Early treatment of severe psoriasis may curb comorbidities

Montreal - There is a suggestion that early treatment of severe psoriasis will decrease the risk of cardiovascular comorbidities that have been associated with severe psoriasis such as stroke and heart attack, according to a clinical professor dermatology at the State University of New York Buffalo School of Medicine.

Discussing the systemic impact of psoriasis at a dermatology symposium here, Robert Kalb, M.D., F.A.A.D., a dermatologist at the Buffalo Medical Group in Buffalo, N.Y., said six different meta-analyses published within the last year demonstrate that psoriasis is an independent risk factor for cardiovascular disease.

But it remains to be determined if initiation of therapy as early as possible will diminish the likelihood of appearance of comorbidities.

“The current evidence is suggestive but not definitive,” Dr. Kalb tells Dermatology Times. “If you treat early, you may decrease the systemic inflammation and thereby decrease the chance of arthritis developing or decrease the chance of having a heart attack or stroke.

“The state of the art is to aggressively manage the comorbid factors that are present such as decreasing weight, lowering blood pressure, controlling diabetes, lowering of lipids, cessation of smoking, and promoting exercise,” he says.

The impact of treatment on comorbidities is not limited to biologic treatments, Dr. Kalb says, noting the effect has been observed with methotrexate.

Cutaneous complications

Patients who are on a regimen of biologic therapies to treat nondermatological conditions can develop cutaneous complications, but the development of these side effects should not be a signal for ceasing biologic therapy, according to Christina Han, M.D.

“In most cases, patients can continue with their biologics,” says Dr. Han, clinical instructor at the University of British Columbia department of dermatology, Vancouver. She spoke in Montreal at a dermatology symposium. “If patients are considering discontinuing their (biologic) therapy, we should collaborate with our colleagues in gastroenterology and rheumatology.”

Some of the complications include the paradoxical development of psoriasis induced by tumor necrosis factor (TNF)-alpha blockers, notes Dr. Han, citing a patient with ulcerative colitis who developed psoriasis while taking TNF-alpha blockers.

“This paradoxical phenomenon of anti-TNF-alpha-induced psoriasis is fairly well-documented in the literature,” Dr. Han says. “We are trying to eludicate why this happens.”

One of the theories has been unopposed interferon alpha production, which stimulates T-cells, Dr. Han says. But since the vast majority of users of TNF-alpha blockers do not develop such a paradoxical response, there is likely more at play, such as genetics, she says.

Eczema is another cutaneous adverse event that has developed in an ulcerative colitis patient taking infliximab, Dr. Han notes.

Another possible complication of anti-TNF-alpha agents is the development of herpes zoster. A study in 2012 found that one-third of patients with herpes zoster who were receiving TNF-alpha blockers had severe herpes zoster. Another finding was an elevated risk of herpes zoster with monoclonal anti-TNF-alpha antibodies than with soluble TNF-alpha receptor (Serac G, Tubach F, Mariette X, et al. J Invest Dermatol. 2012;132(3 Pt 1):726-729).

But Dr. Han also notes a large cohort study published this year suggested that patients who are started on anti-TNF agents are at an equivalent risk of herpes zoster as patients who use non-biologic therapies (Winthrop KL, Badley JW, Chen L, et al. JAMA. 2013;309(9):887-895).

Biologic registries

A decade of use of biologic agents has led to the development of registries which offer longer-term information that supplements the evidence that comes from randomized, controlled trials (RCTs), which are typically short in duration, according to Melinda Gooderham, M.D., F.R.C.P.C., medical director, Skin Centre for Dermatology, Peterborough, Ontario, and assistant professor at Queen’s University, Kingston, Ontario.

“Registries, particularly biologic registries, offer us a lot of information that we don’t get from RCTs, and they provide us with information on patients who may not be included in RCTs,” Dr. Gooderham says, discussing the value of biologic registries. “We can put the two (registries and RCTs) together to get more information.”

There are many factors that may confound the data that come from registries such as options for flexible dosing, physician preferences and patient preferences, Dr. Gooderham says.

Still, many of the registries look at the retention of patients, which can serve as a proxy for variables like safety, efficacy, and tolerability of a medication, she says.

Disclosures: Dr. Kalb is an investigator and consultant for AbbVie, Janssen and Amgen. Dr. Han has been a consultant, advisory board member and speaker for Amgen, Ortho Janssen, AbbVie, and LEO Pharma. Dr. Gooderham is an investigator for the Psoriasis Longitudinal Assessment and Registry.