The effect of subcutaneous methotrexate on markers of metabolic syndrome in psoriatic patients - preliminary report

Metabolomic Alterations in Methotrexate Treatment of Moderate-to-Severe Psoriasis

BACKGROUND Aberrant lipid metabolism alterations in skin tissue, blood, or urine have been implicated in psoriasis. Here, we examined lipid metabolites related to psoriasis and their association with the age of disease onset. MATERIAL AND METHODS Differences in lipid metabolites before and after methotrexate (MTX) treatment were evaluated. The discovery cohort and validation cohort consisted of 50 and 46 patients, respectively, with moderate-to-severe psoriasis. After MTX treatment, the patients were divided into response (Psoriasis Area and Severity Index [PASI] 75 and above) and non-response (PASI below 75) groups, blood was collected for serum metabolomics, and multivariate statistical analysis was performed. RESULTS We detected 1546 lipid metabolites. The proportion of the top 3 metabolites was as follows: triglycerides (TG, 34.8%), phospholipids (PE, 14.5%), phosphatidylcholine (PC, 12.4%); diglycerides (DG) (16: 1/18: 1), and DG (18: 1/18: 1) showed strong positive correlations with onset age. There were marked changes in TG (16: 0/18: 0/20: 0), TG (18: 0/18: 0/22: 0), TG (14: 0/18: 0/22: 0), TG (14: 0/20: 0/20: 0), lysophosphatidylcholine (LPC) (16: 0/0: 0), LPC (18: 0/0: 0), LPC (14: 0/0: 0), and LPC (18: 1/0: 0) levels before and after 12 weeks of MTX treatment. The glycerophospholipid metabolic pathway was implicated in psoriasis development. Of the 96 recruited patients, 35% were MTX responders and 65% non-responders. PE (34: 4) and PE (38: 1) levels were significantly different between the groups. Obvious differences in lipid metabolism were found between early-onset (<40 years) and late-onset (≥40 years) psoriasis. Significant changes in serum lipid profile before and after MTX treatment were observed. CONCLUSIONS The specific lipid level changes in responders may serve as an index for MTX treatment efficacy evaluation.

Methotrexate and cardiovascular prevention: an appraisal of the current evidence

New evidence continues to accumulate regarding a significant association between excessive inflammation and dysregulated immunity (local and systemic) and the risk of cardiovascular events in different patient cohorts. Whilst research has sought to identify novel atheroprotective therapies targeting inflammation and immunity, several marketed drugs for rheumatological conditions may serve a similar purpose. One such drug, methotrexate, has been used since 1948 for treating cancer and, more recently, for a wide range of dysimmune conditions. Over the last 30 years, epidemiological and experimental studies have shown that methotrexate is independently associated with a reduced risk of cardiovascular disease, particularly in rheumatological patients, and exerts several beneficial effects on vascular homeostasis and blood pressure control. This review article discusses the current challenges with managing cardiovascular risk and the new frontiers offered by drug discovery and drug repurposing targeting inflammation and immunity with a focus on methotrexate. Specifically, the article critically appraises the results of observational, cross-sectional and intervention studies investigating the effects of methotrexate on overall cardiovascular risk and individual risk factors. It also discusses the putative molecular mechanisms underpinning the atheroprotective effects of methotrexate and the practical advantages of using methotrexate in cardiovascular prevention, and highlights future research directions in this area.

B7-H4 Polymorphism Influences the Prevalence of Diabetes Mellitus and Pro-Atherogenic Dyslipidemia in Patients with Psoriasis

Background: The co-inhibitory molecule B7-H4 is located in the genomic regions associated with type 1 diabetes (T1D) susceptibility. However, the correlation of B7-H4 with glycometabolism and dyslipidemia has never been studied. Objective: To explore the influence of B7-H4 polymorphism on the prevalence of diabetes mellitus (DM) and dyslipidemia in psoriasis. Methods: In this single-center cross-sectional study, we recruited 265 psoriatic patients receiving methotrexate (MTX) treatment. Thirteen single-nucleotide polymorphisms (SNPs) in B7-H4 were genotyped. Serum levels of total cholesterol (TC), triglycerides (TG), lipoprotein (a) (LP(a)), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein (LDL), apolipoprotein A1 (ApoA1), and apolipoprotein B (ApoB) were measured at baseline and week 12. Results: The GG genotype carriers of rs12025144 in B7-H4 had a higher prevalence of DM (57.14% vs. 17.71% vs. 18.67%, p = 0.0018), and had a poorer response to MTX in diabetic patients (p < 0.05), compared with AA or AG genotype carriers. The AG genotype of rs2066398 was associated with higher levels of pro-atherogenic lipids. MTX significantly downregulated the level of anti-atherogenic lipid ApoA1 in AA genotype carriers of rs2066398. Conclusions: The genotypes rs12025144 and rs2066398 in B7-H4 were correlated with a higher prevalence of DM and dyslipidemia in psoriasis, respectively.

Clinical Efficacy and Safety of Psoriasis Treatments in Patients with Concomitant Metabolic Syndrome: A Narrative Review

Metabolic syndrome (MetS) is well recognized as a frequent comorbidity of psoriasis with important implications for efficacy and safety of psoriasis treatment. The presence of concomitant MetS is associated with decreased efficacy response to biologic treatment for psoriasis in observational studies. In post hoc analyses of clinical trial data, the anti–IL-23p19 antibody tildrakizumab appears to maintain efficacy in patients compared to those without MetS; no published subgroup analyses by MetS status are yet available for other biologics. However, there is some evidence that obese patients have decreased psoriasis treatment efficacy with biologics with certain mechanisms of action relative to overweight patients. This confounds interpretation of the effect of MetS due to the association between MetS and body weight. Because of the association between MetS and cardiovascular risk, treatment of psoriasis in patients with concomitant MetS requires special consideration for cardiovascular safety and attention to potential for exacerbation of MetS and related conditions, including nonalcoholic fatty liver disease. Additional studies are needed to clarify the risks for treatment failure and cardiovascular safety concerns in patients with psoriasis and concomitant MetS.

Interstitial lung disease progression in patients with anti-aminoacyl transfer-RNA-synthetase autoantibodies is characterized by higher levels of sCD163

BACKGROUND

Patients with anti-tRNA autoantibodies are characterized by arthritis, mechanic´s hands, fever, Raynaud´s phenomenon, and interstitial lung disease (ILD), in at least two clinical scenarios: the antisynthetase syndrome (ASSD) and interstitial pneumonia with autoimmune features (IPAF). The anti-tRNA-ILD treatment is centered on the administration of corticosteroids and a wide variety of immunosuppressive drugs; however, the effectiveness of the treatment depends on factors not fully understood. This research work aimed to quantify the serum levels of two molecules related to pulmonary fibrosis and explore their relationship with the progression of ILD associated with ASSD METHODOLOGY: Serum levels of sCD163 and TGF-β1 from baseline and after six months of treatment of ILD patients' positives to anti-tRNA were included in the current study. At six months, patients were classified as with or without ILD progression RESULTS: Forty patients were included (anti-Jo1, anti-PL7, anti-PL12, and anti-Ej). Five patients (12.5%) had ILD progression and were characterized by higher levels of sCD163 at baseline. Baseline sCD163 serum levels showed good discriminatory capacity in patients with ILD progression. On the other hand, at follow-up, serum TGF-β1 levels significantly increased in both patients' groups, with and without progression CONCLUSION: Basal levels of sCD163 were higher in patients who later developed ILD progression and kinetics of both molecules suggests the participation of M2 macrophages in the development of ILD.

Skin and metabolic syndrome: A review of the possible associations

Metabolic syndrome (MeTS) is a well-known health-related problem with several end-organ damages and the resulted side effects such as rising in the blood glucose and lipid and blood pressure. Although MeTS might show several skin symptoms such as acanthosis nigricans, skin tags, acne, and androgenic alopecia, it could also be implicated in the pathophysiology of numerous dermatologic disorders. Furthermore, some dermatologic drugs might be implicated in the incidence or exacerbation of MeTS. Consequently, MeTS and skin problem could interfere closely with each other and each one could predispose the patient to the other one and vice versa. Remembering these close relationships help us to have better therapeutic choices regarding each inflammatory skin conditions. Moreover, some of the skin symptoms should be followed cautiously to define the underlying MeTS.

The impact of methotrexate therapy with vitamin D supplementation on the cardiovascular risk factors among patients with psoriasis; a prospective randomized comparative study

BACKGROUND

Controlling psoriasis with various systemic treatments, including methotrexate, may significantly decrease associated cardiovascular risk problems.

OBJECTIVE

To assess the value of vitamin D supplementation on clinical response as well as changes in cardiovascular risk parameters in psoriasis patients treated with methotrexate.

METHODS

This prospective randomized comparative study included 30 patients with moderate to severe psoriasis divided randomly to receive either methotrexate alone (Mtx) or methotrexate plus intramuscular vitamin D (MtxD) for 3 months. Lipid profile, HsCRP, carotid intima-media thickness (CIMT) and blood pressure (BP) measurements were recorded before and after the therapy.

RESULTS

At end of study period, significant clinical improvement in both groups was observed. CIMT and systolic BP decreased in both groups but only statistically significant in Mtx group. HsCRP decreased in both groups but didn't reach statistical significance. We also observed, an increase in triglycerides and cholesterol levels in the Mtx group with the latter decreasing in the combined Mtx and vitamin D therapy group.

CONCLUSION

Treating psoriasis with methotrexate may decrease cardiovascular disease risk factors. Adding vitamin D supplementation to methotrexate may protect lipid homeostasis, specifically cholesterol and triglycerides.

Analysis of key markers: IL-10/sHLA-G in psoriasis patients and the identification of 14-bp INDEL in the HLA-G gene

BACKGROUND

Psoriasis is a chronic inflammation resulting from interactions between immunological and genetic factors. An important tolerogenic role in this autoimmunological disease is played by HLA-G, which is modulated by IL-10. Therefore, this study (N.=80) aimed to evaluate changes in the serum sHLA-G and IL-10 levels in active psoriasis vulgaris and in the early stages of treatment with Methotrexate (MTX) compared to healthy controls. The 14-bp INDEL of the HLA-G gene was evaluated to find possible associations with clinical and laboratory variables.

METHODS

The level of sHLA-G and IL-10 in serum was evaluated (ELISA tests) in patients before the first dose of MTX and at week 12 of treatment, compared to healthy control donors. The 14-bp INDEL in 3'UTR of the HLA-G gene was identified using gDNA templates isolated from full blood. HLA-G amplicons were obtained by PCR, separated by electrophoresis and sequenced.

RESULTS

The mean serum IL-10 level was 4.653±3.33 pg/mL in psoriatic patients, 13.3±9.64 pg/mL after short MTX treatment, compared to 6.23 pg/mL in healthy controls. In addition, the serum level of sHLA-G was 0.275±0.03 ng/mL and 0.332±0.06 ng/mL in patients before and after MTX treatment, respectively, and 0.302±0.08 ng/mL in the control group. A correlation was found (r=-0.43; P<0.005) between the IL-10 and BSA serum levels in psoriasis patients after MTX treatment, indicating health improvement. The three genotypes identified in the 3'UTR of the HLA-G revealed no association with sHLA-G level in serum.

CONCLUSIONS

The mean levels of sHLA-G and the key anti-inflammatory cytokine IL-10 in the blood of pretreatment psoriasis patients are low and indicate that the immunotolerance mechanisms have failed. Treatment of psoriasis patients with low systemic levels of sHLA-G and IL-10 brings them to the same or higher protein levels, respectively, as in healthy donors. Higher sHLA-G levels in healthy donors and after MTX treatment, compared to the sHLA-G levels in the acute phase of psoriasis, indicates its immune system surveillance function.

The influence of tumour necrosis factor α inhibitors treatment - etanercept on serum concentration of biomarkers of inflammation and cartilage turnover in psoriatic arthritis patients

INTRODUCTION

Effective treatment in psoriatic arthritis (PsA) patients can protect them from severe musculoskeletal complications. For appropriate monitoring of anti-tumour necrosis factor α (anti-TNF-α) treatment in PsA, specific biomarkers are needed.

AIM

To investigate whether biological treatment with anti-TNF-α (etanercept 50 mg once a week subcutaneously) affects the activity of selected mediators of inflammation and destruction of articular cartilage: interleukin-6 (IL-6), interleukin-18 (IL-18), matrix metalloproteinases 1 and 3 (MMP-1, MMP-3), cartilage oligomeric matrix protein (COMP), human cartilage glycoprotein (YKL-40) in serum of patients with PsA.

MATERIAL AND METHODS

The study included 25 patients with PsA. The concentration of IL-6, IL-18, MMP-1, MMP-3, COMP and YKL-40 in serum was determined before, and 6 and 12 weeks after the beginning of anti-TNF-α treatment. Clinical severity of the disease according to the Body Surface Area, Psoriasis Area and Severity Index and Dermatology Life Quality Index as well as tender and swollen joint count (TJC, SJC) were also evaluated.

RESULTS

The study disclosed a statistically significant reduction in the serum concentration of IL-6, MMP-1 and YKL-40 in PsA patients after 6 and 12 weeks from the beginning of anti-TNF-α treatment (p = 0.00018 for IL-6; p = 0.01242 for MMP-1; p = 0.03263 for YKL-40).

CONCLUSIONS

IL-6, MMP-1 and YKL-40 may be useful for monitoring the effectiveness of anti-TNF-α treatment.

Effect of methotrexate treatment on the expression of epidermal-fatty acid-binding protein (E-FABP) and apolipoproteins in patients with psoriasis

Introduction

Epidermal-fatty acid-binding protein (E-FABP) is a marker of transiently amplifying cells which are formed from stem cells in epidermis. Their role is an uptake of fatty acids and metabolism. Psoriatic keratinocytes overexpress E-FABPs, which leads to acanthosis and may explain the lipid’s disturbances in psoriasis.

Aim

Assessment of FABP and apolipoprotein expression in patients treated with methotrexate (MTX).

Material and methods

FABP expression in the lesional and perilesional psoriatic skin from 11 male patients compared to 5 healthy skin samples were evaluated by immunohistochemistry. FABP, apolipoprotein A1 (ApoA1) and B (ApoB) serum levels were assessed by ELISA. These parameters were evaluated before and after treatment with subcutaneous MTX (15 mg/wk for 12 weeks).

Results

Expression of E-FABP was lower in the control group than in the lesional and perilesional psoriatic skin, before and after treatment. After treatment the expression decreased in the lesional and perilesional skin. Serum E-FABP was higher in the control group (482.855 ±240.550 pg/ml) compared to patients, but not statistically significantly. After MTX treatment, a statistically significant reduction was observed in psoriatic patients. ApoA1 levels did not differ in the control and patients groups, both before and after treatment. In contrast, ApoB levels did not differ statistically between the control group (1447.126 ±311.11 ng/ml) and patients before treatment, while they were the lowest after treatment (1081.67 ±117.83 ng/ml vs. 808.306 ±103.72 ng/ml; p < 0.01).

Conclusions

Our study confirms the beneficial effect of MTX, not only as an anti-proliferative effect, but also reducing the cardiovascular risk by decreasing atherogenic ApoB.

Systemic Psoriasis Therapies and Comorbid Disease in Patients with Psoriasis: A Review of Potential Risks and Benefits

Psoriasis is an inflammatory skin disease that is associated with many comorbidities. Several psoriasis treatments approved by the United States Food and Drug Administration have been shown to have beneficial effects on these comorbidities, while others might lead to an exacerbation of these conditions. In this article, we review studies of psoriasis treatments and their level of evidence for use in co-occurring diseases. An awareness of the multifaceted effects of certain psoriasis medications can enable physicians to provide more personalized treatment to their most complicated patients.

Repurposing existing drugs for cardiovascular risk management: a focus on methotrexate

About 20% of patients with a history of atherosclerotic cardiovascular disease will experience further cardiovascular events despite maximal pharmacological treatment with cardioprotective drugs. This highlights the presence of residual cardiovascular risk in a significant proportion of patients and the need for novel, more effective therapies. These therapies should ideally target different pathophysiological pathways involved in the onset and the progression of atherosclerosis, particularly the inflammatory and immune pathways. Methotrexate is a first-line disease-modifying antirheumatic drug that is widely used for the management of autoimmune and chronic inflammatory disorders. There is some in vitro and in vivo evidence that methotrexate might exert a unique combination of anti-inflammatory, blood pressure lowering, and vasculoprotective effects. Pending the results of large prospective studies investigating surrogate end-points as well as morbidity and mortality, repurposing methotrexate for cardiovascular risk management might represent a cost-effective strategy with immediate public health benefits. This review discusses the current challenges in the management of cardiovascular disease; the available evidence on the effects of methotrexate on inflammation, blood pressure, and surrogate markers of arterial function; suggestions for future research directions; and practical considerations with the use of methotrexate in this context.