Lithium, antipsychotics, and risk of psoriasis

Psychiatric medications and the risk of autoimmune and immune-mediated inflammatory diseases: A systematic review and meta-analysis of observational studies

BACKGROUND

Pharmacovigilance reports have suggested that certain commonly used medications may trigger autoimmune diseases (ADs) and immune-mediated inflammatory diseases (IMIDs). We systematically reviewed the literature to evaluate whether psychiatric medication use is associated with ADs and IMIDs.

METHODS

The protocol was registered in PROSPERO (CRD42022296524) before the start of the study. We searched Medline Ovid and Scopus up to November 28th, 2021, for comparative studies, with any psychiatric medication as exposure and ADs and IMIDs as outcomes. Meta-analysis was performed using DerSimonian-Laird random-effects modeling. The PRISMA 2020 guidelines were followed in reporting. Study-level risk of bias was assessed using the Newcastle-Ottawa Scale, and the overall certainty of evidence using GRADE.

RESULTS

There were 7,265 citations from which 31 studies were eligible, all from high-income countries, covering 15 distinct immune diseases. The evidence for the association between selective serotonin reuptake inhibitor (SSRI) use and higher risk of microscopic colitis (meta-OR 2.60, 95% CI 1.05-6.39, I2 97.5%, 6 studies) was of low certainty. A subgroup analysis by the histological type of microscopic colitis showed a statistically significant association only with lymphocytic colitis (meta-OR 2.88, 95% CI 2.60-3.18, I2 00.00%, three studies). In two case-control studies, SSRI use had no significant association with psoriasis (meta-OR 0.80, 95% CI 0.58-1.10, I2 82.4%). The risk of acute pancreatitis was slightly increased with exposure to SSRIs (meta-OR 1.13, 95% CI 1.01-1.26, I2 00.0%), as was the risk of bullous pemphigoid after exposure to antipsychotics (meta-OR 1.79, 95% CI 1.17-2.73, I2 0%).

CONCLUSIONS

We reviewed the literature on whether psychiatric medications associate with the risk of ADs and IMIDs and concluded that, despite several signals, the credibility of evidence remains low at best. Prospective cohort studies would be needed as the next step to confirm the suggestions of increased risk.

Psoriasis risk after betablocker exposure: description of a pharmacovigilance signal

AIM

We aimed to investigate French pharmacovigilance data. The objective was to characterize psoriatic conditions occurred after BB exposure and bright to light a possible pharmacovigilance signal.

METHODS

Spontaneous reports of psoriatic conditions recorded in the French national Pharmacovigilance database (FPVD) between 1985 and 2019 were extracted. We performed a retrospective, descriptive analysis of reports linked to BB exposure. Association between psoriasis risk and BB exposure was assessed using a case/non-case study.

RESULTS

Two hundred and twenty-five reports of psoriatic conditions after BB exposure were recorded in the FPVD during the study period. Both, cardioselective and non-cardioselective, topical and systemic, BBs are involved. Therapeutic indication of BB was mainly hypertension Mean time to onset was 5 months and outcome was favorable in 68% after BB discontinuation. These features were concordant with those of literature reports. The reporting odds ratio (ROR) was 8.95 (95%CI 7.75 - 10.33).

CONCLUSION

We highlighted a statistically significant disproportionality which constitutes a pharmacovigilance signal. Psoriasis risk with BBs is a class effect. Increasing surveillance during the 1^st year of BB exposure is needed.

Association of Benzodiazepine Receptor Agonist Use With Changes in Psoriasis Severity in Adult Population: A Population-Based Study

To date, it remains uncertain whether benzodiazepine receptor agonists (BZRAs) are aggravating factors even though these drugs can elevate the levels of biomarkers associated with the development of psoriasis. Therefore, this study aimed to investigate the association of BZRA use with changes in psoriasis severity. All data were sourced from the National Health Insurance system in Taiwan. We conducted a population-based retrospective cross-sectional study of 15,727 psoriasis patients who received BZRAs (BZRA users), and 18,856 psoriasis patients who did not receive BZRAs (nonusers). At least a 1-year washout period without any BZRA prescriptions was required. The main outcome was the change in psoriasis severity between before and after BZRA exposure. This study detected the exacerbation of psoriasis severity in mild psoriasis population by using a logistic model. Then, this study carried another logistic model among those patients who had severe psoriasis to calculate the odds ratios (ORs) for the improvement of the psoriasis severity. Among patients with mild psoriasis, BZRA users had a significantly higher probability of psoriasis severity exacerbation (IPTW-adjusted OR = 1.46). Mild psoriasis patients who received high and low doses of BZRAs had 1.70- and 1.39-fold higher probabilities of psoriasis severity exacerbation, respectively, than the non-users. Furthermore, in the severe psoriasis population, more low-dose BZRA users improved psoriasis severity than non-users. In conclusion, this study provided clinical evidence of the effects of BZRA use on patients with psoriasis severity. Among patients with mild psoriasis, high-dose BZRA users may be associated with the changes in psoriasis severity. However, low-dose BZRA exposure only slightly exacerbated disease severity among patients with mild psoriasis. Accordingly, clinicians should evaluate the risks and benefits of the BZRA usage.

The role of xenobiotics in triggering psoriasis

Psoriasis is a common inflammatory skin disease affecting approximately 2% of the world population. A complex interplay of genetic predisposition and risk factors contributes to the risk of its onset. Several xenobiotics have been implicated in the pathogenesis of psoriasis. Drugs are among the most investigated trigger factors; strong association with disease induction or exacerbation has been reported for β-blockers, lithium, NSAIDs and ACE inhibitors, all of which are commonly used in the management of various comorbidities in psoriasis patients. Furthermore, inhibitors of TNF have a well-documented potential for triggering new-onset psoriasis when used for other indications (e.g. Crohn's disease or rheumatoid arthritis), while post-marketing data have revealed the same association for ustekinumab. Several other drugs have been connected with psoriasis, but the evidence is less compelling. Smoking and alcohol have been reported to increase the risk for occurrence of psoriasis, but can also affect unfavorably the course of the disease and its response to treatment. Furthermore, exposure to secondhand smoke, especially in childhood, also mediates the risk. Emerging data now suggest that air pollution also has a detrimental effect on skin disease, including psoriasis, but this association needs further investigation. Understanding of the toxic effect of xenobiotics on the initiation and clinical course of psoriasis can contribute to its better control, as it can help with the avoidance of triggering factors and, in some cases, influence the success of pharmacological treatment. It, therefore, has an important place in the comprehensive management of psoriasis.

Psoriasis After Exposure to Angiotensin-Converting Enzyme Inhibitors: French Pharmacovigilance Data and Review of the Literature

INTRODUCTION

Angiotensin-converting enzyme inhibitors (ACEIs) can induce or aggravate psoriasis. This risk is not specified in the Summary of Product Characteristics (SmPC) of some drugs of this class, such as captopril or enalapril. We aimed to investigate the association between psoriasis and ACEI exposure.

METHODS

We analyzed spontaneous reports recorded in the French national Pharmacovigilance Database (FPVD) from 1985 to 31 December 2018. The association between psoriasis and ACEI exposure was assessed using the case/non-case method. We also reviewed literature reports.

RESULTS

One hundred reports of psoriasis after ACEI exposure were registered in the FPVD. The reporting odds ratio (ROR) was 2.40 (95% CI 1.96-2.95). Time to onset was < 1 year in 67% of reports. Outcome was favorable in 73% of reports after ACEI discontinuation. Almost all ACEIs were concerned. In the literature, we found 21 published reports of psoriasis with ACEIs. Time to onset ranged from 1 week to 4 months. Outcome was also favorable after ACEI discontinuation in over half of the literature reports.

CONCLUSIONS

We found a statistically significant association between psoriasis and ACEI, which constitutes a potential safety signal. The risk of psoriasis is a class effect, time to onset is less than 1 year, and outcome is favorable after ACEI discontinuation. Psoriasis should be mentioned in the SmPCs of all ACEIs, and healthcare professionals should be informed about this risk.

Diagnostic and therapeutic guidelines for plaque psoriasis - Brazilian Society of Dermatology

Psoriasis is a chronic inflammatory disease that affects 1.3% of the Brazilian population. The most common clinical manifestations are erythematous, scaling lesions that affect both genders and can occur on any anatomical site, preferentially involving the knees, elbows, scalp and genitals. Besides the impact on the quality of life, the systemic nature of the disease makes psoriasis an independent risk factor for cardiovascular disease, especially in young patients with severe disease. By an initiative of the Brazilian Society of Dermatology, dermatologists with renowned clinical experience in the management of psoriasis were invited to form a work group that, in a partnership with the Brazilian Medical Association, dedicated themselves to create the Plaque Psoriasis Diagnostic and Treatment Guidelines. The relevant issues for the diagnosis (evaluation of severity and comorbidities) and treatment of plaque psoriasis were defined. The issues generated a search strategy in the Medline-PubMed database up to July 2018. Subsequently, the answers to the questions of the recommendations were devised, and each reference selected presented the respective level of recommendation and strength of scientific evidence. The final recommendations for making up the final text were worded by the coordinators.

Psoriasis during angiotensin receptor blocker exposure: an underestimated adverse drug reaction

BACKGROUND

Angiotensin receptor blockers (ARBs) can induce or exacerbate psoriasis. Psoriasis is unlisted in the Summary of Product Characteristics (SmPC) of ARBs. We aimed to investigate the association between psoriasis and ARB exposure.

METHODS

We reviewed spontaneous reports recorded in the French national Pharmacovigilance Database (FPVD). The association between psoriasis and ARB exposure was assessed using the case/non-case method. We also analyzed literature reports.

RESULTS

We identified 89 reports of psoriasis during ARB exposure in the FPVD. Time to onset was most often less than 1 year. Outcome was favorable in 67% of reports after ARB discontinuation. Almost all ARBs were concerned. The reporting odds ratio (ROR) for psoriasis with this therapeutic class was 4.86 (95%CI 3.92-6.03). In the literature, we found 14 published reports of psoriasis with ARB exposure. Time to onset ranged from 6 weeks to 9 months. Outcome was also favorable after ARB discontinuation in the literature.

CONCLUSIONS

This underestimated adverse drug reaction is a class effect, time to onset is most often less than 1 year and outcome seems favorable after ARB discontinuation. The case/non-case approach highlights a potential safety signal. The SmPC of ARBs should be updated, increased awareness among healthcare professionals is warranted.

Drug-induced psoriasis: clinical perspectives

Exposure to certain drugs can elicit an induction or exacerbation of psoriasis. Although well-conducted systematic studies on drug-related psoriasis are mostly lacking, traditionally strong associations have been documented for beta-blockers, lithium, antimalarial drugs such as (hydroxy)chloroquine, interferons, imiquimod, and terbinafine. More recently, new associations have been reported for monoclonal antibody- and small-molecule-based targeted therapies used for oncological and immunological indications, such as tumor necrosis factor-alpha antagonists and anti-programmed cell death protein 1 immune checkpoint inhibitors. Recognizing potential drug-related psoriasis is of clinical relevance to allow an optimal management of psoriasis. However, in clinical practice, identifying medication-related exacerbations and induction of psoriasis can be challenging. The clinical and histopathological features of drug-provoked psoriasis may differ little from that of “classical” nondrug-related forms of psoriasis. In addition, the latency period between start of the medication and onset of psoriasis can be significantly long for some drugs. Assessment of the Naranjo adverse drug reaction probability scale could be used as a practical tool to better differentiate drug-related psoriasis. The first step in the management of drug-related psoriasis is cessation and replacement of the offending drug when deemed clinically possible. However, the induced psoriasis skin lesions may persist after treatment withdrawal. Additional skin-directed treatment options for drug-related psoriasis follows the conventional psoriasis treatment guidelines and includes topical steroids and vitamin D analogs, ultraviolet phototherapy, systemic treatments, such as acitretin, methotrexate, and fumaric acid esters, and biological treatments.

Antipsychotic-associated psoriatic rash - a case report

BACKGROUND

Antipsychotics are a heterogeneous group of drugs. Although, antipsychotics have been used for years, unexpected side effects may still occur. With this case report we focus on a possible association between psoriasis and antipsychotics. Data on the patient's course of psychiatric disease, onset of psoriasis and its evolution were extracted from the patient's medical files.

CASE PRESENTATION

We present a case of a 21-year-old female diagnosed with schizophrenia. She was initially treated with quetiapine, and later switched to aripiprazole due to weight gain. After initiation of antipsychotic treatment, the patient suffered from severe psoriasis lesions.

CONCLUSIONS

Antipsychotics may possess immunological properties that may be involved in immune-mediated conditions, such as psoriatic rash. Further studies are warranted to determine causality and mechanism.

Triggering drug use in patients with psoriasis: an investigative report from Turkey

INTRODUCTION

The patients clinically diagnosed with psoriasis were investigated for drug use that may trigger psoriasis.

AIM

To minimize the triggering drug use and help the medical treatment of psoriasis patients.

MATERIAL AND METHODS

The study involved 289 psoriatic patients who attended our clinic in 2010-2012 and were asked to bring their drug lists of the last year, which they obtained from the pharmacy's record system. They were advised not to use the drugs that may trigger psoriasis. Data analyses were performed using SPSS program version 19.0.

RESULTS

A total of 289 patients were included in the study. Two hundred and twenty-one patients were using non-steroidal anti-inflammatory drugs; 133 patients were using anti-reflux drugs; 35 patients were using antidiabetic drugs; 31 patients were using calcium-channel blockers and 24 patients were using β-blockers. In our study group, there was no significantly difference between median PASI scores of the patients using a triggering drug and those of who are not using a triggering drug. However, there was a positive low correlation between PASI rates and numbers of drugs used (r = 0.180, p = 0.013).

CONCLUSIONS

Many other factors may trigger psoriasis, therefore the effect of stopping or minimizing the drug use on disease remission is not known. Because of the high triggering drug use rate, it is important to enlighten psoriasis patients about triggering drugs.

Statin use and risk of first-time psoriasis diagnosis

BACKGROUND

Statins have been suggested as a potential treatment for psoriasis because of their anti-inflammatory properties. However, evidence on the benefits of statins is scarce.

OBJECTIVE

We sought to study the association between use of statins or other lipid-lowering agents and the risk of developing psoriasis.

METHODS

We conducted a case-control analysis using the United Kingdom-based General Practice Research Database. We identified patients with an incident psoriasis diagnosis between 1994 and 2005 and matched one control subject to each patient on age, sex, general practice, calendar time, and years of history in the database. We estimated odds ratios (ORs) with 95% confidence intervals (CIs), stratified exposure by timing and duration, and adjusted the ORs for potential confounders.

RESULTS

We identified 36,702 incident psoriasis cases and the same number of matched controls. Adjusted ORs for current use (last prescription <30 days before index date) of 1 to 4, 5 to 19, or greater than or equal to 20 prescriptions for statins, as compared with nonuse, were 0.60 (95% CI 0.45-0.80), 1.00 (95% CI 0.84-1.18), and 1.08 (95% CI 0.92-1.28), respectively. The ORs for recent and past use (last prescription 30-89 days and ≥90 days ago, respectively) were around 1, except for past use of 1 to 4 prescriptions (OR 1.39; 95% CI 1.09-1.78).

LIMITATIONS

Potential of residual confounding as a result of retrospective study design is a limitation.

CONCLUSIONS

This large case-control study does not provide evidence for an altered risk of developing psoriasis in association with long-term use of statins. The reduced psoriasis risk for current short-term statin users is interesting, but whether the association is indeed causal needs further investigation.