ORLANDO – A recent study that found a high prevalence of undiagnosed or untreated cardiovascular risk factors among patients with moderate to severe psoriasis reinforces the need for routine screening, said Dr. Jeffrey P. Callen.
Cardiovascular disease risk "seems to be increased in our patients with moderate to severe psoriasis, the kinds of patients who require systemic therapy," said Dr. Callen.
Dr. Jeffrey P. Callen
In the study, a total 59% of patients had at least two established cardiovascular risk factors, and 29% had three or more. Importantly, using Framingham risk scores, the investigators found 19% were at high risk for a cardiovascular event (J. Am. Acad. Dermatol. 2012;67:76-85).
Although comorbidities of psoriasis have garnered a lot of research, "what is relatively new is some of our systemic therapies might moderate or lessen these comorbidities and lessen patient risks in the future," said Dr. Callen, chief of the division of dermatology at the University of Louisville (Ky.).
Methotrexate therapy, for example, reduced the incidence of vascular disease in veterans with psoriasis or rheumatoid arthritis (J. Am. Acad. Dermatol. 2005;52:262-7). A lower to moderate cumulative dose appeared to be more beneficial than higher dose methotrexate, he said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.
In a more recent study, tumor necrosis factor (TNF) antagonist therapy improved aortic stiffness among 60 patients with inflammatory arthropathies, including psoriatic arthritis, rheumatoid arthritis, and ankylosing spondylitis (Hypertension 2010;55:333-8). "Those treated had a decrease in aortic stiffness, suggesting there is something we are doing with our systemic therapies," Dr. Callen said. "At least in the short run, this intervention might have some impact on cardiovascular disease."
How much of a concern is aortic stiffness? A comparison of 58 normotensive patients with psoriasis and 36 controls found significantly higher rates of abnormal aortic stiffness in the psoriasis group (Blood Press. 2010:19:351-8).
Another study suggests that treatment with a TNF inhibitor or hydroxychloroquine reduces the risk for new-onset diabetes mellitus among patients with psoriasis or rheumatoid arthritis (JAMA 2011;305:2525-31). The decrease was statistically significant, compared with treatment with other nonbiologic disease-modifying antirheumatic drugs.
"Dermatologists often overlook systemic aspects of skin disease, including psoriasis," said Dr. Callen.
For this reason, Dr. Callen recommends a comprehensive comorbidity monitoring plan, especially for patients with severe psoriasis. Assess blood pressure, heart rate, and body mass index every 2 years, for example. Order a lipid profile and check fasting blood glucose every 5 years (or more frequently in the presence of other risk factors). Ask patients questions about arthritis symptoms regularly, as well. He adapted these recommendations from a report in the British Medical Journal (2010;340:b5666).
Also ask your psoriasis patients about the other medical professionals they consult. "There are patients with severe psoriasis who are not seeing other doctors. I see patients who come in and list me as their primary care physician. I’m not a PCP," he said.
Dr. Callen said he is a consultant to Amgen and a member of the safety monitoring committee for Celgene.