Psoriasis and Cardiometabolic Diseases: The Impact of Inflammation on Vascular Health

The Use of Microbial Modifying Therapies to Prevent Psoriasis Exacerbation and Associated Cardiovascular Comorbidity

Psoriasis has emerged as a systemic disease characterized by skin and joint manifestations as well as systemic inflammation and cardiovascular comorbidities. Many progresses have been made in the comprehension of the immunological mechanisms involved in the exacerbation of psoriatic plaques, and initial studies have investigated the mechanisms that lead to extracutaneous disease manifestations, including endothelial disfunction and cardiovascular disease. In the past decade, the involvement of gut dysbiosis in the development of pathologies with inflammatory and autoimmune basis has clearly emerged. More recently, a major role for the skin microbiota in establishing the immunological tolerance in early life and as a source of antigens leading to cross-reactive responses towards self-antigens in adult life has also been evidenced. Gut microbiota can indeed be involved in shaping the immune and inflammatory response at systemic level and in fueling inflammation in the cutaneous and vascular compartments. Here, we summarized the microbiota-mediated mechanisms that, in the skin and gut, may promote and modulate local or systemic inflammation involved in psoriatic disease and endothelial dysfunction. We also analyze the emerging strategies for correcting dysbiosis or modulating skin and gut microbiota composition to integrate systemically existing pharmacological therapies for psoriatic disease. The possibility of merging systemic treatment and tailored microbial modifying therapies could increase the efficacy of the current treatments and potentially lower the effect on patient's life quality.

Increased vascular inflammation on PET/CT in psoriatic arthritis patients in comparison with controls

BACKGROUND

Patients with psoriatic arthritis (PsA) have an increased risk of cardiovascular disease, possibly due to a chronic inflammatory state.

OBJECTIVES

The main objective of this study was to investigate the difference in vascular inflammation, measured with 18-fluorodeoxyglucose positron emission tomography/CT (PET/CT), in PsA patients and controls. We conducted a secondary analysis to assess the association between clinical parameters of disease activity with vascular inflammation in PsA.

METHODS

We included a total of 75 PsA patients with active peripheral arthritis (defined as ≥2 tender and swollen joints) from an ongoing clinical trial (EudraCT 2017-003900-28) and a retrospective group of 40 controls diagnosed with melanoma, without distant metastases and not receiving immunotherapy. The main outcome measure was aortic vascular inflammation which was measured on PET/CT scans using target-to-background ratios. Clinical disease activity in PsA was assessed with joint counts, body surface area and the Disease Activity index for PsA. Laboratory assessments included C reactive protein and erythrocyte sedimentation rate.

RESULTS

Vascular inflammation was increased in patients with PsA in comparison with controls (mean target-to-background ratio for entire aorta, respectively, 1.63±0.17 vs 1.49±0.16; p=<0.001). This association remained significant after correction for gender, age, body mass index, mean arterial pressure and aortic calcification (p=0.002). Vascular inflammation was not associated with disease-related parameters.

CONCLUSIONS

Aortic vascular inflammation was significantly increased in patients with active PsA compared with controls. This evidence supports the theory that inflammation in PsA is not limited to the skin and joints but also involves the vascular system.

Prevention and risk assessment of cardiovascular events in a population of patients with psoriasis and psoriatic arthritis

Psoriasis is a chronic, inflammatory, often relapsing disease that is frequently associated with other diseases of similar pathogenesis. The multi-morbidity in the psoriasis population significantly impedes both diagnosis and implementation of appropriate preventive measures. However, the common denominator for this group of diseases is the inflammatory process that initiates the appearance of subsequent symptoms and health consequences, most of which can be avoided or alleviated by modifying the patient’s lifestyle and incorporating appropriate treatment. Health consequences associated with systemic inflammation include cardiovascular incidents and other cardiometabolic diseases.

This article was based on available publications on the onset, incidence, and prevention of cardiovascular disease in the psoriasis patient population.

The cardiometabolic conditions of psoriatic disease

Psoriasis (PsO) and psoriatic arthritis (PsA), together known as psoriatic disease (PsD), are immune-mediated diseases with a chronic and relapsing course that affect the skin, the joints or both. The pathophysiology of PsO is complex and involves abnormal expression of keratinocytes and infiltration of the skin with dendritic cells, macrophages, neutrophils and T lymphocytes. Around 30% of patients with PsO develop arthritis with axial and/or peripheral manifestations. Both PsO and PsA share similar Th1- and Th17-driven inflammation, with increased production of inflammatory cytokines, including TNFα, IFN-γ, IL-17, IL-22, IL-23 in the skin and the synovial membrane. PsD is associated with a high burden of cardiometabolic diseases such as hypertension, diabetes, dyslipidemia, obesity, metabolic syndrome and cardiovascular (CV) complications as compared to the general population. These comorbidities share common immunopathogenic pathways linked to systemic inflammation, and are associated with the extent and severity of the disease. Morever, they can influence treatment outcomes in PsD. In this short review, we summarize the available evidence on the epidemiology, clinical aspects and mechanisms of cardiometabolic conditions in patients with PsD. We also discuss the impact of targeted treatments such as methotrexate and biological agents on these cardiometabolic conditions.

Perivascular adipose tissue in autoimmune rheumatic diseases

Perivascular adipose tissue (PVAT) resides at the outermost boundary of the vascular wall, surrounding most conduit blood vessels, except for the cerebral vessels, in humans. A growing body of evidence suggests that inflammation localized within PVAT may contribute to the pathogenesis of cardiovascular disease (CVD). Patients with autoimmune rheumatic diseases (ARDs), e.g., systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), psoriasis, etc., exhibit heightened systemic inflammation and are at increased risk for CVD. Data from clinical studies in patients with ARDs support a linkage between dysfunctional adipose tissue, and PVAT in particular, in disease pathogenesis. Here, we review the data linking PVAT to the pathogenesis of CVD in patients with ARDs, focusing on the role of novel PVAT imaging techniques in defining disease risk and responses to biological therapies.