Psoriasis

PARK CITY, UTAH – Dr. John J. Zone first began to study gluten sensitivity in 1977, an interest that left some of his clinician colleagues wondering why.

“Everybody told me I was crazy – that this was extremely rare. So I always say I was gluten when gluten wasn’t cool,” Dr. Zone, professor and chairman of dermatology at the University of Utah, Salt Lake City, told attendees at the annual meeting of the Pacific Dermatologic Association.

These days, it’s hard to shop in a food market without noticing all the gluten-free foods available, from pizza dough to beer. Many restaurants also serve gluten-free dishes. But is it hype, or is gluten sensitivity that common? Five percent of people in the United States “will say they are gluten sensitive,” he said. “In fact, 1% of Caucasians actually have celiac disease and 1% of Caucasians have gluten sensitivity that can be documented by challenge but don’t have celiac disease, while 3% have nothing.”

Gluten is a group of proteins contained in wheat, barley, and rye that is insoluble in water. Dr. Zone described celiac disease as a “spectrum of disease” characterized by inflammation of the small intestinal mucosa that occurs with the ingestion of gluten. The condition improves when gluten is removed from the diet. From a genetic standpoint, having a predisposition to express human leukocyte antigen-DQ2 or HLA-DQ8 is required for a diagnosis of celiac disease (CD). An estimated 20%-25% of whites “have that HLA background, but it is rare in Asians,” he said. “The receptors coded by HLA genes are essential for the processing of the gliadin antigen in CD.”

The hallmark for CD is a blood test for immunoglobulin A (IgA) anti-tissue transglutaminase antibodies, which are detectable in patients with untreated disease. “You should be able to get that test for $50 or $60 in any laboratory in the country,” Dr. Zone said. “It’s about 98% reliable. You also want to do a total serum IgA to rule out IgA-deficiency.”

CD clusters with other autoimmune disorders such as Addison’s disease, autoimmune thyroiditis, atrophic gastritis, systemic lupus erythematosus, rheumatoid arthritis, myasthenia gravis, and vitiligo. It’s also common in Down syndrome. “Many patients with histological inflammation have atypical intestinal symptoms or none at all,” he said. “Clinical studies have shown that only 15%-20% of CD patients identified by serology and confirmed by biopsy have classical symptoms of diarrhea and malabsorption.” The presenting symptom in patients with celiac disease may be limited to only aphthous stomatitis, eczema, alopecia areata, psoriasis, or diabetes, along with fatigue or anemia.

Researchers who analyzed the prevalence of CD in the United States estimated the risk to be 1:133 among individuals deemed not to be at risk, 1:56 in symptomatic patients, 1:39 in second-degree relatives, and 1:22 in first-degree relatives (Arch Intern Med. 2003;163[3]:286-92.). “We tested 2,100 people in Utah and found the prevalence among first-degree relatives was 1:12,” Dr. Zone said. “The point is that CD is common, not rare. It’s as common as psoriasis. It profoundly affects the immune system, which is the modulator of inflammatory skin disease.”

Dr. Zone reported having no financial disclosures.

[email protected]

PARK CITY, UTAH – Dr. John J. Zone first began to study gluten sensitivity in 1977, an interest that left some of his clinician colleagues wondering why.

“Everybody told me I was crazy – that this was extremely rare. So I always say I was gluten when gluten wasn’t cool,” Dr. Zone, professor and chairman of dermatology at the University of Utah, Salt Lake City, told attendees at the annual meeting of the Pacific Dermatologic Association.

These days, it’s hard to shop in a food market without noticing all the gluten-free foods available, from pizza dough to beer. Many restaurants also serve gluten-free dishes. But is it hype, or is gluten sensitivity that common? Five percent of people in the United States “will say they are gluten sensitive,” he said. “In fact, 1% of Caucasians actually have celiac disease and 1% of Caucasians have gluten sensitivity that can be documented by challenge but don’t have celiac disease, while 3% have nothing.”

Gluten is a group of proteins contained in wheat, barley, and rye that is insoluble in water. Dr. Zone described celiac disease as a “spectrum of disease” characterized by inflammation of the small intestinal mucosa that occurs with the ingestion of gluten. The condition improves when gluten is removed from the diet. From a genetic standpoint, having a predisposition to express human leukocyte antigen-DQ2 or HLA-DQ8 is required for a diagnosis of celiac disease (CD). An estimated 20%-25% of whites “have that HLA background, but it is rare in Asians,” he said. “The receptors coded by HLA genes are essential for the processing of the gliadin antigen in CD.”

The hallmark for CD is a blood test for immunoglobulin A (IgA) anti-tissue transglutaminase antibodies, which are detectable in patients with untreated disease. “You should be able to get that test for $50 or $60 in any laboratory in the country,” Dr. Zone said. “It’s about 98% reliable. You also want to do a total serum IgA to rule out IgA-deficiency.”

CD clusters with other autoimmune disorders such as Addison’s disease, autoimmune thyroiditis, atrophic gastritis, systemic lupus erythematosus, rheumatoid arthritis, myasthenia gravis, and vitiligo. It’s also common in Down syndrome. “Many patients with histological inflammation have atypical intestinal symptoms or none at all,” he said. “Clinical studies have shown that only 15%-20% of CD patients identified by serology and confirmed by biopsy have classical symptoms of diarrhea and malabsorption.” The presenting symptom in patients with celiac disease may be limited to only aphthous stomatitis, eczema, alopecia areata, psoriasis, or diabetes, along with fatigue or anemia.

Researchers who analyzed the prevalence of CD in the United States estimated the risk to be 1:133 among individuals deemed not to be at risk, 1:56 in symptomatic patients, 1:39 in second-degree relatives, and 1:22 in first-degree relatives (Arch Intern Med. 2003;163[3]:286-92.). “We tested 2,100 people in Utah and found the prevalence among first-degree relatives was 1:12,” Dr. Zone said. “The point is that CD is common, not rare. It’s as common as psoriasis. It profoundly affects the immune system, which is the modulator of inflammatory skin disease.”

Dr. Zone reported having no financial disclosures.

[email protected]

PARK CITY, UTAH – Dr. John J. Zone first began to study gluten sensitivity in 1977, an interest that left some of his clinician colleagues wondering why.

“Everybody told me I was crazy – that this was extremely rare. So I always say I was gluten when gluten wasn’t cool,” Dr. Zone, professor and chairman of dermatology at the University of Utah, Salt Lake City, told attendees at the annual meeting of the Pacific Dermatologic Association.

These days, it’s hard to shop in a food market without noticing all the gluten-free foods available, from pizza dough to beer. Many restaurants also serve gluten-free dishes. But is it hype, or is gluten sensitivity that common? Five percent of people in the United States “will say they are gluten sensitive,” he said. “In fact, 1% of Caucasians actually have celiac disease and 1% of Caucasians have gluten sensitivity that can be documented by challenge but don’t have celiac disease, while 3% have nothing.”

Gluten is a group of proteins contained in wheat, barley, and rye that is insoluble in water. Dr. Zone described celiac disease as a “spectrum of disease” characterized by inflammation of the small intestinal mucosa that occurs with the ingestion of gluten. The condition improves when gluten is removed from the diet. From a genetic standpoint, having a predisposition to express human leukocyte antigen-DQ2 or HLA-DQ8 is required for a diagnosis of celiac disease (CD). An estimated 20%-25% of whites “have that HLA background, but it is rare in Asians,” he said. “The receptors coded by HLA genes are essential for the processing of the gliadin antigen in CD.”

The hallmark for CD is a blood test for immunoglobulin A (IgA) anti-tissue transglutaminase antibodies, which are detectable in patients with untreated disease. “You should be able to get that test for $50 or $60 in any laboratory in the country,” Dr. Zone said. “It’s about 98% reliable. You also want to do a total serum IgA to rule out IgA-deficiency.”

CD clusters with other autoimmune disorders such as Addison’s disease, autoimmune thyroiditis, atrophic gastritis, systemic lupus erythematosus, rheumatoid arthritis, myasthenia gravis, and vitiligo. It’s also common in Down syndrome. “Many patients with histological inflammation have atypical intestinal symptoms or none at all,” he said. “Clinical studies have shown that only 15%-20% of CD patients identified by serology and confirmed by biopsy have classical symptoms of diarrhea and malabsorption.” The presenting symptom in patients with celiac disease may be limited to only aphthous stomatitis, eczema, alopecia areata, psoriasis, or diabetes, along with fatigue or anemia.

Researchers who analyzed the prevalence of CD in the United States estimated the risk to be 1:133 among individuals deemed not to be at risk, 1:56 in symptomatic patients, 1:39 in second-degree relatives, and 1:22 in first-degree relatives (Arch Intern Med. 2003;163[3]:286-92.). “We tested 2,100 people in Utah and found the prevalence among first-degree relatives was 1:12,” Dr. Zone said. “The point is that CD is common, not rare. It’s as common as psoriasis. It profoundly affects the immune system, which is the modulator of inflammatory skin disease.”

Dr. Zone reported having no financial disclosures.

[email protected]

PARK CITY, UTAH – Since most people with psoriatic arthritis (PsA) develop psoriasis before joint symptoms, it’s helpful to have a simple screening test for the condition.

One of Dr. Philip Mease’s favorite PsA screening tools is the Psoriasis Epidemiology Screening Test (PEST), which was first described at the 2009 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and consists of five simple questions. They are: Have you ever had a swollen joint (or joints)? Has a doctor ever told you that you have arthritis? Do your fingernails or toes have holes or pits? Have you had pain in your heel? Have you had a finger or toe that was completely swollen and painful for no apparent reason? (Clin Exp Rheumatol. 2009;27:469-74).

“Just these five simple questions, or trying to remember a few of them, can help you in your review of systems,” Dr. Mease, director of arthritis research at Swedish Medical Center, Seattle, said at the annual meeting of the Pacific Dermatologic Association. “I think patients appreciate it when you look beyond the skin in your questioning. These can pick up [PsA] with a high sensitivity and specificity” of 0.92 and 0.78, respectively.

He went on to discuss current PsA treatment approaches. According to an evidence review that he and his associates in GRAPPA published in 2009, biologics (anti–tumor necrosis factor inhibitors) as a group were found to be effective in all five domains of the disease: peripheral arthritis, skin and nail disease, axial disease, dactylitis, and enthesitis, while the oral disease-modifying antirheumatic drugs (DMARDs) were effective for peripheral arthritis and skin and nail disease.

Other treatments that were found effective are: psoralen and UVA/UVB for skin and nail disease, physiotherapy for axial disease, intra-articular steroids for peripheral arthritis, and NSAIDs for peripheral arthritis and axial disease (J Rheum. 2009;33:1417-21). “Patients with mild disease can be tried on NSAIDs, especially in a patient with monoarticular disease, but for the most part we need to move on to using systemic medication,” he said. Updated recommendations from GRAPPA include new data regarding ustekinumab, apremilast, and secukinumab, as well as data on comorbidities (J Rheumatol. 2015;42[6]:1052-5).

According to Dr. Mease, controlled trials of DMARDs in PsA patients have yielded treatment effects that range from marginal in the joints to marginal or none at all in the skin. Data from the Methotrexate in Psoriatic Arthritis trial conducted in the United Kingdom and published in 2012 showed no evidence that methotrexate improves inflammatory synovitis in active PsA (Rheumatol. 2012;51:1368-77).

“There were issues with this trial, including the fact that it took 5 years to enroll patients, and many dropped out, so I don’t think it’s a very reliable study,” said Dr. Mease, who is also a professor of medicine in the division of rheumatology at the University of Washington, Seattle. “Currently, Amgen is in the process of starting a trial in which the goal is to enroll 840 subjects with early PsA who are being randomized to methotrexate alone, Enbrel alone, or Enbrel plus methotrexate. This, I think, is going to give us a better answer about the effectiveness of methotrexate. It will also teach us about whether there’s a value in combining an anti-TNF inhibitor with methotrexate. We still don’t know the answer to that question.”

The most recent data on methotrexate come from an open-label trial known as TICOPA, which used a tight control treatment paradigm through 48 weeks of treatment. A subanalysis of 188 patients treated with methotrexate through 12 weeks was presented at the 2015 meeting of the European League Against Rheumatism. It revealed that 41% of patients achieved an ACR 20, 22% achieved minimal disease activity, 62% experienced an improvement in dactylitis, and 25% experienced an improvement in enthesitis.

“So we have a few data suggesting that methotrexate may be modestly effective in treating PsA,” Dr. Mease said. “We often will start with methotrexate unless the patient has really aggressive disease activity. If they get some effect from the drug but not enough, we’ll often add a biologic agent but often keep some methotrexate in the background, even at 10 mg per week, in order to reduce immunogenicity from a biologic.”

Dr. Mease disclosed that he has received research grants, consultation fees, and/or speaker honoraria from AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, Genentech, GlaxoSmithKline, Janssen, Eli Lilly, Merck, Novartis, Pfizer, and UCB.

[email protected]

PARK CITY, UTAH – Since most people with psoriatic arthritis (PsA) develop psoriasis before joint symptoms, it’s helpful to have a simple screening test for the condition.

One of Dr. Philip Mease’s favorite PsA screening tools is the Psoriasis Epidemiology Screening Test (PEST), which was first described at the 2009 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and consists of five simple questions. They are: Have you ever had a swollen joint (or joints)? Has a doctor ever told you that you have arthritis? Do your fingernails or toes have holes or pits? Have you had pain in your heel? Have you had a finger or toe that was completely swollen and painful for no apparent reason? (Clin Exp Rheumatol. 2009;27:469-74).

“Just these five simple questions, or trying to remember a few of them, can help you in your review of systems,” Dr. Mease, director of arthritis research at Swedish Medical Center, Seattle, said at the annual meeting of the Pacific Dermatologic Association. “I think patients appreciate it when you look beyond the skin in your questioning. These can pick up [PsA] with a high sensitivity and specificity” of 0.92 and 0.78, respectively.

He went on to discuss current PsA treatment approaches. According to an evidence review that he and his associates in GRAPPA published in 2009, biologics (anti–tumor necrosis factor inhibitors) as a group were found to be effective in all five domains of the disease: peripheral arthritis, skin and nail disease, axial disease, dactylitis, and enthesitis, while the oral disease-modifying antirheumatic drugs (DMARDs) were effective for peripheral arthritis and skin and nail disease.

Other treatments that were found effective are: psoralen and UVA/UVB for skin and nail disease, physiotherapy for axial disease, intra-articular steroids for peripheral arthritis, and NSAIDs for peripheral arthritis and axial disease (J Rheum. 2009;33:1417-21). “Patients with mild disease can be tried on NSAIDs, especially in a patient with monoarticular disease, but for the most part we need to move on to using systemic medication,” he said. Updated recommendations from GRAPPA include new data regarding ustekinumab, apremilast, and secukinumab, as well as data on comorbidities (J Rheumatol. 2015;42[6]:1052-5).

According to Dr. Mease, controlled trials of DMARDs in PsA patients have yielded treatment effects that range from marginal in the joints to marginal or none at all in the skin. Data from the Methotrexate in Psoriatic Arthritis trial conducted in the United Kingdom and published in 2012 showed no evidence that methotrexate improves inflammatory synovitis in active PsA (Rheumatol. 2012;51:1368-77).

“There were issues with this trial, including the fact that it took 5 years to enroll patients, and many dropped out, so I don’t think it’s a very reliable study,” said Dr. Mease, who is also a professor of medicine in the division of rheumatology at the University of Washington, Seattle. “Currently, Amgen is in the process of starting a trial in which the goal is to enroll 840 subjects with early PsA who are being randomized to methotrexate alone, Enbrel alone, or Enbrel plus methotrexate. This, I think, is going to give us a better answer about the effectiveness of methotrexate. It will also teach us about whether there’s a value in combining an anti-TNF inhibitor with methotrexate. We still don’t know the answer to that question.”

The most recent data on methotrexate come from an open-label trial known as TICOPA, which used a tight control treatment paradigm through 48 weeks of treatment. A subanalysis of 188 patients treated with methotrexate through 12 weeks was presented at the 2015 meeting of the European League Against Rheumatism. It revealed that 41% of patients achieved an ACR 20, 22% achieved minimal disease activity, 62% experienced an improvement in dactylitis, and 25% experienced an improvement in enthesitis.

“So we have a few data suggesting that methotrexate may be modestly effective in treating PsA,” Dr. Mease said. “We often will start with methotrexate unless the patient has really aggressive disease activity. If they get some effect from the drug but not enough, we’ll often add a biologic agent but often keep some methotrexate in the background, even at 10 mg per week, in order to reduce immunogenicity from a biologic.”

Dr. Mease disclosed that he has received research grants, consultation fees, and/or speaker honoraria from AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, Genentech, GlaxoSmithKline, Janssen, Eli Lilly, Merck, Novartis, Pfizer, and UCB.

[email protected]

PARK CITY, UTAH – Since most people with psoriatic arthritis (PsA) develop psoriasis before joint symptoms, it’s helpful to have a simple screening test for the condition.

One of Dr. Philip Mease’s favorite PsA screening tools is the Psoriasis Epidemiology Screening Test (PEST), which was first described at the 2009 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and consists of five simple questions. They are: Have you ever had a swollen joint (or joints)? Has a doctor ever told you that you have arthritis? Do your fingernails or toes have holes or pits? Have you had pain in your heel? Have you had a finger or toe that was completely swollen and painful for no apparent reason? (Clin Exp Rheumatol. 2009;27:469-74).

“Just these five simple questions, or trying to remember a few of them, can help you in your review of systems,” Dr. Mease, director of arthritis research at Swedish Medical Center, Seattle, said at the annual meeting of the Pacific Dermatologic Association. “I think patients appreciate it when you look beyond the skin in your questioning. These can pick up [PsA] with a high sensitivity and specificity” of 0.92 and 0.78, respectively.

He went on to discuss current PsA treatment approaches. According to an evidence review that he and his associates in GRAPPA published in 2009, biologics (anti–tumor necrosis factor inhibitors) as a group were found to be effective in all five domains of the disease: peripheral arthritis, skin and nail disease, axial disease, dactylitis, and enthesitis, while the oral disease-modifying antirheumatic drugs (DMARDs) were effective for peripheral arthritis and skin and nail disease.

Other treatments that were found effective are: psoralen and UVA/UVB for skin and nail disease, physiotherapy for axial disease, intra-articular steroids for peripheral arthritis, and NSAIDs for peripheral arthritis and axial disease (J Rheum. 2009;33:1417-21). “Patients with mild disease can be tried on NSAIDs, especially in a patient with monoarticular disease, but for the most part we need to move on to using systemic medication,” he said. Updated recommendations from GRAPPA include new data regarding ustekinumab, apremilast, and secukinumab, as well as data on comorbidities (J Rheumatol. 2015;42[6]:1052-5).

According to Dr. Mease, controlled trials of DMARDs in PsA patients have yielded treatment effects that range from marginal in the joints to marginal or none at all in the skin. Data from the Methotrexate in Psoriatic Arthritis trial conducted in the United Kingdom and published in 2012 showed no evidence that methotrexate improves inflammatory synovitis in active PsA (Rheumatol. 2012;51:1368-77).

“There were issues with this trial, including the fact that it took 5 years to enroll patients, and many dropped out, so I don’t think it’s a very reliable study,” said Dr. Mease, who is also a professor of medicine in the division of rheumatology at the University of Washington, Seattle. “Currently, Amgen is in the process of starting a trial in which the goal is to enroll 840 subjects with early PsA who are being randomized to methotrexate alone, Enbrel alone, or Enbrel plus methotrexate. This, I think, is going to give us a better answer about the effectiveness of methotrexate. It will also teach us about whether there’s a value in combining an anti-TNF inhibitor with methotrexate. We still don’t know the answer to that question.”

The most recent data on methotrexate come from an open-label trial known as TICOPA, which used a tight control treatment paradigm through 48 weeks of treatment. A subanalysis of 188 patients treated with methotrexate through 12 weeks was presented at the 2015 meeting of the European League Against Rheumatism. It revealed that 41% of patients achieved an ACR 20, 22% achieved minimal disease activity, 62% experienced an improvement in dactylitis, and 25% experienced an improvement in enthesitis.

“So we have a few data suggesting that methotrexate may be modestly effective in treating PsA,” Dr. Mease said. “We often will start with methotrexate unless the patient has really aggressive disease activity. If they get some effect from the drug but not enough, we’ll often add a biologic agent but often keep some methotrexate in the background, even at 10 mg per week, in order to reduce immunogenicity from a biologic.”

Dr. Mease disclosed that he has received research grants, consultation fees, and/or speaker honoraria from AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, Genentech, GlaxoSmithKline, Janssen, Eli Lilly, Merck, Novartis, Pfizer, and UCB.

[email protected]

Adherence to psoriasis therapies, especially topical therapy, is remarkably poor. Dr. Steven Feldman discusses the patient-physician relationship and ways that physicians can help patients so they're not fearful of taking their medications. He discusses follow-up with patients and special considerations for patients with scalp psoriasis.

The psoriasis audiocast series is created in collaboration with Cutis^® and the National Psoriasis Foundation^®.

Adherence to psoriasis therapies, especially topical therapy, is remarkably poor. Dr. Steven Feldman discusses the patient-physician relationship and ways that physicians can help patients so they're not fearful of taking their medications. He discusses follow-up with patients and special considerations for patients with scalp psoriasis.

The psoriasis audiocast series is created in collaboration with Cutis^® and the National Psoriasis Foundation^®.

Adherence to psoriasis therapies, especially topical therapy, is remarkably poor. Dr. Steven Feldman discusses the patient-physician relationship and ways that physicians can help patients so they're not fearful of taking their medications. He discusses follow-up with patients and special considerations for patients with scalp psoriasis.

The psoriasis audiocast series is created in collaboration with Cutis^® and the National Psoriasis Foundation^®.

At 6 months, quality of life is largely the same whether psoriasis patients stay on their initial etanercept (Enbrel) dose of 50 mg twice weekly or step down to 50 mg once weekly with topical corticosteroids, according to a Canadian trial published in the Journal of The European Academy of Dermatology and Venereology.

“The opportunity to use a topical agent seemed to improve [patients’] overall satisfaction,” and weekly “etanercept and topical may be a less costly option compared with” etanercept twice weekly, said the investigators, led by Dr. Kim Papp, of Probity Medical Research in Waterloo, Ont.

Previously, the investigators showed that the step-down strategy works as well as full-dose maintenance in clearing the skin. They wanted to check if that also held true for quality of life, as assessed by the Dermatology Life Quality Index (DLQI) and the Treatment Satisfaction Questionnaire for Medication (TSQM). (J Eur Acad Dermatol Venereol. 2015 Aug;29(8):1555-61).

The 287 patients, all with moderate-to-severe plaque psoriasis for at least half a year, received etanercept 50 mg twice weekly for 12 weeks; 144 were then randomized to stay on that dose, and 143 others to drop to 50 mg weekly with the addition of topicals as required through week 24. The mean age of patients in the trial was 45 years; 88% of the subjects were white and 65% were men.

Topicals included hydrocortisone 2.5%, beta methasone valerate 0.1%, betamethasone dipropionate 0.05%, clobetasol 0.05%, calcitriol, or calcipotriol plus betamethasone dipropionate 0.05%; the topicals were selected by the researchers, who were allowed to change them as needed.

The mean change in DLQI from baseline to week 24 was 10.7 points in the etanercept group and 9.9 points in the etanercept-plus-topical group. Mean change in TSQM effectiveness, convenience, side-effects, and global satisfaction was 27.1, 14.8, -0.7 and 26.7 points in the etanercept group, and 32.5, 18.5, 1.3, and 28.4 points in the etanercept-plus-topical group. Healthcare visits, employment status, work productivity, and ability to perform daily activities were similar between the treatment arms.

The study was descriptive; the investigators didn’t run statistical analyses. Even so, measures of quality of life “were numerically similar in patients who stayed on etanercept 50 mg [twice weekly] and patients who received etanercept 50 mg [weekly] plus topical therapies. No notable differences between treatment arms ... were observed. Additionally, improvements in [Psoriasis Area and Severity Index] scores appeared to correlate with improvements in patient reported outcomes,” the investigators said.

“The duration of treatment with topical therapies was only 12 weeks; a longer duration may result in loss of efficacy as adherence to topical therapies may decrease with time,” they noted.

The work was funded by etanercept’s maker, Amgen. Dr. Papp reported consulting for the company. Two other investigators have been Amgen advisors and reported research grants, speakers fees, or other payments.

[email protected]

At 6 months, quality of life is largely the same whether psoriasis patients stay on their initial etanercept (Enbrel) dose of 50 mg twice weekly or step down to 50 mg once weekly with topical corticosteroids, according to a Canadian trial published in the Journal of The European Academy of Dermatology and Venereology.

“The opportunity to use a topical agent seemed to improve [patients’] overall satisfaction,” and weekly “etanercept and topical may be a less costly option compared with” etanercept twice weekly, said the investigators, led by Dr. Kim Papp, of Probity Medical Research in Waterloo, Ont.

Previously, the investigators showed that the step-down strategy works as well as full-dose maintenance in clearing the skin. They wanted to check if that also held true for quality of life, as assessed by the Dermatology Life Quality Index (DLQI) and the Treatment Satisfaction Questionnaire for Medication (TSQM). (J Eur Acad Dermatol Venereol. 2015 Aug;29(8):1555-61).

The 287 patients, all with moderate-to-severe plaque psoriasis for at least half a year, received etanercept 50 mg twice weekly for 12 weeks; 144 were then randomized to stay on that dose, and 143 others to drop to 50 mg weekly with the addition of topicals as required through week 24. The mean age of patients in the trial was 45 years; 88% of the subjects were white and 65% were men.

Topicals included hydrocortisone 2.5%, beta methasone valerate 0.1%, betamethasone dipropionate 0.05%, clobetasol 0.05%, calcitriol, or calcipotriol plus betamethasone dipropionate 0.05%; the topicals were selected by the researchers, who were allowed to change them as needed.

The mean change in DLQI from baseline to week 24 was 10.7 points in the etanercept group and 9.9 points in the etanercept-plus-topical group. Mean change in TSQM effectiveness, convenience, side-effects, and global satisfaction was 27.1, 14.8, -0.7 and 26.7 points in the etanercept group, and 32.5, 18.5, 1.3, and 28.4 points in the etanercept-plus-topical group. Healthcare visits, employment status, work productivity, and ability to perform daily activities were similar between the treatment arms.

The study was descriptive; the investigators didn’t run statistical analyses. Even so, measures of quality of life “were numerically similar in patients who stayed on etanercept 50 mg [twice weekly] and patients who received etanercept 50 mg [weekly] plus topical therapies. No notable differences between treatment arms ... were observed. Additionally, improvements in [Psoriasis Area and Severity Index] scores appeared to correlate with improvements in patient reported outcomes,” the investigators said.

“The duration of treatment with topical therapies was only 12 weeks; a longer duration may result in loss of efficacy as adherence to topical therapies may decrease with time,” they noted.

The work was funded by etanercept’s maker, Amgen. Dr. Papp reported consulting for the company. Two other investigators have been Amgen advisors and reported research grants, speakers fees, or other payments.

[email protected]

At 6 months, quality of life is largely the same whether psoriasis patients stay on their initial etanercept (Enbrel) dose of 50 mg twice weekly or step down to 50 mg once weekly with topical corticosteroids, according to a Canadian trial published in the Journal of The European Academy of Dermatology and Venereology.

“The opportunity to use a topical agent seemed to improve [patients’] overall satisfaction,” and weekly “etanercept and topical may be a less costly option compared with” etanercept twice weekly, said the investigators, led by Dr. Kim Papp, of Probity Medical Research in Waterloo, Ont.

Previously, the investigators showed that the step-down strategy works as well as full-dose maintenance in clearing the skin. They wanted to check if that also held true for quality of life, as assessed by the Dermatology Life Quality Index (DLQI) and the Treatment Satisfaction Questionnaire for Medication (TSQM). (J Eur Acad Dermatol Venereol. 2015 Aug;29(8):1555-61).

The 287 patients, all with moderate-to-severe plaque psoriasis for at least half a year, received etanercept 50 mg twice weekly for 12 weeks; 144 were then randomized to stay on that dose, and 143 others to drop to 50 mg weekly with the addition of topicals as required through week 24. The mean age of patients in the trial was 45 years; 88% of the subjects were white and 65% were men.

Topicals included hydrocortisone 2.5%, beta methasone valerate 0.1%, betamethasone dipropionate 0.05%, clobetasol 0.05%, calcitriol, or calcipotriol plus betamethasone dipropionate 0.05%; the topicals were selected by the researchers, who were allowed to change them as needed.

The mean change in DLQI from baseline to week 24 was 10.7 points in the etanercept group and 9.9 points in the etanercept-plus-topical group. Mean change in TSQM effectiveness, convenience, side-effects, and global satisfaction was 27.1, 14.8, -0.7 and 26.7 points in the etanercept group, and 32.5, 18.5, 1.3, and 28.4 points in the etanercept-plus-topical group. Healthcare visits, employment status, work productivity, and ability to perform daily activities were similar between the treatment arms.

The study was descriptive; the investigators didn’t run statistical analyses. Even so, measures of quality of life “were numerically similar in patients who stayed on etanercept 50 mg [twice weekly] and patients who received etanercept 50 mg [weekly] plus topical therapies. No notable differences between treatment arms ... were observed. Additionally, improvements in [Psoriasis Area and Severity Index] scores appeared to correlate with improvements in patient reported outcomes,” the investigators said.

“The duration of treatment with topical therapies was only 12 weeks; a longer duration may result in loss of efficacy as adherence to topical therapies may decrease with time,” they noted.

The work was funded by etanercept’s maker, Amgen. Dr. Papp reported consulting for the company. Two other investigators have been Amgen advisors and reported research grants, speakers fees, or other payments.

[email protected]

PARK CITY, UTAH – Evidence is mounting that the use of biologic therapies is associated with certain cardiovascular benefits in patients with psoriasis.

However, until the strength of the evidence becomes more robust, Dr. Jashin J. Wu does not recommend that patients are prescribed tumor necrosis factor (TNF) inhibitors specifically to reduce the risk of cardiovascular disease. “If systemic therapy is a consideration in the setting of CVD [cardiovascular disease] risk, it would appear that TNF inhibitors and methotrexate offer the best evidence of benefit,” Dr. Wu, director of the psoriasis clinic and director of dermatology research in the department of dermatology at Kaiser Permanente Los Angeles Medical Center, said at the annual meeting of the Pacific Dermatologic Association.

The National Psoriasis Foundation recently published a consensus statement about the potential impact of current therapies on cardiovascular disease, including the risk of diabetes (J Am Acad Dermatol. 2014;70[1]:168-77). In a retrospective study of 121,280 patients with rheumatoid arthritis (RA) or psoriasis, drug regimens were categorized into four mutually exclusive groups: TNF inhibitors with or without other disease-modifying antirheumatic drugs (DMARDs), methotrexate without TNF inhibitors or hydroxychloroquine, hydroxychloroquine without TNF inhibitors or methotrexate; and other nonbiologic DMARDs without TNF inhibitors, methotrexate or hydroxychloroquine (referent group). The researchers found that adjusted Cox proportional hazards for the risk of diabetes were lower among those on TNF inhibitors (hazard ratio, 0.62; 95% confidence interval, 0.42-0.91) and hydroxychloroquine (HR, 0.54; 95% CI, 0.36-0.80), compared with those on methotrexate (HR, 0.77, 95% CI, 0.53-1.13) (JAMA. 2011 Jun 22;305[24]:2525-31).

Increased carotid intimal media thickness (IMT) is also an independent predictor of CVD. In a prospective, observational study, 20 psoriasis patients received a 12-week treatment of TNF inhibitors (Ann Rheum Dis. 2011 Apr;70[4]:705-6). After 12 weeks, 9 patients continued on their TNF-inhibitor regimen (group 1), while 11 discontinued treatment because of financial constraints (group 2). Another 20 psoriasis patients who did not receive biologic therapy served as controls (group 3). The researchers measured IMT by carotid ultrasound at baseline, week 12 and at 2 years. They found that between baseline and 2 years, IMT decreased from 0.70 mm to 0.63 mm in group 1, from 0.71 to 0.67 in group 2, and increased from 0.79 to 0.82 in group 3. “This seems to suggest that the use of TNF inhibitors may improve atherosclerosis,” said Dr. Wu, who is currently running seven clinical trials of psoriasis patients. Similar findings were seen in a larger study that examined 224 patients with psoriatic arthritis and followed them for a mean of 55 months: 124 on TNF inhibitors, 104 on DMARDs, and 305 matched controls (Arterioscler Thromb Vasc Biol. 2011 Mar;31[3]:705-120).

In a separate study of 16 psoriasis patients treated with TNF inhibitors, researchers used ultrasound to measure IMT of carotid and brachial arteries after 6 months of therapy (J Am Acad Dermatol. 2013 Oct;69[4]:523-9). At baseline, all 16 patients had an IMT greater than normal. In those without initial calcified atherosclerotic plaques, 13 of 16 had a significant decrease of IMT (P = .0002). In those with initial calcified atherosclerotic plaques, 3 of 16 patients had a nonsignificant increase in IMT.

Increased arterial stiffness is another independent predictor of CVD. In a controlled study of 55 patients with psoriatic arthritis, RA, or ankylosing spondylitis, researchers used aortic pulse-wave velocity to measure aortic stiffness. Almost 35% of the patients (36) received TNF inhibitors while the remaining 19 did not receive treatment (Am J Hypertens. 2012 Jun;25[6]:644-50). After 1 year of follow-up, use of TNF inhibitors was associated with a significant improvement in aortic pulse-wave velocity (P = .02) and reduced carotid IMT progression (P = .04).

Other evidence suggests that systemic therapy with TNF inhibitors is associated with the reduction of cardiovascular events, including myocardial infarction. In a study led by Dr. Wu, 8,845 Kaiser Permanente patients with psoriasis were evaluated between Jan. 1, 2004, and Nov. 30, 2010, and placed into one of three groups: treatment with a TNF inhibitor, treatment with oral therapy or phototherapy, or treatment with a topical agent (referent group) (Arch Dermatol. 2012 Nov;148[11]:1244-50). On multivariate analysis, the investigators found that the use of TNF inhibitors was associated with a significant reduction in the rate of incident MI (HR, 0.50; P = .003), compared with the use of topical agents.

Dr. Wu went on to note that C-reactive protein (CRP) is a predictor of CVD such as MI, peripheral arterial disease, and sudden cardiac death. In a retrospective cohort study, Dr. Wu and his associates evaluated Kaiser Permanente patients with psoriasis, psoriatic arthritis, or RA who were treated with a combination of TNF plus methotrexate, or with methotrexate alone from Jan. 1, 2002, to July 31, 2011 (J. Am. Acad. Dermatol. 2015;72[5]:917-9). Only patients in the combination therapy group had a clinically and statistically significant decrease in CRP, compared with baseline (a mean decrease of 5.18 mg/dL). No significant changes between the two groups were observed in terms of BMI, blood pressure, fasting glucose, hemoglobin A_1C, total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, or alanine aminotransferase.

HDL cholesterol composition and function have also been studied in psoriasis patients. In one trial, HDL cholesterol was isolated from 15 psoriasis patients at baseline and after effective topical and/or systemic psoriasis therapy, and from 15 healthy controls matched for age and sex (J. Invest. Dermatol. 2014;134[3]:635-42). The researchers found that HDL cholesterol from psoriasis patients showed a significantly impaired capability to mobilize cholesterol from macrophages. However, psoriasis therapy recovered HDL cholesterol composition and function, but had no effect on serum HDL cholesterol levels.

A better understanding of the cardiovascular effects of biologic therapy should be gleaned from the Vascular Inflammation in Psoriasis Trial, which includes $3.8 million in funding from the National Institutes of Health, to prospectively study the effect of therapy on biomarkers and on positron emission tomography with ¹⁸fluorodeoxyglucose (FDG-PET)/CT scan. The 1-year study just completed enrolling patients into one of three treatment groups: adalimumab, UVB phototherapy, or placebo. Biomarkers such as CRP, lipids, and imaging will be assessed at baseline, weeks 4, 8, 12, and then every 12 weeks. “The theory is that adalimumab, but not UVB phototherapy, will improve biomarkers and reduce vascular inflammation as measured by FDG-PET/CT scan,” Dr. Wu said. “Aggressive systemic therapy may alter the natural history of cardiovascular disease.”

Current recommendations from the National Psoriasis Foundation call for an assessment of blood pressure, pulse, and body mass index every 2 years, and an assessment of fasting blood glucose and lipid levels every 5 years, or every 2 years if the patient has additional risk factors.

Dr. Wu reported that he has received research and consulting fees from numerous pharmaceutical companies, including AbbVie and Amgen. These go to his employer.

[email protected]

PARK CITY, UTAH – Evidence is mounting that the use of biologic therapies is associated with certain cardiovascular benefits in patients with psoriasis.

However, until the strength of the evidence becomes more robust, Dr. Jashin J. Wu does not recommend that patients are prescribed tumor necrosis factor (TNF) inhibitors specifically to reduce the risk of cardiovascular disease. “If systemic therapy is a consideration in the setting of CVD [cardiovascular disease] risk, it would appear that TNF inhibitors and methotrexate offer the best evidence of benefit,” Dr. Wu, director of the psoriasis clinic and director of dermatology research in the department of dermatology at Kaiser Permanente Los Angeles Medical Center, said at the annual meeting of the Pacific Dermatologic Association.

The National Psoriasis Foundation recently published a consensus statement about the potential impact of current therapies on cardiovascular disease, including the risk of diabetes (J Am Acad Dermatol. 2014;70[1]:168-77). In a retrospective study of 121,280 patients with rheumatoid arthritis (RA) or psoriasis, drug regimens were categorized into four mutually exclusive groups: TNF inhibitors with or without other disease-modifying antirheumatic drugs (DMARDs), methotrexate without TNF inhibitors or hydroxychloroquine, hydroxychloroquine without TNF inhibitors or methotrexate; and other nonbiologic DMARDs without TNF inhibitors, methotrexate or hydroxychloroquine (referent group). The researchers found that adjusted Cox proportional hazards for the risk of diabetes were lower among those on TNF inhibitors (hazard ratio, 0.62; 95% confidence interval, 0.42-0.91) and hydroxychloroquine (HR, 0.54; 95% CI, 0.36-0.80), compared with those on methotrexate (HR, 0.77, 95% CI, 0.53-1.13) (JAMA. 2011 Jun 22;305[24]:2525-31).

Increased carotid intimal media thickness (IMT) is also an independent predictor of CVD. In a prospective, observational study, 20 psoriasis patients received a 12-week treatment of TNF inhibitors (Ann Rheum Dis. 2011 Apr;70[4]:705-6). After 12 weeks, 9 patients continued on their TNF-inhibitor regimen (group 1), while 11 discontinued treatment because of financial constraints (group 2). Another 20 psoriasis patients who did not receive biologic therapy served as controls (group 3). The researchers measured IMT by carotid ultrasound at baseline, week 12 and at 2 years. They found that between baseline and 2 years, IMT decreased from 0.70 mm to 0.63 mm in group 1, from 0.71 to 0.67 in group 2, and increased from 0.79 to 0.82 in group 3. “This seems to suggest that the use of TNF inhibitors may improve atherosclerosis,” said Dr. Wu, who is currently running seven clinical trials of psoriasis patients. Similar findings were seen in a larger study that examined 224 patients with psoriatic arthritis and followed them for a mean of 55 months: 124 on TNF inhibitors, 104 on DMARDs, and 305 matched controls (Arterioscler Thromb Vasc Biol. 2011 Mar;31[3]:705-120).

In a separate study of 16 psoriasis patients treated with TNF inhibitors, researchers used ultrasound to measure IMT of carotid and brachial arteries after 6 months of therapy (J Am Acad Dermatol. 2013 Oct;69[4]:523-9). At baseline, all 16 patients had an IMT greater than normal. In those without initial calcified atherosclerotic plaques, 13 of 16 had a significant decrease of IMT (P = .0002). In those with initial calcified atherosclerotic plaques, 3 of 16 patients had a nonsignificant increase in IMT.

Increased arterial stiffness is another independent predictor of CVD. In a controlled study of 55 patients with psoriatic arthritis, RA, or ankylosing spondylitis, researchers used aortic pulse-wave velocity to measure aortic stiffness. Almost 35% of the patients (36) received TNF inhibitors while the remaining 19 did not receive treatment (Am J Hypertens. 2012 Jun;25[6]:644-50). After 1 year of follow-up, use of TNF inhibitors was associated with a significant improvement in aortic pulse-wave velocity (P = .02) and reduced carotid IMT progression (P = .04).

Other evidence suggests that systemic therapy with TNF inhibitors is associated with the reduction of cardiovascular events, including myocardial infarction. In a study led by Dr. Wu, 8,845 Kaiser Permanente patients with psoriasis were evaluated between Jan. 1, 2004, and Nov. 30, 2010, and placed into one of three groups: treatment with a TNF inhibitor, treatment with oral therapy or phototherapy, or treatment with a topical agent (referent group) (Arch Dermatol. 2012 Nov;148[11]:1244-50). On multivariate analysis, the investigators found that the use of TNF inhibitors was associated with a significant reduction in the rate of incident MI (HR, 0.50; P = .003), compared with the use of topical agents.

Dr. Wu went on to note that C-reactive protein (CRP) is a predictor of CVD such as MI, peripheral arterial disease, and sudden cardiac death. In a retrospective cohort study, Dr. Wu and his associates evaluated Kaiser Permanente patients with psoriasis, psoriatic arthritis, or RA who were treated with a combination of TNF plus methotrexate, or with methotrexate alone from Jan. 1, 2002, to July 31, 2011 (J. Am. Acad. Dermatol. 2015;72[5]:917-9). Only patients in the combination therapy group had a clinically and statistically significant decrease in CRP, compared with baseline (a mean decrease of 5.18 mg/dL). No significant changes between the two groups were observed in terms of BMI, blood pressure, fasting glucose, hemoglobin A_1C, total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, or alanine aminotransferase.

HDL cholesterol composition and function have also been studied in psoriasis patients. In one trial, HDL cholesterol was isolated from 15 psoriasis patients at baseline and after effective topical and/or systemic psoriasis therapy, and from 15 healthy controls matched for age and sex (J. Invest. Dermatol. 2014;134[3]:635-42). The researchers found that HDL cholesterol from psoriasis patients showed a significantly impaired capability to mobilize cholesterol from macrophages. However, psoriasis therapy recovered HDL cholesterol composition and function, but had no effect on serum HDL cholesterol levels.

A better understanding of the cardiovascular effects of biologic therapy should be gleaned from the Vascular Inflammation in Psoriasis Trial, which includes $3.8 million in funding from the National Institutes of Health, to prospectively study the effect of therapy on biomarkers and on positron emission tomography with ¹⁸fluorodeoxyglucose (FDG-PET)/CT scan. The 1-year study just completed enrolling patients into one of three treatment groups: adalimumab, UVB phototherapy, or placebo. Biomarkers such as CRP, lipids, and imaging will be assessed at baseline, weeks 4, 8, 12, and then every 12 weeks. “The theory is that adalimumab, but not UVB phototherapy, will improve biomarkers and reduce vascular inflammation as measured by FDG-PET/CT scan,” Dr. Wu said. “Aggressive systemic therapy may alter the natural history of cardiovascular disease.”

Current recommendations from the National Psoriasis Foundation call for an assessment of blood pressure, pulse, and body mass index every 2 years, and an assessment of fasting blood glucose and lipid levels every 5 years, or every 2 years if the patient has additional risk factors.

Dr. Wu reported that he has received research and consulting fees from numerous pharmaceutical companies, including AbbVie and Amgen. These go to his employer.

[email protected]

PARK CITY, UTAH – Evidence is mounting that the use of biologic therapies is associated with certain cardiovascular benefits in patients with psoriasis.

However, until the strength of the evidence becomes more robust, Dr. Jashin J. Wu does not recommend that patients are prescribed tumor necrosis factor (TNF) inhibitors specifically to reduce the risk of cardiovascular disease. “If systemic therapy is a consideration in the setting of CVD [cardiovascular disease] risk, it would appear that TNF inhibitors and methotrexate offer the best evidence of benefit,” Dr. Wu, director of the psoriasis clinic and director of dermatology research in the department of dermatology at Kaiser Permanente Los Angeles Medical Center, said at the annual meeting of the Pacific Dermatologic Association.

The National Psoriasis Foundation recently published a consensus statement about the potential impact of current therapies on cardiovascular disease, including the risk of diabetes (J Am Acad Dermatol. 2014;70[1]:168-77). In a retrospective study of 121,280 patients with rheumatoid arthritis (RA) or psoriasis, drug regimens were categorized into four mutually exclusive groups: TNF inhibitors with or without other disease-modifying antirheumatic drugs (DMARDs), methotrexate without TNF inhibitors or hydroxychloroquine, hydroxychloroquine without TNF inhibitors or methotrexate; and other nonbiologic DMARDs without TNF inhibitors, methotrexate or hydroxychloroquine (referent group). The researchers found that adjusted Cox proportional hazards for the risk of diabetes were lower among those on TNF inhibitors (hazard ratio, 0.62; 95% confidence interval, 0.42-0.91) and hydroxychloroquine (HR, 0.54; 95% CI, 0.36-0.80), compared with those on methotrexate (HR, 0.77, 95% CI, 0.53-1.13) (JAMA. 2011 Jun 22;305[24]:2525-31).

Increased carotid intimal media thickness (IMT) is also an independent predictor of CVD. In a prospective, observational study, 20 psoriasis patients received a 12-week treatment of TNF inhibitors (Ann Rheum Dis. 2011 Apr;70[4]:705-6). After 12 weeks, 9 patients continued on their TNF-inhibitor regimen (group 1), while 11 discontinued treatment because of financial constraints (group 2). Another 20 psoriasis patients who did not receive biologic therapy served as controls (group 3). The researchers measured IMT by carotid ultrasound at baseline, week 12 and at 2 years. They found that between baseline and 2 years, IMT decreased from 0.70 mm to 0.63 mm in group 1, from 0.71 to 0.67 in group 2, and increased from 0.79 to 0.82 in group 3. “This seems to suggest that the use of TNF inhibitors may improve atherosclerosis,” said Dr. Wu, who is currently running seven clinical trials of psoriasis patients. Similar findings were seen in a larger study that examined 224 patients with psoriatic arthritis and followed them for a mean of 55 months: 124 on TNF inhibitors, 104 on DMARDs, and 305 matched controls (Arterioscler Thromb Vasc Biol. 2011 Mar;31[3]:705-120).

In a separate study of 16 psoriasis patients treated with TNF inhibitors, researchers used ultrasound to measure IMT of carotid and brachial arteries after 6 months of therapy (J Am Acad Dermatol. 2013 Oct;69[4]:523-9). At baseline, all 16 patients had an IMT greater than normal. In those without initial calcified atherosclerotic plaques, 13 of 16 had a significant decrease of IMT (P = .0002). In those with initial calcified atherosclerotic plaques, 3 of 16 patients had a nonsignificant increase in IMT.

Increased arterial stiffness is another independent predictor of CVD. In a controlled study of 55 patients with psoriatic arthritis, RA, or ankylosing spondylitis, researchers used aortic pulse-wave velocity to measure aortic stiffness. Almost 35% of the patients (36) received TNF inhibitors while the remaining 19 did not receive treatment (Am J Hypertens. 2012 Jun;25[6]:644-50). After 1 year of follow-up, use of TNF inhibitors was associated with a significant improvement in aortic pulse-wave velocity (P = .02) and reduced carotid IMT progression (P = .04).

Other evidence suggests that systemic therapy with TNF inhibitors is associated with the reduction of cardiovascular events, including myocardial infarction. In a study led by Dr. Wu, 8,845 Kaiser Permanente patients with psoriasis were evaluated between Jan. 1, 2004, and Nov. 30, 2010, and placed into one of three groups: treatment with a TNF inhibitor, treatment with oral therapy or phototherapy, or treatment with a topical agent (referent group) (Arch Dermatol. 2012 Nov;148[11]:1244-50). On multivariate analysis, the investigators found that the use of TNF inhibitors was associated with a significant reduction in the rate of incident MI (HR, 0.50; P = .003), compared with the use of topical agents.

Dr. Wu went on to note that C-reactive protein (CRP) is a predictor of CVD such as MI, peripheral arterial disease, and sudden cardiac death. In a retrospective cohort study, Dr. Wu and his associates evaluated Kaiser Permanente patients with psoriasis, psoriatic arthritis, or RA who were treated with a combination of TNF plus methotrexate, or with methotrexate alone from Jan. 1, 2002, to July 31, 2011 (J. Am. Acad. Dermatol. 2015;72[5]:917-9). Only patients in the combination therapy group had a clinically and statistically significant decrease in CRP, compared with baseline (a mean decrease of 5.18 mg/dL). No significant changes between the two groups were observed in terms of BMI, blood pressure, fasting glucose, hemoglobin A_1C, total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, or alanine aminotransferase.

HDL cholesterol composition and function have also been studied in psoriasis patients. In one trial, HDL cholesterol was isolated from 15 psoriasis patients at baseline and after effective topical and/or systemic psoriasis therapy, and from 15 healthy controls matched for age and sex (J. Invest. Dermatol. 2014;134[3]:635-42). The researchers found that HDL cholesterol from psoriasis patients showed a significantly impaired capability to mobilize cholesterol from macrophages. However, psoriasis therapy recovered HDL cholesterol composition and function, but had no effect on serum HDL cholesterol levels.

A better understanding of the cardiovascular effects of biologic therapy should be gleaned from the Vascular Inflammation in Psoriasis Trial, which includes $3.8 million in funding from the National Institutes of Health, to prospectively study the effect of therapy on biomarkers and on positron emission tomography with ¹⁸fluorodeoxyglucose (FDG-PET)/CT scan. The 1-year study just completed enrolling patients into one of three treatment groups: adalimumab, UVB phototherapy, or placebo. Biomarkers such as CRP, lipids, and imaging will be assessed at baseline, weeks 4, 8, 12, and then every 12 weeks. “The theory is that adalimumab, but not UVB phototherapy, will improve biomarkers and reduce vascular inflammation as measured by FDG-PET/CT scan,” Dr. Wu said. “Aggressive systemic therapy may alter the natural history of cardiovascular disease.”

Current recommendations from the National Psoriasis Foundation call for an assessment of blood pressure, pulse, and body mass index every 2 years, and an assessment of fasting blood glucose and lipid levels every 5 years, or every 2 years if the patient has additional risk factors.

Dr. Wu reported that he has received research and consulting fees from numerous pharmaceutical companies, including AbbVie and Amgen. These go to his employer.

[email protected]

Tuberculosis is the only condition in patients with psoriasis or psoriatic arthritis who are being treated with systemic biologic agents for which there is strong evidence in favor of baseline screening, according to a literature review.

Analysis of 26 studies of systemic biologic treatments and screening tests – 13 of which included patients with hepatitis C, hepatitis B, or congestive heart failure – found the highest level evidence (grade B) in favor of tuberculin skin testing or interferon-gamma release assay, with the latter being preferred for its higher sensitivity and specificity.

CDC/James Archer

“Based on the [U.S. Preventive Services Task Force] grading system, it is recommended this screen be provided because there is high certainty that the net benefit is moderate, or medium certainty that the net benefit is moderate to substantial,” wrote Dr. Christine S. Ahn of Wake Forest University, Winston-Salem, N.C., and coauthors in the Journal of the American Academy of Dermatology.

Screening for hepatitis B or C infection only was supported by grade-C evidence, and there was insufficient evidence for HIV screening, with the authors suggesting that selective screening should be performed based on professional judgment, clinical context, or patient preference (J Am Acad Dermatol. 2015 July 14 doi: 10.1016/j.jaad.2015.06.004).

Similarly, there was insufficient evidence to support complete blood cell count screening, and, given the low grade evidence on monitoring hepatic function, the authors suggested this should be performed at the clinician’s discretion, particularly among patients treated with infliximab.

Tuberculosis is the only condition in patients with psoriasis or psoriatic arthritis who are being treated with systemic biologic agents for which there is strong evidence in favor of baseline screening, according to a literature review.

Analysis of 26 studies of systemic biologic treatments and screening tests – 13 of which included patients with hepatitis C, hepatitis B, or congestive heart failure – found the highest level evidence (grade B) in favor of tuberculin skin testing or interferon-gamma release assay, with the latter being preferred for its higher sensitivity and specificity.

CDC/James Archer

“Based on the [U.S. Preventive Services Task Force] grading system, it is recommended this screen be provided because there is high certainty that the net benefit is moderate, or medium certainty that the net benefit is moderate to substantial,” wrote Dr. Christine S. Ahn of Wake Forest University, Winston-Salem, N.C., and coauthors in the Journal of the American Academy of Dermatology.

Screening for hepatitis B or C infection only was supported by grade-C evidence, and there was insufficient evidence for HIV screening, with the authors suggesting that selective screening should be performed based on professional judgment, clinical context, or patient preference (J Am Acad Dermatol. 2015 July 14 doi: 10.1016/j.jaad.2015.06.004).

Similarly, there was insufficient evidence to support complete blood cell count screening, and, given the low grade evidence on monitoring hepatic function, the authors suggested this should be performed at the clinician’s discretion, particularly among patients treated with infliximab.

Tuberculosis is the only condition in patients with psoriasis or psoriatic arthritis who are being treated with systemic biologic agents for which there is strong evidence in favor of baseline screening, according to a literature review.

Analysis of 26 studies of systemic biologic treatments and screening tests – 13 of which included patients with hepatitis C, hepatitis B, or congestive heart failure – found the highest level evidence (grade B) in favor of tuberculin skin testing or interferon-gamma release assay, with the latter being preferred for its higher sensitivity and specificity.

CDC/James Archer

“Based on the [U.S. Preventive Services Task Force] grading system, it is recommended this screen be provided because there is high certainty that the net benefit is moderate, or medium certainty that the net benefit is moderate to substantial,” wrote Dr. Christine S. Ahn of Wake Forest University, Winston-Salem, N.C., and coauthors in the Journal of the American Academy of Dermatology.

Screening for hepatitis B or C infection only was supported by grade-C evidence, and there was insufficient evidence for HIV screening, with the authors suggesting that selective screening should be performed based on professional judgment, clinical context, or patient preference (J Am Acad Dermatol. 2015 July 14 doi: 10.1016/j.jaad.2015.06.004).

Similarly, there was insufficient evidence to support complete blood cell count screening, and, given the low grade evidence on monitoring hepatic function, the authors suggested this should be performed at the clinician’s discretion, particularly among patients treated with infliximab.

Researchers have uncovered a bidirectional relationship between psoriatic disease – psoriasis and psoriatic arthritis – and uveitis, with either condition significantly increasing the risk of the other.

A Danish nationwide cohort study of 74,129 individuals with psoriasis, including 6,735 with psoriatic arthritis, showed that patients with mild psoriasis had a 38% increased risk of uveitis, while those with psoriatic arthritis had a 2.5-fold increase in risk and those with psoriatic spondylitis had a greater than eight-fold increased risk, according to a paper published online in JAMA Dermatology.

Elsevier 2009

There was a nonsignificant increase in the risk of uveitis in patients with severe psoriasis, but this failed to reach significance because of the small number of patients.

Similarly, patients with uveitis had a 59% greater risk of mild psoriasis, a twofold greater risk of severe psoriasis, a nearly fourfold increase in the risk of psoriatic arthritis, and an eightfold increase in the risk of psoriatic spondylitis (JAMA Dermatol. 2015 July 29 doi: 10.1001/jamadermatol.2015.1986).

The authors suggested that an increased focus on eye symptoms in patients with psoriasis and psoriatic arthritis and on skin and joint symptoms in patients with uveitis may be appropriate.

“The bidirectional relationship between psoriasis and psoriatic arthritis and uveitis suggests a shared pathogenic pathway, and increased systemic inflammation may contribute to the observed relationship,” wrote Dr. Alexander Egeberg of Pfizer and his coauthors. Dr. Egeberg was at the University of Copenhagen, Hellerup, when the study was conducted.

The study was supported by Pfizer, the LEO Foundation, and the Novo Nordisk Foundation. One author is employed by Eli Lilly. No other conflicts of interest were declared.

Researchers have uncovered a bidirectional relationship between psoriatic disease – psoriasis and psoriatic arthritis – and uveitis, with either condition significantly increasing the risk of the other.

A Danish nationwide cohort study of 74,129 individuals with psoriasis, including 6,735 with psoriatic arthritis, showed that patients with mild psoriasis had a 38% increased risk of uveitis, while those with psoriatic arthritis had a 2.5-fold increase in risk and those with psoriatic spondylitis had a greater than eight-fold increased risk, according to a paper published online in JAMA Dermatology.

Elsevier 2009

There was a nonsignificant increase in the risk of uveitis in patients with severe psoriasis, but this failed to reach significance because of the small number of patients.

Similarly, patients with uveitis had a 59% greater risk of mild psoriasis, a twofold greater risk of severe psoriasis, a nearly fourfold increase in the risk of psoriatic arthritis, and an eightfold increase in the risk of psoriatic spondylitis (JAMA Dermatol. 2015 July 29 doi: 10.1001/jamadermatol.2015.1986).

The authors suggested that an increased focus on eye symptoms in patients with psoriasis and psoriatic arthritis and on skin and joint symptoms in patients with uveitis may be appropriate.

“The bidirectional relationship between psoriasis and psoriatic arthritis and uveitis suggests a shared pathogenic pathway, and increased systemic inflammation may contribute to the observed relationship,” wrote Dr. Alexander Egeberg of Pfizer and his coauthors. Dr. Egeberg was at the University of Copenhagen, Hellerup, when the study was conducted.

The study was supported by Pfizer, the LEO Foundation, and the Novo Nordisk Foundation. One author is employed by Eli Lilly. No other conflicts of interest were declared.

Researchers have uncovered a bidirectional relationship between psoriatic disease – psoriasis and psoriatic arthritis – and uveitis, with either condition significantly increasing the risk of the other.

A Danish nationwide cohort study of 74,129 individuals with psoriasis, including 6,735 with psoriatic arthritis, showed that patients with mild psoriasis had a 38% increased risk of uveitis, while those with psoriatic arthritis had a 2.5-fold increase in risk and those with psoriatic spondylitis had a greater than eight-fold increased risk, according to a paper published online in JAMA Dermatology.

Elsevier 2009

There was a nonsignificant increase in the risk of uveitis in patients with severe psoriasis, but this failed to reach significance because of the small number of patients.

Similarly, patients with uveitis had a 59% greater risk of mild psoriasis, a twofold greater risk of severe psoriasis, a nearly fourfold increase in the risk of psoriatic arthritis, and an eightfold increase in the risk of psoriatic spondylitis (JAMA Dermatol. 2015 July 29 doi: 10.1001/jamadermatol.2015.1986).

The authors suggested that an increased focus on eye symptoms in patients with psoriasis and psoriatic arthritis and on skin and joint symptoms in patients with uveitis may be appropriate.

“The bidirectional relationship between psoriasis and psoriatic arthritis and uveitis suggests a shared pathogenic pathway, and increased systemic inflammation may contribute to the observed relationship,” wrote Dr. Alexander Egeberg of Pfizer and his coauthors. Dr. Egeberg was at the University of Copenhagen, Hellerup, when the study was conducted.

The study was supported by Pfizer, the LEO Foundation, and the Novo Nordisk Foundation. One author is employed by Eli Lilly. No other conflicts of interest were declared.

New criteria that define psoriatic arthritis disease activity and treatment response establish cutpoints and percentage changes on the Disease Activity Index for Psoriatic Arthritis scores, Dr. Monika M. Schoels of the Second Department of Internal Medicine at Hietzing Hospital, Vienna, and her coauthors reported.

Dr. Schoels and her colleagues collected 30 patient profiles from an observational data set and then surveyed 44 rheumatology experts (getting 33 responses) to assess the patients’ disease activity based on swollen joint count, tender joint count, global activity, C-reactive protein, and pain ratings. Based on the distribution of Disease Activity Index for Psoriatic Arthritis (DAPSA) scores in the patient population, the investigators then calculated the 25th and 75th percentiles to determine the thresholds for different disease states.

Courtesy Wikimedia Commons/James Heilman/Creative Commons License

Based on the results, the investigators suggested cutoff values of 4 or less for remission, more than 4 and up to 14 for low disease activity, more than 14 and up to 28 for moderate disease activity, and greater than 28 for high disease activity.

They also found that percentage changes of 50%, 75%, and 85% on the DAPSA corresponded to minor, moderate, and major treatment responses based on American College of Rheumatology 20, 50, and 70 responses observed in three randomized trials.

The study findings provide a “definition of treatment targets … as well as the definition of inclusion criteria for clinical trials for patients in” moderate and high disease activity, Dr. Schoels and her colleagues wrote. “The new response levels will help assess treatment in many settings.”

Read the full study in Annals of the Rheumatic Diseases.

[email protected]

New criteria that define psoriatic arthritis disease activity and treatment response establish cutpoints and percentage changes on the Disease Activity Index for Psoriatic Arthritis scores, Dr. Monika M. Schoels of the Second Department of Internal Medicine at Hietzing Hospital, Vienna, and her coauthors reported.

Dr. Schoels and her colleagues collected 30 patient profiles from an observational data set and then surveyed 44 rheumatology experts (getting 33 responses) to assess the patients’ disease activity based on swollen joint count, tender joint count, global activity, C-reactive protein, and pain ratings. Based on the distribution of Disease Activity Index for Psoriatic Arthritis (DAPSA) scores in the patient population, the investigators then calculated the 25th and 75th percentiles to determine the thresholds for different disease states.

Courtesy Wikimedia Commons/James Heilman/Creative Commons License

Based on the results, the investigators suggested cutoff values of 4 or less for remission, more than 4 and up to 14 for low disease activity, more than 14 and up to 28 for moderate disease activity, and greater than 28 for high disease activity.

They also found that percentage changes of 50%, 75%, and 85% on the DAPSA corresponded to minor, moderate, and major treatment responses based on American College of Rheumatology 20, 50, and 70 responses observed in three randomized trials.

The study findings provide a “definition of treatment targets … as well as the definition of inclusion criteria for clinical trials for patients in” moderate and high disease activity, Dr. Schoels and her colleagues wrote. “The new response levels will help assess treatment in many settings.”

Read the full study in Annals of the Rheumatic Diseases.

[email protected]

New criteria that define psoriatic arthritis disease activity and treatment response establish cutpoints and percentage changes on the Disease Activity Index for Psoriatic Arthritis scores, Dr. Monika M. Schoels of the Second Department of Internal Medicine at Hietzing Hospital, Vienna, and her coauthors reported.

Dr. Schoels and her colleagues collected 30 patient profiles from an observational data set and then surveyed 44 rheumatology experts (getting 33 responses) to assess the patients’ disease activity based on swollen joint count, tender joint count, global activity, C-reactive protein, and pain ratings. Based on the distribution of Disease Activity Index for Psoriatic Arthritis (DAPSA) scores in the patient population, the investigators then calculated the 25th and 75th percentiles to determine the thresholds for different disease states.

Courtesy Wikimedia Commons/James Heilman/Creative Commons License

Based on the results, the investigators suggested cutoff values of 4 or less for remission, more than 4 and up to 14 for low disease activity, more than 14 and up to 28 for moderate disease activity, and greater than 28 for high disease activity.

They also found that percentage changes of 50%, 75%, and 85% on the DAPSA corresponded to minor, moderate, and major treatment responses based on American College of Rheumatology 20, 50, and 70 responses observed in three randomized trials.

The study findings provide a “definition of treatment targets … as well as the definition of inclusion criteria for clinical trials for patients in” moderate and high disease activity, Dr. Schoels and her colleagues wrote. “The new response levels will help assess treatment in many settings.”

Read the full study in Annals of the Rheumatic Diseases.

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What do your patients need to know at the first visit?

Pregnant patients need to know that it is important to carefully monitor them throughout their pregnancy. Although many drugs are not contraindicated, it is still important for the dermatologist to consult with the patient’s obstetrician to discuss risks and benefits of different therapies. Some women see an improvement in the severity of their psoriasis during pregnancy, while others report their condition gets worse. Changes in severity of psoriasis vary by individual and from pregnancy to pregnancy.

What are your go-to treatments? What are the side effects?

UV therapy, particularly narrowband UVB, is a good choice during pregnancy. Excimer laser is another good choice. Topical therapies are standardly employed. Although many of these topical therapies are pregnancy category C, we still employ them regularly in consultation with the patient’s obstetrician. Most biologic therapies are pregnancy category B. We still use these drugs with caution in the setting of pregnancy. If a pregnant patient does wish to continue a biologic therapy, close monitoring and enrollment in a pregnancy registry (http: //www.pregnancystudies.org) would be good options. This registry is analyzing whether medications that are used to treat autoimmune diseases are safe to take during pregnancy. Specifically, the investigators are looking at medications used to treat Crohn disease, rheumatoid arthritis, psoriasis, psoriatic arthritis, and multiple sclerosis. Generally speaking, systemic and biologic drugs should be avoided while pregnant or breastfeeding unless there is a clear medical need. Women of childbearing potential should avoid oral retinoids, methotrexate, and cyclosporine due to a link to birth defects with each of those treatments.

How do you keep patients compliant with treatment?

We see the patients regularly, and I am always available to take telephone calls if any questions arise.

What do you do if patients refuse treatment?

We keep the dialogue ongoing and monitor their condition. They may change their attitude if their condition worsens.

What resources do you recommend to patients for more information?

Patients should consult the National Psoriasis Foundation (http://www.psoriasis.org).

Quick access to more resources on our PSORIASIS page

What do your patients need to know at the first visit?

Pregnant patients need to know that it is important to carefully monitor them throughout their pregnancy. Although many drugs are not contraindicated, it is still important for the dermatologist to consult with the patient’s obstetrician to discuss risks and benefits of different therapies. Some women see an improvement in the severity of their psoriasis during pregnancy, while others report their condition gets worse. Changes in severity of psoriasis vary by individual and from pregnancy to pregnancy.

What are your go-to treatments? What are the side effects?

UV therapy, particularly narrowband UVB, is a good choice during pregnancy. Excimer laser is another good choice. Topical therapies are standardly employed. Although many of these topical therapies are pregnancy category C, we still employ them regularly in consultation with the patient’s obstetrician. Most biologic therapies are pregnancy category B. We still use these drugs with caution in the setting of pregnancy. If a pregnant patient does wish to continue a biologic therapy, close monitoring and enrollment in a pregnancy registry (http: //www.pregnancystudies.org) would be good options. This registry is analyzing whether medications that are used to treat autoimmune diseases are safe to take during pregnancy. Specifically, the investigators are looking at medications used to treat Crohn disease, rheumatoid arthritis, psoriasis, psoriatic arthritis, and multiple sclerosis. Generally speaking, systemic and biologic drugs should be avoided while pregnant or breastfeeding unless there is a clear medical need. Women of childbearing potential should avoid oral retinoids, methotrexate, and cyclosporine due to a link to birth defects with each of those treatments.

How do you keep patients compliant with treatment?

We see the patients regularly, and I am always available to take telephone calls if any questions arise.

What do you do if patients refuse treatment?

We keep the dialogue ongoing and monitor their condition. They may change their attitude if their condition worsens.

What resources do you recommend to patients for more information?

Patients should consult the National Psoriasis Foundation (http://www.psoriasis.org).

Quick access to more resources on our PSORIASIS page

What do your patients need to know at the first visit?

Pregnant patients need to know that it is important to carefully monitor them throughout their pregnancy. Although many drugs are not contraindicated, it is still important for the dermatologist to consult with the patient’s obstetrician to discuss risks and benefits of different therapies. Some women see an improvement in the severity of their psoriasis during pregnancy, while others report their condition gets worse. Changes in severity of psoriasis vary by individual and from pregnancy to pregnancy.

What are your go-to treatments? What are the side effects?

UV therapy, particularly narrowband UVB, is a good choice during pregnancy. Excimer laser is another good choice. Topical therapies are standardly employed. Although many of these topical therapies are pregnancy category C, we still employ them regularly in consultation with the patient’s obstetrician. Most biologic therapies are pregnancy category B. We still use these drugs with caution in the setting of pregnancy. If a pregnant patient does wish to continue a biologic therapy, close monitoring and enrollment in a pregnancy registry (http: //www.pregnancystudies.org) would be good options. This registry is analyzing whether medications that are used to treat autoimmune diseases are safe to take during pregnancy. Specifically, the investigators are looking at medications used to treat Crohn disease, rheumatoid arthritis, psoriasis, psoriatic arthritis, and multiple sclerosis. Generally speaking, systemic and biologic drugs should be avoided while pregnant or breastfeeding unless there is a clear medical need. Women of childbearing potential should avoid oral retinoids, methotrexate, and cyclosporine due to a link to birth defects with each of those treatments.

How do you keep patients compliant with treatment?

We see the patients regularly, and I am always available to take telephone calls if any questions arise.

What do you do if patients refuse treatment?

We keep the dialogue ongoing and monitor their condition. They may change their attitude if their condition worsens.

What resources do you recommend to patients for more information?

Patients should consult the National Psoriasis Foundation (http://www.psoriasis.org).

Quick access to more resources on our PSORIASIS page