Can early treatment with biologicals modify the natural history of comorbidities?

Association of Complete Blood Cell Count-Derived Inflammatory Biomarkers with Psoriasis and Mortality

Background and Aim

Psoriasis is a persistent inflammatory disorder that affects 3% of the population and is associated with cardiovascular diseases. Therefore, this study aimed to investigate the correlations between complete blood cell count (CBC)-derived inflammatory biomarkers, psoriasis prevalence, and all-cause mortality.

Methods

Data were obtained from the National Health and Nutrition Examination Survey (NHANES) spanning 2003-2006 and 2009-2014. Mortality data up to December 31, 2019 were obtained using the National Death Index. The following CBC-derived inflammatory biomarkers were examined: neutrophil/lymphocyte ratio (NLR), neutrophil/(white blood cells - neutrophils) ratio (dNLR), monocyte count/lymphocyte ratio (MLR), (neutrophil + monocyte)/lymphocyte ratio (NMLR), platelet/lymphocyte ratio (PLR), and systemic inflammatory response index (SIRI). Weighted logistic and Cox regression analyses were used to calculate odds ratios, hazard ratios, and the corresponding 95% confidence intervals. Additionally, the prognostic value of the inflammatory indicators was assessed and ranked using the random survival forest approach.

Results

In total, data from 21,431 participants with average age of 45.02 ± 0.27 years (49.51% male) were included in the study, among which 600 participants were positive for psoriasis (prevalence rate, 2.80%). Additionally, 79 all-cause deaths were recorded during a median follow-up period of 8.83 (6.67-11.00) years. Moreover, NLR, dNLR, NMLR, PLR, and SIRI were positively associated with the prevalence of psoriasis. Furthermore, MLR, NMLR, and SIRI were positively correlated with all-cause mortality in patients with psoriasis, with NMLR being the most valuable predictor of all-cause mortality.

Conclusion

CBC-derived inflammatory biomarkers were associated with psoriasis prevalence, NMLR, SIRI, and MLR values were associated with all-cause mortality in patients with psoriasis. Overall, assessment of these CBC-derived indicators may serve as a simple method for screening high-risk individuals among patients with psoriasis.

Comorbidity in Adult Psoriasis: Considerations for the Clinician

Psoriasis is associated with several comorbidities ranging from cardiovascular comorbidity and mental disorders to other immune mediated inflammatory diseases. However, most of these co-morbidities are often overlooked or diagnosed late. Furthermore, evidence suggests that comorbidities are undertreated. Here, we provide an overview of comorbidities in psoriasis and present a simple rundown of considerations of relevance to the clinician. We hope that this review may raise clinicians' awareness of comorbidities in psoriasis and provide simple guidance regarding screening tools and treatment decisions in psoriasis with comorbidities.

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

BACKGROUND

Psoriasis is a risk factor for cardiovascular events.

OBJECTIVE

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Psoriasis comorbidities: complications and benefits of immunobiological treatment

During the last decade, different studies have converged to evidence the high prevalence of comorbidities in subjects with psoriasis. Although a causal relation has not been fully elucidated, genetic relation, inflammatory pathways and/or common environmental factors appear to be underlying the development of psoriasis and the metabolic comorbidities. The concept of psoriasis as a systemic disease directed the attention of the scientific community in order to investigate the extent to which therapeutic interventions influence the onset and evolution of the most prevalent comorbidities in patients with psoriasis. This study presents scientific evidence of the influence of immunobiological treatments for psoriasis available in Brazil (infliximab, adalimumab, etanercept and ustekinumab) on the main comorbidities related to psoriasis. It highlights the importance of the inflammatory burden on the clinical outcome of patients, not only on disease activity, but also on the comorbidities. In this sense, systemic treatments, whether immunobiologicals or classic, can play a critical role to effectively control the inflammatory burden in psoriatic patients.

Cardiovascular event risk assessment in psoriasis patients treated with tumor necrosis factor-α inhibitors versus methotrexate

BACKGROUND

Psoriasis is associated with increased risk for cardiovascular disease.

OBJECTIVE

To compare major cardiovascular event risk in psoriasis patients receiving methotrexate or tumor necrosis factor-α inhibitor (TNFi) and to assess TNFi treatment duration impact on major cardiovascular event risk.

METHODS

Adult psoriasis patients with ≥2 TNFi or methotrexate prescriptions in the Truven MarketScan Databases (Q1 2000-Q3 2011) were classified as TNFi or methotrexate users. The index date for each of these drugs was the TNFi initiation date or a randomly selected methotrexate dispensing date, respectively. Cardiovascular event risks and cumulative TNFi effect were analyzed by using multivariate Cox proportional-hazards models.

RESULTS

By 12 months, TNFi users (N = 9148) had fewer cardiovascular events than methotrexate users (N = 8581) (Kaplan-Meier rates: 1.45% vs 4.09%: P < .01). TNFi users had overall lower cardiovascular event hazards than methotrexate users (hazard ratio = 0.55; P < .01). Over 24 months' median follow-up, every 6 months of cumulative exposure to TNFis were associated with an 11% cardiovascular event risk reduction (P = .02).

LIMITATIONS

Lack of clinical assessment measures.

CONCLUSIONS

Psoriasis patients receiving TNFis had a lower major cardiovascular event risk compared to those receiving methotrexate. Cumulative exposure to TNFis was associated with a reduced risk for major cardiovascular events.

Economic and Comorbidity Burden Among Patients with Moderate-to-Severe Psoriasis

BACKGROUND

Previous studies demonstrated substantial economic and comorbidity burden associated with psoriasis (PsO) before biologics were available. Biologics have changed PsO treatment paradigms and potentially improved patient outcomes. There is a need to reassess the economic and comorbidity burden of PsO in the biologic era.

OBJECTIVE

To compare the prevalence of comorbidities, health care resource utilization, and costs between moderate-to-severe PsO patients and demographically matched controls. 

METHODS

Adults aged 18-64 years with at least 2 PsO diagnoses (ICD-9-CM code 696.1) were identified in the OptumHealth Reporting and Insights claims database from January 2007 to March 2012. Moderate-to-severe PsO patients were identified as those receiving ≥ 1 systemic therapy or phototherapy during the 12-month study period following the index date (randomly selected date after the first PsO diagnosis). Controls were free of PsO and psoriatic arthritis (PsA) and were matched 1:1 with PsO patients on age, gender, and geographic region. All patients had at least 12 months of continuous enrollment after the index date. Selected comorbidities, medication use, all-cause health care utilization, and costs were compared between PsO patients and controls. Multivariate regression models were performed to examine the association between PsO and selected comorbidities, medication use, and health care costs and utilization, adjusting for demographics, index year, insurance type, and other comorbidities. Odds ratios (ORs) were reported for any medication use, hospitalization, emergency room visit, and outpatient visit, and incidence rate ratios (IRRs) were reported for the number of medications filled. Adjusted cost differences between PsO patient and controls were also estimated. 

RESULTS

A total of 5,492 matched pairs of moderate-to-severe PsO patients and controls were selected, with a mean age of 47.6 years and 55.5% of patients being male. PsO patients were significantly more likely to have most of the comorbidities examined, with the top 3 most common in both groups being hyperlipidemia (33.3% vs. 27.3%), hypertension (32.8% vs. 23.5%), and diabetes (15.8% vs. 9.7%). Compared with controls, PsO patients were more likely to have any medication filled (OR = 27.5) and had more distinct number of prescription medications (IRR = 2.1; both P  less than  0.01). PsO patients were more likely to have any inpatient admission (OR = 1.3), emergency room visit (OR = 1.3), and outpatient visit (OR = 29.3; all P  less than  0.01). PsO patients also incurred significantly higher total, pharmacy, and medical costs (adjusted annual costs differences: $18,960, $13,990, and $3,895 per patient, respectively; all P  less than  0.01) than controls. 

CONCLUSIONS

Compared with PsO- and PsA-free controls, moderate-to-severe PsO patients were more likely to have selected comorbidities and higher health care utilization and costs.

Economic and comorbidity burden among moderate-to-severe psoriasis patients with comorbid psoriatic arthritis

OBJECTIVE

To compare the prevalence of comorbidities, health care utilization, and costs between moderate-to-severe psoriasis (PsO) patients with comorbid psoriatic arthritis (PsA) and matched controls.

METHODS

Adults ages 18-64 years with concomitant diagnoses of PsO and PsA (PsO+PsA) were identified in the OptumHealth Reporting and Insights claims database between January 2007 and March 2012. Moderate-to-severe PsO was defined based on the use of at least one systemic or phototherapy during the 12-month study period after the index date (randomly selected date after the first PsO diagnosis). Control patients without PsO and PsA were demographically matched 1:1 with PsO+PsA patients. Multivariate regressions were employed to examine PsO/PsA-related comorbidities, medications, health care utilization, and costs between PsO+PsA patients and controls, adjusting for demographics, index year, insurance type, and non-PsO/PsA-related comorbidities.

RESULTS

Among 1,230 matched pairs of PsO+PsA patients and controls, PsO+PsA patients had significantly more PsO/PsA-related comorbidities, with the top 3 most common in both groups being hypertension (35.8% versus 23.5%), hyperlipidemia (34.6% versus 28.5%), and diabetes mellitus (15.9% versus 10.0%). Compared with controls, PsO+PsA patients had a higher number of distinct prescriptions filled (incidence rate ratio 2.3, P < 0.05); were more likely to have inpatient admissions (odds ratio [OR] 1.6), emergency room visits (OR 1.3), and outpatient visits (OR 62.7) (all P < 0.05); and incurred significantly higher total, pharmacy, and medical costs (adjusted annual cost differences per patient $23,160, $17,696, and $5,077, respectively; all P < 0.01).

CONCLUSION

Compared with matched PsO- and PsA-free controls, moderate-to-severe PsO patients with comorbid PsA had higher comorbidity and health care utilization and costs.

Comparative efficacy of biologics in psoriasis: a review

BACKGROUND

Psoriasis is a chronic, immune-mediated skin disease that also has systemic manifestations. Safe and effective long-term treatments are needed. Biologic treatments that inhibit the immunopathogenesis of psoriasis have helped meet this need.

PURPOSE

The purpose of this study was to compare the efficacy of biologic therapies used for psoriasis.

METHODS

A literature search was performed using PubMed and the keywords '(PASI-75 OR efficacy) AND psoriasis AND (adalimumab OR alefacept OR etanercept OR infliximab OR ustekinumab).' Randomized, double-blind, and placebo-controlled studies on US FDA-approved biologics were selected. Studies assessing the proportion of subjects achieving 75% improvement in Psoriasis Area and Severity Index (PASI-75) within a 12-week period were included. Studies on pediatric populations and psoriatic arthritis were excluded. The weighted average of PASI-75 for each reported regimen was calculated to determine the efficacy of biologic agents used for moderate-to-severe psoriasis. Tolerance and secondary efficacy measures were also examined for the selected studies.

RESULTS

FDA-approved regimens of adalimumab, infliximab, ustekinumab, and alefacept were effective in treating moderate-to-severe psoriasis. Weighted average PASI-75 scores for infliximab, ustekinumab, adalimumab, etanercept, and alefacept were 78.6%, 72.1%, 70.5%, 48.1%, and 21%, respectively.

LIMITATIONS

The comparative efficacy of biologic agents data was limited to 12 weeks, thus generalizing the results to longer treatment periods may not be accurate.

CONCLUSIONS

Various biologic agents for psoriasis were effective at 12 weeks in placebo-controlled trials. Available data cannot fully account for situations in clinical practice, in which combination and longer duration of therapy may be required. When choosing the most effective or best agent, multiple factors should be considered including patient preference, cost, tolerance, adverse effects, dosing schedule, and mode of administration.

[Diagnosis and therapy of early psoriatic arthritis]

Early diagnosis of psoriatic arthritis is of importance because an erosive disease is already detectable after a 2-year duration of symptoms. Often psoriatic arthritis cannot easily be detected because of the diversity of disease manifestations in early stages. As up to 30% of psoriasis patients develop psoriatic arthritis an interdisciplinary dermatologic/rheumatologic approach to diagnose findings and treatment decisions would be desirable. Screening tools, such as validated questionnaires allow an early detection and selection of patients with a high probability of psoriatic arthritis even in dermatological care or on a house physician basis. The implementation of the CASPAR criteria as a classification tool for psoriatic arthritis has also improved the diagnosis finding in patients with a recent onset of active musculoskeletal disease. Data from early psoriatic arthritis cohorts illustrate that drug-free remission is rare. An adequate treatment is of importance. The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) has developed treatment recommendations based on the available evidence for different treatment modalities.