Negative impact of comorbidities on all-cause mortality of patients with psoriasis is partially alleviated by biologic treatment: A real-world case-control study

BACKGROUND

Cardiovascular comorbidities are believed to cause higher mortality in psoriasis patients. Conversely, systemic therapy may improve overall survival.

OBJECTIVE

To evaluate the impact of different comorbidities and therapy on mortality risk of psoriasis patients in the entire population of Alberta, Canada (population 4.37 million).

METHODS

Cohorts of psoriasis cases (n = 18,618) and controls (ambulatory patients matched 1:3 by age and sex) were retrieved from Alberta Health Services Data Repository of Reporting database within the period 2012 to 2019. Cases were stratified according to Charlson Comorbidity Index, and the type of therapy.

RESULTS

Mortality in psoriasis cohort was significantly higher than in the controls (median age of death 72.0 years vs 74.4 years, respectively). Charlson Comorbidity Index and comorbidities were strong predictors of mortality, in particular drug induced liver injury (hazard ratio 1.8, affective bipolar disease, hazard ratio 1.6, and major cardiovascular diseases. Mortality was lower in patients treated with biologics (hazard ratio 0.54).

LIMITATIONS

Some factors (psoriasis type and severity, response to treatment, smoking, alcohol intake) could not be measured.

CONCLUSIONS

Hepatic injury, psychiatric affective disorders and cardiovascular disease were major determinants of overall survival in psoriasis. Biologic therapy was associated with a reduced mortality risk.

Real World Studies of Psoriasis and Mental Illness in Newfoundland and Labrador

Background

Psoriasis is a chronic, immune-mediated inflammatory disease with an implied connection to psychiatric disorders.

Objective

This study aims to illustrate an association between psoriasis and psychiatric disorders using real world data gathered from the Newfoundland and Labrador population.

Methods

Data on 15,100 patients with psoriasis and 75,500 controls (1:5) was collected from the Newfoundland and Labrador Centre for Health Information’s Electronic Health Records. The cases and controls were matched for age, sex, and geography. Indicators for psychiatric disorders include diagnosis of mental illnesses from physician’s visits and hospitalization records (all coded for mental health using ICD-9 and ICD-10 codes).

Results

9,991 (66.2%) cases were identified to have at least one visit with a diagnostic code for mental illness compared to 42,276 (56.0%), P < .0001 in the control group. The percentage of people coded for anxiety was 36.50% compared to 28.95%, P < .0001; depression was 37.04% compared to 30.19%, P < .0001; and adjustment disorder was 6.89% versus 5.48%, P < .0001, among those with and without psoriasis, respectively. The greatest risk for anxiety [OR 1.4 (1.20, 1.67)] and depression [OR 1.65 (1.36, 2.00)] among psoriasis patients was between the 0 to 20 age group. Women with psoriasis are more likely to have anxiety [OR 1.08 (1.03, 1.13)], depression [OR 1.04 (1.01, 1.09)] and adjustment disorder [OR 1.07 (0.98, 1.17)] compared to female controls.

Conclusion

Our result shows that patients with psoriasis have an increased prevalence of mental illness. Using real world data to carry out further investigations will better elucidate this association and provide an increased understanding of the association between psoriasis and mental disorders.

Differences in Clinical Features and Comorbid Burden between HLA-C∗06:02 Carrier Groups in >9,000 People with Psoriasis

The identification of robust endotypes-disease subgroups of clinical relevance-is fundamental to stratified medicine. We hypothesized that HLA-C∗06:02 status, the major genetic determinant of psoriasis, defines a psoriasis endotype of clinical relevance. Using two United Kingdom-based cross-sectional datasets-an observational severe-psoriasis study (Biomarkers of Systemic Treatment Outcomes in Psoriasis; n = 3,767) and a large population-based bioresource (UK Biobank, including n = 5,519 individuals with psoriasis)-we compared demographic, environmental, and clinical variables of interest in HLA-C∗06:02-positive (one or two copies of the HLA-C∗06:02 allele) with those in HLA-C∗06:02‒negative (no copies) individuals of European ancestry. We used multivariable regression analyses to account for mediation effects established a priori. We confirm previous observations that HLA-C∗06:02-positive status is associated with earlier age of psoriasis onset and extend findings to reveal an association with disease expressivity in females (Biomarkers of Systemic Treatment Outcomes in Psoriasis: P = 2.7 × 10-14, UK Biobank: P = 1.0 × 10-8). We also show HLA-C∗06:02-negative status to be associated with characteristic clinical features (large plaque disease, OR for HLA-C∗06:02 = 0.73, P = 7.4 × 10-4; nail involvement, OR = 0.70, P = 2.4 × 10-6); higher central adiposity (Biomarkers of Systemic Treatment Outcomes in Psoriasis: waist circumference difference of 2.0 cm, P = 8.4 × 10-4; UK Biobank: waist circumference difference of 1.4 cm, P = 1.5 × 10-4), especially in women; and a higher prevalence of other cardiometabolic comorbidities. These findings extend the clinical phenotype delineated by HLA-C∗06:02 and highlight its potential as an important biomarker to consider in future multimarker stratified medicine approaches.

HLA-Cw6 status and treatment responses between psoriasis patients

Background

The number of treatment options in psoriasis has increased considerably, so biomarkers should be searched to assist in the selection of the optimal treatment agent. The most common of these biomarkers is HLA-Cw6.

Objective:

The aim was to determine whether there is a relationship between HLA-Cw6-positivity (HLA-Cw6-POS) and the response of treatment agents in psoriasis.

Methods:

Blood samples of 124 patients were subjected to genetic study for HLA-Cw6.

Results:

Psoriasis area severity index (PASI) score of more than 75% (PASI75) response was received in 34 (73.9%) of the HLA-Cw6-POS methotrexate-treated patients, 30 (78.9%) of the HLA-Cw6-POS cyclosporine-treated patients, and 8 (37.5%) of the HLA-Cw6-POS acitretin-treated patients. The differences were not statistically significant (P = 0.634-0.071-0.409). PASI75 response was received in 73 (68.2%) of the HLA-Cw6-POS patients in patients treated with conventional agents. In adalimumab-treated patients, PASI75 response was received in 8 (53.3%) of the HLA-Cw6-POS patients, 6 (75%) of the HLA-Cw6-POS infliximab-treated patients, and 4 (57.1%) of the HLA-Cw6-POS ustekinumab-treated patients. The differences were not statistically significant (P = 0.245-1.00-0.322). PASI75 response was received in 24 (64.9%) of the HLA-Cw6-POS and 33 (84.6%) of HLA-Cw6 negative (HLA-Cw6-NEG) patients with biological agents. The biological agent response was statistically significantly lower in HLA-Cw6-POS.

Conclusion:

None of the agents were affected by HLA-Cw6. When biological agents were evaluated collectively, the treatment response of HLA-Cw6-POS patients was lower.

Addictive behaviors, cardiovascular and metabolic comorbidities in North African psoriatic patients: case-control study

We propose to study the epidemiological aspects of North African psoriasis and determine the cardiovascular comorbidities and addictive behaviors associated with psoriasis. This is a North African case-control study which was conducted over a five year period (October 2008 through August 2013), involving 671 psoriatic patients and 1,242 controls identified in various Algerian, Tunisian and Moroccan university hospitals. For each patient, epidemiological characteristic, addictive behaviors, and cardiovascular pathologies associated with psoriasis were noted. Six hundred and seventy one psoriasis patients and 1,242 controls were included in this study. The average age was 47.24 years and the M/F sex-ratio was 1.11 (354 men and 317 women). Statistical analysis showed that psoriasis patients were more likely to develop addictive behaviors than controls (smoking p<10-5 and alcohol consumption: p < 10-5), together with dyslipidemia (30.1% of patients p < 10-5), obesity (23.8% of patients p < 10-4), hypertension (22.3% of patients p < 10-5), diabetes (21.7% of occurrences p < 10-5) and metabolic syndrome (37.4% of patients p<10-5). The relative risk for developing psoriasis was 1.9 in hypertensive patients, 1.7 in diabetic patients, 3.9 in dyslipidemic patients, 1.8 in obese patients, 2.6 in those with metabolic syndrome, 2.1 in smokers and 2.8 in alcoholics. Our work confirms the high incidence of addictive behaviors and of cardiovascular and metabolic comorbidities during the North-African psoriasis, hence the need for a multidisciplinary comprehensive care based on a guideline suited to the characteristics of North-African psoriatic patients.

Psoriasis: Keratinocytes or Immune Cells - Which Is the Trigger?

BACKGROUND

Psoriasis is a common, chronic inflammatory skin disorder, which can significantly impact quality of life. Despite major breakthroughs in our understanding of the pathogenesis of psoriasis, the chronological order of the underlying mechanisms leading to the development of psoriatic plaques remains to be completely understood.

SUMMARY

Although psoriasis is classically perceived as a T-cell disease, it is now well recognized that T lymphocytes do not function in exclusivity. This theory is supported by evidence from transgenic murine models that develop marked psoriasiform disease. In addition, immune cells and cytokines regulate both early and late events involved in the pathogenesis of psoriasis. Key Messages: Psoriasis is a complex disease - a dynamic interplay between immune cells, keratinocytes, and various other skin-resident cells, such as endothelial and immune cells. The contribution of each cell type is crucial in the initiation and maintenance phases of psoriatic alterations.

An Investigation of Comorbid Disease and Health Service Utilization Among Patients With Moderate to Severe Psoriasis in Newfoundland and Labrador

Psoriasis is an inflammatory skin condition affecting 2% to 3% of the population and is associated with several comorbidities, including cardiovascular disease, depression, inflammatory bowel disease, metabolic syndrome, mood disorder, psoriatic arthritis, and weight gain. Psoriasis is treated with a number of topical and systemic therapies, including biologic drugs that directly target proinflammatory cytokines. This cross-sectional retrospective study investigated comorbid conditions reported in the Newfoundland and Labrador psoriasis population, outcomes associated with therapeutic treatment, and use of health care resources. Of the psoriasis comorbidities investigated, psoriatic arthritis was significantly associated with the use of biologic therapy while a failure to respond to biologics was associated with a higher incidence of cardiovascular disease. Patients responsive to biologic treatment had fewer hospital stays than patients treated with other therapies. Our results suggest that biologic therapies have a cardioprotective effect and reduce the number of hospital visits in patients whose symptoms are responsive to treatment.

Biologic Therapy Utilization in Patients With Moderate to Severe Psoriasis and Psoriatic Arthritis: An Observational Summary of Biologic Therapy Use in a Clinical Setting

Plaque psoriasis affects approximately 2% to 3% of the global population, with psoriatic arthritis observed in approximately 20% to 30% of these individuals. Upon advances in research pathophysiology and treatment over the past decade, biologic therapies have been used more to treat moderate to severe psoriasis. In Canada, reimbursement bodies have defined prior authorization criteria to determine patient eligibility for funding of biologic treatments in moderate to severe plaque psoriasis. Generally, patients will have been treated with conventional therapies such as topical steroids, phototherapy, or systemic treatments such as methotrexate and cyclosporine before starting a biologic therapy. In difficult cases or severe flares in otherwise controlled disease, practitioners may augment the regimen with one or more conventional treatments. The objective of this observational report was to identify treatment pathways for psoriasis and psoriatic arthritis patients in Canada by examining initial biologic treatment and subsequent treatment optimization patterns for informed reimbursement discussions and decisions. A retrospective chart review was conducted at Newlab Clinical Research using medical records of patients who received at least 1 of 4 biologic agents approved at that time of the survey in Canada for the treatment of plaque psoriasis (adalimumab, etanercept, infliximab, ustekinumab). The study population consisted of patients who had moderate to severe plaque psoriasis, diagnosed by a dermatologist, for at least 6 months before the study index date and who attended Newlab Clinical Research between 2008 and 2013. All current and previous agents prescribed for the treatment of psoriasis were captured. A total of 248 patients with psoriasis treated with biologics were identified, of whom 27 (10.9%) were also diagnosed with psoriatic arthritis. Prior to initiating treatment with a biologic, most patients (72.1%) were treated with (or contraindicated to) methotrexate/cyclosporine. Treatment was supplemented with topical agents (70.6%) and/or followed by a course of ultraviolet light phototherapy (51.6%). Only 2.4% of patients were treated with a biologic first. Of 248 patients treated with biologics, almost half (47.6%) needed add-on therapy, whereas 16.5% of patients had an increase in dose or dosing interval. Furthermore, 14.1% of patients added a topical agent, 10.5% a topical steroid, or 6.5% a course of phototherapy while continuing biologic therapies. Finally, 30.4% of patients switched to another biologic treatment. Adalimumab was the most common agent used as a second-line agent (37.2%), and patients who started on adalimumab mainly switched to ustekinumab as a second-line agent (73.9%). Infliximab was the agent least often used as second-line therapy.

HLA-Cw6 and psoriasis

Psoriasis is a multifactorial disease with a strong genetic background. HLA-Cw6 is one of the most strongly associated psoriasis susceptibility alleles. It is repeatedly observed to affect disease course, phenotypic features, severity, comorbidities and treatment outcomes. To the best of our knowledge, the roles of HLA-Cw6 in psoriasis have not yet been thoroughly reviewed. The worldwide frequency of the HLA-Cw6 allele varies greatly, with it being generally higher in white people than in Asians. The allele is associated with type I early-onset psoriasis. Stress, obesity and streptococcal pharyngitis are commonly observed in HLA-Cw6-positive patients. Phenotypically, HLA-Cw6 has been found to be associated with guttate psoriasis. In addition, patients carrying the allele are more likely to have arm, leg and trunk involvement, and the Koebner phenomenon. Patients with psoriatic arthritis with HLA-Cw6 more often have early onset and tend to show cutaneous symptoms before musculoskeletal symptoms. HLA-Cw6-positive patients have been shown in several studies to be more responsive to methotrexate and ustekinumab. However, this difference in ustekinumab efficacy was only moderate in a post-hoc analysis of a pivotal phase III study. HLA-Cw6 positivity also tends to be less frequent in high-need patients who fail conventional therapy. Small studies have also investigated the role of HLA-Cw6 in remission of psoriasis during pregnancy, and with the comorbidities of photosensitivity and atherosclerosis. Given the diverse nature of psoriasis pathogenesis, as well as the difference of HLA-Cw6 positivity in different ethnic groups, more studies are needed to confirm the role of HLA-Cw6 in psoriasis.

The effect of tumor necrosis factor inhibitor therapy on the incidence of myocardial infarction in patients with psoriasis: a retrospective study

BACKGROUND

Psoriasis has been shown to be associated with increased incidence of myocardial infarction (MI). The data on the effect of tumor necrosis factor (TNF) inhibitors on MI in psoriasis are scarce.

OBJECTIVE

To evaluate the effect of TNF inhibitors on the risk of MI in psoriasis patients compared with methotrexate (MTX) and topical agents.

METHODS

Data were obtained from the Electronic Health Records database of Farwaniya Hospital from psoriasis patients seen from January 2008 to December 2014. Patients were categorized into TNF inhibitor, MTX and topical cohorts.

RESULTS

The study included 4762 psoriasis patients. Both TNF inhibitor and MTX cohorts showed a statistically lower rate of MI compared with topical cohort. However, there was no statistically significant difference in MI rate between TNF inhibitor and MTX cohorts (P = .32). The probability of MI was lower in TNF inhibitor responders compared with non-responders (p = .001).

CONCLUSIONS

The use of TNF inhibitors in psoriasis showed a significant reduction in the risk of MI compared with topical agents and a non-significant reduction compared with MTX. Responders to TNF inhibitor therapy showed a reduction in MI rate compared with non-responders.

Psoriasis Patients Treated With Biologics and Methotrexate Have a Reduced Rate of Myocardial Infarction

Psoriasis is a chronic inflammatory skin condition characterised by the formation of red scaly plaques on the skin. It is an autoimmune disease cause by the dysregulation of cytokines controlling the inflammatory pathways, a mechanism likely contributing to various comorbidities observed in patients with psoriasis. Cardiovascular disease is one comorbidity observed more frequently in the psoriasis patient population. Biologic treatments specifically target the dysregulation of cytokines in the inflammation pathway and have shown to be an effective treatment for moderate to severe psoriasis where other systemic treatments have failed. More recently, biologics have been shown to reduce the incidence of myocardial infarction in patients with psoriasis compared to patients treated with topical agents. In the present study, 4 international psoriasis patient cohorts are combined and analyzed to examine the effect that biologic or methotrexate treatment has on reducing the incidence of myocardial infarction. Both methotrexate and biologic treatments were found to lower the incidence of myocardial infarction in moderate to severe psoriasis patient populations.

Management of Cardiovascular Risk in Patients with Chronic Inflammatory Diseases: Current Evidence and Future Perspectives

An increased risk of cardiovascular disease (CVD) has been observed in a range of chronic inflammatory diseases (CID), including rheumatoid arthritis (RA), psoriasis, inflammatory bowel diseases (IBD), and systemic lupus erythematosus (SLE). The increased risk of CVDs and reduced life expectancy in these conditions has stimulated considerable research and started an ongoing discussion on the need for a multidisciplinary approach and dedicated guidelines on CVD prevention in these patients. In addition, the possibility of inhibiting inflammation as a means to preventing CVD in these patients has gained considerable interest in recent years. We briefly summarize the current level of evidence of the association between CIDs and CVD and cardiovascular risk management recommendations. Perspectives of ongoing and planned trials are discussed in consideration of potential ways to improve primary and secondary CVD prevention in patients with CID.

Demography, baseline disease characteristics and treatment history of patients with psoriasis enrolled in a multicentre, prospective, disease-based registry (PSOLAR)

BACKGROUND

Psoriasis is associated with several comorbidities and behavioural risk factors.

OBJECTIVES

To evaluate demographic and disease characteristics in patients enrolled in the Psoriasis Longitudinal Assessment and Registry (PSOLAR).

METHODS

PSOLAR is a global, prospective, longitudinal, disease-based registry that includes a postmarketing commitment to evaluate safety in patients with psoriasis. Enrolled patients had to be receiving, or be eligible to receive, conventional systemic or biological agents. Demographic/disease characteristics, medical histories, lifestyle risk factors and previous treatments are collected at enrolment. Efficacy and safety data are collected every 6 months for 8 years, and data are extracted annually. Selected parameters are evaluated by age quartile using post hoc analyses.

RESULTS

As of 23 August 2012, 11 900 patients were enrolled at 301 sites in North America, Europe and Latin America. Over half of the PSOLAR population (54·7%) is male, with a mean age of 48·6 years and mean body mass index of 30·9 kg m(-2) at enrolment. Mean duration of disease at enrolment was 17·5 years, and mean Physician's Global Assessment score was 2·0. Psoriatic arthritis (35·5%) and cardiovascular diseases (38·2%) were highly prevalent. Diabetes mellitus type II was reported in 11·4% of patients. Depression and anxiety were noted in 14·7% and 11·1% of patients, respectively; 79·0% reported any alcohol use and 56·7% reported smoking or a history of smoking. The occurrence of most comorbidities, including cardiovascular disease and risk factors, increased with age.

CONCLUSIONS

In the PSOLAR population, multiple and age-appropriate comorbidities are associated with psoriasis and may affect the selection of psoriasis treatments.

Psoriasis, cardiovascular events, cancer risk and alcohol use: evidence-based recommendations based on systematic review and expert opinion

The relationship between psoriasis, chronic inflammation, cardiovascular risk and risk of cancer has long been debated. In addition, it has been suggested that alcohol consumption may be a risk factor for psoriasis onset and severity. The aim of this study was to develop evidence-based recommendations on the risk of comorbidities and its management for daily clinical use, focusing on cardiovascular risk, risk of cancer and alcohol use in psoriasis. A scientific committee identified and selected through the Delphi method clinically relevant questions about cardiovascular risk, risk of cancer and alcohol use in psoriasis. To address these questions, a systematic literature search was performed in Medline, Embase and the Cochrane Library databases. Systematic literature reviews including meta-analysis whenever possible were performed. Subsequently, an Expert board meeting involving 39 dermatologists took place to analyse the evidence and to elaborate recommendations on the selected questions. Recommendations were graded according to the Oxford level of evidence grading system. The degree of agreement of these recommendations was assessed on a 10-point scale, as well as their potential impact on daily clinical practice. A total of 3242 articles were identified through the systematic literature searches, among which 110 were included in the systematic reviews. Overall, 12 recommendations were elaborated regarding comorbidities management in psoriasis patients. A moderate increased risk of cardiovascular diseases (CVD), mainly myocardial infarction (MI) [meta-analysis of cohort studies: OR = 1.25 (95% CI 1.03-1.52) and of cross-sectional studies: OR = 1.57 (95% CI 1.08-2.27)], and coronary artery disease (CAD) [meta-analysis of cross-sectional: OR = 1.19 (95% CI 1.14-1.24), of cohort studies: OR = 1.20 (95% CI 1.13-1.27) and of case-control studies: OR = 1.84 (95% CI 1.09-3.09)] was acknowledged. This increased cardiovascular risk requires appropriate prevention measures. There was a lack of substantial evidence that conventional systemic treatment has any effect on cardiovascular risk although methotrexate might be cardioprotective. An increased risk of solid cancer potentially associated with smoking and alcohol use was identified. The role of systemic treatment on cancer risk could not be assessed thoroughly due to limited long-term follow-up data. A higher risk of non-melanoma skin cancers especially squamous cell carcinoma was shown, mainly due to previous exposure to oral 8-methoxypsoralen-ultraviolet-A (PUVA), ciclosporin and possibly methotrexate. No firm conclusion could be drawn regarding alcohol and psoriasis due to high variability in alcohol usage assessment in studies. Clinical experience suggests higher alcohol consumption among psoriasis patients compared to the general population. The mean expert participants' level of agreement on these recommendations varied from 6.8 to 9.4. These 12 recommendations are evidence based and supported by a panel of expert dermatologists. The next step is now to disseminate these recommendations to dermatologists who did not participate in the Expert board meeting and to assess their opinion about the recommendations.

Prognosis after percutaneous coronary intervention in patients with psoriasis: a cohort study using Danish nationwide registries

Background

Psoriasis is an inflammatory disease associated with increased risk of coronary artery disease. However, the potential impact of psoriasis on the prognosis following percutaneous coronary revascularization (PCI) is unknown.

Methods

The study comprised the entire Danish population undergoing first-time PCI in the period 2002–09. Cox regression models, controlling for age, gender, socioeconomic status, pharmacological treatment, and comorbidity were used to assess the risk of 1) all-cause mortality and 2) a composite endpoint of death, myocardial infarction, and stroke.

Results

A total of 53,141 patients with first-time PCI in the study period were identified. Of these, 1074 had mild psoriasis and 315 had severe psoriasis. Patients with severe psoriasis, but not those with mild disease had increased risk of both endpoints compared to patients without psoriasis. The incidence rates for all-cause mortality were 30.5 (CI 29.7-31.3), 29.9 (CI 24.7-36.1), and 47.2 (CI 35.0-63.6) per 1000 patient years for patients without psoriasis, with mild psoriasis, and with severe psoriasis, respectively. Hazard ratios were 1.10 (CI 0.91-1.33) and 1.67 (CI 1.24-2.26) for mild and severe psoriasis, respectively. Patients with severe psoriasis were less likely to receive secondary prevention pharmacotherapy with betablockers, statins and platelet inhibitors.

Conclusion

This first study of the prognosis following PCI in patients with psoriasis demonstrated an increased risk of all-cause mortality and of a composite of death, myocardial infarction and stroke, respectively, in patients with severe psoriasis compared to patients without psoriasis. Further studies of this novel association are needed.