{"id":334957,"date":"2020-01-24T01:00:00","date_gmt":"2020-01-24T00:00:00","guid":{"rendered":"https:\/\/medizinonline.com\/complex-interaction-structure-implications-for-therapy\/"},"modified":"2020-01-24T01:00:00","modified_gmt":"2020-01-24T00:00:00","slug":"complex-interaction-structure-implications-for-therapy","status":"publish","type":"post","link":"https:\/\/medizinonline.com\/en\/complex-interaction-structure-implications-for-therapy\/","title":{"rendered":"Complex interaction structure: Implications for therapy"},"content":{"rendered":"

Cardiovascular comorbidities in psoriasis may lead to a reciprocal influence of systemic therapies with implications for disease progression. Early detection and treatment are important factors in disease management<\/strong><\/p>\n

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The rate of comorbidity is increased in psoriasis sufferers – about 70% of affected adults have at least one concomitant disease [1]. Psoriatic arthritis occurs in approximately 20% of patients with dermatologically treated psoriasis [1]. There is a significantly increased prevalence of cardiovascular disease, obesity, diabetes, metabolic syndrome, depression, inflammatory autoimmune diseases, and addiction (Fig. 1)<\/strong>. Tiago Torres, MD, PhD, University of Porto, presented empirical findings on cardiovascular comorbidities at this year’s EADV Congress [2].<\/p>\n

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Coronary artery disease, atherosclerotic plaques and the obesity factor<\/h2>\n

Severe psoriasis not only increases the risk of myocardial infarction and stroke, but also cardiovascular mortality [3]. According to data from a secondary analysis, the prevalence of moderate to severe coronary calcification is fivefold higher in patients with psoriasis than in a healthy control group [4]. In addition, it has been shown that psoriasis sufferers have a similar risk of coronary heart disease as patients 10 years older with hyperlipidemia [2,5]. Cytokine-mediated inflammatory processes implicated in the etiology of psoriasis are thought to be an independent risk factor for cardiovascular comorbidities, which in turn influence the inflammatory mechanisms underlying psoriasis [2]. (Fig. 2). <\/strong>An ultrasound study published in 2019 showed that psoriasis patients have an increased number of arteriosclerotic plaques in the femoral artery compared to a control group and insulin resistance is the most important determinant of atherosclerosis [6]. Obesity is a risk factor for both psoriasis and cardiovascular disease and is associated at the cellular level (proinflammatory cytokines, inflammatory adipokines, anti-inflammatory adipokines) with a state of chronic inflammation [2]. A BMI >30 kg\/m2<\/sup> doubles the risk of psoriasis and the severity of psoriasis is positively correlated with obesity [7]. Adipose tissue is an active endocrine organ that plays an important role in lipid and glucose metabolism and inflammatory processes [7].<\/p>\n

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Comorbidities must be taken into account<\/h2>\n

Cardiovascular comorbidities should be considered in the choice of systemic psoriasis therapy, as they may influence efficacy and safety [2]. There is evidence that obesity increases the risk for hepatic and renal toxicity of methotrexate and ciclosporin [7]. In addition, obesity can impair the clinical response of any systemic therapy (conventional and biologics), so a healthy lifestyle and weight loss should be supported [7]. The speaker also drew attention to the fact that some medications used to treat cardiovascular comorbidities may affect psoriasis therapy [2]: Antihypertensives including beta-blockers and ACE inhibitors may worsen psoriasis symptoms in some patients, and interactions between ciclosporins and statins may induce rabdomiolysis. A cohort study demonstrated that improvement in psoriasis severity was associated with a reduction in aortic vascular inflammation at one-year follow-up [8]. And a recent study found that ustekinumab led to significant improvement in aortic inflammatory processes compared with placebo after a 12-week period [9]. A cohort study published in 2019 in patients with moderate to severe psoriasis demonstrated that in biologic-na\u00efve patients (n=89), biologic therapy resulted in a significant reduction in coronary inflammation compared with the conventionally treated control group (n=32) at follow-up one year after baseline [10]. In a retrospective cohort study, TNF inhibitors (TNFi) had a significantly lower risk of major adverse cardiac event (MACE) compared with topical therapy (HR 0.80; 95% CI; 0.66-0.98) [11].<\/p>\n

Screening and information are beneficial<\/h2>\n

According to an international multicenter study published in 2018 (n=2254), there are gaps in diagnosis and care regarding hypertension and dyslipidemia in psoriasis patients [12]. The prevalence of undiagnosed and untreated cardiovascular risk factors in those with severe psoriasis is high [2]. A survey regarding the management of cardiovascular risk factors in patients with severe psoriasis among Portuguese dermatologists found that 45% performed screening\/monitoring, but 40% neither clarified cardiovascular risk nor considered it in therapy [13]. An observational study to evaluate the effects of patient education regarding cardiovascular comorbidities showed the following. [14]: before the intervention, the subjects had a low knowledge of appropriate correlations; 6 months after the training, 60.4% increased the frequency of physical activity, 49.1% achieved a weight reduction of 2.3 kg on average, and 50% reduced their nicotine consumption.<\/p>\n

Source: EADV, Madrid<\/em><\/p>\n

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\nLiterature:<\/p>\n

    \n
  1. Augustin M, et al: Use of system therapeutics and biologics in guideline-based therapy of moderate to severe psoriasis vulgaris. PsoNet Magazine 2017\/1.<\/li>\n
  2. Torres T: Treating psoriasis in patients with metabolic comorbidities. Psoriasis treatment, slide presentation, Tiago Torres, MD, PhD, EADV Congress, Madrid, Oct. 12, 2019.<\/li>\n
  3. Armstrong EJ, Harskamp CT, Armstrong AW: Psoriasis and Major Adverse Cardiovascular Events: A Systematic Review and Meta-Analysis of Observational Studies. J Am Heart Assoc 2013; 2(2): e000062.<\/li>\n
  4. Mansouri B, et al: Comparison of Coronary Artery Calcium Scores Between Patients With Psoriasis and Type 2 Diabetes. JAMA Dermatol 2016; 152(11): 1244-1253.<\/li>\n
  5. Lerman JB, et al: Coronary Plaque Characterization in Psoriasis Reveals High-Risk Features That Improve After Treatment in a Prospective Observational Study Circulation 2017; 136(3): 263-276.<\/li>\n
  6. Gonzalez-Cantero A, et al: Subclinical atherosclerosis in psoriasis. Usefulness of femoral artery ultrasound for the diagnosis, and analysis of its relationship with insulin resistance. PLoS One 2019; 14 (2): e0211808.<\/li>\n
  7. Gisondi P, Del Giglio M, Girolomoni G: Considerations for Systemic Treatment of Psoriasis in Obese Patients. Am J Clin Dermatol 2016; 17(6): 609-615.<\/li>\n
  8. Dey AK: Association Between Skin and Aortic Vascular Inflammation in Patients With Psoriasis. A Case-Cohort Study Using Positron Emission Tomography\/Computed Tomography. JAMA Cardiol 2017; 2(9).<\/li>\n
  9. Gelfand JM, et al: A Phase IV, Randomized, Double-Blind, Placebo-Controlled Crossover Study of the Effects of Ustekinumab on Vascular Inflammation in Psoriasis (the VIP-U Trial). J Invest Dermatol. 2019 Jul 19. pii: S0022-202X(19)32537-0.<\/li>\n
  10. Elnabawi YA, et al: Association of Biologic Therapy With Coronary Inflammation in Patients With Psoriasis as Assessed by Perivascular Fat Attenuation Index. JAMA Cardiol 2019; 4(9): 885-891.<\/li>\n
  11. Wu JJ, et al: Anti-inflammatory therapy with tumor necrosis factor inhibitors is associated with reduced risk of major adverse cardiovascular events in psoriasis. J Eur Acad Dermatol Venereol 2018; 32(8): 1320-1326.<\/li>\n
  12. Eder L, et al: Gaps in Diagnosis and Treatment of Cardiovascular Risk Factors in Patients with Psoriatic Disease: An International Multicenter Study. The Journal of Rheumatology 2018; 45(3): 378-384.<\/li>\n
  13. Raposo I, et al: Awareness and screening attitudes of Portuguese dermatologists on cardiovascular risk factors in psoriatic patients. Eur J Dermatol 2017; 27(4): 443-445.<\/li>\n
  14. Mota F, Selores M, Torres T: Importance of educational sessions on cardiometabolic comorbidities. Awareness among psoriasis patients. Actas Dermosifiliogr 2016; 107: 539-541.<\/li>\n<\/ol>\n

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    DERMATOLOGIE PRAXIS 2019; 29(6): 32-33 (published 12\/6\/19, ahead of print).<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

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