Psoriasis associated with ulcerative colitis and Crohn's disease

OPT-In; Optimized Patient Treatment Outcomes in Plaque Psoriasis: A 3-Year State-Transition Treatment-Sequencing Model in the Italian Setting

INTRODUCTION

There are several treatment options for plaque psoriasis (PsO), but uncertainty remains around the optimal sequencing of treatments. The aims of this study were to investigate how adopting a best-treatment-first treatment sequence impacts patient outcomes and healthcare systems and to quantify the cost of treatment failure to the healthcare system.

METHODS

A 3-year state-transition treatment-sequencing model which identifies all possible treatment sequences in PsO was adapted to the Italian healthcare setting. Treatments considered in the model are those with European Medicines Agency marketing authorization and reimbursement in Italy as of December 2022. Italian market share data (2019-2021) and list prices (2022) informed the current prescribed sequences; these sequences were compared against all possible sequences to determine opportunities for improvement. Both the national perspective in Italy as well as the local perspective from seven regions were considered. The cost of treatment failure was informed through a questionnaire circulated to Italian dermatologists.

RESULTS

Overall, 1284 possible treatment sequences are possible when four lines of treatment are considered for patients with moderate-to-severe PsO in Italy. Within the estimated range of treatment failures across those sequences (0.97-2.56 per patient over 3 years), current prescribing behavior from the national perspective suggests patients will face 1.44 failures on average; this highlights the potential for improvement. For every treatment failure, the cost borne by the Italian National Healthcare Service (NHS) is €676.80. Overall, prescribing more optimized treatment sequences results in a 22.95% reduction in failures with a 2.27% increase in costs. The regional analyses found similar trends.

CONCLUSIONS

Results suggest that selecting the most effective treatment sequences for incident patients provides the greatest opportunity to reduce treatment failures and maximize patient outcomes with a modest impact on costs. While regional variations exist, there is room for improvement across the board, which could translate to more efficient local healthcare systems.

Dermatologic manifestations in pediatric patients with inflammatory bowel disease

BACKGROUND

Despite studies of dermatologic manifestations in adults with inflammatory bowel disease (IBD), little is known about the prevalence of IBD-associated skin lesions and their correlation with IBD severity in children. We aimed to address these knowledge gaps in our single-center cohort of children with IBD.

METHODS

Retrospective chart review of 528 children and adolescents (≤18 years old) with IBD and seen at Mayo Clinic (Rochester, MN) between 1999 and 2017 was conducted. The Chi-Square/Fischer's exact test (with p ≤ .05 to signify statistical significance) was applied to compare categorical outcomes between Crohn's disease (CD) and ulcerative colitis (UC) patients.

RESULTS

In total, 425 IBD patients (64.9% CD, 53% males) and ≥1 dermatologic diagnosis were included. Presence of ≥1 cutaneous infection was recorded in 42.8% of participants. Acne was the most common non-infectious dermatologic condition (30.8%), followed by eczema (15.8%) and perianal skin tags (14.6%). Angular cheilitis (p = .024), keratosis pilaris (KP, p = .003), and perianal skin complications (i.e., skin tags, fistula, and abscesses; all p < .001) were more frequently diagnosed among children with CD, while fungal skin infections (p = .017) were more frequently diagnosed in UC patients. Severity of IBD correlated with higher prevalence of perianal fistula (p = .003), perianal abscess (p = .041), psoriasis (p < .001), and pyoderma gangrenosum (PG, p = .003).

CONCLUSIONS

Both IBD-specific and IBD-nonspecific dermatologic conditions are very prevalent in childhood IBD, the most common being infectious. Children with CD are more likely to experience angular cheilitis, KP, and perianal skin findings than those with UC. Perianal disease, psoriasis, and PG are associated with more severe IBD.

The Skin Microbiome and its Significance for Dermatologists

The skin is a physical and immunological barrier to the external environment. Its large surface area is colonized by diverse communities of microorganisms, including bacteria, viruses, fungi, and Demodex species mites. These microorganisms and their genetic material together create the skin microbiome. Physiologic and anatomic properties of skin sites create biogeographical habitats (dry, moist, and sebaceous) where distinct microbiota communities reside. Although, in general, the composition of these habitats is maintained from person to person, the skin microbiome of an individual also has unique microbial features. Dysbiosis occurs when the normal abundance, composition, or location of the microbiota is changed, most notably there is a decrease in flora diversity. Certain skin diseases, including atopic dermatitis, rosacea, and psoriasis are associated with cutaneous dysbiosis, and even disruption of the gut microbiota. Studies have shown that current treatments for these dermatologic conditions can alter/stabilize the skin microbiome, and there is emerging research detailing the impact of prebiotics, probiotics, and postbiotics on these conditions. Although clinical guidelines do not currently exist, clinical studies support the safety and possible benefits of using topical prebiotics and postbiotics and oral probiotics for a variety of skin conditions. Until such guidelines exist, utilizing carefully designed clinical studies to inform clinical practice is recommended.

Identification of potential crucial genes shared in psoriasis and ulcerative colitis by machine learning and integrated bioinformatics

BACKGROUND

Mounting evidence suggest that there are an association between psoriasis and ulcerative colitis (UC), although the common pathogeneses are not fully understood. Our study aimed to find potential crucial genes in psoriasis and UC through machine learning and integrated bioinformatics.

METHODS

The overlapping differentially expressed genes (DEGs) of the datasets GSE13355 and GSE87466 were identified. Then the functional enrichment analysis was performed. The overlapping genes in LASSO, SVM-RFE and key module in WGCNA were considered as potential crucial genes. The receiver operator characteristic (ROC) curve was used to estimate their diagnostic confidence. The CIBERSORT was conducted to evaluate immune cell infiltration. Finally, the datasets GSE30999 and GSE107499 were retrieved to validate.

RESULTS

112 overlapping DEGs were identified in psoriasis and UC and the functional enrichment analysis revealed they were closely related to the inflammatory and immune response. Eight genes, including S100A9, PI3, KYNU, WNT5A, SERPINB3, CHI3L2, ARNTL2, and SLAMF7, were ultimately identified as potential crucial genes. ROC curves showed they all had high confidence in the test and validation datasets. CIBERSORT analysis indicated there was a correlation between infiltrating immune cells and potential crucial genes.

CONCLUSION

In our study, we focused on the comprehensive understanding of pathogeneses in psoriasis and UC. The identification of eight potential crucial genes may contribute to not only understanding the common mechanism, but also identifying occult UC in psoriasis patients, even serving as therapeutic targets in the future.

Mucosal expression of PI3, ANXA1, and VDR discriminates Crohn's disease from ulcerative colitis

Differential diagnosis of inflammatory bowel disease (IBD) to Crohn's disease (CD) or ulcerative colitis (UC) is crucial for treatment decision making. With the aim of generating a clinically applicable molecular-based tool to classify IBD patients, we assessed whole transcriptome analysis on endoscopy samples. A total of 408 patient samples were included covering both internal and external samples cohorts. Whole transcriptome analysis was performed on an internal cohort of FFPE IBD samples (CD, n = 16 and UC, n = 17). The 100 most significantly differentially expressed genes (DEG) were tested in two external cohorts. Ten of the DEG were further processed by functional enrichment analysis from which seven were found to show consistent significant performance in discriminating CD from UC: PI3, ANXA1, VDR, MTCL1, SH3PXD2A-AS1, CLCF1, and CD180. Differential expression of PI3, ANXA1, and VDR was reproduced by RT-qPCR, which was performed on an independent sample cohort of 97 patient samples (CD, n = 44 and UC, n = 53). Gene expression levels of the three-gene profile, resulted in an area under the curve of 0.84 (P = 0.02) in discriminating CD from UC, and therefore appear as an attractive molecular-based diagnostic tool for clinicians to distinguish CD from UC.

Psoriasis paradox-infliximab-induced psoriasis in a patient with Crohn's disease: a case report and mini-review

Biologic drugs are therapeutic modalities designed to inhibit specific cytokine signaling pathways. The introduction of these drugs in the management of autoimmune diseases has dramatically changed the treatment paradigm of chronic systemic immune-mediated inflammatory disorders. However, despite their overall acceptable safety profiles, paradoxical reactions have been reported in some real-life cases including case studies and clinical trials. In this study, we report a patient with Crohn's disease who developed infliximab-induced psoriasis vulgaris after starting infliximab treatment. In this case, infliximab was discontinued, and low-dose steroids and subcutaneous methotrexate were introduced to control both his psoriasis and bowel condition with satisfying responses.

Evaluation of Auditory Functions in Patients with Psoriasis

Our study aims to evaluate the functions of the middle and inner ear and the efferent auditory system in psoriasis. Hearing thresholds, resonance frequency, otoacoustic emission amplitudes with and without contralateral acoustic stimulation, contralateral suppression levels were evaluated in 35 psoriasis patients and 40 controls. The air-conduction hearing thresholds of the patients were significantly higher than the controls at 125, 250, 500, 1000, 2000, 4000, and 12,000 Hz frequencies in the left ear, and 125, 250, 500, 1000, 2000, and 4000 Hz frequencies in the right ear, and the bone-conduction hearing thresholds of the patients were found to be significantly higher than the controls at all frequencies in the left ear, and 250, 500, 1000 and 2000 Hz in the right ear (p < 0.05). The resonance frequencies of patients were found to be significantly lower than the controls (p < 0.001). The emission amplitudes obtained with contralateral acoustic stimulation were significantly lower than without contralateral acoustic stimulation at 1 kHz frequency in both groups (p < 0.01). There was no significant difference in contralateral suppression levels of the two groups (p > 0.05). Our findings indicate that middle ear mechanics can be affected by psoriasis. There was no significant difference between psoriasis patients and healthy controls in terms of efferent auditory functions. There was a significant difference at limited frequency in hearing thresholds and emission amplitudes between the groups.

Seronegative spondyloarthropathy-associated inflammatory bowel disease

Seronegative spondyloarthropathy (SpA) usually starts in the third decade of life with negative rheumatoid factor, human leukocyte antigen-B27 genetic marker and clinical features of spinal and peripheral arthritis, dactylitis, enthesitis and extra-articular manifestations (EAMs). Cases can be classified as ankylosing spondylitis, psoriatic arthritis, reactive arthritis, enteropathic arthritis, or juvenile-onset spondyloarthritis. Joint and gut inflammation is intricately linked in SpA and inflammatory bowel disease (IBD), with shared genetic and immunopathogenic mechanisms. IBD is a common EAM in SpA patients, while extraintestinal manifestations in IBD patients mostly affect the joints. Although individual protocols are available for the management of each disease, the standard therapeutic guidelines of SpA-associated IBD patients remain to be established. Nonsteroidal anti-inflammatory drugs are recommended as initial therapy of peripheral and axial SpA, whereas their use is controversial in IBD due to associated disease flares. Conventional disease-modifying anti-rheumatic drugs are beneficial for peripheral arthritis but ineffective for axial SpA or IBD therapy. Anti-tumor necrosis factor monoclonal antibodies are effective medications with indicated use in SpA and IBD, and a drug of choice for treating SpA-associated IBD. Janus kinase inhibitors, approved for treating SpA and ulcerative colitis, are promising therapeutics in SpA coexistent with ulcerative colitis. A tight collaboration between gastroenterologists and rheumatologists with mutual referral from early accurate diagnosis to appropriately prompt therapy is required in this complex clinical scenario.

Biologic and Small-Molecule Therapies for Moderate-to-Severe Psoriasis: Focus on Psoriasis Comorbidities

Psoriasis is a systemic immune-mediated disease associated with an increased risk of comorbidities, such as psoriatic arthritis, cardiovascular disease, metabolic syndrome, inflammatory bowel disease, psychiatric disorders, and malignancy. In recent years, with the advent of biological agents, the efficacy and safety of psoriasis treatments have dramatically improved. Presently, tumor necrosis factor-α inhibitors, interleukin-17 inhibitors, interleukin-12/23 inhibitors, and interleukin-23 inhibitors are approved to treat moderate-to-severe psoriasis. Small-molecule inhibitors, such as apremilast and deucravacitinib, are also approved for the treatment of psoriasis. Although it is still unclear, systemic agents used to treat psoriasis also have a significant impact on its comorbidities by altering the systemic inflammatory state. Data from clinical trials and studies on the safety and efficacy of biologics and small-molecule inhibitors provide important information for the personalized care and treatment for patients with psoriasis. Notably, treatment with interleukin-17 inhibitors is associated with new-onset or exacerbations of inflammatory bowel disease. In addition, great caution needs to be taken when using tumor necrosis factor-α inhibitors in patients with psoriasis with concomitant congestive heart failure, multiple sclerosis, and malignancy. Apremilast may induce weight loss as an adverse effect, presenting also with some beneficial metabolic actions. A better understanding of the characteristics of biologics and small-molecule inhibitors in the treatment of psoriasis comorbidities can provide more definitive guidance for patients with distinct comorbidities.

The causal relationship between psoriasis, psoriatic arthritis, and inflammatory bowel diseases

Psoriasis is more common in patients with inflammatory bowel disease (IBD) than in the general population. Similarly, patients with psoriasis or psoriatic arthritis (PsA) have a higher incidence of IBD. However, whether this association is causal remains unknown. Therefore, we used a two-sample bidirectional Mendelian randomization (MR) analysis to identify this relationship. According to MR analysis, psoriasis and PsA causally increased the odds of developing Crohn's disease (OR = 1.350 (1.066-1.709) P = 0.013; OR = 1.319 (1.166-1.492) P < 0.001). In contrast, MR estimates gave little support to a possible causal effect of psoriasis, PsA, on ulcerative colitis (OR = 1.101 (0.905-1.340) P = 0.335; OR = 1.007 (0.941-1.078) P = 0.831). Similarly, the reverse analysis suggested the Crohn's disease causally increased the odds of psoriasis and PsA (OR = 1.425 (1.174-1.731) P < 0.001; OR = 1.448 (1.156-1.182) P = 0.001), whereas there are no causal association between ulcerative colitis and psoriasis, PsA (OR = 1.192 (0.921-1.542) P = 0.182; OR = 1.166 (0.818-1.664) P = 0.396). In summary, our MR analysis strengthens the evidence for the bidirectional dual causality between psoriasis (including PsA) and Crohn's disease.

Evaluation of the Role of Faecal Calprotectin in the Management of Psoriatic Patients under Treatment with Biologic Drugs

Background: Fecal calprotectin has emerged as a significant, validated, and non-invasive biomarker allowing for the evaluation of inflammatory bowel disease. Our study assessed the reliability of the use of faecal calprotectin as a valuable tool in the management of psoriatic patients on biological therapy. Methods: This was a single-centre prospective study including adult patients affected by moderate-to-severe psoriasis starting biological therapy. Faecal calprotectin levels were evaluated at baseline and at week 24 (W24) of treatment in all enrolled patients. Results: Overall, 129 patients were enrolled. The mean baseline faecal calprotectin levels were 74.7 μg/g and a significant reduction was detected at W24 of biological therapy (57.5 μg/g). An analysis of faecal CP values stratified by therapy type was performed. No significant reduction was assessed at W24 for any of the anti-IL17 drugs, whereas a significant reduction was detected for all IL23 inhibitors. Conclusions: Our study showed the potential use of faecal CP levels as a valuable tool for exploring intestinal inflammation in the management of psoriatic patients undergoing treatment with biologic drugs.

Drug safety evaluation of ixekizumab for psoriasis: a review of the current knowledge

INTRODUCTION

Since Anti-IL-17s availability, concerns about their safety have been raised due to the inhibition of physiological activities that IL-17A plays in the immune response against infections. Ixekizumab is a humanized monoclonal antibody specifically targeting IL-17A approved for the treatment of moderate-to-severe psoriasis.

AREAS COVERED

The aim of this review is to evaluate the safety profile of ixekizumab in moderate to severe psoriasis patients. A compressive literature review included article since March 2022.

EXPERT OPINION

in our analysis, most of the reported AEs were mild or moderate and rarely required treatment discontinuation. Among the class specific AEs to consider during ixekizumab treatment, there are the risk of Candida spp infections and the risk of IBD, which both were reported more frequently than if compared with placebo or other biologics (etanercept, ustekinumab, guselkumab). However, the reported candidiasis resulted mild-to moderate, and easily managed. The risk of IBD (both exacerbation and de novo diagnosis) represents a class effect of IL-17 inhibitors, which should be well evaluated before considering starting ixekizumab treatment. the most common AEs were represented by nasopharyngitis, upper respiratory tract infection, and injection-site reactions. The analysed studies confirmed the favourable safety profile of ixekizumab even in more recently published studies.

Phenome of coeliac disease vs. inflammatory bowel disease

Coeliac disease (CeD) is characterized by gliadin-induced intestinal inflammation appearing in genetically susceptible individuals, such as HLA-DQ2.5 carriers. CeD, as well as other chronic intestinal disorders, such as Crohn's disease (CD) and ulcerative colitis, has been associated with increased morbidity and mortality, but the causes are unknown. We systematically analysed CeD-associated diagnoses and compared them to conditions enriched in subjects with CD/UC as well as in HLA-DQ2.5 carriers without CeD. We compared the overall and cause-specific mortality and morbidity of 3,001 patients with CeD, 2,020 with CD, 4,399 with UC and 492,200 controls in the community-based UK Biobank. Disease-specific phenotypes were assessed with the multivariable Phenome Wide Association Study (PheWAS) method. Associations were adjusted for age, sex and body mass index. All disease groups displayed higher overall mortality than controls (CD: aHR = 1.91[1.70-2.17]; UC: aHR = 1.32 [1.20-1.46]; CeD: aHR = 1.38 [1.22-1.55]). Cardiovascular and cancer-related deaths were responsible for the majority of fatalities. PheWAS analysis revealed 166 Phecodes overrepresented in all three disorders, whereas only ~ 20% of enriched Phecodes were disease specific. Seven of the 58 identified CeD-specific Phecodes were enriched in individuals homozygous for HLA-DQ2.5 without diagnosed CeD. Four out of these seven Phecodes and eight out of 19 HLA-DQ2.5 specific Phecodes were more common in homozygous HLA-DQ2.5 subjects with vs. without CeD, highlighting the interplay between genetics and diagnosis-related factors. Our study illustrates that the morbidity and mortality in CeD share similarities with CD/UC, while the CeD-restricted conditions might be driven by both inherited and acquired factors.

Psoriasis – Differentialdiagnosen und Therapie

Die Psoriasis vulgaris, syn. Schuppenflechte, stellt eine der häufigsten ambulanten als auch stationären Behandlungsdiagnosen der Dermatologie dar. Die klassischerweise durch erythematosquamöse Plaques gekennzeichnete Hauterkrankung ist mit einem chronisch schubweisen Verlauf, sowie verschiedenen Komorbiditäten assoziiert. Die Patienten leiden im Falle einer Plaque-Psoriasis an typischen rötlichen, scharf begrenzten Plaques mit einer festhaftenden, groblamellären und weißlich-silbrigen Schuppung, wobei dies je nach Subtyp variieren kann. Typische Komorbiditäten aufgrund einer systemischen Inflammation betreffen unter anderem das kardiovaskuläre System, als auch den Bewegungsapparat. Neuartige, systemische Therapien ermöglichen es mittlerweile auch schwer Betroffenen eine Therapie-Option anzubieten und die Lebensqualität um ein hohes Maß zu steigern.

Inflammatory bowel disease and immune-mediated inflammatory diseases: looking at the less frequent associations

Patients with inflammatory bowel disease (IBD) often have other immune-mediated inflammatory diseases (IMIDs), and the prevalence of any IMID is higher in IBD patients than in the general population. IBD and other IMIDs involve alterations in innate and adaptive immune responses. Their co-occurrence depends on shared immune and inflammatory processes, pathogenic mechanisms, and genetic and environmental risk factors, including drugs, especially tumor necrosis factor inhibitors. The more common IMIDs associated with IBD have been widely described, so this review focuses on the less frequent associations. The IMIDs discussed here are skin disorders (psoriasis, atopic dermatitis, vitiligo, epidermolysis bullosa acquisita, cutaneous polyarteritis nodosa, and hidradenitis suppurativa), hepato-pancreatic diseases (autoimmune hepatitis, granulomatous hepatitis, and autoimmune pancreatitis), endocrine diseases (autoimmune thyroid diseases, and type 1 diabetes mellitus), multiple sclerosis, and respiratory diseases (asthma, bronchiectasis, and interstitial pneumonia). The early detection of IMIDs in IBD patients is important to prevent their deleterious clinical course and limit their psychological impact. Care for IBD patients with IMIDs should be multispecialist, with a single therapeutic strategy instead of treating each disease separately.

Overlapping Features of Psoriasis and Atopic dermatitis: From Genetics to Immunopathogenesis to Phenotypes

Psoriasis (PSO) and atopic dermatitis (AD) were once considered to be mutually exclusive diseases, but gradually regarded as a spectrum of disease. Shared genetic loci of both diseases were noted in some populations, including Chinese. Shared immunopathogenesis involving Th17, Th1, Th22 cells, or even IL-13 was found in certain stages or phenotypes. This review discusses the overlapping genetic susceptibility, shared cytokines, immune-mediated comorbidities, and clinical presentations. Overlapping conditions could be classified into mainly PSO lesions with AD features or vice versa, concomitant PSO and AD, or disease transformation as a result of biologics treatment.

Incidence Rates of Psoriasis in Children with Inflammatory Bowel Disease and Juvenile Arthritis Treated with TNFi Agents and DMARDs

Objective

To estimate the differential effect of tumor necrosis factor inhibitor (TNFi) therapies and presence/absence of conventional synthetic disease-modifying antirheumatic drug (DMARD) on the incidence of psoriasis in children with inflammatory bowel disease (IBD), juvenile idiopathic arthritis (JIA), and chronic nonbacterial osteomyelitis (CNO).

Methods

This was a retrospective cohort study from 2008 to 2020. TNFi and DMARD exposures were dichotomized as ever/never. The primary outcome was incident psoriasis. Incidence rates (IRs) of psoriasis were stratified by underlying diagnosis, TNFi agent, and DMARD use. Poisson regression was used to assess the IR ratios (IRR) between exposure groups.

Results

5088 children met inclusion criteria – 3794 (75%) had IBD, 1189 (23%) had JIA, and 105 (2%) had CNO. 613 (30%) and 1410 (70%) had TNFi exposure with or without a DMARD, respectively. IRR of developing psoriasis in patients exposed to adalimumab was 2.70 times higher (95% CI: 1.52-4.75; p<0.001) than those who did not receive any TNFi treatment, when controlling for DMARD, sex, and family history of psoriasis. IRR was lower, but not significantly different, for patients exposed to infliximab (IRR=2.34; 95% CI: 1.56-3.51; p<0.001) and etanercept (IRR=2.22; 95% CI: 1.17-4.21; p=0.006) compared to TNFi unexposed patients. IRR of TNFi exposure was lower by 0.25 (p<0.001) in DMARD exposed patients compared to non- DMARD exposed patients.

Conclusion

IRR of TNFi-induced psoriasis was not significantly different amongst adalimumab, infliximab, and etanercept. However, for patients with exposure to any of the TNFi evaluated, the IRR was significantly lower in those also exposed to a DMARD.

Oxidative Stress and Gut Microbiome in Inflammatory Skin Diseases

Oxidative stress plays a dominant role in inflammatory skin diseases. Emerging evidence has shown that the close interaction occurred between oxidative stress and the gut microbiome. Overall, in this review, we have summarized the impact of oxidative stress and gut microbiome during the progression and treatment for inflammatory skin diseases, the interactions between gut dysbiosis and redox imbalance, and discussed the potential possible role of oxidative stress in the gut-skin axis. In addition, we have also elucidated the promising gut microbiome/redox-targeted therapeutic strategies for inflammatory skin diseases.

The Effectiveness and Safety of Probiotic Supplements for Psoriasis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Preclinical Trials

Background

Patients with psoriasis need long-term medication to control their condition. Recent studies suggest that changing the intestinal flora may be a potential treatment.

Methods

The databases were utilized to search the randomized controlled trials (RCTs) and preclinical trials about probiotic supplement in the treatment of psoriasis. The retrieval time is from the establishment of these databases to December 2020. RevMan5.3 was used for the risk assessment of bias and meta-analysis. This systematic review was registered in PROSPERO (CRD42021232756).

Results

A total of 3 RCTs involving 164 participants were included. Two RCTs showed that probiotics can improve PASI and thereby improve the condition. For inflammation-related indicators, only one RCT showed that probiotics can improve the levels of CRP and TNF-α but have no obvious improvement effect on IL6. One RCT demonstrated the total effective rate of probiotics in the treatment of psoriasis. For adverse events, one RCT showed that the incidence of adverse events of probiotic treatment was low. Preclinical studies showed that continuous intervention with oral probiotics can significantly improve the progression of psoriasis and reduce the expression of inflammatory factors. The meta-analysis showed that the PASI between two groups was of no statistical significance (SMD 1.83 [-0.41, 4.07], P = 0.11). Meanwhile, probiotics may improve skin thickness (SMD -5.87 [-11.34, -0.41], P = 0.04) in animal model.

Conclusion

Prebiotics may have a positive effect on alleviating the clinical symptoms of psoriasis, but a large sample of RCTs is still needed to support its therapeutic effect in psoriasis.

The Use of Metrics in Daily Practice and the Perception of Psoriasis-Associated Comorbidities: Discrepancies Between Research and Real-World

Objective

To assess the feasibility of the future implementation of a recently published Belgian treat-to-target scoring in daily practice, we investigated to what extent Belgian dermatologists use metrics and take comorbidities into account in the follow-up of psoriasis patients.

Methods

Belgian dermatologists were addressed to fill out an online questionnaire in April 2020.

Results

A total of 149 dermatologists completed the survey. About 55% (n = 78) indicated to do a full-body examination during every visit. Psoriasis Area Severity Index (PASI) was the most frequently used clinical score: 25% (n = 35) and 61% (n = 87) indicated to use it every visit or sometimes (>1/year), respectively. The most frequently used patient-reported outcome scoring system was the Dermatology Life Quality Index: 35% use it sometimes. Overall, there is awareness for the association with metabolic syndrome.

Conclusion

Among tools for follow-up on moderate-to-severe psoriasis patients, Belgian dermatologists most frequently apply full-body examination and PASI score. Patient-reported outcome scoring systems are used infrequently. Psoriasis is perceived as a disease with comorbidities beyond the skin, especially obesity and hypertension. These real-world data on the use of clinical scores and PROs indicate a discrepancy from the academic setting in which new drugs are developed and evaluated. Furthermore, these data are imperative to estimate the feasibility of implementing a treat-to-target strategy published earlier by a Belgian expert group.

Risk of infections in psoriasis: assessment and challenges in daily management

INTRODUCTION

In daily practice management of psoriasis, evaluation of risk factors for infections is having a growing influence. Indeed, in psoriatic patients, risk of infections may be due to psoriasis itself, immunomodulatory therapy, and comorbidities that may increase this risk and patient hospitalization.

AREAS COVERED

Given the greater understanding of psoriasis pathogenesis and the increasing number of treatment options, it is particularly important to customize therapy according to each, single patient; psoriasis features and comorbidities are also essential to tailor treatment goals.

EXPERT OPINION

In this perspective, the current knowledge on the infectious risk in psoriatic patient, related to comorbidities, such as diabetes mellitus, cardiovascular disease, and chronic obstructive pulmonary, to 'special populations,' to chronic infections, such as latent tuberculosis, chronic hepatitis B and C, and HIV, and to the most recent Covid-19 pandemic scenario, is reviewed and discussed in order to suggest the most appropriate approach and achieve the best available therapeutic option.

Paradoxical psoriasis in pediatric patients: A systematic review

BACKGROUND

Paradoxical psoriasis occurs in pediatric patients following treatment with biologic agents. These presentations are not well described, and optimal treatment strategies have not been established.

OBJECTIVE

To describe the reported rates, demographic characteristics, clinical presentation, and treatment options for TNF-α inhibitor-induced psoriasis.

METHODS

Systematic review of published cases and cohort studies of paradoxical psoriasis induced by biologic agents, with specific reference to TNF-α inhibitors.

RESULTS

We identified 4564 pediatric patients treated with TNF-α inhibitors, of whom 210 (4.6%) developed paradoxical psoriasis. Infliximab was the drug most likely to induce psoriasis (8.3%), followed by adalimumab (3.3%). Individual-level data were acquired from 129 individuals with a mean age of 13.6 years (SD: 4.0); 45.0% were male. The scalp was the most commonly affected area (47.5%), followed by the ears (30.8%). Most (63.3%) patients were continued on TNF-α inhibitor therapy. Among those who switched TNF-α inhibitors, only 32.0% had complete clearance of their skin lesions. Among patients who were switched to a non-TNF-α inhibitor, 81% had complete clearance of their paradoxical psoriasis.

LIMITATIONS

Data were acquired from retrospective studies including case reports and case series.

CONCLUSION

TNF-α inhibitor-induced psoriasis is a common adverse effect; however, most patients can continue their original therapy and be managed with skin-directed topical or systemic medications. If a patient requires medication discontinuation, switching to a new TNF-α inhibitor is unlikely to lead to resolution of their skin lesions.

Thrombosis in Psoriasis: Cutaneous Cytokine Production as a Potential Driving Force of Haemostatic Dysregulation and Subsequent Cardiovascular Risk

Psoriasis (PsO) is a common T cell-mediated inflammatory disorder of the skin with an estimated prevalence of 2%. The condition manifests most commonly as erythematous plaques covered with scales. The aetiology of PsO is multifactorial and disease initiation involves interactions between environmental factors, susceptibility genes, and innate and adaptive immune responses. The underlying pathology is mainly driven by interleukin-17. In addition, various inflammatory mediators from specific T helper (T_H) cell subsets, namely T_H1, T_H17, and T_H22, are overexpressed in cutaneous lesions and may also be detected in the peripheral blood of psoriatic patients. Moreover, these individuals are also at greater risk, compared to the general population, of developing multiple comorbid conditions. Cardiovascular disease (CVD) has been recognised as a prominent comorbidity of PsO. A potential mechanism contributing to this association may be the presence of a hypercoagulable state in these individuals. Inflammation and coagulation are closely related. The presence of chronic, low-grade systemic inflammation may promote thrombosis – one of the major determinants of CVD. A pro-inflammatory milieu may induce the expression of tissue factor, augment platelet activity, and perturb the vascular endothelium. Altogether, these changes will result in a prothrombotic state. In this review, we describe the aetiology of PsO, as well as the pathophysiology of the condition. We also consider its relationship to CVD. Given the systemic inflammatory nature of PsO, we evaluate the potential contribution of prominent inflammatory mediators (implicated in PsO pathogenesis) to establishing a prothrombotic state in psoriatic patients.

Comparison of guidelines for the use of Ustekinumab for psoriasis in the United States, Europe, and the United Kingdom: A critical appraisal and comprehensive review

The aim of this review is to compare and contrast evidence-based clinical practice guidelines from global dermatological organizations for the use of ustekinumab in psoriasis. Clinical practice guidelines from the American Academy of Dermatology, National Psoriasis Foundation, British Association of Dermatologists, and European S3 were reviewed and compared. Practice guidelines from the three dermatological organizations are similar with regards to treatment dosage and initiation but differ in their recommendations for baseline screening and interval laboratory monitoring, treatment in patients undergoing surgery or receiving live vaccines, and treatment contraindications. Ustekinumab is an effective and well-tolerated systemic treatment for patients with psoriasis and should be considered in the line of therapy that dermatologists discuss with their patients. Consideration should be given to evidence-based practice guidelines of global dermatology organizations to effectively guide treatment decisions in patients with psoriasis.

IL-17 Inhibitors and Inflammatory Bowel Diseases: A Postmarketing Study in Vigibase

Several gastrointestinal symptoms and chronic inflammatory bowel diseases (IBDs) have been reported after therapy with IL-17 inhibitors. To date, however, no study has shown a clear association between these drugs and IBD onset. We searched on Vigibase, the worldwide pharmacovigilance database, to investigate reporting prevalence, characteristics, and prognosis of all gastroenterological adverse events in patients treated with IL-17 inhibitors. In total, 1,129 gastrointestinal Individual Case Safety Reports (ICSRs) were identified, including 850 IBD (42.5% Crohn's disease, 31.9% ulcerative colitis, and 25.6% undifferentiated IBD) and 279 colitis (mainly undifferentiated colitis (79.2%), and microscopic colitis (10.4%)). ICSRs were associated with secukinumab (SEC, 83.6%) or ixekizumab (IXE, 16.3%), whereas only one colitis occurred with brodalumab (0.1%). Most IBD and colitis cases were detected within 6 months from therapy start in both the SEC (68.8% and 73.5%) and IXE groups (100% and 66.7%). Patients' outcomes were reported in 428 ICSRs (37.9%). Complete or ongoing recovery from symptoms was detected in about two-thirds of patients experiencing IBD (59.5%) or colitis (64.2%), whereas in the other cases, there was no recovery (33.9% and 29.5%) or there were sequelae (5.4% and 4.2%). Fatal events occurred in four patients (1.2%) in the IBD group (3 after SEC and on1e with IXE) and two SEC-treated subjects in the colitis group (2.1%). Treatment with IL-17 inhibitors is associated with a relevant number of exacerbations and new onset of IBD and colitis. Careful evaluation of gastrointestinal symptoms and the monitoring of intestinal inflammatory biomarkers should be recommended before prescribing these drugs.

Comorbidities in a Cohort of 66 Patients With Psoriatic Arthritis Mutilans-Results From the Nordic PAM Study

Objective: Psoriatic arthritis mutilans (PAM) is the most severe phenotype of psoriatic arthritis due to excessive bone erosion causing joint destruction and decreased functional capacity. The aim of this study was to investigate the prevalence of comorbidities among patients with PAM and the association between comorbidities and joint involvement. Methods: A total of 66 patients aged ≥18 years from the Nordic countries with past or present psoriasis along with at least one mutilated joint were included in the present study. Results: The median number of comorbid conditions per patient was 1 [interquartile range (IQR) 0-2] and 16.7% reported three or more comorbidities. The most frequent comorbidity was hypertension (36.4%). The median number of mutilated joints per patient was 3 (IQR 1-8.3; range 1-38). Conclusion: Two thirds of the patients with PAM reported comorbid conditions and the most frequent was hypertension which affected more than a third of the patients. However, this study was unable to detect any association between comorbidities and the severity of PAM.

Safety of ixekizumab in adult patients with plaque psoriasis, psoriatic arthritis and axial spondyloarthritis: data from 21 clinical trials

OBJECTIVES

The aim of this integrated analysis is to evaluate the long-term safety and tolerability of ixekizumab in adults with psoriasis, PsA and axial SpA.

METHODS

Integrated safety data from 21 clinical trials are presented by indication in patients who received at least one dose of ixekizumab. Adverse events (AEs) and treatment-emergent adverse events (TEAEs) adjusted incidence rates (IRs) per 100 patient-years (PY) up to 5 years' exposure are reported.

RESULTS

A total of 8228 patients with an ixekizumab exposure of 20 895.9 PY were included in this analysis. The most common TEAEs were nasopharyngitis, upper respiratory tract infection and injection-site reactions. Across populations, IRs were low for AEs leading to discontinuation (IRs ≤5.1 per 100 PY), serious AEs (IRs ≤6.0 per 100 PY) and death (IRs ≤0.3 per 100 PY). The most reported TEAEs of special interest were infections (IRs ≤35.8 per 100 PY). Patients rarely reported malignancies (IR ≤0.8), IBD including ulcerative colitis and Crohn's disease (IR ≤0.8) and major adverse cardiovascular events (IR ≤0.5). TEAEs were most commonly reported the first 2 years of exposure with ixekizumab and IR decreased over the years (infections, injection-site reactions and depression) or remained constant over the entire treatment period (serious infections, major adverse cardiovascular events, malignancies and IBD).

CONCLUSION

This long-term analysis on the safety of ixekizumab was consistent with previously published reports and did not show any new safety signals. The safety profile and tolerability reported in this integrated analysis remained consistent with the known safety profile for ixekizumab.

Ixekizumab treatment of biologic-naïve patients with active psoriatic arthritis: 3-year results from a phase III clinical trial (SPIRIT-P1)

OBJECTIVE

The aim was to assess the safety and efficacy of up to 156 weeks of ixekizumab (an IL-17A antagonist) treatment in PsA patients.

METHODS

In a phase III study, patients naïve to biologic treatment were randomized to placebo, adalimumab 40 mg every 2 weeks (ADA; active reference) or ixekizumab 80 mg every 2 weeks (IXEQ2W) or every 4 weeks (IXEQ4W) after an initial dose of 160 mg. At week 24 (week 16 for inadequate responders), ADA (after 8-week washout) and placebo patients were re-randomized to IXEQ2W or IXEQ4W. Outcomes were evaluated using a modified non-responder imputation [linear extrapolation for radiographic progression (modified total Sharp score = 0)] during extended treatment until week 156.

RESULTS

Of 417 patients, 381 entered the extension, and 243 of 381 (63.8%) completed the 156-week study. Incidence rates of treatment-emergent and serious adverse events, respectively, were 38.0 and 5.2 with IXEQ2W (n = 189) and 38.1 and 8.0 with IXEQ4W (n = 197). One death occurred (IXEQ4W). With IXEQ2W and IXEQ4W, respectively, the response rates persisted to week 156 as measured by the ACR response ≥20% (62.5 and 69.8%), ≥50% (56.1 and 51.8%) and ≥70% (43.8 and 33.4%), psoriasis area and severity index (PASI) 75 (69.1 and 63.5%), PASI 90 (64.5 and 51.2%) and PASI 100 (60.5 and 43.6%). Inhibition of radiographic progression also persisted to week 156 in 61% of IXEQ2W and 71% of IXEQ4W patients.

CONCLUSION

In this 156-week study of ixekizumab, the safety profile remained consistent with previous reports, and improvements in signs and symptoms of PsA were observed, including persistent low rates of radiographic progression.

TRIAL REGISTRATION

ClinicalTrials.gov, http://clinicaltrials.gov, NCT01695239, EudraCT 2011-002326-49.

Psoriasis Associated With Tumor Necrosis Factor Inhibitors in Children With Inflammatory Diseases

OBJECTIVE

To estimate the incidence rate (IR) of psoriasis in children with inflammatory bowel disease (IBD), juvenile idiopathic arthritis (JIA), and chronic noninfectious osteomyelitis (CNO) with tumor necrosis factor inhibitor (TNFi) exposure as compared to children without TNFi exposure and to the general pediatric population.

METHODS

This was a single-center retrospective cohort study of children with IBD, JIA, or CNO from 2008 to 2018. TNFi exposure was defined as a prescription for adalimumab, etanercept, infliximab, certolizumab, or golimumab, and the primary outcome was incident psoriasis. IRs and standardized incidence ratios (SIRs) were calculated. Cox proportional hazards models were used to assess the association of psoriasis with TNFi exposure and other risk factors.

RESULTS

Of the 4,111 children who met inclusion criteria, 1,614 (39%) had TNFi exposure and 2,497 (61%) did not, with 4,705 and 6,604 person-years of follow-up, respectively. There were 58 cases (IR 12.3 per 1,000 person-years) and 25 cases (IR 3.8 per 1,000 person-years) of psoriasis in children with and without TNFi exposure, respectively. The SIR was 18 (95% confidence interval [95% CI] 15-22) overall, 30 (95% CI 23-39) for children with TNFi exposure, and 9.3 (95% CI 6.3-14) for children without TNFi exposure. The hazard ratio of psoriasis comparing TNFi exposure to no TNFi exposure was 3.84 (95% CI 2.28-6.47; P < 0.001).

CONCLUSION

Children with IBD, JIA, and CNO had an increased rate of psoriasis compared to the general pediatric population, with the highest rate in those with TNFi exposure.

Coexisting psoriasis is associated with an increased risk of hospitalization for patients with inflammatory bowel disease: an analysis of the National Inpatient Sample database

This study compares the odds of being admitted for inflammatory bowel disease (IBD) in patients with psoriasis compared with those without psoriasis alone. We also compared hospital outcomes of patients admitted primarily for IBD with and without a secondary diagnosis of psoriasis. Data were abstracted from the National Inpatient Sample (NIS) 2016 and 2017 database to search for hospitalizations of interest using International Classification of Diseases, 10th Revision codes. Multivariate logistic regression model was used to calculate the adjusted OR (AOR) of IBD being the principal diagnosis for hospitalizations with and without a secondary diagnosis of psoriasis. Multivariate logistic and linear regression analyses were used accordingly to compare outcomes of hospitalizations for IBD with and without secondary diagnosis of psoriasis. There were over 71 million discharges included in the combined 2016 and 2017 NIS database. Hospitalizations with a secondary diagnosis of psoriasis have an AOR of 2.66 (95% CI 2.40 to 2.96, p<0.0001) of IBD being the principal reason for hospitalization compared with hospitalizations without psoriasis as a secondary diagnosis. IBD hospitalizations with coexisting psoriasis have similar lengths of stay, hospital charges, need for blood transfusion, and similar likelihood of having a secondary discharge diagnosis of deep venous thrombosis, gastrointestinal bleed, sepsis, and acute kidney injury compared with those without coexisting psoriasis. Patients with coexisting psoriasis have almost three times the odds of being admitted for IBD compared with patients without psoriasis. Hospitalizations for IBD with coexisting psoriasis have similar hospital outcomes compared with those without coexisting psoriasis.

Coping with Psoriasis or Hidradenitis Suppurativa: A Qualitative Study

OBJECTIVE

Psoriasis and hidradenitis suppurativa (HS) are both chronic inflammatory skin diseases with significant comorbidity. This study aimed to examine how patients with psoriasis or HS cope with their conditions on a personal and psychosocial level, especially in times of clinical exacerbation and symptom deterioration.

DESIGN

This qualitative initial study used the phenomenology model to examine patients' lived experiences through the lens of their disease. Via semistructured interviews and content analysis, researchers aimed to describe the subjective reality of people with HS or psoriasis and identify any common issues.

PATIENTS AND INTERVENTION

Six open pilot interviews with three patients with HS and three patients with psoriasis uncovered five cardinal domains affecting patients' lives. After completing all the interviews, transcripts were analyzed and classified numerically by frequency of identified terms and keywords. After classifications and data ranking, the main issues were identified and separated into the five domains.

MAIN RESULTS

Researchers interviewed 20 patients (10 with psoriasis and 10 with HS). The five domains were distressing symptoms, struggling to cope with the disease, avoiding acute or recurrent eruptions, dealing with eruption, and information sources regarding the disease. Pain and pruritus were the most disturbing symptoms, and the remaining issues concerned the emotional, functional, and financial burden of these chronic conditions.

CONCLUSIONS

Even though the symptoms of HS and psoriasis are different, this study reveals common denominators regarding the emotional side of living with chronic skin disease.

Supporting young adults with psoriatic arthritis

Psoriatic arthritis (PsA) is associated with psoriasis, a chronic inflammatory skin disease. About 30% of patients with psoriasis develop PsA, and some of these patients are children and young adults. Because onset can be gradual, PsA signs and symptoms are easily attributed to other causes, especially in younger patients. This article discusses the assessment, pathophysiology, and diagnosis of PsA and informs nurses how best to support patients with PsA.

The Risk of Systemic Diseases in Those with Psoriasis and Psoriatic Arthritis: From Mechanisms to Clinic

Psoriasis and psoriatic arthritis (PsA) have been recently considered as chronic systemic inflammatory disorders. Over the past decades, enormous evidence indicates that patients with psoriasis and PsA have a higher risk of developing various comorbidities including cardiovascular disease, metabolic disease, cancers, infections, autoimmune disease, and psychiatric diseases. However, reported risks of some comorbidities in those with psoriasis and PsA are somewhat different according to the research design. Moreover, pathomechanisms underlying comorbidities of those with psoriasis and PsA remain poorly elucidated. The purpose of this review is to provide the most updated comprehensive view of the risk of systemic comorbidities in those with psoriasis and PsA. Molecular mechanisms associated with the development of various comorbidities in those with psoriasis and PsA are also reviewed based on recent laboratory and clinical investigations. Identifying the risk of systemic comorbidities and its associated pathomechanisms in those with psoriasis and PsA could provide a sufficient basis to use a multi-disciplinary approach for treating patients with psoriasis and PsA.

Association between psoriasis, psoriatic arthritis and gastrointestinal disease : An exploratory nationwide inpatient sample analysis

BACKGROUND

Psoriasis is associated with cardiovascular disease, inflammatory bowel disease (IBD), metabolic syndrome, and psychiatric disease. Furthermore, psoriasis is associated with immune dysregulation and systemic inflammation.

OBJECTIVE

To determine the association of psoriasis and psoriatic arthritis with IBD and the association of the combination of psoriasis or psoriatic arthritis with IBD and other gastrointestinal illnesses.

METHODS

Discharge data from the 2000-2014 Nationwide Inpatient Sample, Healthcare Cost and Utilization Project (HCUP), which approximates a 20% stratified sample of all US hospitalizations, were analyzed. Multivariable logistic regression was used to examine the association between psoriasis and psoriatic arthritis with IBD and 23 gastrointestinal illnesses adjusting for sociodemographic characteristics.

RESULTS

Psoriasis was associated with IBD (Crohn's disease adjusted odds ratio (aOR) = 2.13, 95% confidence interval (CI) [2.0-2.3], p < 0.001). When adjusting for sociodemographics and IBD, psoriasis was associated with 21 of 23 gastrointestinal diseases examined, most notably celiac disease, autoimmune hepatitis, and non-alcoholic fatty liver disease. Psoriatic arthritis was also associated with IBD (Crohn's disease, aOR = 1.95, 95% CI [1.7-2.2], and ulcerative colitis, aOR = 2.66, 95% CI [2.4-2.9]).

CONCLUSION

Psoriasis and psoriatic arthritis inpatients have an associated increase in IBD and numerous other gastrointestinal illnesses.

Comorbidities in patients with palmoplantar plaque psoriasis

BACKGROUND

Psoriasis has been shown to be associated with several comorbidities. Whether the palmoplantar subtype of plaque psoriasis carries similar risks for comorbidities as generalized plaque psoriasis remains to be defined.

OBJECTIVE

To examine the association between palmoplantar plaque psoriasis and comorbidities known to be associated with generalized plaque psoriasis.

METHODS

We retrospectively compared the prevalence of comorbidities previously found to be associated with generalized plaque psoriasis among 163 patients with palmoplantar plaque psoriasis who had been treated with topical psoralen and ultraviolet A from 2009 to 2017 and a cohort of 781 control individuals. Each patient with psoriasis was matched according to sex and age (±1 year) with up to 5 control individuals. Conditional logistic regression was used to evaluate the associations after matching.

RESULTS

Diabetes mellitus (odds ratio [OR], 2.296), cardiovascular disease (OR, 1.797), and most remarkably, mood disorders (OR, 6.232) were significantly associated with palmoplantar plaque psoriasis. Dyslipidemia, hypertension, and psoriatic arthritis were more frequent among patients with palmoplantar plaque psoriasis, but those associations did not reach statistical significance.

LIMITATIONS

The retrospective nature of this study, the fact that some data were collected through a survey questionnaire, and the relatively small sample size suggest the need to validate the present data in a prospective manner. Additionally, within the psoriasis group, patients were assessed for the presence of comorbidities during the whole follow-up period, whereas the comorbidities of individuals in the control group were assessed during a baseline visit.

CONCLUSIONS

Several comorbidities known to be associated with psoriasis vulgaris were also found to be prevalent in a series of patients with plaque palmoplantar psoriasis. Individuals affected with plaque palmoplantar psoriasis showed a particularly high risk for mood disorders.

Is Psoriasis Treatment a Risk Factor for Inflammatory Bowel Disease?

Inflammatory bowel diseases—ulcerative colitis and Crohn’s disease—are linked with several environmental and genetic risk factors. There are also known drugs able to induce de novo disease or to exacerbate its course. Several autoimmune disorders are more frequent in patients with inflammatory bowel diseases, including psoriasis. The aim of the presented review was to summarise current knowledge on the links between psoriasis therapy and inflammatory bowel diseases. The interleukin-17 inhibitors (secukinumab, brodalumab and ixekizumab) and tumour necrosis factor inhibitor (etanercept), have the potential to induce ulcerative colitis and Crohn’s disease de novo or exacerbate existing but silent diseases. There is no evidence that other biologic agents used in psoriasis are lined with such risk. The biologic drugs for psoriasis differ in their potential to induce or worsen inflammatory bowel diseases. Currently, there are no recommendations in European guidelines to screen patients with psoriasis for inflammatory bowel diseases. However, based on available evidence, inflammatory bowel diseases should not be forgotten on in-depth diagnostics in patients with psoriasis.

Secukinumab Use in Patients with Moderate to Severe Psoriasis, Psoriatic Arthritis and Ankylosing Spondylitis in Real-World Setting in Europe: Baseline Data from SERENA Study

INTRODUCTION

Secukinumab, a fully human monoclonal antibody that directly inhibits interleukin-17A, has demonstrated robust efficacy in the treatment of moderate to severe psoriasis (PsO), psoriatic arthritis (PsA) and ankylosing spondylitis (AS), with a rapid onset of action, sustained long-term clinical responses and a consistently favourable safety profile across phase 3 trials. Here, we report the clinical data at enrolment from SERENA, designed to investigate the real-world use of secukinumab across all three indications.

METHODS

SERENA is an ongoing, longitudinal, observational study conducted at 438 sites across Europe in patients with moderate to severe plaque PsO, active PsA or active AS. Patients should have received at least 16 weeks of secukinumab treatment before enrolment in the study.

RESULTS

Overall 2800 patients were included in the safety set; patients with PsA (N = 541) were older than patients with PsO (N = 1799) and patients with AS (N = 460); patients with PsO had a higher mean body weight than patients with PsA and patients with AS; and patients with PsO and patients with AS were predominantly male. Time since diagnosis was longer in patients with PsO compared with patients with PsA and patients with AS, and about 40% of patients were either current or former smokers. The proportion of obese patients (body mass index ≥ 30 kg/m2) was similar across indications. Patients were treated with secukinumab for a mean duration of 1 year prior to enrolment (range 0.89-1.04). The percentages of patients with prior biologics exposure were 31.5% PsO, 59.7% PsA and 55% AS. The percentages of patients prescribed secukinumab monotherapy were 75% (n = 1349) in PsO, 48.2% (n = 261) in PsA and 48.9% (n = 225) in AS groups.

CONCLUSION

Baseline demographics of the study population are consistent with existing literature. This large observational study across all secukinumab indications will provide valuable information on the long-term effectiveness and safety of secukinumab in the real-world setting.

Risk for development of inflammatory bowel disease under inhibition of interleukin 17: A systematic review and meta-analysis

Objective

Cases of inflammatory bowel disease (IBD) during treatment with interleukin (IL)-17 antagonists have been reported from trials in psoriasis, psoriatic arthritis, and ankylosing spondylitis. The aim of this study was to assess the overall risk for development of IBD due to IL-17 inhibition.

Design

Systematic review and meta-analysis of studies conducted 2010–2018 of treatment with IL-17 antagonists in patients with psoriasis, psoriatic arthritis, ankylosing spondylitis, and rheumatoid arthritis. We compared risk of IBD development in anti-IL-17 treated patients compared to placebo treatments. We also computed incident rates of IBD overall. A ‘worst case scenario’ defining subjects ambiguous for prevalent versus incident cases for the latter was also applied.

Results

Sixty-six studies of 14,390 patients exposed to induction and 19,380 patients exposed to induction and/or maintenance treatment were included. During induction, 11 incident cases of IBD were reported, whereas 33 cases were diagnosed during the entire treatment period. There was no difference in the pooled risk of new-onset IBD during induction studies for both the best-case [risk difference (RD) 0.0001 (95% CI: -0.0011, 0.0013)] and worst-case scenario [RD 0.0008 (95% CI: -0.0005, 0.0022)]. The risk of IBD was not different from placebo when including data from maintenance and long-term extension studies [RD 0.0007 (95% CI: -0.0023, 0.0036) and RD 0.0022 (95% CI: -0.0010, 0.0055), respectively].

Conclusions

The risk for development of IBD in patients treated with IL-17 antagonists is not elevated. Prospective surveillance of patients treated with IL-17 antagonists with symptom and biomarker assessments is warranted to assess for onset of IBD in these patients.

Psoriasis and fatty liver: a harmful synergy

Numerous epidemiology studies confirm the increasing prevalence of non-alcoholic fatty liver disease in severe psoriasis, with more than double the risk reported for patients without psoriasis (odds ratio [OR] 2.15). Liver disease is more severe in patients with psoriasis than in controls without psoriasis and is associated with the severity. Similarly, patients with fatty liver disease have more severe psoriasis. This harmful synergy has a common pathogenic origin, resulting from the frequent association between both diseases, insulin resistance and the metabolic syndrome. The disease manifests with a greater intensity when both conditions co-occur than when each manifests separately. Furthermore, psoriasis and fatty liver also have a common cytokine-mediated inflammatory background, which involves an imbalance between pro-inflammatory and anti-inflammatory cytokines. In fact, each disease plays a role in the course of the other. The dermatologist should usually detect liver disease after a specific assessment of patients who present with the metabolic syndrome. The hepatologist should be aware of the more severe condition of these patients. Various medications, such as acitretin, cyclosporine and methotrexate may prove harmful for patients with liver disease. Biologics have proven to be safe in patients with chronic liver disease. Hepatologists and dermatologists should work together to ensure the careful evaluation of the optimal therapy for each patient depending on the severity of both diseases, taking care to avoid, where possible, hepatotoxic drugs and select options that may even have a shared benefit for both diseases.

Healthcare resource utilization and costs associated with inflammatory bowel disease among patients with chronic inflammatory diseases: a retrospective cohort study

Background

Chronic inflammatory diseases (CIDs; ankylosing spondylitis [AS], psoriatic arthritis [PsA], psoriasis [PsO], or rheumatoid arthritis [RA]) and inflammatory bowel disease (IBD; Crohn’s disease and ulcerative colitis) are associated with substantial economic burden. The relative increased costs among patients with CIDs and concomitant IBD compared to those without IBD is an important consideration when deciding on the clinical management of patient symptoms. Given the increasing use of novel agents for the treatment of CIDs, including those that may increase the risk of IBD in patients with CIDs, the objective of the study was to describe the incidence of IBD and to quantify healthcare resource utilization (HRU) and costs associated with IBD among patients with CIDs.

Methods

The IBM MarketScan® Research Databases (1/2010–7/2017) were used to identify adult patients with ≥2 claims with a diagnosis of either AS/PsA/PsO/RA (index date was a random claim for AS/PsA/PsO/RA). The one-year incidence rate of IBD was calculated following the index date. HRU and healthcare costs were compared between patients developing and not developing IBD in the year following the index date, adjusting for baseline characteristics.

Results

A total of 537,450 patients with CIDs (mean age = 54.0 years; 63.1% female) were included in the study. The 1-year incidence rate of IBD was 0.52% (range = 0.39% in patients with PsO but without PsA to 1.73% in patients with AS). Patients who developed IBD (N = 2778) had significantly higher rates of inpatient, outpatient, and emergency room visits (incidence rate ratios [IRR] = 2.91, 1.35, 1.81; all P < 0.0001), compared to patients without IBD (N = 534,672). Patients who developed IBD had $18,500 (P < 0.0001) higher total costs per year, including $15,121 (P < 0.0001) higher medical costs and $3380 higher pharmacy costs (P < 0.0001).

Conclusion

Higher HRU and costs were observed in patients with concomitant CID and IBD compared to patients with CID alone. Consideration should be given to treatment decisions that adequately manage CID and IBD to ensure optimal clinical and economic outcomes.

Global Prevalence and Bidirectional Association Between Psoriasis and Inflammatory Bowel Disease-A Systematic Review and Meta-analysis

BACKGROUND AND AIMS

Epidemiological studies have established an association between psoriasis and inflammatory bowel disease [IBD], i.e. ulcerative colitis [UC] and Crohn's disease [CD], but results are inconsistent. The aim of this study was therefore to quantify the prevalences and association between IBD and psoriasis.

METHODS

PubMed, Web of Science, and EMBASE were searched from database inception through April 2018 for studies reporting data on psoriasis among patients with IBD and vice versa. Meta-analysis was performed to estimate, respectively, the prevalences and association between IBD and psoriasis. Data extraction was according to the PRISMA guideline, and quality assessment was made using the Newcastle-Ottawa Scale. The main outcomes were the proportion of psoriasis patients with IBD and vice versa, as well as the association (odds ratio [OR]) of IBD in psoriasis and psoriasis in IBD, respectively.

RESULTS

Based on quantitative analysis of 93 studies, the prevalence of psoriasis in CD and in UC was 3.6% (95% confidence interval [CI] 3.1%-4.6%) and 2.8% [95% CI 2.0%-3.8%] respectively. The prevalence of CD and UC was 0.7% [95% CI 0.2%-1.3%] and 0.5% [95% CI 0.3%-0.8%], respectively, among patients with psoriasis. Presence of CD or UC was significantly associated with psoriasis, with OR 2.0 [95% CI 1.4-2.9] and OR 1.5 [95% CI 1.2-2.0], respectively. Presence of psoriasis was significantly associated with CD: OR 2.2 [95% CI 1.6-3.1] and with UC: OR 1.6 [95% CI 1.3-2.0].

CONCLUSIONS

We found significant bidirectional associations between psoriasis and IBD, warranting increased awareness among clinicians in the diagnostic process, especially in children and adolescents with IBD. Last, this study showed an increased frequency of paradoxical psoriasis in patients treated with biologics.

Efficacy and Safety of Biologics for Psoriasis and Psoriatic Arthritis and Their Impact on Comorbidities: A Literature Review

Psoriasis is a chronic inflammatory skin disease characterized by scaly indurated erythema. It impairs patients’ quality of life enormously. It has been recognized not only as a skin disease but as a systemic disease, since it also causes arthritis (psoriatic arthritis) and mental disorders. Furthermore, an association with cardiovascular events is indicated. With the advent of biologics, treatment of psoriasis dramatically changed due to its high efficacy and tolerable safety. A variety of biologic agents are available for the treatment of psoriasis nowadays. However, characteristics such as rapidity of onset, long-term efficacy, safety profile, and effects on comorbidities are different. Better understanding of those characteristic leads to the right choice for individual patients, resulting in higher persistence, longer drug survival, higher patient satisfaction, and minimizing the disease impact of psoriasis. In this paper, we focus on the efficacy and safety profile of biologics in psoriasis patients, including plaque psoriasis and psoriatic arthritis. In addition, we discuss the impact of biologics on comorbidities caused by psoriasis.

Pathogenesis of Chronic Plaque Psoriasis and Its Intersection With Cardio-Metabolic Comorbidities

Psoriasis is a chronic, systemic immune-mediated disease characterized by development of erythematous, indurated, scaly, pruritic plaques on the skin. Psoriasis is frequently associated to comorbidities, including psoriatic arthritis, cardiovascular diseases, diabetes mellitus, obesity, non-alcoholic fatty liver disease, and inflammatory bowel diseases. In this review, we discuss the pathophysiological relationship between psoriasis and cardio-metabolic comorbidities and the importance of therapeutic strategies to reduce systemic inflammation in patients with moderate-to-severe psoriasis. Pathogenesis of psoriasis and its comorbidities share both genetic predisposition and inflammatory pathways, which include the TNFα and the IL-23/IL-17 pathways. These pathways are selectively addressed by biological treatments, which have substantially changed the outcomes of psoriasis therapy and affect positively comorbidities including reducing cardiovascular risk, allowing a more comprehensive approach to the patient.

Pharmacodynamics OF TNF α inhibitors for the treatment of psoriasis

Introduction: The treatment of psoriasis with conventional topical therapies and disease-modifying anti-rheumatic drugs (DMARDs) is often linked to unsatisfactory outcomes and the risk of serious adverse events. Over the last decades, research advances in understanding the role of tumor necrosis factor alpha (TNF α) and other cytokines in the pathogenesis of psoriasis have driven the introduction of biologic agents targeting specific immune mediators in everyday clinical practice. TNF α inhibitors are a consolidated treatment option for patients with moderate-to-severe disease with remarkable efficacy and a reassuring safety profile.Areas covered: The PubMed database was searched using combinations of the following keywords: psoriasis, TNF α inhibitors, biologic therapy, pharmacodynamics, adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, adverse effects. The aim of this review is to describe the pharmacodynamic profile of anti-TNF α inhibitors, currently approved by the European Medicines Agency (EMA) for the treatment of psoriasis, focusing on related clinical implications, also in comparison to the new generation biological therapies targeting the interleukin 23/interleukin 17 axis.Expert opinion: Pharmacodynamics of TNF α inhibitors should be fully considered in planning patient's therapy strategies, especially in case of secondary failures, poor adherence to treatment, instable psoriasis, high risk of infection, pregnant or lactating women, metabolic comorbidities, coexistence of other immune-mediated inflammatory diseases.

Real-world incidence of inflammatory bowel disease among patients with other chronic inflammatory diseases treated with interleukin-17a or phosphodiesterase 4 inhibitors

Objectives: (1) To assess the real-world incidence of inflammatory bowel disease (IBD) in patients with or without other chronic inflammatory diseases (CIDs), and (2) to understand whether IBD incidence differs in CID patients receiving interleukin-17a signaling antagonists (anti-IL-17a) or phosphodiesterase 4 inhibitors (PDE4i) versus patients using a biologic not indicated for IBD or biologic-naïve patients. Methods: The MarketScan Research Databases (January 2010-July 2017) were used. A CID population was created from patients with ankylosing spondylitis, psoriatic arthritis, psoriasis or rheumatoid arthritis (RA). The CID population was stratified into different cohorts based on the baseline treatments received: (1) anti-IL-17a, (2) PDE4i, (3) biologic-naïve, and (4) non-IBD-indicated biologic (i.e. biologics not indicated for the treatment of IBD and excluding anti-IL-17a and PDE4i); a non-CID cohort was also created. The 1 year incidence rate (IR) of IBD was compared between cohorts using a logistic regression model adjusting for baseline characteristics. Results: CID cohorts included older patients than the non-CID cohort (mean age range: 48.4-54.4 versus 46.3 years). The 1 year IR of IBD was 1.41% in the anti-IL-17a cohort (N = 355), 0.68% in the PDE4i cohort (N = 2195), 0.47% in the biologic-naïve cohort (N = 424,767), 0.51% in the non-IBD-indicated biologic cohort (N = 56,317) cohort and 0.25% in the non-CID cohort (N = 1,008,436). After 1 year of follow-up, the odds of having IBD were 2.85 (p = .0213) and 1.42 (p = .1891) times higher in the anti-IL-17a and PDE4i cohorts, respectively, compared to the biologic-naïve cohort, and 2.86 (p = .0253) and 1.21 (p = .4978) times higher compared to the non-IBD-indicated biologic cohort. Similar results were observed in sensitivity analyses where patients with RA only were excluded (since anti-IL-17a and PDE4i agents are not indicated for RA). Conclusions: Anti-IL-17a treatment was associated with a nearly three-fold higher risk of IBD in CID patients. Treatment decisions for patients with CIDs should take into account the risk of developing of IBD.

Association of Psoriasis With Inflammatory Bowel Disease: A Systematic Review and Meta-analysis

Importance

Patients with psoriasis may experience comorbidities involving cardiovascular diseases, chronic kidney disease, uveitis, psychiatric disturbances, and metabolic syndrome. However, the association between psoriasis and inflammatory bowel disease (IBD) has been largely unclear.

Objective

To investigate the association of psoriasis with IBD.

Data Sources

For this systematic review and meta-analysis, MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched for relevant studies from inception to January 17, 2018.

Study Selection

Case-control, cross-sectional, or cohort studies that examined either the odds or risk of IBD in patients with psoriasis were included. No geographic or language limitations were used in the search.

Data Extraction and Synthesis

The PRISMA and MOOSE guidelines were followed for data extraction. The Newcastle-Ottawa Scale was used to evaluate the risk of bias of included studies. Crohn disease and ulcerative colitis were analyzed separately and random-effects model meta-analysis was conducted. A subgroup analysis was performed on psoriatic arthritis.

Main Outcomes and Measures

The risk and odds of IBD, Crohn disease, and ulcerative colitis in patients with psoriasis.

Results

A total of 5 case-control or cross-sectional studies and 4 cohort studies with 7 794 087 study participants were included. Significant associations were found between psoriasis and Crohn disease (odds ratio, 1.70; 95% CI, 1.20-2.40) and between psoriasis and ulcerative colitis (odds ratio, 1.75; 95% CI, 1.49-2.05). Patients with psoriasis had an increased risk of Crohn disease (risk ratio, 2.53; 95% CI, 1.65-3.89) and ulcerative colitis (risk ratio, 1.71; 95% CI, 1.55-1.89).

Conclusions and Relevance

These findings suggest that psoriasis is significantly associated with IBD. Gastroenterology consultation may be indicated when patients with psoriasis present with bowel symptoms.

Systematic review with meta-analysis: risk of new onset IBD with the use of anti-interleukin-17 agents

BACKGROUND

New onset IBD has been reported with the use of anti-IL-17 agents, but it remains unclear to what extent this is attributed to treatment or to underlying disease.

AIM

To evaluate the risk of new onset IBD with the use of anti-IL-17 agents METHODS: Electronic databases were searched for randomised controlled trials (RCT) of anti-IL-17 agents (brodalumab, ixekizumab and secukinumab). Risk of new onset IBD was compared to placebo by Mantel-Haenszel (MH) risk difference (RD). Sensitivity analyses including meta-analysis using fixed-effect model, MH and Peto odds ratio and MH risk ratio were performed due to incidence of rare adverse events. The risk of diarrhoea was also assessed due to the possibility of underdiagnosis of IBD.

RESULTS

Thirty-eight RCTs including 16 690 patients treated with anti-IL-17 agents were included. Twelve cases of new onset IBD were reported with anti-IL-17 agents in five studies, whereas no cases were reported with placebo. There was no difference in the risk of developing new onset IBD with anti-IL-17 agents compared to placebo (MH RD 0.00062, 95% CI -0.00072-0.0021, P = 0.35). Sensitivity analyses demonstrated no consistent risk with any method. There was no difference in the risk of diarrhoea (MH RD 0.0013, 95% CI -0.0014-0.0041, P = 0.34).

CONCLUSIONS

New onset IBD with the use of anti-IL-17 agents was rare. Interpretation of the results needs caution due to the presence of many zero-event studies.