Review
From the Medical Board of the National Psoriasis Foundation: The risk of cardiovascular disease in individuals with psoriasis and the potential impact of current therapies

https://doi.org/10.1016/j.jaad.2013.09.020Get rights and content

Background

Many studies have identified cardiovascular risk factors in patients with psoriasis. Some psoriasis therapies may increase cardiovascular disease (CVD) and others may decrease CVD.

Objective

We reviewed the literature to define the impact of common psoriasis therapies on cardiovascular measures and outcomes.

Results

Phototherapy has no major cardiovascular impact and may reduce levels of proinflammatory cytokines. Acitretin increases serum lipids and triglycerides, but has not been shown to increase cardiovascular risk. Cyclosporine A increases blood pressure, serum triglycerides, and total cholesterol. Methotrexate is associated with a decreased risk of CVD morbidity and mortality. Among the biologics, data for tumor necrosis factor inhibitors suggest an overall reduction in cardiovascular events. Most data on short-term ustekinumab use suggest no effect on major adverse cardiovascular events, however some authorities remain concerned. Nevertheless, ustekinumab use over a 4-year period shows a decrease in major adverse cardiovascular events when compared both with the general US population and with psoriatics in Great Britain.

Limitations

Most studies lack the power and randomization of large clinical trials and long-term follow-up periods. In addition, the increased risk of CVD associated with psoriasis itself is a confounding factor.

Conclusion

Some therapies for moderate to severe psoriasis, including methotrexate and tumor necrosis factor inhibitors, may reduce cardiovascular events in psoriatic patients. Ustekinumab appears to be neutral but there may be a long-term benefit. Appropriate patient counseling and selection and clinical follow-up are necessary to maximize safety with these agents. Further long-term study is necessary to quantify the benefits and risks associated with biologic therapies.

Section snippets

Association of the psoriatic disease state and CVD

In 1995, the association of psoriasis with diabetes mellitus (DM), obesity, heart failure, and hypertension (HTN) was first observed.10 Since then, cardiovascular risk factors have been demonstrated in numerous studies. In fact, some reports suggest psoriasis is an independent risk factor for cardiovascular morbidity.11, 12, 13 Patients with psoriasis may have a predisposition to DM and HTN,14 and several studies have shown higher rates of DM, HTN, hyperlipidemia, smoking, obesity, and

Association of therapeutic modalities and CVD

Given the increased risk of CVD, an area of interest has been evaluating how therapeutic modalities might modulate cardiovascular risk.

Biomarkers of inflammation

Treatment with TNF inhibitors (TNFi) has been shown to modify C-reactive protein, adiponectin, VEGF, and resistin. C-reactive protein is a predictor of CVD such as MI, peripheral arterial disease, and sudden cardiac death.90, 91, 92 Adiponectin has anti-inflammatory, antiatherogenic, and antidiabetic properties,93, 94 VEGF may reflect inflammation and hypoxia such as in acute MI,95 and resistin is related to insulin resistance.96 Etanercept was shown to decrease levels of C-reactive protein in

Conclusion

Currently, there is not enough evidence to recommend therapies for psoriasis solely based on cardiovascular impact. However, if systemic therapy is a consideration in the setting of CVD or risk, it would appear that, based on current data, TNFi and MTX offer the best evidence of benefit. As the initial clinician seen for most cases of psoriasis, the dermatologist should actively screen patients with severe disease for cardiovascular risk factors and provide appropriate counseling, treatment,

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    Funding sources: None.

    Disclosure: Dr Van Voorhees has served on advisory boards for Amgen, Abbott Laboratories, Genentech, Novartis, Warner Chilcott, Centocor/Janssen Biotech, and LEO Pharma; has been an investigator and consultant for Amgen; and has been a speaker for Amgen, Abbott Laboratories, and Centocor/Janssen Biotech. Dr Bagel has served as consultant, on advisory boards, and as a speaker and investigator for Amgen and Abbott Laboratories. Dr Lebwohl has served as consultant and investigator for Abbott Laboratories, Amgen, Celgene, Eli Lilly & Co, Janssen Biotech, and LEO Pharma; as an investigator for Ranbaxy; and as a consultant for Anacor Pharmaceuticals, BioLineRX, Dermipsor, Galderma, GlaxoSmithKline-Stiefel, Maruho, Novartis, Pfizer, and Valeant. Dr Blauvelt has served on advisory boards and as investigator and consultant for Janssen Biotech, Novartis, and Eli Lilly & Co; as a speaker for Janssen Biotech; and as an investigator for Abbott Laboratories, Amgen, and Celgene. Dr Hsu has served on advisory boards for Abbott Laboratories, Amgen, Biogen Idec, Centocor/Janssen Biotech, and Genentech; and has been an investigator for Centocor/Janssen Biotech. Dr Weinberg has served as a speaker for Abbott Laboratories, Amgen, and Genentech, and has performed clinical research for Amgen, Celgene, and Janssen Biotech. Drs Hugh and Nijhawan have no conflicts of interest to declare.

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