Cardiovascular Risk in Patients With Psoriasis

Psoriatic disease has a well recognized adverse impact on cardiometabolic risk factors, including obesity, dyslipidemia, and diabetes. Patients with psoriasis and psoriatic arthritis have an increased risk of premature cardiovascular mortality. As discussed during a session at the American Academy of Dermatology (AAD) annual meeting, better understanding of psoriasis treatments' effects on cardiometabolic pathways is needed.

MedPage Today brought together three expert leaders in the field: moderator Andrew Blauvelt, MD, of the Oregon Medical Research Center in Portland, is joined by Joel Gelfand, MD, of the University of Pennsylvania in Philadelphia, and Neil Korman, MD, of Case Western Reserve University in Cleveland, for a virtual roundtable discussion. This first of four exclusive episodes focuses on the ways psoriasis therapy affects cardiovascular risk factors.

Following is a transcript of their remarks:

Blauvelt: Hello, everyone. My name is Dr. Andy Blauvelt. I'm a dermatologist from Portland, Oregon, at the Oregon Medical Research Center. I'm happy to be joined today by two of my friends and colleagues, Dr. Joel Gelfand from University of Pennsylvania, and Dr. Neil Korman from Case Western Reserve University. So, welcome to Joel and to Neil.

Today we're going to discuss highlights from the AAD, and also just kind of highlights in psoriasis literature and psoriasis goings-on these days at this current time. So, the hot topics for us, we're going try to cover in this session. I'm going to kick it off by first asking Joel to tell us about a paper he presented at the AAD meeting on apremilast [Otezla] in heart disease. Joel?

Gelfand: Sure. And first of all, it's great to be with you, Andy. Great to see you, Neil. So, as hopefully our colleagues know, we've been investigating the cardiovascular effects of psoriasis treatments for quite some time now. And our latest study is the Vascular Inflammation in Psoriasis-Apremilast trial. This is an open-label study. All patients got apremilast, 70 patients. We image them at week 16 and again at week 52.

And the topline findings were number one, in terms of the effect of apremilast on aortic vascular inflammation, in the overall patient population the effect was neutral. We didn't see any worsening or any improvement in aortic vascular inflammation.

You know, interestingly, in a subanalysis, in a small population of patients, those who had substantially elevated markers of inflammation aortic baseline, they did see a decrease over 52 weeks period of time. And that needs to be repeated in additional studies.

But the most striking thing we saw is that patients on apremilast had about a 5% reduction in visceral body fat after 16 weeks. And they maintained it for 52 weeks of the treatment during the study time. And that's likely to portend better metabolic and health outcomes over time, because we know visceral fat is associated with cardiovascular disease, atherosclerosis, other bad health outcomes. So that's a pretty striking finding and something we're pretty excited about.

Blauvelt: Thank you, Joel. So, do you think that -- were you surprised at all at the results? And I want you to comment also, you're using a different method these days to look at effects of biologic treatments or psoriasis treatments on heart disease -- angio CT. Do you think you may have seen something different with that particular imaging tool?

Gelfand: Yeah, so, you know angio CT is more challenging to use from a research perspective, because it takes about a year or longer to see changes in that metric. And that's why we've focused on aortic vascular inflammation at this point in time. It's certainly possible we may see changes in that metric if one was looking at it, but you need larger studies, longer-term follow-up.

I'm not surprised by the change in visceral adiposity. It was important to demonstrate. Because we know patients on apremilast could lose some body weight. And the question is, where is that coming from? Are they losing muscle mass, is it this subcutaneous fat -- which is not of any medical benefit for the most part, it's more of a cosmetic benefit. And so the fact that they're losing 5% of the visceral adiposity, a form of fat tissue that we know is pathogenic, is a pretty important observation to document and is pretty much a new finding.

Blauvelt: Yeah. And I'd like to ask Neil, how do you talk to your patients about heart disease -- psoriasis and heart disease? Is this an important part of your practice with your psoriasis patients?

Korman: Absolutely. Although, first time I meet somebody, I don't slam them too hard with that. So, I want to kind of get to know the lay of the land with the patient and understand where their understanding is at. So, when they come in, they come in to see a derm, they expect us to concentrate on their skin. And I do. I certainly talk about, that this is a systemic disease and that it can affect other parts of the body. And I usually, on my first visit with somebody who's got severe disease, say you have a risk of maybe a quarter or a third of the time people go on to get arthritis. I don't instantly talk about heart disease, but I will as I get to know the patient a little better, certainly if they're diabetic or they're hypertensive or they're overweight, which most of our patients are all of the above. Then, I'm getting on it.

Like, today, as a matter of fact, I saw a lady who weighed about, I don't know, 350 lb. And the first time I met her, we could only get her on Humira [adalimumab], I didn't talk about it. But after she failed Humira and now she's on Skyrizi [risankizumab] and she's almost clear, I started talking about weight loss today and she was amenable to it because her skin is clear and she feels like she could actually be seen outside, going to the gym, walking, whatever. So I think it's a very important part of the care of our patients.

Gelfand: Recently, we published a paper in JAMA Dermatology. We did qualitative interviews with patients with psoriasis, both psoriatic arthritis and psoriasis, and did survey work. And patients really welcome hearing from that dermatologist or rheumatologist about comorbidities and the impact that cardiovascular, the context of receiving disease care for psoriatic disease. So, when a dermatologist says, "oh, by the way, you need to know that psoriasis patients have higher rates of cardiovascular problems over time related to their skin disease," that's something that really the patients appreciate and helps to better understand what's going on with their bodies. So, I really want to encourage our colleagues to make these connections for our patients.

Blauvelt: Yeah, absolutely. And I do it as well. I do it on the first visit, Neil, and many times my patients say, you know, "I've never heard that before." So, I think we still have to work on telling patients about heart disease.

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