Multiple sclerosis is associated with psoriasis. A case–control study

Reverse causation between multiple sclerosis and psoriasis: a genetic correlation and Mendelian randomization study

Observational studies have found a potential bidirectional positive association between multiple sclerosis and psoriasis, but these studies are susceptible to confounding factors. We examined the directionality of causation using Mendelian randomization and estimated the genetic correlation using the linkage disequilibrium score. We performed Mendelian randomization analysis using large-scale genome-wide association studies datasets from the International Multiple Sclerosis Genetics Consortium (IMSGC, 115,803 individuals of European ancestry) and FinnGen (252,323 individuals of European ancestry). We selected several Mendelian randomization methods including causal analysis using summary effect (CAUSE), inverse variance-weighted (IVW), and pleiotropy-robust methods. According to CAUSE and IVW the genetic liability to MS reduces the risk of psoriasis (CAUSE odds ratio [OR] 0.93, p = 0.045; IVW OR 0.93, p = 2.51 × 10-20), and vice versa (CAUSE OR 0.72, p = 0.001; IVW OR 0.71, p = 4.80 × 10-26). Pleiotropy-robust methods show the same results, with all p-values < 0.05. The linkage disequilibrium score showed no genetic correlation between psoriasis and MS (rg =  - 0.071, p = 0.2852). In summary, there is genetic evidence that MS reduces the risk of psoriasis, and vice versa.

Treatment of autoimmunity: The impact of disease-modifying therapies in multiple sclerosis and comorbid autoimmune disorders

More than 10 disease-modifying therapies (DMT) are approved by the European Medicines Agency (EMA) and the US Food and Drug Administration (FDA) for the treatment of multiple sclerosis (MS) and new therapeutic options are on the horizon. Due to different underlying therapeutic mechanisms, a more individualized selection of DMTs in MS is possible, taking into account the patient's current situation. Therefore, concomitant treatment of various comorbid conditions, including autoimmune mediated disorders such as rheumatoid arthritis, should be considered in MS patients. Because the pathomechanisms of autoimmunity partially overlap, DMT could also treat concomitant inflammatory diseases and simplify the patient's treatment. In contrast, the exacerbation and even new occurrence of several autoimmune diseases have been reported as a result of immunomodulatory treatment of MS. To simplify treatment and avoid disease exacerbation, knowledge of the beneficial and adverse effects of DMT in other autoimmune disorders is critical. Therefore, we conducted a literature search and described the beneficial and adverse effects of approved and currently studied DMT in a large number of comorbid autoimmune diseases, including rheumatoid arthritis, ankylosing spondylitis, inflammatory bowel diseases, cutaneous disorders including psoriasis, Sjögren´s syndrome, systemic lupus erythematosus, systemic vasculitis, autoimmune hepatitis, and ocular autoimmune disorders. Our review aims to facilitate the selection of an appropriate DMT in patients with MS and comorbid autoimmune diseases.

Exploring comorbidity and pharmacological treatment patterns in psoriasis - a retrospective population-based cross-sectional study

Background

Individuals with psoriasis face an increased risk of suffering from various comorbid conditions. However, there haven´t been any studies conducted in Sweden to examine the frequency of comorbidities and the corresponding treatment for these conditions among psoriasis patients.

Methods

The Cosmic electronic medical record represents a comprehensive repository of medical information including all residents of Region Jönköping. To conduct a population-based retrospective cross-sectional study, all individuals diagnosed with psoriasis between April 9, 2008 and July 1, 2016, were identified via the electronic medical records using ICD-10 codes. Data on comorbidity and dispensation of prescribed drugs against these comorbid conditions were analyzed.

Results

During the study period, 1.7% of the population (4,587 individuals) were diagnosed with psoriasis, with 74.3% of cases classified as mild to moderate psoriasis and 25.7% as severe. The remaining 268,949 individuals did not receive a psoriasis diagnosis. The study showed that psoriasis patients had higher odds of experiencing the majority of the comorbid conditions examined. Arthritis other than psoriasis arthritis was found to be the most prevalent comorbid diagnosis among psoriasis patients (adjusted OR 7.2, CI 95% 6.4-8.2, p < 0.001), followed by obesity (OR 2.4, CI 95% 1.9-3.1, p < 0,001). There was no significant difference in drug prescription for comorbid diseases between patients with psoriasis and patients without psoriasis except for arthritis and smoking cessation treatment.

Conclusions

Individuals with psoriasis are more susceptible to experiencing multiple comorbid conditions compared to the general population, particularly those with severe psoriasis. There is no evidence of undertreatment of comorbidity except for arthritis among psoriasis patients.

Multiple Sclerosis and Autoimmune Comorbidities

Multiple sclerosis (MS) is a chronic inflammatory and neurodegenerative disease of the central nervous system characterized by broad inter- and intraindividual heterogeneity and different prognoses. Multisystem comorbidities are frequent features in people with MS (PwMS) and can affect treatment choices, quality of life, disability and mortality. In this scenario, autoimmune comorbidities play a cardinal role for several reasons, such as the implication on MS pathogenesis, diagnostic delay, disease activity, disability progression, brain atrophy, and treatment choice. However, the impact of an autoimmune comorbid condition on MS is not fully elucidated. This review aims to summarize the currently available data on the incidence and prevalence of autoimmune diseases in PwMS, the possible effect of this association on clinical and neuroradiological MS course and its impact on treatment choice.

A systematic review of morbidities suggestive of the multiple sclerosis prodrome

INTRODUCTION

The identification of a prodromal phase in multiple sclerosis (MS) could have major implications for earlier recognition and management of MS. The authors conducted a systematic review assessing studies of morbidities before, or at, MS onset or diagnosis.Areas covered: Two independent reviewers searched Medline, Embase, Psycinfo and CINAHL from inception to February 8^th, 2019. To be eligible, studies had to be published in English and report the relative occurrence of at least one morbidity or symptom before, or at, MS onset or diagnosis among MS cases in comparison to a control group not known to have MS. Findings were narratively synthesized. Study quality was assessed using the Newcastle-Ottawa scale (NOS, maximum score 9).Expert opinion: Twenty-nine studies were included, which comprised 83,590 MS cases and 396,343 controls. Most were case-control studies (25/29), 8/29 were of high quality (NOS≥8) and 19/29 examined the period before MS symptom onset. Most studies assessing anxiety, depression, migraine and lower cognitive performance found these conditions to be more prevalent before MS onset or diagnosis relative to controls. There was limited evidence to implicate other conditions. Thus, there is evidence that anxiety, depression, migraine and lower cognitive performance form part of the MS prodrome.

A narrative review of psoriasis and multiple sclerosis: links and risks

The association of psoriasis (PsO) with other autoimmune and autoinflammatory diseases has long been a topic of interest. Although previous studies have attempted to clarify the specific relationship between PsO and multiple sclerosis (MS), it remains obscure, with limited and conflicting evidence regarding a link between the two entities. Herein, we review the etiology, pathogenesis, and treatment of each disease and present the available literature to-date regarding a possible relationship between PsO and MS. We conclude that further study is necessary to discern whether there may be a significant relationship between PsO and MS. In the meantime, clinicians may find it appropriate to screen for MS in patients with PsO, allowing for timely referral to a neurologist should it be necessary.

Association of Multiple Sclerosis with Psoriasis: A Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND

Previous studies have reported the occurrence of psoriasis together with multiple sclerosis (MS). Although similar predisposing genes and pathomechanisms have been hypothesized, the relationship between the two remains obscure.

OBJECTIVE

The aim of this systematic review and meta-analysis was to investigate the association between psoriasis and MS.

METHODS

We searched MEDLINE, Embase, and CENTRAL in July 2018 for case-control, cross-sectional, or cohort studies that examined either the odds or risk of psoriasis in subjects with multiple sclerosis. The risk of bias of included studies was assessed using the Newcastle-Ottawa Scale. A random-effects model meta-analysis was used to calculate the odds ratio (OR) for case-control/cross-sectional studies and hazard ratio (HR) for cohort studies.

RESULTS

We included 10 publications that reported a total of 11 studies (5 case-control, 4 cross-sectional and 2 cohort studies). The case-control and cross-sectional studies included 18,456 MS patients and 870,149 controls, while the two cohort studies involved 25,187 MS patients and 227,225 controls in total. Three studies were rated with a high risk of bias in comparability, non-response rate, and selection of controls. MS was associated with increased odds (OR 1.29; 95% confidence interval [CI] 1.14-1.45) and risk for psoriasis (HR 1.92; 95% CI 1.32-2.80).

CONCLUSION

Patients with MS display both increased prevalence and incidence of psoriasis.

Choosing First-Line Biologic Treatment for Moderate-to-Severe Psoriasis: What Does the Evidence Say?

An advanced understanding of the pathogenesis of psoriasis has led to the development of multiple therapeutic options for moderate-to-severe psoriasis. Tumor necrosis factor inhibitors, ustekinumab, interleukin-17 inhibitors, and guselkumab (an interleukin-23 inhibitor recently approved for psoriasis) are commercially available biologic agents for psoriasis. Evidence from clinical trials provides pertinent information regarding the safety and efficacy of biologic agents for psoriasis, which should be integrated into clinical decision making. However, disease presentations, disease severity, and comorbid conditions can complicate the choice of initial treatment, which underscores the importance of providing personalized therapy for patients with psoriasis. Furthermore, each biologic agent offers unique benefits and limitations for the treatment of patients with psoriasis. Here, evidence-based recommendations are presented and discussed regarding first-line biologic therapy options for patients with psoriasis and distinct comorbid conditions or patient-related factors. We discuss the comorbid conditions of psoriatic arthritis, multiple sclerosis, congestive heart failure, inflammatory bowel disease, hepatitis B, and latent tuberculosis. Moreover, we describe treatment recommendations for distinct patient populations with psoriasis, including pediatric patients with psoriasis and patients with psoriasis of childbearing potential and nursing.

Comorbidity of Narcolepsy Type 1 With Autoimmune Diseases and Other Immunopathological Disorders: A Case-Control Study

Background

Several evidences suggest that autoimmune diseases (ADs) tend to co-occur in an individual and within the same family. Narcolepsy type 1 (NT1) is a chronic sleep disorder caused by a selective loss of hypocretin-producing neurons due to a mechanism of neural destruction that indicates an autoimmune pathogenesis, although no evidence is available. We report on the comorbidity of ADs and other immunopathological diseases (including allergy diseases) in narcolepsy.

Methods

We studied 158 Caucasian NT1 patients (60.7% male; mean age 49.4 ± 19.7 years), in whom the diagnosis was confirmed by polysomnography followed by a multiple sleep latency test, or by hypocretin-1 levels measurements.

Results

Thirty out of 158 patients (18.99%; 53.3% female; 29 sporadic and one familial cases) had one or more immunopathological diseases associated. A control group of 151 subjects were matched by gender and age with the narcolepsy patients. Results demonstrated that there was a higher frequency of ADs in our series of narcolepsy patients compared to the sample of general population (odds ratio: 3.17; 95% confidence interval: 1.01 - 10.07; P = 0.040). A temporal relationship with the age at onset of the diseases was found.

Conclusions

Cataplexy was significantly more severe in NT1 patients with immunopathological diseases, and immunopathological diseases are a risk factor for severe forms of cataplexy in our series (odds ratio: 23.6; 95% confidence interval: 5.5 - 100.1).

Polyautoimmunity in a Greek cohort of multiple sclerosis

OBJECTIVES

The aim of this study was to assess the existence of polyautoimmunity in a Greek cohort of multiple sclerosis (MS), particularly multiple autoimmune syndrome (MAS), i.e., the presence of three or more distinct autoimmune disorders (ADs) in the same individual.

METHODS

Cross-sectional control study.

RESULTS

The overall prevalence of polyautoimmunity in 2140 MS patients (female to male ratio: 2.1:1) was 8.3% (vs 6.07% in 1580 matched control participants, P = 0.008) mainly due to differences in autoimmune thyroid disorders (AITD) and vitiligo. The prevalence of MAS was 1.0%. The most frequent diseases encountered in MS were organ-specific ADs. There was no statistical difference in the total rates of ADs between female and male MS patients. There were higher rates of AITD in women (P = 0.004) and higher rates of iritis (P = 0.039) and ankylosing spondylitis (P = 0.003) in men. MS was diagnosed in the same year with AD in 7.4% of patients with additional ADs, earlier than AD in 42.0% and later than AD in 50.6%.

CONCLUSION

Polyautoimmunity and particularly MAS occur more frequently in MS patients than in control participants indicating that MS may be part of a generalized susceptibility to autoimmunity. Therefore, polyautoimmunity may be implicated in the etiopathogenesis of MS-related ADs, with a potential impact on relative therapeutic strategies.

Fumaric acid esters in the management of psoriasis

Fumaric acid esters (FAE) are small molecules with immunomodulating, anti-inflammatory, and anti-oxidative effects. FAE were introduced as a systemic psoriasis treatment in 1959 and empirically developed further between 1970 and 1990 in Germany, Switzerland, and the Netherlands. The development of FAE as psoriasis treatment did not follow the traditional drug development phases. Nonetheless, in 1994 FAE were approved in Germany for the treatment of severe plaque psoriasis. FAE are currently one of the most commonly used treatments in Germany, and FAE are increasingly being used as an unlicensed treatment in several other European countries. To date, six randomized controlled trials and 29 observational studies have evaluated FAE in a combined total of 3,439 patients. The efficacy and safety profile of FAE is favorable. About 50%-70% of patients achieve at least 75% improvement in psoriasis severity after 16 weeks of treatment. Common adverse events of FAE include gastrointestinal complaints and flushing symptoms, which lead to treatment discontinuation in up to 40% of patients. Lymphocytopenia, eosinophilia, and proteinuria are commonly observed during FAE treatment, but rarely require treatment discontinuation. The long-term safety profile of continuous FAE treatment is favorable without an increased risk for infections, malignancies, or other serious adverse events. There are no known drug-interactions for FAE. The 2009 European evidence-based S3-guidelines on psoriasis treatment recommend FAE and suggest it as a first-line systemic treatment for moderate-to-severe plaque psoriasis. This review is aimed to give an overview of FAE treatment in the management of psoriasis.