Psoriasis treatment should be stratified in order to better assess the cardiovascular event rates

Abstract

We have read with great interest the recently published article entitled ‘Cardiovascular disease event rates in patients with severe psoriasis treated with systemic anti-inflammatory drugs: a Danish real-world cohort study’ by Ahlehoff et al. 1. In that very well-presented article, they aimed to evaluate the rates of cardiovascular disease events in patients with severe psoriasis treated with systemic anti-inflammatory drugs. They concluded that in this nation-wide study of patients with severe psoriasis treated with systemic anti-inflammatory therapies, the use of biological agents and methotrexate was associated with lower rates of death, myocardial infarction and stroke compared with patients treated with other agents. Systemic treatments for psoriasis including methotrexate, cyclosporine, retinoids and biological agents may contribute to either reducing or increasing the cardiovascular risk 2. Indeed, it has been reported that American veterans affected by psoriasis treated with moderate doses of methotrexate have a reduced risk of major cardiovascular events compared with nontreated patients. This effect is possibly attributable to the anti-inflammatory effects of the drug 3. Cyclosporine and retinoids may increase serum cholesterol and triglycerides. Therefore, cyclosporine and retinoids should be chosen with caution in patients with cardiovascular risk factors. Furthermore, in patients with psoriasis, systemic anti-inflammatory therapy with tumour necrosis factor-alpha inhibitors may reduce the incidence of cardiovascular disease, and it can reduce endothelial cell activation 2. The present study concluded that patients with severe psoriasis or on systemic anti-inflammatory treatment with biological agents or methotrexate had reduced cardiovascular disease event rates. But the effects of cyclosporine and retinoids on cardiovascular event risk have not been determined exactly. In a study by Balci et al., no association between acitretin use and subclinical atherosclerosis was found 4. As we know, long-term management of severe psoriasis requires an individualized approach. The selection of a treatment is based on the clinical presentation of psoriasis and whether contraindications might exist. Most psoriasis treatments should be prescribed for restricted periods of time 5. Rotational treatment is a practical approach to reduce the cumulative toxicity and allow effective treatments to be maintained for many years 6. In the present study, patients with severe psoriasis were divided into three treatment groups: as biological agents, methotrexate and other therapies like retinoids, cyclosporine, phototherapy and/or climate therapy. In our opinion, we think that it would be better if the effects of each agent on cardiovascular disease were investigated separately. More severe psoriasis was significantly associated with the following: longer disease duration; higher prevalence of concomitant disease; greater involvement of the nails, scalp, flexures, palms and soles; and a poorer quality of life 7. Severe psoriasis is also associated with increased risk of adverse cardiovascular events and all-cause mortality 8, 9. In our opinion, in the present study, the activity of the disease before starting treatment, the duration of the disease and the presence of psoriatic arthritis should also have been determined. Coronary artery disease (CAD) is the major cause of deaths worldwide 10. Systolic heart failure is the most common cause of mortality in patients with CAD. Diabetes mellitus, hypertension, hyperlipidaemia and modifiable risk factors like obesity, smoking and alcohol are the most prominent risk factors for CAD 11. Furthermore, the prognosis of CAD may be associated with risk factors including increasing age, duration of diabetes and hypertension, obstructive sleep apnoea, obesity, lifestyle programmes and psychological disturbances. In addition to standard biochemical [sodium, potassium, creatinine/estimated glomerular filtration rate (eGFR)] and haematological tests (haemoglobin, haematocrit, ferritin, leucocytes and platelets), thyroid-stimulating hormone (thyrotropin) representing a thyroidal disorder can affect the prognosis of patients with CAD. In this point of view, it would be useful, if further effort was held on to assess these factors. In conclusion, severe psoriasis treated with systemic anti-inflammatory therapies, the use of biological agents and methotrexate were associated with lower rates of CAD mortality and morbidity as presented in this study. However, risk factors for CAD and the systemic anti-inflammatory therapies for psoriasis are very complex, so they deserve further large-scale prospective randomized clinical trials. We also believe that those findings obtained from this study will lead to further large-scale studies examining the relationship between CAD events and severe psoriasis. No conflict of interest was declared.