LAS VEGAS – Dermatologists may be doing patients with psoriasis a disservice if they don’t prescribe a good anti-inflammatory drug to reduce the risk of MI, according to Dr. Bruce E. Strober.
Dr. Bruce Strober
People with psoriasis are more likely to have comorbidities and behaviors associated with cardiovascular disease including smoking, alcohol misuse, hypertension, diabetes, dyslipidemia, and obesity. Dyslipidemia therapies that patients with psoriasis may take such as corticosteroids, acitretin, and cyclosporine can also increase cardiovascular risk.
Aside from these, psoriasis is independently associated with a higher risk for MI, stroke and death, probably due to the cardiovascular effects of uncontrolled inflammation, Dr. Strober said at the seminar sponsored by Skin Disease Education Foundation (SDEF).
"You might say to a patient, this is a disease that has every bit as much an effect as hypertension on mortality. The data on hypertension are not even as impressive as this," said Dr. Strober of the department of dermatology at New York University. "Maybe this is a big deal that cardiologists need to think about. They are starting to catch on."
Rheumatoid arthritis studies show that methotrexate and tumor necrosis factor blockers reduce comorbid risks, and the same may be true for psoriasis. "That’s why I sometimes say methotrexate may have an overall net benefit when given to patients with severe psoriasis," he said. Any potential toxicity from methotrexate should be weighed against its potential cardiovascular advantages. A prospective, British population–based cohort study found that the incidence of MI was 3.6 per 1,000 patient-years among 556,995 control patients without psoriasis, 4.0 among 127,139 patients with mild psoriasis, and 5.1 among 3,837 patients with severe psoriasis after controlling for other cardiovascular risk factors (JAMA 2006;296:1735-41).
Younger patients with severe psoriasis had the greatest risk. The relative risk for MI with mild psoriasis was 1.3 in 30-year-olds and 1.1 in 60-year-olds. The relative risk for MI with severe psoriasis was 3.1 for 30-year-olds and 1.4 for 60-year-olds.
The study may have underestimated the cardiovascular risk of severe psoriasis by limiting the definition of severe disease to patients on systemic therapy, Dr. Strober added. Some with severe disease may have been assigned to the mild psoriasis category.
The most likely cause of this increased risk for MI is uncontrolled inflammation in systemic psoriasis, not unlike rheumatoid arthritis and lupus, which also are known to create MI risk, he said. Psoriasis has immune effects and creates a hyperinflammatory state. Uncontrolled inflammation leads to endothelial dysfunction and dyslipidemia.
A separate study of the same British database found that women and men with psoriasis died 3.5 years and 4.4 years, respectively, earlier than people without psoriasis after controlling for other risk factors for mortality (Arch. Dermatol. 2007;143:1493-99).
Other data sets have substantiated this concept in the Medicare population. "People with psoriasis die younger. We have to think of this as a disease that has a direct effect on mortality," Dr. Strober said.
Will dermatologists accept the role of primary screeners for comorbidities that increase the risk for cardiovascular disease and other problems? That remains to be seen, but the National Psoriasis Foundation’s 2008 clinical consensus statement provided guidance for dermatologists willing to screen (J. Am. Acad. Dermatol. 2008;58:1031-42).
Basic screening steps include assessing blood pressure and overweight or obese status and getting laboratory evaluations – a fasting comprehensive metabolic panel and fasting lipids. Physicians also should ask about use of alcohol, smoking, depression, and arthritis.
Comorbidities may make it harder to treat psoriasis, and vice versa, though data are sparse, Dr. Strober said. Obese patients, for example, may need larger doses of psoriasis medications. The hyperinflammatory state of psoriasis may make treating psoriasis difficult unless it’s addressed, and conceivably make it more difficult to treat hypertension or dyslipidemia, but this has not been studied, he said.
Dr. Strober has received grants from or been a consultant, speaker or advisor for Abbott, Amgen, Centocor, Johnson & Johnson, Pfizer, and Celgene.
SDEF and this news organization are owned by Elsevier.