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    Beyond the plaque

    Psoriasis patients may suffer metabolic problems

    Dermatologists who assess psoriasis patients should look beyond the plaques on the skin and consider not just the increased risk to the joints, but also the heart, mind and more.

    "Psoriatic arthritis is the most common and well-known co-morbidity of psoriasis, however, to me, the increased risk for cardiovascular disease, such as heart attack and stroke, is the most important co-morbidity associated with moderate-to severe psoriasis," Andrew Blauvelt, M.D., M.B.A., president and investigator, Oregon Medical Research Center, Portland, Ore.

    Cardiovascular and metabolic risk factors among psoriasis patients should be top of mind for dermatologists, according to Joel M. Gelfand, M.D., M.S.C.E., professor of dermatology and epidemiology, vice chair of clinical research, and director of the Psoriasis and Phototherapy Treatment Center University of Pennsylvania Perelman School of Medicine, Philadelphia. Dr. Gelfand has spent much of his career researching psoriasis and presented on the metabolic impact of psoriasis at last January’s Maui Derm for Dermatologists 2016 meeting in Maui, Hawaii.

    “We know from dozens, if not more, studies that psoriasis is linked to the metabolic syndrome, as well as its individual components,” says Dr. Gelfand.

    For example, as the body surface area affected by psoriasis increases from being very limited, at less than 2 percent, to 3 to 10 percent and to more than 10 percent, patients’ odds of having hyperglycemia and hypertriglyceridemia increase in a dose-response manner, according to a study by Dr. Gelfand and colleagues in the March 2012 Journal of Investigative Dermatology.1

    “What we’ve learned in this research is that the severity of skin disease, itself, seems to be related to metabolic problems not driven solely by obesity per se,” Dr. Gelfand says.

    When Dr. Gelfand and colleagues looked at the risk of major adverse cardiovascular events among patients with psoriatic arthritis (PsA), rheumatoid arthritis (RA) and psoriasis compared to the general population, they found that people with psoriasis taking disease-modifying antirheumatic drugs (DMARDs) were 42 percent more likely than the general population to have a major adverse cardiovascular event which is very similar to the risk of MACE in patients with RA treated with DMARDs.]

    Dr. Blauvelt, who also presented on psoriasis at Maui Derm’s 2016 meeting, cites a recent study in which Dr. Gelfand was among the researchers that suggests a linear correlation with the level of psoriatic skin disease and the level of inflammation documented in the aorta.3

    “Aortic inflammation is linked to atherosclerosis, so these data really emphasize the need to discuss the risk of heart disease in patients with extensive skin disease," Dr. Blauvelt says

    The knowledge should translate to more vigilance in dermatologic practice, Dr. Gelfand says.

    “Dermatologists should educate patients with psoriasis that they are more likely to have risk factors for cardiovascular disease, such as high blood pressure, insulin resistance, abnormal lipids. They should also educate especially those who have more severe psoriasis (the patients you’re considering systemic medications or phototherapy for) that they have a higher risk of cardiovascular events over time,” he says.

    Psoriasis patients should be seeing their primary care doctors to make sure they’re up to date on age-appropriate cardiovascular risk screenings. In general, those include a blood pressure check every one to two years; diabetes screening every three years; and a cardiovascular risk assessment for lipid levels every four to six years, according to Dr. Gelfand.

    “If they have other risk factors, like they smoke, encourage them to stop smoking. If they are overweight, encourage them to lose weight with a healthy diet—things of that nature,” Dr. Gelfand says. “Many of our psoriasis patients might only be seeing a dermatologist (and not other doctors). In my  practice, I picked up a lot of undiagnosed hypertension and a fair amount of undiagnosed diabetes.”

    Having moderate-to-severe psoriasis patients’ comorbidities well controlled is important not only for their overall health, to also to allow for optimal treatment with biologics, according to Dr. Gelfand.

    “…some of these conditions can make them more predisposed to complications of biologics. For example, if you have diabetes, that puts you at higher risk of infection,” he says.

    NEXT: Other comorbidities

     

    Lisette Hilton
    Lisette Hilton is president of Words Come Alive, based in Boca Raton, Florida.

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