campinas, Campinas, SP, Brazil
| | | | - Luciana Bertoldi Nucci
- Postgraduate Program, Pontifícia Universidade Católica de Campinas, Campinas, SP, Brazil
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Verhoeven F, Prati C, Demougeot C, Wendling D. Cardiovascular risk in psoriatic arthritis, a narrative review. Joint Bone Spine 2020; 87:413-418. [PMID: 31958573 DOI: 10.1016/j.jbspin.2019.12.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 12/03/2019] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Frank Verhoeven
- Service de rhumatologie, CHRU de Besanço, 25030 Besançon cedex, France; EA 4267 « PEPITE », université de Bourgogne Franche-Comté, 25000 Besançon, France.
| | - Clément Prati
- Service de rhumatologie, CHRU de Besanço, 25030 Besançon cedex, France; EA 4267 « PEPITE », université de Bourgogne Franche-Comté, 25000 Besançon, France
| | - Céline Demougeot
- EA 4267 « PEPITE », université de Bourgogne Franche-Comté, 25000 Besançon, France
| | - Daniel Wendling
- Service de rhumatologie, CHRU de Besanço, 25030 Besançon cedex, France; EA 4266 «EPILAB », université de Bourgogne Franche-Comté, 25000 Besançon,France
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Sbidian E, Chaimani A, Afach S, Doney L, Dressler C, Hua C, Mazaud C, Phan C, Hughes C, Riddle D, Naldi L, Garcia-Doval I, Le Cleach L. Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis. Cochrane Database Syst Rev 2020; 1:CD011535. [PMID: 31917873 PMCID: PMC6956468 DOI: 10.1002/14651858.cd011535.pub3] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Psoriasis is an immune-mediated disease for which some people have a genetic predisposition. The condition manifests in inflammatory effects on either the skin or joints, or both, and it has a major impact on quality of life. Although there is currently no cure for psoriasis, various treatment strategies allow sustained control of disease signs and symptoms. Several randomised controlled trials (RCTs) have compared the efficacy of the different systemic treatments in psoriasis against placebo. However, the relative benefit of these treatments remains unclear due to the limited number of trials comparing them directly head-to-head, which is why we chose to conduct a network meta-analysis. This is the baseline update of a Cochrane Review first published in 2017, in preparation for this Cochrane Review becoming a living systematic review. OBJECTIVES To compare the efficacy and safety of conventional systemic agents, small molecules, and biologics for people with moderate-to-severe psoriasis, and to provide a ranking of these treatments according to their efficacy and safety. SEARCH METHODS We updated our research using the following databases to January 2019: the Cochrane Skin Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS and the conference proceedings of a number of dermatology meetings. We also searched five trials registers and the US Food and Drug Administration (FDA) and European Medicines Agency (EMA) reports (until June 2019). We checked the reference lists of included and excluded studies for further references to relevant RCTs. SELECTION CRITERIA Randomised controlled trials (RCTs) of systemic treatments in adults (over 18 years of age) with moderate-to-severe plaque psoriasis or psoriatic arthritis whose skin had been clinically diagnosed with moderate-to-severe psoriasis, at any stage of treatment, in comparison to placebo or another active agent. The primary outcomes of this review were: the proportion of participants who achieved clear or almost clear skin, that is, at least Psoriasis Area and Severity Index (PASI) 90 at induction phase (from 8 to 24 weeks after the randomisation), and the proportion of participants with serious adverse effects (SAEs) at induction phase. We did not evaluate differences in specific adverse effects. DATA COLLECTION AND ANALYSIS Several groups of two review authors independently undertook study selection, data extraction, 'Risk of bias' assessment, and analyses. We synthesised the data using pair-wise and network meta-analysis (NMA) to compare the treatments of interest and rank them according to their effectiveness (as measured by the PASI 90 score) and acceptability (the inverse of serious adverse effects). We assessed the certainty of the body of evidence from the NMA for the two primary outcomes, according to GRADE, as either very low, low, moderate, or high. We contacted study authors when data were unclear or missing. MAIN RESULTS We included 140 studies (31 new studies for the update) in our review (51,749 randomised participants, 68% men, mainly recruited from hospitals). The overall average age was 45 years; the overall mean PASI score at baseline was 20 (range: 9.5 to 39). Most of these studies were placebo-controlled (59%), 30% were head-to-head studies, and 11% were multi-armed studies with both an active comparator and a placebo. We have assessed a total of 19 treatments. In all, 117 trials were multicentric (two to 231 centres). All but two of the outcomes included in this review were limited to the induction phase (assessment from 8 to 24 weeks after randomisation). We assessed many studies (57/140) as being at high risk of bias; 42 were at an unclear risk, and 41 at low risk. Most studies (107/140) declared funding by a pharmaceutical company, and 22 studies did not report the source of funding. Network meta-analysis at class level showed that all of the interventions (conventional systemic agents, small molecules, and biological treatments) were significantly more effective than placebo in terms of reaching PASI 90. At class level, in terms of reaching PASI 90, the biologic treatments anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha were significantly more effective than the small molecules and the conventional systemic agents. At drug level, in terms of reaching PASI 90, infliximab, all of the anti-IL17 drugs (ixekizumab, secukinumab, bimekizumab and brodalumab) and the anti-IL23 drugs (risankizumab and guselkumab, but not tildrakizumab) were significantly more effective in reaching PASI 90 than ustekinumab and 3 anti-TNF alpha agents: adalimumab, certolizumab and etanercept. Adalimumab and ustekinumab were significantly more effective in reaching PASI 90 than certolizumab and etanercept. There was no significant difference between tofacitinib or apremilast and between two conventional drugs: ciclosporin and methotrexate. Network meta-analysis also showed that infliximab, ixekizumab, risankizumab, bimekizumab, guselkumab, secukinumab and brodalumab outperformed other drugs when compared to placebo in reaching PASI 90. The clinical effectiveness for these seven drugs was similar: infliximab (versus placebo): risk ratio (RR) 29.52, 95% confidence interval (CI) 19.94 to 43.70, Surface Under the Cumulative Ranking (SUCRA) = 88.5; moderate-certainty evidence; ixekizumab (versus placebo): RR 28.12, 95% CI 23.17 to 34.12, SUCRA = 88.3, moderate-certainty evidence; risankizumab (versus placebo): RR 27.67, 95% CI 22.86 to 33.49, SUCRA = 87.5, high-certainty evidence; bimekizumab (versus placebo): RR 58.64, 95% CI 3.72 to 923.86, SUCRA = 83.5, low-certainty evidence; guselkumab (versus placebo): RR 25.84, 95% CI 20.90 to 31.95; SUCRA = 81; moderate-certainty evidence; secukinumab (versus placebo): RR 23.97, 95% CI 20.03 to 28.70, SUCRA = 75.4; high-certainty evidence; and brodalumab (versus placebo): RR 21.96, 95% CI 18.17 to 26.53, SUCRA = 68.7; moderate-certainty evidence. Conservative interpretation is warranted for the results for bimekizumab (as well as tyrosine kinase 2 inhibitor, acitretin, ciclosporin, fumaric acid esters, and methotrexate), as these drugs, in the NMA, have been evaluated in few trials. We found no significant difference between any of the interventions and the placebo for the risk of SAEs. Nevertheless, the SAE analyses were based on a very low number of events with low to very low certainty for just under half of the treatment estimates in total, and moderate for the others. Thus, the results have to be viewed with caution and we cannot be sure of the ranking. For other efficacy outcomes (PASI 75 and Physician Global Assessment (PGA) 0/1) the results were very similar to the results for PASI 90. Information on quality of life was often poorly reported and was absent for several of the interventions. AUTHORS' CONCLUSIONS Our review shows that compared to placebo, the biologics infliximab, ixekizumab, risankizumab, bimekizumab, guselkumab, secukinumab and brodalumab were the best choices for achieving PASI 90 in people with moderate-to-severe psoriasis on the basis of moderate- to high-certainty evidence (low-certainty evidence for bimekizumab). This NMA evidence is limited to induction therapy (outcomes were measured from 8 to 24 weeks after randomisation) and is not sufficient for evaluation of longer-term outcomes in this chronic disease. Moreover, we found low numbers of studies for some of the interventions, and the young age (mean age of 45 years) and high level of disease severity (PASI 20 at baseline) may not be typical of patients seen in daily clinical practice. Another major concern is that short-term trials provide scanty and sometimes poorly-reported safety data and thus do not provide useful evidence to create a reliable risk profile of treatments. Indeed, we found no significant difference in the assessed interventions and placebo in terms of SAEs, but the evidence for all the interventions was of very low to moderate quality. In order to provide long-term information on the safety of the treatments included in this review, it will also be necessary to evaluate non-randomised studies and postmarketing reports released from regulatory agencies. In terms of future research, randomised trials comparing directly active agents are necessary once high-quality evidence of benefit against placebo is established, including head-to-head trials amongst and between conventional systemic and small molecules, and between biological agents (anti-IL17 versus anti-IL23, anti-IL23 versus anti-IL12/23, anti-TNF alpha versus anti-IL12/23). Future trials should also undertake systematic subgroup analyses (e.g. assessing biological-naïve participants, baseline psoriasis severity, presence of psoriatic arthritis, etc.). Finally, outcome measure harmonisation is needed in psoriasis trials, and researchers should look at the medium- and long-term benefit and safety of the interventions and the comparative safety of different agents. Editorial note: This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Emilie Sbidian
- Hôpital Henri Mondor, Department of Dermatology, 51 Avenue du Maréchal de Lattre de Tassigny, Créteil, France, 94000
- Hôpital Henri Mondor, Clinical Investigation Centre, Créteil, France, 94010
- Université Paris Est Créteil (UPEC), Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Créteil, France
| | - Anna Chaimani
- Université de Paris, Research Center in Epidemiology and Statistics Sorbonne Paris Cité (CRESS-UMR1153), Inserm, Inra, F-75004, Paris, France
- Cochrane France, Paris, France
| | - Sivem Afach
- Université Paris Est Créteil (UPEC), Epidemiology in dermatology and evaluation of therapeutics (EpiDermE) - EA 7379, Créteil, France
| | - Liz Doney
- Cochrane Skin Group, The University of Nottingham, Centre of Evidence Based Dermatology, A103, King's Meadow Campus, Lenton Lane, Nottingham, UK, NG7 2NR
| | - Corinna Dressler
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Division of Evidence Based Medicine, Department of Dermatology, Venerology and Allergology, Charitéplatz 1, Berlin, Germany, 10117
| | - Camille Hua
- Hôpital Henri Mondor, Department of Dermatology, 51 Avenue du Maréchal de Lattre de Tassigny, Créteil, France, 94000
| | - Canelle Mazaud
- Hôpital Henri Mondor, Department of Dermatology, 51 Avenue du Maréchal de Lattre de Tassigny, Créteil, France, 94000
| | - Céline Phan
- Centre Hospitalier Victor Dupouy, Department of Dermatology, Argenteuil, France
| | - Carolyn Hughes
- The University of Nottingham, c/o Cochrane Skin Group, A103, King's Meadow Campus, Lenton Lane, Nottingham, UK, NG7 2NR
| | - Dru Riddle
- Texas Christian University (TCU), School of Nurse Anesthesia, Fort Worth, Texas, USA
| | - Luigi Naldi
- Padiglione Mazzoleni - Presidio Ospedaliero Matteo Rota, Centro Studi GISED (Italian Group for Epidemiologic Research in Dermatology) - FROM (Research Foundation of Ospedale Maggiore Bergamo), Via Garibaldi 13/15, Bergamo, Italy, 24122
| | - Ignacio Garcia-Doval
- Complexo Hospitalario Universitario de Vigo, Department of Dermatology, Meixoeiro sn, Vigo, Spain, 36214
| | - Laurence Le Cleach
- Hôpital Henri Mondor, Department of Dermatology, 51 Avenue du Maréchal de Lattre de Tassigny, Créteil, France, 94000
- Université Paris Est Créteil (UPEC), Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Créteil, France
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Gelfand JM, Shin DB, Alavi A, Torigian DA, Werner T, Papadopoulos M, Takeshita J, Noe MH, Dey AK, Playford MP, Mehta NN. A Phase IV, Randomized, Double-Blind, Placebo-Controlled Crossover Study of the Effects of Ustekinumab on Vascular Inflammation in Psoriasis (the VIP-U Trial). J Invest Dermatol 2020; 140:85-93.e2. [PMID: 31326395 PMCID: PMC6926160 DOI: 10.1016/j.jid.2019.07.679] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/06/2019] [Accepted: 07/03/2019] [Indexed: 02/08/2023]
Abstract
Psoriasis is a T helper type 17 autoimmune disease associated with an increased risk cardiovascular events and mortality. Ustekinumab, an antibody to p40, blocks cytokines IL-12 and IL-23, and is a highly effective and safe treatment for psoriasis. We conducted a randomized double-blinded placebo-controlled trial to determine the effect of ustekinumab on aortic vascular inflammation (AVI) measured by imaging, and key biomarkers of inflammation, lipid, and glucose metabolism in the blood of patients with moderate-to-severe psoriasis. A total of 43 patients were randomized, and at week 12, ustekinumab-treated patients had a -18.65% (95% confidence interval = -29.45% to -7.85%) reduction in AVI, a reduction in inflammatory biomarkers, and an increase in apolipoprotein B lipoproteins compared with placebo. At week 12, placebo patients were crossed over such that all patients received ustekinumab for 52 weeks. At the end of 52 weeks of ustekinumab treatment, there was no change in AVI compared with baseline, inflammatory markers were reduced, and there were increases in selected measures of lipids and leptin. These results show that blockade of IL-12 and/or IL-23 may transiently reduce AVI, with more durable reduction in inflammatory cytokines associated with cardiovascular disease.
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Affiliation(s)
- Joel M Gelfand
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Daniel B Shin
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Abass Alavi
- Department of Radiology (Nuclear Medicine), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Drew A Torigian
- Department of Radiology (Nuclear Medicine), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tom Werner
- Department of Radiology (Nuclear Medicine), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maryte Papadopoulos
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Junko Takeshita
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Megan H Noe
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amit K Dey
- Section of Inflammation and Cardiometabolic Diseases, National Heart Lung Blood Institute, Bethesda, Maryland, USA
| | - Martin P Playford
- Section of Inflammation and Cardiometabolic Diseases, National Heart Lung Blood Institute, Bethesda, Maryland, USA
| | - Nehal N Mehta
- Section of Inflammation and Cardiometabolic Diseases, National Heart Lung Blood Institute, Bethesda, Maryland, USA
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Rungapiromnan W, Mason KJ, Lunt M, McElhone K, Burden AD, Rutter MK, Warren RB, Griffiths CEM, Ashcroft DM. Risk of major cardiovascular events in patients with psoriasis receiving biologic therapies: a prospective cohort study. J Eur Acad Dermatol Venereol 2019; 34:769-778. [PMID: 31633837 PMCID: PMC7155017 DOI: 10.1111/jdv.16018] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 09/30/2019] [Indexed: 12/21/2022]
Abstract
Background The cardiovascular safety profile of biologic therapies used for psoriasis is unclear. Objectives To compare the risk of major cardiovascular events (CVEs; acute coronary syndrome, unstable angina, myocardial infarction and stroke) in patients with chronic plaque psoriasis treated with adalimumab, etanercept or ustekinumab in a large prospective cohort. Methods Prospective cohort study examining the comparative risk of major CVEs was conducted using the British Association of Dermatologists Biologics and Immunomodulators Register. The main analysis compared adults with chronic plaque psoriasis receiving ustekinumab with tumour necrosis‐α inhibitors (TNFi: etanercept and adalimumab), whilst the secondary analyses compared ustekinumab, etanercept or methotrexate against adalimumab. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using overlap weights by propensity score to balance baseline covariates among comparison groups. Results We included 5468 biologic‐naïve patients subsequently exposed (951 ustekinumab; 1313 etanercept; and 3204 adalimumab) in the main analysis. The secondary analyses also included 2189 patients receiving methotrexate. The median (p25–p75) follow‐up times for patients using ustekinumab, TNFi, adalimumab, etanercept and methotrexate were as follows: 2.01 (1.16–3.21), 1.93 (1.05–3.34), 1.94 (1.09–3.32), 1.92 (0.93–3.45) and 1.43 (0.84–2.53) years, respectively. Ustekinumab, TNFi, adalimumab, etanercept and methotrexate groups had 7, 29, 23, 6 and 9 patients experiencing major CVEs, respectively. No differences in the risk of major CVEs were observed between biologic therapies [adjusted HR for ustekinumab vs. TNFi: 0.96 (95% CI 0.41–2.22); ustekinumab vs. adalimumab: 0.81 (0.30–2.17); etanercept vs. adalimumab: 0.81 (0.28–2.30)] and methotrexate against adalimumab [1.05 (0.34–3.28)]. Conclusions In this large prospective cohort study, we found no significant differences in the risk of major CVEs between three different biologic therapies and methotrexate. Additional studies, with longer term follow‐up, are needed to investigate the potential effects of biologic therapies on incidence of major CVEs. Linked Commentary: K. Kridin and A.D. Cohen. J Eur Acad Dermatol Venereol 2020; 34: 668–669. https://doi.org/10.1111/jdv.16345.
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Affiliation(s)
- W Rungapiromnan
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - K J Mason
- Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - M Lunt
- Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - K McElhone
- Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - A D Burden
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - M K Rutter
- Division of Endocrinology, Diabetes and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Manchester Diabetes Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - R B Warren
- Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Dermatology Centre, Salford Royal NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - C E M Griffiths
- Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Dermatology Centre, Salford Royal NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - D M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Korman NJ. Management of psoriasis as a systemic disease: what is the evidence? Br J Dermatol 2019; 182:840-848. [PMID: 31225638 PMCID: PMC7187293 DOI: 10.1111/bjd.18245] [Citation(s) in RCA: 209] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2019] [Indexed: 12/16/2022]
Abstract
Background Psoriasis is a chronic, systemic immune‐mediated disease characterized by development of erythematous, indurated, scaly, pruritic and often painful skin plaques. Psoriasis pathogenesis is driven by proinflammatory cytokines and psoriasis is associated with increased risk for comorbidities, including, but not limited to, psoriatic arthritis, cardiovascular disease, diabetes mellitus, obesity, inflammatory bowel disease and nonalcoholic fatty liver disease compared with the general population. Objectives To explore the pathophysiological relationship between psoriasis and its common comorbidities and discuss the need for new treatment paradigms that include strategies to reduce systemic inflammation in patients with moderate‐to‐severe psoriasis. Methods This narrative review summarizes the published evidence related to the ability of biological therapies to ameliorate the consequences of systemic inflammation in patients with psoriasis. Results Current evidence suggests that preventing damage associated with inflammation, and preventing development of future inflammatory damage and comorbidities, may be a potentially achievable treatment goal for many patients with moderate‐to‐severe plaque psoriasis when biological therapies are utilized early in the disease. Encouraging data from recent studies suggest that the loftier goal of reversing existing inflammatory damage and improving signs and symptoms of inflammatory comorbidities could also possibly be attainable. Conclusions Results from ongoing prospective studies regarding the effects of biologics on markers of systemic inflammation in patients with psoriasis will strengthen the clinical evidence base that can be used to inform treatment decisions for patients with moderate‐to‐severe psoriasis. What's already known about this topic? Psoriasis is a systemic inflammatory disease and treatments are needed to optimize patient outcomes.
What does this study add? This review discusses new psoriasis treatment paradigms that may potentially reduce effects of systemic inflammation. Evidence demonstrating that biological treatment may prevent or reverse inflammatory damage associated with psoriasis comorbidities is reviewed.
Linked Comment:https://doi.org/10.1111/bjd.18456
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Affiliation(s)
- N J Korman
- Department of Dermatology, Case Western Reserve University, Cleveland, OH, U.S.A.,University Hospitals Cleveland Medical Center, Cleveland, OH, U.S.A
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Gerdes S, Pinter A, Papavassilis C, Reinhardt M. Effects of secukinumab on metabolic and liver parameters in plaque psoriasis patients. J Eur Acad Dermatol Venereol 2019; 34:533-541. [PMID: 31599476 PMCID: PMC7065121 DOI: 10.1111/jdv.16004] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 09/13/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Psoriasis is associated with metabolic, liver and cardiovascular comorbidity. Secukinumab, a fully human monoclonal antibody that selectively neutralizes interleukin-17A, has shown significant and sustained efficacy in the treatment of moderate to severe psoriasis. OBJECTIVES This was an exploratory post hoc analysis of pooled data from three phase 3 studies in plaque psoriasis patient populations. The objective was to show the course of metabolic and liver parameters under secukinumab, etanercept or placebo treatment over time. A further objective was to assess the impact of selected comorbidities and metabolic characteristics on high-sensitivity C-reactive protein (hs-CRP), as a surrogate marker of systemic inflammation. METHODS Data from the phase 3 randomized controlled trials [FIXTURE (NCT01358578), ERASURE (NCT01365455) and SCULPTURE (NCT01406938); n = 3010] were included in this analysis. Patients were treated with secukinumab 150 mg or 300 mg, placebo or etanercept 50 mg (FIXTURE only) as active comparator. A set of metabolic and liver parameters was longitudinally assessed over 52 weeks. Multivariate regression analyses assessed the impact of selected comorbidities and metabolic characteristics on hs-CRP levels at baseline and under treatment. RESULTS Secukinumab treatment reduced hs-CRP levels. Body weight and uric acid levels tended to decrease over 52 weeks with secukinumab. Secukinumab showed a neutral effect on fasting plasma glucose, lipid parameters and liver enzymes. Psoriatic arthritis, metabolic syndrome, obesity, impaired glucose metabolism, and hyperuricemia were each associated with increased hs-CRP levels at baseline. Concomitant obesity attenuated the decline in hs-CRP under treatment. CONCLUSIONS These analyses suggest neutral to favourable long-term trends in metabolic and liver parameters under secukinumab treatment. Metabolic comorbidities were associated with increased hs-CRP levels, reflecting the role of systemic inflammatory processes in their pathophysiology.
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Affiliation(s)
- S Gerdes
- Psoriasis-Center, Department of Dermatology, University Medical Center Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - A Pinter
- Department of Dermatology, Venereology and Allergology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - M Reinhardt
- Novartis Pharma AG, Basel, Switzerland.,Novartis Pharma GmbH, Nürnberg, Germany
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Mehta NN, Shin DB, Joshi AA, Dey AK, Armstrong AW, Duffin KC, Fuxench ZC, Harrington CL, Hubbard RA, Kalb RE, Menter A, Rader DJ, Reilly MP, Simpson EL, Takeshita J, Torigian DA, Werner TJ, Troxel AB, Tyring SK, Vanderbeek SB, Van Voorhees AS, Playford MP, Ahlman MA, Alavi A, Gelfand JM. Effect of 2 Psoriasis Treatments on Vascular Inflammation and Novel Inflammatory Cardiovascular Biomarkers: A Randomized Placebo-Controlled Trial. Circ Cardiovasc Imaging 2019; 11:e007394. [PMID: 29776990 DOI: 10.1161/circimaging.117.007394] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 04/02/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Psoriasis is a chronic inflammatory disease associated with dyslipidemia, cardiovascular events, and mortality. We aimed to assess and compare the effect of treatment of moderate-to-severe psoriasis with adalimumab or phototherapy on vascular inflammation and cardiovascular biomarkers. METHODS AND RESULTS Randomized, double-blind, trial of adalimumab, phototherapy, and placebo (1:1:1) for 12 weeks, with crossover to adalimumab for 52 weeks total. Outcomes included vascular inflammation by 18F-fluorodeoxyglucose positron emission tomography/computed tomography and biomarkers of inflammation, insulin resistance, and lipoproteins. Ninety-seven patients were randomized, 92 completed the randomized controlled trial portion; 81 entered the adalimumab extension with 61 completing 52 weeks of adalimumab. There was no difference in change in vascular inflammation at week 12 in the adalimumab group (change compared with placebo, 0.64%; 95% confidence interval, -5.84% to 7.12%) or the phototherapy group (-1.60%; 95% confidence interval, -6.78% to 3.59%) or after 52-week adalimumab treatment (0.02% compared with initiation; 95% confidence interval, -2.85% to 2.90%). Both adalimumab and phototherapy decreased inflammation by serum CRP, interleukin-6. Only adalimumab reduced tumor necrosis factor and glycoprotein acetylation at 12 and 52 weeks. Neither had an impact on metabolic markers (insulin, adiponectin, and leptin). Only phototherapy increased high-density lipoprotein-p at 12 weeks. At 52-week of adalimumab cholesterol efflux and high-density lipoprotein-p were reduced. CONCLUSIONS Adalimumab reduced key markers of inflammation including glycoprotein acetylation compared with phototherapy with no effect on glucose metabolism and vascular inflammation, and potential adverse effects on high-density lipoprotein. Glycoprotein acetylation improvement may partially explain the beneficial effects of adalimumab seen in observational studies. Larger studies with more detailed phenotyping of vascular disease should assess the comparative differences in the effects of adalimumab and phototherapy seen in our study. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifiers: NCT01866592 and NCT01553058.
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Affiliation(s)
- Nehal N Mehta
- Cardiopulmonary Branch, National Heart, Lung, and Blood Institute, Bethesda, MD (N.N.M., A.A.J., A.K.D., C.L.H., M.P.P.).
| | - Daniel B Shin
- Department of Dermatology, Perelman School of Medicine (D.B.S., Z.C.F., J.T., S.B.V., J.M.G.)
| | - Aditya A Joshi
- Cardiopulmonary Branch, National Heart, Lung, and Blood Institute, Bethesda, MD (N.N.M., A.A.J., A.K.D., C.L.H., M.P.P.)
| | - Amit K Dey
- Cardiopulmonary Branch, National Heart, Lung, and Blood Institute, Bethesda, MD (N.N.M., A.A.J., A.K.D., C.L.H., M.P.P.)
| | - April W Armstrong
- University of Pennsylvania, Philadelphia. Department of Dermatology, University of Southern California, Los Angeles (A.W.A.)
| | | | - Zelma Chiesa Fuxench
- Department of Dermatology, Perelman School of Medicine (D.B.S., Z.C.F., J.T., S.B.V., J.M.G.)
| | - Charlotte L Harrington
- Cardiopulmonary Branch, National Heart, Lung, and Blood Institute, Bethesda, MD (N.N.M., A.A.J., A.K.D., C.L.H., M.P.P.)
| | - Rebecca A Hubbard
- Department of Epidemiology and Biostatistics, Perelman School of Medicine (R.A.H., J.T., A.B.T., J.M.G.).,The Center for Clinical Epidemiology and Biostatistics (R.A.H., J.T., J.M.G.)
| | - Robert E Kalb
- Department of Dermatology, Buffalo School of Medicine and Biomedical Sciences, State University of New York (R.E.K.)
| | - Alan Menter
- Department of Dermatology, Baylor University Medical Center, Dallas, TX (A.M.)
| | | | - Muredach P Reilly
- Department of Cardiology, Division of Medicine, Vagelos College of Physician and Surgeons, and the Irving Institute for Clinical and Translational Research, Columbia University Irving Medical Center, New York, NY (M.P.R.)
| | - Eric L Simpson
- Department of Dermatology, Oregon Health & Science University, Portland (E.L.S.)
| | - Junko Takeshita
- Department of Dermatology, Perelman School of Medicine (D.B.S., Z.C.F., J.T., S.B.V., J.M.G.).,Department of Epidemiology and Biostatistics, Perelman School of Medicine (R.A.H., J.T., A.B.T., J.M.G.).,The Center for Clinical Epidemiology and Biostatistics (R.A.H., J.T., J.M.G.)
| | - Drew A Torigian
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia (D.A.T., T.J.W., A.A.)
| | - Thomas J Werner
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia (D.A.T., T.J.W., A.A.)
| | - Andrea B Troxel
- Department of Epidemiology and Biostatistics, Perelman School of Medicine (R.A.H., J.T., A.B.T., J.M.G.)
| | - Stephen K Tyring
- Department of Dermatology, McGovern Medical School at Houston, TX (S.K.T.)
| | - Suzette Baez Vanderbeek
- Department of Dermatology, Perelman School of Medicine (D.B.S., Z.C.F., J.T., S.B.V., J.M.G.)
| | - Abby S Van Voorhees
- Department of Dermatology, Eastern Virginia Medical School, Norfolk (A.S.V.V.)
| | - Martin P Playford
- Cardiopulmonary Branch, National Heart, Lung, and Blood Institute, Bethesda, MD (N.N.M., A.A.J., A.K.D., C.L.H., M.P.P.)
| | - Mark A Ahlman
- Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Research Center, Bethesda, MD (M.A.A.)
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia (D.A.T., T.J.W., A.A.)
| | - Joel M Gelfand
- Department of Dermatology, Perelman School of Medicine (D.B.S., Z.C.F., J.T., S.B.V., J.M.G.) .,Department of Epidemiology and Biostatistics, Perelman School of Medicine (R.A.H., J.T., A.B.T., J.M.G.).,The Center for Clinical Epidemiology and Biostatistics (R.A.H., J.T., J.M.G.)
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49
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Affiliation(s)
| | - David Newby
- Professor of Cardiology (D.N.), University of Edinburgh, Centre for Cardiovascular Science, Scotland, United Kingdom
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50
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Takeshita J, Eriksen WT, Raziano VT, Bocage C, Hur L, Shah RV, Gelfand JM, Barg FK. Racial Differences in Perceptions of Psoriasis Therapies: Implications for Racial Disparities in Psoriasis Treatment. J Invest Dermatol 2019; 139:1672-1679.e1. [PMID: 30738054 DOI: 10.1016/j.jid.2018.12.032] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 12/05/2018] [Accepted: 12/18/2018] [Indexed: 12/11/2022]
Abstract
In the United States, black patients are less likely than white patients to receive biologic treatment for their psoriasis. We conducted a qualitative free-listing study to identify patient-generated factors that may explain this apparent racial disparity in psoriasis treatment by comparing the perceptions of biologics and other psoriasis therapies between white and black adults with psoriasis. Participants included 68 white and black adults with moderate to severe psoriasis who had and had not received biologic treatment. Each participant was asked to list words in response to verbal probes querying five psoriasis treatments: self-injectable biologics, infliximab, methotrexate, apremilast, and phototherapy. Salience scores indicating the relative importance of each word were calculated, and salient words were compared across each race/treatment group. Participants who had experience with biologics generally associated positive words with self-injectable biologics. Among biologic-naïve participants, "apprehension," "side effects," and "immune suppression" were most salient. "Unfamiliar" and "dislike needles" were salient only among black participants who were biologic naïve. Participants were generally unfamiliar with the other psoriasis therapies except phototherapy. Unfamiliarity with biologics, particularly among black, biologic-naïve patients, may partly explain the existing racial disparity in biologic treatment for psoriasis and might stem from lack of exposure to or poor understanding of biologics.
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Affiliation(s)
- Junko Takeshita
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Whitney T Eriksen
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Valerie T Raziano
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Claire Bocage
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lynn Hur
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ruchi V Shah
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey, USA
| | - Joel M Gelfand
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Frances K Barg
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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