Derms may be first to spot cardiovascular risk in psoriasis patients

People who live with psoriasis have a higher risk of death from cardiovascular disease, according to one expert on comorbid disease in psoriasis.

Joel M. Gelfand, MD, MSCE, says that dermatologists are in an ideal position to identify such patients’ cardiovascular risks and educate patients about preventive therapy.

Dr. Gelfand, an associate professor of dermatology and epidemiology at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, discussed these issues in a presentation at the 71^st annual meeting of the American Academy of Dermatology and at the 14^th annual Residents Meeting on Psoriasis and Psoriatic Arthritis sponsored by the National Psoriasis Foundation.  

He stresses that while the link to cardiovascular disease is now well established, the precise mechanism of the link has not been established.

“There is extensive literature suggesting that psoriasis, particularly when more severe, is an independent risk factor for cardiovascular disease,” he says.

He notes that evidence is growing that also supports a link to diabetes, as well. Scientists believe that the link between psoriasis and cardiovascular disease may be chronic inflammation which both disorders have in common.

Dermatologists: often the principal physicians

While the precise reason for these comorbid risks is not yet known, the obligation of dermatologists is clear, Dr. Gelfand says.

“Psoriasis patients may often only be seeing a dermatologist as their skin disease is there primary health concern,” he says. Therefore, dermatologists need to inform psoriasis patients about risks of co-morbid diseases and either initiated appropriate screening such checking blood pressure, and weight, as well as blood levels of glucose and cholesterol or direct them to a primary care physician for these evaluations.

The information is concerning. “People with severe psoriatic disease have a shortened life span,” he says. “Much of the decrease in life expectancy is due to cardiovascular disease, such as heart attack, stroke, or sudden cardiac death (JAMA 2006).

Studies by Gelfand and his colleagues have shown that patients with more severe psoriasis have a six percent risk of having a major cardiovascular event attributable to their psoriasis and not traditional risk factors over a 10-year period of time.

Dr. Gelfand notes that this 10 year risk of CV events attributable to psoriasis is similar to the degree of risk conferred by diabetes.

Putting this risk in perspective, he notes that a patient with severe psoriasis is 30 times more likely to experience a major cardiovascular event attributable to their skin disease then they are to develop a melanoma.

“Despite these important risks, cardiovascular risk factors appear to be under-recognized and under treated in psoriasis patients according to emerging studies of patients in clinical trials.” he says.

Although the cause for the link has not been established, its existence gives dermatologists a particular responsibility and opportunity to screen for cardiovascular risk factors in psoriasis patients and to encourage them to get treatment for it, Dr. Gelfand says.

“I routinely pick up undiagnosed hypertension and diabetes in my own practice,” he says.

The monitoring is the same for people with psoriasis as for the general population, Dr. Gelfand says. These include taking the patient’s blood pressure; screening for diabetes either through a fasting serum glucose or HbA1c (which may be non-fasting), beginning with the diagnosis of psoriasis; and lipid screening every five years.

He encouraged dermatologists to take the initiative and talk to psoriasis patients about the risk of cardiovascular disease and steps they can take to lower this risk.

VIP study

If psoriasis is associated with an increased risk of cardiovascular disease, could psoriasis therapies lower that risk?

Because the two conditions share the link of chronic inflammation, one logical step would be to see whether anti-inflammatory therapy used in the treatment of psoriasis lowers cardiovascular risks, as well.

Dr. Gelfand is leading a study to answer that question. “There’s emerging observational evidence that anti-inflammatory treatment such as methotrexate and TNF [tumor necrosis factor] inhibitors may reduce cardiovascular risk,” he says.

The study, Vascular Inflammation in Psoriasis (VIP), is funded by a nearly $4 million grant from the National Heart Lung and Blood Institute of the National Institutes of Health (NIH) (see below). After a treatment washout period, the study will randomize patients to 12 weeks of adalimumab (Humira), phototherapy, or placebo. The investigators will then assess the patients’ responses to therapy regarding their psoriasis and also determine the impact of treatment on vascular inflammation measured by FDG-PET/CT and lipid metabolism.

While the adalimumab and placebo arms of the study will be double-blinded, the phototherapy arm will be open.

Vascular inflammation of the aorta, as measured by FDG/PET/CT, is an important surrogate marker of the risk of future CV events, and is known to be modified by cardio-protective treatments such as statins.

Dr. Gelfand notes that this sophisticated test also appears to be able to track psoriasis activity in the skin. These initial data show that psoriasis treatment reduces psoriasis inflammatory activity in the skin – stay tuned to see if it also decreases inflammation in vital structures such as the aorta, he says.

Disclosures: Humira is manufactured by Abbott Laboratories. Dr. Gelfand has been an investigator and/or consultant for Amgen, Abbott, Centocor, Merck, Pfizer, Celgene, Novartis, and Genentech. He stated that he has no significant conflicts of interest as they are defined by the American Association of Medical Colleges.

For more information:

Abuabara K, Azfar RS, Shin DB, Neimann AL, Troxel AB, and Gelfand JM: Cause-specific mortality in patients with severe psoriasis: A population-based cohort study in the United Kingdom. British Journal of Dermatology 2010, 163(3): 586-592.

Gelfand JM, Neimann AI, Shin DR, Wang X, Margolis DJ, Troxel AB. Risk of myocardial infarction in patients with psoriasis. JAMA 2006, 296(14):1735-41.

Vascular Inflammation in Psoriasis (VIP) Trial: http://clinicaltrials.gov/ct2/show/NCT01553058