Inflammatory Responses: Managing Psoriasis in Light of Comorbidities
The accumulated evidence suggests that dermatologists must take an active role in addressing risks.
Patients with moderate to severe psoriasis are at risk for certain comorbidities, such as psoriatic arthritis, cardiovascular disease, and type 2 diabetes. This has emerged as an accepted fact. Less clear, however, is the dermatologist’s role in educating patients about these risks and managing or co-managing them in the long term. The American Academy of Dermatology and the National Psoriasis Foundation (NPF) are drafting Guidelines for Management of Comorbidities, due next year. Meanwhile, psoriasis experts urge clinicians to inform their psoriasis patients about risks, offer treatment most appropriate for the patient’s presentation, and make referrals when necessary to optimize care.
Candid dialogue is essential. “In general, all patients with psoriasis should be educated about the risk of major comorbidities associated with this disease. The risk of these comorbidities increases with severity of skin disease, therefore, education is especially important in those with moderate to severe disease (BSA>10 percent, or candidates for systemic or phototherapy),” says Joel Gelfand, MD of the University of Pennsylvania (See a listing of his latest research on the next page under “Further Reading”). “In my practice, I emphasize psoriatic arthritis, cardiovascular disease, and diabetes, as these conditions are very common and cause significant morbidity and mortality, in the case of cardiovascular disease.”
“I have found that our patients are increasingly interested in learning as much as they can about their disease and taking control of their healthcare,” says Joseph Merola, MD of Brigham and Women’s Hospital in Boston. “Most patients want to know about the risks associated with their disease, and this information helps inform their treatment decision-making process. We often spread out discussion of every aspect of relevant disease over several visits to help make the amount of information manageable and provide helpful resources, such as the National Psoriasis Foundation website and patient navigator program details.”
St. Louis dermatologist Craig Leonardi, MD tailors the conversation to each patient. “It has a lot to do with the patient, and how much I think the patient can absorb. I do tell everybody about psoriatic arthritis,” he says. “That’s a sufficiently strange comorbidity, so to speak, so that you have to plant that association in the patient’s head. There’s no intuitive way for them to link skin disease and joint disease.”
Cardiovascular comorbidities are “a mixed bag,” Dr. Leonardi says. “If my patients have had a cardiovascular event, then I’ll sit down and I’ll tell them everything we know about it, and how psoriasis could have an important role, and how important it is to keep your psoriasis under control.” For other patients, he tends to provide a general overview of CV risk and the need to monitor their health. He refers all patients back to their general practitioners for monitoring and additional referrals, such as to cardiologists and endocrinologists.
“The big chore is usually to get them hooked up with a primary care physician,” Dr. Leonardi observes. “A surprising number of patients, even in 2018, don’t have a physician. And they come to us, they get put on systemic therapies, and then they start to look at me as their primary care provider. I’ll try to help them as much as I can. But the idea is, I’m doing that while we are actively placing them with a PCP.”
Regardless who orders them, “age appropriate screenings for CV risk factors and diabetes, such as blood pressure, lipids, and HbA1c, provide an opportunity to prevent cardiometabolic morbidity and mortality through therapeutic lifestyle changes and treatment of established CV risk factors,” Dr. Gelfand stresses.
Leon Kircik, MD of Louisville, KY, also encourages his psoriasis patients to visit their primary care doctors. At subsequent visits, he asks if they have followed up, and continues to urge them to do so if they have not. Though he doesn’t make lifestyle modification a focus of patient education, he will address specific issues like smoking and high blood pressure when relevant. “I always tell people to go to the NPF website,” he adds. “I always say that.”
Dr. Leonardi acknowledges that some lifestyle issues are more likely to be addressed by staff members who inevitably spend more time with each patient than he typically does.
Patients with severe psoriasis (10 percent or more of body surface area) typically need a systemic agent, stresses Jashin Wu, MD of Kaiser-Permanente in Los Angeles. “Giving just topical agents to these patients is doing them a disservice,” he maintains. And, he adds, “Those with moderate psoriasis (3-10 percent BSA) may also need a systemic agent.”
“We have small prospective studies and large retrospective studies that indicate that TNF inhibitors improve or are correlated with improvement with CV measurements and outcomes, but we really need large prospective clinical trials to prove that this is really the case,” Dr. Wu says. He notes a need for more data on IL-17 and IL-23 inhibitors, as well.
Dr. Leonardi points to research by Dr. Wu and others. “Data show, for example, that in the database of psoriasis patients who were on TNF antagonists, there is a near 50 percent reduction in heart attack risk, just for being treated with TNF antagonists, as opposed to patients who are on other types of therapies,” he says. “You’re having a marked difference. You’re not quibbling about five or 10 percent.”
“We have some indirect evidence that controlling patients’ burden of inflammation is likely beneficial to the cardiovascular comorbidity risk, although it is not entirely clear how we modify risk and which treatments are better at modifying this risk in the long-term,” Dr. Merola notes. “For the most part, the known modifiable risk factors are as important to control as anything in this at-risk population.” Modifiable risk factors include smoking, obesity, hypertension, and high cholesterol.
The potential to reduce long-term risks of comorbidities may be important for psoriasis patients who may hesitate to use systemic therapies. Given the nature of safety statements, advertising sometimes leaves patients with a focus on potential side effects of treatment, rather than anticipated benefits. “There are patients who are substantially put off by that safety noise,” Dr. Leonardi says. “I talk to patients about the benefits of treatment, which really don’t get a good fair share in the advertisements for these drugs. I say to the patient, ‘You’re a little bit worried about infections, and so am I. But do you know that there’s evidence that you may have cardiovascular protection from, we call them MACE events, major adverse cardiovascular events?’ I’ll spend some time talking to the patient about that.”
“If dermatologists are not comfortable with the screening and monitoring, this should be done through facilitated discussion with a PCP or other provider who understands the current guidelines for treating psoriatic patients’ cardiovascular risk factors,” Dr. Merola maintains.
“If you don’t want to handle psoriatic arthritis, refer the patient to a rheumatologist. Don’t be afraid,” Dr. Kircik says. In his practice, patients with joint pain are not routinely referred to rheumatology. “It’s irrelevant, because I’m treating them for psoriasis, and the same agents are used in psoriasis and psoriatic arthritis,” he says. However, he adds, “if they tell me that their joint pains are getting worse or are not better, then I refer them to a rheumatologist.”
“If I think the patient has psoriatic arthritis, I have no problem initiating a systemic therapy that will cover psoriatic arthritis,” Dr. Leonardi agrees. He refers everybody back to rheumatology. “I’m not giving the patient away. What I’m asking them to do is to confirm the diagnosis. I want to know if there is something else that should be done to optimize care…And almost always, they agree with me...But I like having that confirmation, that we’re going down the right path.”
Dr. Leonardi notes that when it comes to psoriatic arthritis, the available biologic agents appear to confer similar efficacy across patient groups. However, the efficacy for skin involvement is variable. From their vantage point, then, rheumatologists may advise a therapeutic shift that is not ideal for skin management. Dialogue and collaboration are therefore essential, he stresses.
There remains much to learn about the precise interplay of inflammation in the skin, joints, and the cardiovascular and endocrine systems. It is clear, however, that the connections exist and require thoughtful assessment. Similarly, it seems clear that dermatologists must foster connections with their psoriasis patients and with other specialists in efforts to deliver optimal care.
“Psoriatic disease is often best treated with a multi-disciplinary care approach,” Dr. Merola asserts. “Put together a treatment team to address each of the aspects of disease most relevant to a particular situation—dermatologist, rheumatologist, primary care physician, psychologist, etc.”
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Gelfand JM.Commentary: Does biologic treatment of psoriasis lower the risk of cardiovascular events and mortality?: A critical question that we are only just beginning to answer. J Am Acad Dermatol. 2018 Jul;79(1):69-70.
Mehta NN, et al. Effect of 2 Psoriasis Treatments on Vascular Inflammation and Novel Inflammatory Cardiovascular Biomarkers: A Randomized Placebo-Controlled Trial.
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