New insights into psoriasis comorbidity

Comorbid diseases play an important role in the management of psoriasis. Multiple aspects and new developments of concomitant conditions such as liver disease, cardiovascular (CV) disease, and COVID-19 were discussed at this year’s AAD Annual Meeting.

In patients with psoriasis, the extent of psoriatic skin involvement is an important risk indicator for psoriatic arthritis (PsA): 1% more affected body surface area is linked to an increase of 2% in PsA risk [1]. Other factors that are significantly associated with a heightened risk of both psoriasis and PsA include obesity and moderate alcohol use [2]. Further identified risk factors to bear in mind, according to Prof. Joel Gelfand (University of Pennsylvania, PA, USA), are pharyngitis, previous or current smoking, infectious skin diseases, as well as a history of traumas to bones and joints [3]. The question of whether the use of biologics can also influence the risk of acquiring PsA has not yet been answered satisfactorily. “In my view, some questions are not well suited to observational methods; we need RCTs to answer this question,” Prof. Gelfand stressed.

Liver monitoring during methotrexate treatment

A recent population-based cohort study detected that patients with psoriasis on methotrexate are 1.6–3.4 times more likely to develop liver disease than those who are on the same agent for rheumatoid arthritis [4]. This is in concordance with the recommendations for rigorous liver monitoring in methotrexate-treated patients [3]. Baseline hepatotoxicity monitoring should, for example, include blood serology with a choice of Fibrosis-4 Index, FibroSure™, FibroMeter™, or Hepascore tests [5]. After a cumulative dose of 3.5–4.0 g of cumulative methotrexate, a consult with a gastroenterologist and/or vibration-controlled transient elastography is also advised. The latter should be performed every year in those with risk factors for hepatotoxicity, even if the findings of baseline results were normal.

Cardiovascular disease in psoriatic patients – more prevention is needed

For patients with psoriasis, the evaluation of their CV risk is mandatory [6]. In moderate-to-severe disease, screening of the cardiometabolic status should be performed frequently and, for an adequate evaluation, the resulting risk scores should be multiplied by 1.5.

Assessing the influence of psoriasis therapy on CV risk is an important topic [3]. A review and meta-analysis of RCTs assessing the effect of biologics on CV disease risk revealed that phototherapy is the only treatment that may improve the lipid profile [7]. The systematic review also found that only ustekinumab ameliorated aortic vascular inflammation, and adalimumab was best at reducing biomarkers of cardiometabolic risk such as C-reactive protein [7]. Results from other prospective studies have shown that biologic therapy of psoriasis is linked to an amelioration of coronary plaques and coronary inflammation [3].

Psoriasis treatment during the pandemic – a matter of concern

Much of the recent research on comorbidities and psoriasis has centred around the COVID-19 pandemic. In terms of risk with psoriasis treatment, recent data demonstrated that patients with an immune-mediated inflammatory disease were more prone to hospitalisation/death from COVID-19 when on methotrexate (OR 2.0) or a Janus kinase (JAK) inhibitor (OR 1.82) compared with tumour necrosis factor (TNF) inhibitors, which demonstrated a reduction in risk [8,9]. The National Psoriasis Foundation COVID-19 Task Force has published guidance with over 30 recommendations [10]. Among them is the endorsement for mRNA-COVID-19 vaccination and boosters. Currently, there is no indication of a higher rate of vaccine-induced flares than with other vaccines [3]. As for an immune response to a 2-dose mRNA vaccination, no reduction in humoral immunity was apparent but, compared with healthy controls, the T-cell response was lower in individuals treated with methotrexate, TNF inhibitors, IL-17 inhibitors, or IL-23 inhibitors [3]. For the treatment of non-hospitalised COVID-19 infections, new options are available. “Most importantly, paxlovid is the treatment of choice in outpatients with mild-to-moderate COVID-19, just watch for interactions,” Prof. Gelfand highlighted. All in all, larger scale and population-based trials over longer study durations are still needed to widen the knowledge about psoriasis management and COVID-19 risk.

 

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   1. Ogdie A, et al. Rheumatology (Oxford). 2021;61(5):1877-1884.
   2. Meer E, at al. J Rheumatol. 2022;49(1):53–59.
   3. Gelfand JM. New Developments in Psoriasis Comorbidity and COVID19. S016, AAD 2022 Annual Meeting, 25–29 March, Boston, MA USA.
   4. Gelfand JM, et al. J Am Acad Dermatol. 2021;84(6):1636–1643.
   5. Menter A, et al. J Am Acad Dermatol. 2020;82(6):1445–1486.
   6. Elmets CA, et al. J Am Acad Dermatol. 2019;80(4):1073–1113.
   7. González-Cantero A, et al. J Invest Dermatol. 2021;141(10):2402–2411.
   8. Izadi Z, et al. JAMA Netw Open. 2021;4(10):e2129639.
   9. Curtis JR, et al. J Rheumatol. 2022;49(3):320–329.
   10. National Psoriasis Foundation COVID-19 Task Force. [Accessed on 19 April 2022].

 

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Posted on 17 May 202216 February 2024