Lipoproteins and their subfractions in psoriatic arthritis: identification of an atherogenic profile with active joint disease

Identifying Serum Metabolomic Markers Associated with Skin Disease Activity in Patients with Psoriatic Arthritis

Psoriatic arthritis (PsA) is a chronic, systemic, immune-mediated inflammatory disease causing cutaneous and musculoskeletal inflammation that affects 25% of patients with psoriasis. Current methods for evaluating PsA disease activity are not accurate enough for precision medicine. A metabolomics-based approach can elucidate psoriatic disease pathogenesis, providing potential objective biomarkers. With the hypothesis that serum metabolites are associated with skin disease activity, we aimed to identify serum metabolites associated with skin activity in PsA patients. We obtained serum samples from patients with PsA (n = 150) who were classified into mild, moderate and high disease activity groups based on the Psoriasis Area Severity Index. We used solid-phase microextraction (SPME) for sample preparation, followed by data acquisition via an untargeted liquid chromatography-mass spectrometry (LC-MS) approach. Disease activity levels were predicted using identified metabolites and machine learning algorithms. Some metabolites tentatively identified include eicosanoids with anti- or pro-inflammatory properties, like 12-Hydroxyeicosatetraenoic acid, which was previously implicated in joint disease activity in PsA. Other metabolites of interest were associated with dysregulation of fatty acid metabolism and belonged to classes such as bile acids, oxidized phospholipids, and long-chain fatty acids. We have identified potential metabolites associated with skin disease activity in PsA patients.

Comorbidities in Psoriatic Arthritis: A Narrative Review

PURPOSE

Psoriatic arthritis (PsA) is a common type of inflammatory arthritis. Patients with PsA present with certain extra-articular manifestations and comorbidities (often collectively called psoriatic disease). The purpose of the present review was to highlight the main comorbidities in the setting of PsA.

METHODS

A narrative review was performed using data from articles found in a search of PubMed and Scopus using the terms psoriatic arthritis and comorbidities.

FINDINGS

Cardiovascular disease (CVD), as well as metabolic and mental health disorders, are the most common comorbidities in patients with PsA. In most cases, underlying inflammation seems to be involved in the increased risk for CVD in PsA, while a bidirectional relationship seems to operate between mental health disorders and psoriatic disease. The treatment of patients with PsA, especially with biologic disease-modifying antirheumatic drugs, has been shown to lead to favorable outcomes regarding the CVD risk. However, it is debatable whether specific drug classes are more effective than others or should be avoided in patients with CVD risk factors. Comorbidity of mental health disorders is even more complex, given the difficulties in measuring and reporting these comorbidities in clinical trials and in clinical practice.

IMPLICATIONS

Future studies are needed for a better understanding of the pathogenic mechanisms of, and the development of better protocols for the identification and treatment of patients with, comorbidities in patients with PsA. The education of clinicians, health care professionals in rheumatology, and patients could be useful in achieving this goal.

Psoriatic Arthritis and Metabolic Syndrome: Is There a Role for Disease Modifying Anti-Rheumatic Drugs?

Although psoriatic arthritis (PsA) primarily leads to joint and skin damage, it is associated with higher prevalence of metabolic syndrome (MetS) and its components, namely hypertension, dyslipidemia, obesity, and type II diabetes. Additionally, chronic inflammation is known to aggravate these cardiometabolic factors, thus explaining the enhanced cardiovascular (CV) morbidity and mortality in RA. Furthermore, emerging evidence suggest that some risk factors can fuel inflammation, thus pointing to a bidirectional crosstalk between inflammation and cardiometabolic factors. Therefore, dampening inflammation by disease-modifying anti-rheumatic drugs (DMARDs) may be thought to ameliorate MetS burden and thus, CV risk and disease severity. In fact, recommendations for PsA management emphasize the need of considering comorbidities to guide the treatment decision process. However, the existing evidence on the impact of approved DMARDs in PsA on MetS and MetS components is far from being optimal, thus representing a major challenge for the clinical setting. Although a beneficial effect of some DMARDs such as methotrexate, TNF inhibitors and some small molecules is clear, no head-to-head studies are published and no evidence is available for other therapeutic approaches such as IL-23 or IL-17 inhibitors. This narrative review summarizes the main evidence related to the effect of DMARDs on MetS outcomes in PsA patients and identify the main limitations, research needs and future perspectives in this scenario.

The Association of Psoriatic Arthritis With All-cause Mortality and Leading Causes of Death in Psoriatic Arthritis

OBJECTIVE

To examine the association between psoriatic arthritis (PsA) and all-cause mortality from a large population-based database.

METHODS

Patients with PsA from the Clalit Health Services database were identified between 2003-2018 and matched to 4 controls by age, sex, ethnicity, and index date. Patient demographics, comorbidities, and treatments were extracted. Mortality data were obtained from the Israeli Notification of Death certificate. The proportionate mortality rate (PMR) of the leading causes of death was calculated and compared to that of the general population. Cox proportional hazard regression models were used to estimate the crude and the multivariate adjusted HR for the association between PsA and all-cause mortality and for factors associated with mortality within the PsA group.

RESULTS

There were 5275 patients with PsA and 21,011 controls included and followed for 7.2 ± 4.4 years. The mean age was 51.7 ± 15.4 years, and 53% were females. Among patients with PsA, 38.2% were on biologics. Four hundred seventy-one (8.9%) patients died in the PsA group compared to 1668 (7.9%) in the control group. The crude HR for the association of PsA and all-cause mortality was 1.16 (95% CI 1.04-1.29) and 1.02 (95% CI 0.90-1.15) on multivariate analysis. Malignancy was the leading cause of death (26%), followed by ischemic heart disease (15.8%); this is in keeping with the leading causes of death in the general population. Older age, male sex, lower socioeconomic status, increased BMI, increased Charlson comorbidity index scores, and history of psoriasis or hospitalization in 1 year prior to entry were positive predictors for mortality.

CONCLUSION

No clinically relevant increase in mortality rate was observed in patients with PsA, and specific PMRs were similar to those of the general population.

Psoriatic arthritis in Africa

Psoriatic arthritis is a chronic immune-mediated inflammatory arthritis associated with the skin condition psoriasis. Although there is a large body of evidence regarding epidemiology, outcomes, and response to therapy from the Western world, there is a dearth of published literature from the African continent. There are many challenges responsible for this. Lack of resources, both human and financial, an enormous disease burden, and a focus on communicable diseases leave an unmet need for this important disease. This review explores and identifies these challenges and proposes ways to improve and overcome these deficiencies. We discuss the epidemiology of psoriatic arthritis in Africa, postulating the role of genetic and environmental factors, looking at the role of HLA-B 23, HLA-B 17, and HLA-B 8. Dietary intake as a contributing factor to the low prevalence of psoriatic arthritis and psoriasis is also discussed. Challenges on the African continent regarding limited access to specialised units/specialists, delay in diagnosis, limited attention by healthcare authorities to non-communicable diseases, and the difficulties in implementing international recommendations on the African continent are discussed. We also discuss a relative lack of data from the African continent, the cost of specialised medication in resource-poor countries, and comorbidities of psoriatic arthritis. The lack of validated questionnaires relevant to the African continent is also important and discussed. Finally, we discuss a proposed research agenda that will improve care, quality of life, and outcomes for patients with psoriatic arthritis on the African continent.

Rodent Models of Spondyloarthritis Have Decreased White and Bone Marrow Adipose Tissue Depots

Bone marrow adipose tissue (BMAT) has recently been recognized as a distinct fat depot with endocrine functions. However, if and how it is regulated by chronic inflammation remains unknown. Here, we investigate the amount of white fat and BMAT in HLA-B27 transgenic rats and curdlan-challenged SKG mice, two well-established models of chronic inflammatory spondyloarthritis (SpA). Subcutaneous and gonadal white adipose tissue and BMAT was reduced by 65-70% and by up to 90% in both experimental models. Consistently, B27 rats had a 2-3-fold decrease in the serum concentrations of the adipocyte-derived cytokines adiponectin and leptin as well as a 2-fold lower concentration of triglycerides. The bone marrow of B27 rats was further characterized by higher numbers of neutrophils, lower numbers of erythroblast precursors, and higher numbers of IL-17 producing CD4⁺ T cells. IL-17 concentration was also increased in the serum of B27 rats. Using a cell culture model, we show that high levels of IL-17 in the serum of B27 rats negatively impacted adipogenesis (-76%), an effect that was reversed in the presence of neutralizing anti-IL-17 antibody. In summary, these findings show BMAT is severely reduced in two experimental models of chronic inflammatory SpA and suggest that IL-17 is involved in this process.

Psoriatic arthritis and the association with cardiometabolic disease: a narrative review

Psoriatic arthritis (PsA) is associated with a higher burden of cardiometabolic disorders, such as hypertension, dyslipidemia, diabetes, obesity, and cardiovascular disease (CVD), compared with the general population. These comorbidities are associated with the severity of disease, and adversely affect treatment outcomes in PsA. Comorbidities lead to increased physician visits and medications for patients and make the selection and maintenance of therapies challenging for physicians. Moreover, CVD is a leading cause of mortality in PsA. Therefore, optimal management of PsA should include not only treating the skin and joint disease, but also identifying comorbidities early, and managing them to improve long-term outcomes. Further studies are needed to understand the complex mechanisms, interactions, and trajectories of cardiometabolic comorbidities in psoriatic disease.

Cardiovascular Consequences of Autoimmune Rheumatic Diseases

The increased risk of cardiovascular disease (CVD) among patients with autoimmune rheumatic diseases such as rheumatoid arthritis, spondyloarthritis and systemic lupus erythematosus has been extensively documented. Sub-clinical atherosclerosis can be assessed using various non-invasive imaging techniques. However, the mechanisms underlying the higher risk of atherosclerotic CVD in patients with autoimmune rheumatic diseases are not fully known, although they seem to include chronic low-grade systemic inflammation leading to prolonged endothelial activation, accompanied by a pro-thrombotic/pro-coagulant and autoantibody state. Furthermore, sub-clinical atherosclerosis is also influenced by other traditional risk factors for CVD. Including the individual components of the metabolic syndrome (MetS: obesity, impaired glucose metabolism, dyslipidemia and high blood pressure), the degree of which is higher in these patients than in controls. The aim of this narrative review is to discuss the CV manifestations and risk factors involved in the increased risk of CVD among patients with autoimmune rheumatic diseases.

Cardiovascular Disease in Spondyloarthritides

The spondyloarthritides are a group of chronic systemic inflammatory joint diseases, the main types being ankylosing spondylitis (AS) and psoriatic arthritis (PsA). Evidence accumulating during the last decades suggests that patients with AS or PsA carry an increased risk for cardiovascular disease and cardiovascular death. This risk appears to be mediated by systemic inflammation over and above classical cardiovascular risk factors. The excess cardiovascular risk in those patients has been formally acknowledged by scientific organizations, which have called physicians' attention to the matter. The application by Rheumatologists of new effective anti-rheumatic treatments and treat-to-target strategies seems to benefit patients from a cardiovascular point of view, as well. However, more data are needed in order to verify whether anti-rheumatic treatments do have an effect on cardiovascular risk and whether there are differences among them in this regard. Most importantly, a higher level of awareness of the cardiovascular risk is needed among patients and healthcare providers, better tools to recognize at-risk patients and, ultimately, commitment to address in parallel both the musculoskeletal and the cardiovascular aspect of the disease.

Cardiovascular Comorbidities in Psoriatic Disease

Psoriatic disease (PsD) is a multisystem inflammatory disorder with a high prevalence of cardiovascular (CV) risk factors contributing to accelerated atherosclerosis and its sequelae. Imaging studies, notably with ultrasound, computed tomography, and positron emission tomography (PET) scanning have confirmed significant atherosclerotic change with plaque formation and vessel stenosis. Atherosclerosis is likely driven by a combination of traditional risk factors which occur more frequently in PsD and by systemic inflammation with associated pro-inflammatory cytokine production. While the mechanisms driving atherosclerosis in PsD are incompletely understood, it is now best practice to try to minimize the impact of CV risk factors by regular assessment, prevention, and treatment and also by ensuring that inflammatory musculoskeletal and cutaneous disease is adequately suppressed. Future studies need to focus on improving our understanding of the mechanisms driving atherosclerosis and, as a consequence, developing more rationale approaches to prevention and treatment.

HDL cholesterol efflux capacity is related to disease activity in psoriatic arthritis patients

OBJECTIVE

Cholesterol efflux capacity (CEC) is the ability of high-density lipoprotein (HDL) cholesterol to accept cholesterol from macrophages. CEC is linked to cardiovascular events in the general population, and it has been shown to be disrupted in inflammatory states. The aim of this study was to establish whether CEC is impaired in PsA patients and if this could be explained by disease-related features like disease activity.

METHODS

Case-control study that encompassed 105 individuals: 52 PsA patients and 53 controls. CEC, using an in vitro assay, and lipoprotein serum concentrations were assessed in patients and controls. Disease activity in patients with PsA was measured using the Disease Activity Index for Psoriatic Arthritis (DAPSA). Multivariate analysis was performed to study the differences between CEC in patients and controls, and the relation of CEC with PsA activity-related data and lipid profile.

RESULTS

Total cholesterol, apolipoprotein A1, and LDL cholesterol serum levels were downregulated in PsA patients. CEC did not differ between controls and patients (17 ± 10 vs. 18 ± 2%, p = 0.15) after adjusting for traditional cardiovascular risk factors or other variations in the lipid profile related to the disease. Traditional cardiovascular risk factors, both in patients and controls, were not related to CEC. After multivariate regression analysis, the DAPSA score was inversely and independently associated with CEC (beta coefficient - 0.75 [95%CI - 1.39-- 0.11] %, p = 0.023).

CONCLUSION

CEC is inversely associated with disease activity in PSA patients, reinforcing the role of disease activity as a key factor in the development of accelerated atherosclerosis in these patients.Key Points• Cholesterol efflux capacity is linked to cardiovascular events in the general population.• In patients with psoriatic arthritis, cholesterol efflux capacity is inversely associated with disease activity (beta coefficient - 0.75[95% CI - 1.39-- 0.11] %, p = 0.023).• This finding reinforces the role of disease activity as a key factor in increasing cardiovascular risk in psoriatic arthritis patients.

The role of high-dose vitamin D supplementation on disease severity and lipid profile in psoriatic patients: A pilot study

Background/Aim: Psoriasis is a chronic inflammatory skin disease that is associated with a higher prevalence of cardiovascular (CV) risk factors. The effect of vitamin D on bone health has been long known, but its extraskeletal role especially in cardiovascular disease and skin disease, is the subject of recent research. This study aimed to assess the influence of high-dose vitamin D supplementation on the Psoriasis Area and Severity Index (PASI) score and lipid profile in patients with psoriasis. Methods: The study included 20 adult patients with chronic plaque psoriasis. They received vitamin D capsules in a daily dose of 5,000 IU over 12 weeks. Measured serum concentrations of lipid metabolism parameters were triglycerides (TG), total cholesterol (TC), low-density lipoproteins (LDL) and high-density lipoproteins (HDL). PASI was used to determine the severity of the disease. Results: High-doses vitamin D supplementation had a significant influence on reduction in PASI score in all patients (17.99 ± 12.42 vs 10.27 ± 8.53; p < 0.001). The supplementation of high dose vitamin D induced statistically significant lowering of the TC, LDL-C and TG in the psoriatic patients (p < 0.05). Furthermore, significant increase in serum HDL-C level was observed. The change of PASI score showed week positive correlation with the changes in serum TC and LDL-C (r = 0.303, p = 0.03 and r = 0.357 p = 0.013). Conclusion: High-dose vitamin D supplementation had a positive impact on clinical status of the chronic plaque psoriasis patients, measured by PASI score. It also improved the serum lipid profile of these patients. Double-blinded prospective studies are needed in order to get more comprehensive data related to vitamin D, lipid metabolism and severity of psoriasis.

Cardiometabolic comorbidities in RA and PsA: lessons learned and future directions

Cardiometabolic comorbidities present a considerable burden for patients with rheumatoid arthritis (RA) or psoriatic arthritis (PsA). Both RA and PsA are associated with an increased risk of cardiovascular disease (CVD). PsA more often exhibits an increased risk of metabolically linked comorbidities such as obesity, insulin resistance, type 2 diabetes mellitus and non-alcoholic fatty liver disease. Although both RA and PsA are characterized by a state of chronic inflammation, the mechanisms that contribute to CVD risk in these conditions might not be identical. In RA, systemic inflammation is thought to directly contribute to CVD risk, whereas in PsA, adiposity is thought to contribute to a notable metabolic phenotype that, in turn, contributes to CVD risk. Hence, appropriate management strategies that consider the increased risk of cardiometabolic comorbidities in patients with inflammatory arthropathy are important. In RA, such strategies should focus on the prediction of CVD risk and its management through targeting chronic inflammation and traditional CVD risk factors. In PsA, management strategies should additionally focus on targeting metabolic components, including weight management, which might not only help improve disease activity in the joints, entheses and skin, but also reduce the risk of metabolic comorbidities and improve the quality of life of patients.

Biomarkers of subclinical atherosclerosis in patients with psoriatic arthritis

Background: Psoriatic arthritis (PsA) is a chronic immune-mediated disease. It is associated with an increase in cardiovascular risk factors (obesity, hypertension, diabetes, and dyslipidemia), giving a higher risk of major adverse cardiovascular events. Patients with PsA have an increased incidence of subclinical atherosclerosis and endothelial dysfunction. The aim of this study is to perform a review of the biomarkers of subclinical atherosclerosis in patients with PsA.

Methods: A search was performed in the electronic databases (PubMed, Web of Science, Scopus, and Embase) up until July 2017. Studies were considered if they included data on biomarkers of subclinical atherosclerosis in PsA, and each article was then reviewed for quality and clinical relevance. After completing the literature search, all screened literature was summarized and discussed in our study group (CaRRDs study group).

Results: The initial search produced 532 abstracts, which were limited to 258 potentially relevant articles by preliminary review of the titles and by excluding review articles and case reports (n=274). A further 102 articles were deemed ineligible after examining the abstracts. Full texts of the remaining 156 articles were retrieved. Most articles were excluded because they were not relevant to the biomarkers of subclinical atherosclerosis in psoriasis and/or PsA. In the end, 54 articles were deemed eligible for this review.

Conclusion: Patients with PsA showed more severe atherosclerotic disease compared with patients with only psoriasis. This may have been due to the higher systemic inflammatory burden from the combination of both diseases. In patients with PsA some molecules may be considered as markers of atherosclerotic disease, and their detection may be a prognostic marker, in addition to imaging procedures, for the development of atherosclerotic disease, and could be suitable for the management of patients with PsA.

Cardiovascular morbidity and mortality in ankylosing spondylitis and psoriatic arthritis

The cardiovascular burden in inflammatory rheumatic diseases is well recognized. Recently, this burden has been highlighted in ankylosing spondylitis (also known as radiographic axial spondyloarthritis) and psoriatic arthritis. We review the cardiovascular morbidity and mortality in these diseases, as well as the prevalence and incidence of traditional cardiovascular risk factors. We examine the contribution of anti-inflammatory therapy with nonsteroidal anti-inflammatory drugs, disease-modifying anti-rheumatic drugs, and TNF inhibitors on the cardiovascular risk profile. Finally, we examine the available recommendations for the management of cardiovascular comorbidity, as they apply to the spondyloarthritis population.

Serum lipid metabolism in psoriasis and psoriatic arthritis - an update

INTRODUCTION

Psoriasis and psoriatic arthritis (PSA) are chronic, inflammatory, systemic diseases characterized by metabolic abnormalities, including an increased cardiovascular risk and an oxidative imbalance. This study assessed blood parameters of lipid metabolism and markers of oxidative stress in patients with psoriasis and PSA.

MATERIAL AND METHODS

The study included 93 patients with psoriasis (31 patients with PSA and psoriasis, 62 patients with psoriasis vulgaris), and 60 healthy, age-matched controls. Serum concentrations of the glucose and the following lipid metabolism parameters were measured: triglycerides (TG), total cholesterol (TC), low-density lipoproteins (LDL), very low-density lipoproteins (VLDL), high-density lipoproteins (HDL), and apolipoproteins A and B (ApoA, ApoB). Oxidative status was determined as serum concentrations of ox-LDL/MDA Adduct. The Psoriasis Area and Severity Index (PASI) was used to determine disease severity.

RESULTS

Among the three studied groups, controls had the highest HDL concentration (p < 0.001), patients with PSA had the highest ApoB concentration (p < 0.05), ApoA : ApoB ratio (p < 0.05), ox-LDL/MDA adduct concentration (p < 0.001), and TC: HDL and LDL : HDL ratios (accordingly p < 0.05, p < 0.01). In patients with psoriasis or PSA, oxidative status correlated positively with TC and ApoB concentrations.

CONCLUSIONS

In line with previous research, among patients with psoriasis and PSA, we found lipid metabolism abnormalities and an oxidative imbalance, which might be due to chronic inflammation in these conditions. Effective treatment of patients with psoriasis or PSA could reduce the risk of cardiovascular diseases.

Cardiovascular Risk Markers and Major Adverse Cardiovascular Events in Psoriatic Arthritis Patients

BACKGROUND

Psoriatic arthritis is a chronic inflammatory arthropathy that affects 14%- 30% of patients with skin and/or nail psoriasis, leading to severe physical limitations and disability. It has been included in the group of spondyloarthropathy with which it shares clinical, radiologic, and serologic features in addition to familial and genetic relationship. Beyond skin and joint involvement, psoriatic arthritis is characterized by a high prevalence of extra-articular manifestation and comorbidities, such as autoimmune, infectious and neoplastic diseases. In particular, an increased risk of cardiovascular comorbidity has been observed in psoriatic arthritis patients.

METHODS

A systematic search was performed in the electronic databases (PubMed, Web of Science, Scopus, EMBASE) up until January 2017. Studies were included if they contained data on CV disease and/or risk factors in PsA and each article was then reviewed for quality and clinical relevance. After completing the literature search all screened literature was summarized and discussed in our study group (CaRDDs study group). All literature and comments were included in the systematic review.

RESULTS

The initial search produced 278 abstracts, which were narrowed to 83 potentially relevant articles by preliminary review of the titles and by excluding review articles and case report (n = 195). Thirty articles were deemed ineligible after examining the abstracts. Full texts of the remaining 53 articles were retrieved. The majority of articles excluded were due to only providing data on patients with psoriasis or due to being not relevant to the CV risk in PsA. In the end, 32 articles were deemed eligible for this review.

CONCLUSION

Psoriatic arthritis appeared significantly associated with subclinical atherosclerosis and endothelial dysfunction and, in turn, with an increased cardiovascular risk. Thus, patients with psoriatic arthritis may benefit from a periodic assessment of surrogate markers of cardiovascular risk. This could help to establish more specific cardiovascular prevention strategies for these patients.

Impact of obesity on autoimmune arthritis and its cardiovascular complications

Obesity can instigate and sustain a systemic low-grade inflammatory environment that can amplify autoimmune disorders and their associated comorbidities. Metabolic changes and inflammatory factors produced by the adipose tissue have been reported to aggravate autoimmunity and predispose the patient to cardiovascular disease (CVD) and metabolic comorbidities. Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) are autoimmune arthritic diseases, often linked with altered body mass index (BMI). Severe joint inflammation and bone destruction have a debilitating impact on the patient's life; there is also a staggering risk of cardiovascular morbidity and mortality. Furthermore, these patients are at risk of developing metabolic symptoms, including insulin resistance resulting in type 2 diabetes mellitus (T2DM). In addition, arthritis severity, progression and response to therapy can be markedly affected by the patient's BMI. Hence, a complex integrative pathogenesis interconnects autoimmunity with metabolic and cardiovascular disorders. This review aims to shed light on the network that connects obesity with RA, PsA, systemic lupus erythematosus and Sjӧgren's syndrome. We have focused on clarifying the mechanism by which obesity affects different cell types, inflammatory factors and traditional therapies in these autoimmune disorders. We conclude that to further optimize arthritis therapy and to prevent CVD, it is imperative to uncover the intricate relation between obesity and arthritis pathology.

Prevalence of metabolic syndrome and degree of cardiovascular disease risk in patients with Psoriatic Arthritis

OBJECTIVE

The aim of this study was to identify the prevalence of metabolic syndrome (MetS) and degree of cardiovascular disease (CVD) risk in patients with psoriatic arthritis (PsA).

MATERIAL AND METHODS

We performed a cross-sectional study on 102 adult patients with PsA and a control group of 102 patients with rheumatoid arthritis (RA). MetS was diagnosed according to the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) and International Diabetes Federation (IDF) criteria. The Framingham risk scores of 10-year risk of CVDs and coronary heart disease (CHD) were also calculated.

RESULTS

The prevalence of MetS was higher in patients with PsA than in those with RA, according to the NCEP-ATP III (40.6% vs. 24.7%, respectively; p=0.019) and IDF (46.8% vs. 27.9%, respectively; p=0.05) criteria. The prevalence of MetS was higher in female patients with PsA (p=0.009) than in male patients. A significantly increased prevalence of hypertriglyceridemia was determined in patients with PsA (p=0.019). No significant difference existed between the two groups with respect to 10-year CVD (p=0.333) and CHD (p=0.798) risks. Additionally, there were no significant differences between the clinical subtypes of PsA with regard to MetS (p=0.229).

CONCLUSION

MetS prevalence increased in patients with PsA compared with those with RA, whereas the risks were similar for CVDs and CHD. For this reason, optimal protection measures should be taken and guidelines should be applied to achieve adequate metabolic control in patients with PsA.

Association between small dense LDL and sub-clinical atherosclerosis in patients with psoriatic arthritis

Psoriatic arthritis (PsA) is an inflammatory rheumatic disorder occurring in patients with psoriasis. Several studies have shown an association between Psa and traditional atherosclerotic risk factors. We evaluated the relationship between small dense low-density lipoproteins particles (sd-LDL) a risk marker for atherosclerosis, sub-clinical atherosclerosis and PsA in a group of 50 patients with PsA and in 100 controls. Cholesterol, high-density lipoproteins (HDL), low-density lipoproteins (LDL), triglycerides, insulin, homeostasis model assessment (HOMA), Apo B, and sd-LDL have been measured. LDL particle separation was performed and seven LDL subfractions were obtained, LDL score (percentage of sd-LDL) and mean LDL particle size were calculated. PsA patients and control group differ significantly (p < 0.001) in triglycerides values (119.3 ± 52.0 vs 90.7 ± 40.7 mg/dL), Apo B (1.1 ± 0.2 vs 0.9 ± 0.1 g/L), insulin (8.9 ± 4.9 vs 5.8 ± 3.2 mU/L), HOMA (2.2 ± 1.7 vs 1.3 ± 0.8), BMI (27.7 ± 3.3 vs 25.8 ± 3.8). LDL score is significantly higher in PsA as compared to control (9.0 ± 10.7 vs 2.9 ± 4.7 mg/dL); and mean LDL size is significantly lower in PsA than control (268.1 ± 4.6 vs 271.2 ± 2.7 Å). These differences were confirmed when stratifying PsA patients for treatment and for disease activity. LDL score and LDL diameter significantly were correlated with the carotid IMT in patients with PsA. These findings show a novel relationship between LDL score and mean LDL size with PsA diagnosis and with sub-clinical atherosclerosis. Sd-LDL gives potentially useful information in the risk assessment for atherosclerotic disease in PsA patients.

Transcriptome profiling unveils the role of cholesterol in IL-17A signaling in psoriasis

Psoriasis is a chronic inflammatory skin disease characterized by altered proliferation and differentiation of keratinocytes as well as infiltration of immune cells. Increased expression of Th17 cells and cytokines secreted by them provides evidence for its central role in the pathogenesis of psoriasis. IL-17A, signature cytokine of Th17 cells was found to be highly differentially expressed in psoriatic lesional skin. However, cellular and molecular mechanism by which IL-17A exerts its function on keratinocyte is incompletely understood. To understand IL-17A mediated signal transduction pathways, gene expression profiling was done and differentially expressed genes were analysed by IPA software. Here, we demonstrate that during IL-17A signaling total cholesterol levels were elevated, which in turn resulted in the suppression of genes of cholesterol and fatty acid biosynthesis. We found that accumulation of cholesterol was essential for IL-17A signaling as reduced total cholesterol levels by methyl β cyclodextrin (MBCD), significantly decreased IL-17A induced secretion of CCL20, IL-8 and S100A7 from the keratinocytes. To our knowledge this study for the first time unveils that high level of intracellular cholesterol plays a crucial role in IL-17A signaling in keratinocytes and may explain the strong association between psoriasis and dyslipidemia.

Improving cardiovascular health and metabolic comorbidities in patients with psoriatic arthritis

Numerous studies have suggested a link between psoriatic arthritis (PsA) and comorbidities, in particular cardiovascular disease and metabolic comorbidities such as diabetes. The co-existence of these comorbidities is likely the result of systemic inflammation. In order to improve the health of patients with PsA and provide optimal care, these comorbidities must be addressed. However, little is known about how to improve metabolic and cardiovascular health in patients with PsA. In this perspective, we describe the research needs in the area of improving cardiovascular disease and metabolic comorbidities among patients with PsA.

Metabolic syndrome and its relationship with the achievement of minimal disease activity state in psoriatic arthritis patients: an observational study

The aim of the study was to evaluate the influence of metabolic syndrome (MetS) on achieving minimal disease activity (MDA) in psoriatic arthritis (PsA) patients treated with anti-tumor necrosis factor (TNF)-α with a follow-up period of 24 months. A cohort of PsA patients was assessed at the University Federico II of Naples and at University of Padova. For the aim of the present study, patients' data were collected at baseline (T0), at 12 months (T1) and at 24 months (T2). Assessment of metabolic and disease activity parameters was performed at each visit. The NCEP-ACT III criteria were used to identify subjects with MetS and the MDA criteria to evaluate the disease activity. On the basis of the exclusion and inclusion criteria, 330 subjects were included in the study; 134 patients (40.7%) were classified as not having MetS and 196 (59.3%) as having MetS. An inverse association was found between presence of metabolic syndrome and the probability of achieving MDA. Univariate analysis indicated that patients with metabolic syndrome were less likely to achieve MDA than patients without metabolic syndrome (OR 0.45, p < 0.001). This inverse association remained statistically significant in the multivariate regression model (OR 0.56, p < 0.001). Metabolic syndrome is associated with a lower probability of achieving MDA in PsA patients in therapy with anti-TNF-α.

Measuring psoriatic disease in clinical practice. An expert opinion position paper

Psoriasis is a common, immune-mediated chronic inflammatory disease with a primary involvement of skin and joints, affecting approximately 2% of the population worldwide. Up to one third of patients with psoriasis are diagnosed with psoriatic arthritis (PsA). Psoriasis and PsA are heterogeneous diseases whose severity depends on a number of clinical factors, such as areas affected and pattern of involvement, and are associated with a range of comorbid diseases and risk factors, including obesity, metabolic syndrome, cardiovascular disease and liver disease. Thus measuring the severity of psoriatic disease needs to take into account the multidimensional aspects of the disease. Subjective measures including the impairment in quality of life or in daily living activities as well as the presence of cardio-metabolic comorbidities, are important for the outcome and add further levels of complexity that, to a certain extent, need to be assessed. Because of the wide range of comorbid conditions associated with psoriasis, comprehensive screening and treatment must be implemented for a most effective managing of psoriasis patients. A joint dermatologist-rheumatologist roundtable discussion was convened to share evidence on the real-life use of methods for measuring psoriasis severity comprehensively. Our objective was to provide an expert position on which clinical variables are to be taken into account when considering patients affected by psoriasis and/or PsA globally and on the assessment tools more suitable for measuring disease activity and/or severity in clinical practice.

Impact of 24-month treatment with etanercept, adalimumab, or methotrexate on metabolic syndrome components in a cohort of 210 psoriatic arthritis patients

Psoriatic arthritis (PsA) is a chronic inflammatory condition, characterized by an excess of metabolic disorders. Metabolic syndrome (MetS) is a cluster of classic cardiovascular risk factors, due to an imbalance between pro- and anti-inflammatory adipokines. Tumor necrosis factor (TNF)-α is a pro-inflammatory adipocytokine mainly produced by monocytes and macrophages with a central role in inflammatory responses, but it also induces adipocytes apoptosis, promotes insulin resistance, and stimulates lipolysis. The aim of this study was to evaluate the impact of therapy with etanercept (ETN), adalimumab (ADA), and methotrexate (MTX) on MetS components in a cohort of PsA patients with a follow-up period of 24 months. A retrospective study has been conducted in a cohort of PsA patients. On the basis of the inclusion criteria, we identified the first 70 consecutive patients, respectively, on ADA, ETN, and MTX, for a total of 210 patients achieving PsARC criteria during the observation period. As part of the routine clinical practice, assessment of metabolic parameters and of disease activity was recorded at baseline (T0), at 12 months (T1), and at 24 months (T2). The results show that when the specific components of the MetS were considered, taking also into account by regression analysis the effect of the confounding factors, the patients on etN and ADA show a significant improvement of the metabolic syndrome components (in detail, waist circumference, triglycerides, high-density lipoprotein cholesterol, and glucose) as compared to the MTX group. In conclusion, these data suggest that the biologic treatment in PsA can no longer be taken into consideration only for its positive effect on articular and cutaneous symptoms but also on the various aspects of this complex picture.

Psoriasis vulgaris with or without arthritis and independent of disease severity or duration is a risk factor for hypercholesterolemia

BACKGROUND

Psoriasis (Ps) has been associated with an increased incidence of cardiovascular disease. Interesting epidemiological evidence suggests associations between Ps and dyslipidemia (DL), a well-established risk factor for cardiovascular disease.

OBJECTIVE

This study aimed to investigate the association between Ps and multiple measurements of DL, which include levels of triglycerides (TGs), low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol and total cholesterol (TCh). We also studied the relationship between DL and disease duration.

METHODS

A prospective hospital-based study was conducted. A total of 661 Caucasian patients with chronic plaque Ps and 661 sex- and age-matched controls were enrolled.

RESULTS

Multivariate analysis showed that in psoriatic patients the odds ratio (OR) of TCh >200 mg/dl was 1.406 (95% confidence interval 1.115-1.173), the OR of LDL cholesterol >130 mg/dl was 1.375 (95% confidence interval 1.088-1.738), the OR of HDL cholesterol <40 mg/dl was 0.881 (95% confidence interval 0.599-1.297), and the OR of TGs >150 mg/dl was 1.041 (95% confidence interval 0.783-1.385). We did not find a relationship between lipid levels and disease duration.

CONCLUSION

Based on our population Ps is associated with alterations in TCh and LDL cholesterol, but not in TGs and HDL cholesterol, when ATP III panel levels are used. These alterations are not related to disease duration.

Cardiovascular risk profile in patients with spondyloarthritis

OBJECTIVES

The spondyloarthritides (SpA) are associated with an increased cardiovascular risk. We studied cardiovascular risk factors in patients with SpA.

METHODS

The following risk factors were assessed in SpA patients and healthy controls: smoking, family history of premature ischemic heart disease, obesity, serum lipids, apolipoproteins, urate and carotid intima media thickness (IMT).

RESULTS

Overall 150 patients (73 with ankylosing spondylitis [AS], 71 with psoriatic arthritis [PsA] and six with other SpA types) were included. Generally SpA patients were significantly more often smokers, while PsA patients had greater values of abdominal obesity. AS patients had significantly lower levels of triglyceride, HDL, ApoB, ApoE and Lp(a) and a higher atherogenic index (total cholesterol/HDL). PsA patients had significantly lower levels of HDL, ApoAI and ApoE, an elevated atherogenic index and higher serum urate. In multivariate analysis the atherogenic index was positively associated with SpA across all patient groups independently of smoking and other lipid parameters. Carotid IMT in SpA patients (0.71 mm) was higher than controls (0.63 mm, P=0.017), although after adjusting for smoking this ceased to be significant. Treatment of patients with previously untreated disease resulted in a small but significant decline in ApoB levels at 6 months (P=0.045), which, however, was no longer evident at 12 months.

CONCLUSION

Spondyloarthritis patients are at a greater cardiovascular risk owing to the higher prevalence of smoking and a higher atherogenic index. PsA patients have more abdominal fat and higher urate levels. Immunosuppressive treatment of SpA produces minor and temporary effects on the lipid profile.

Effect of intensive lipid-lowering therapy on cardiovascular outcome in patients with and those without inflammatory joint disease

OBJECTIVE

To examine the effect of intensive lipid-lowering therapy on a composite cardiovascular outcome (cardiovascular disease [CVD]), consisting of mortality and morbidity end points, in patients with inflammatory joint disease (rheumatoid arthritis [RA], ankylosing spondylitis [AS], or psoriatic arthritis [PsA]) by post hoc analysis of 2 prospective trials of statins with a secondary end point of CVD outcome (the Treating to New Targets [TNT] and Incremental Decrease in End Points Through Aggressive Lipid Lowering [IDEAL] studies).

METHODS

Of the 18,889 patients participating in the 2 trials, 199 had RA, 46 had AS, and 35 had PsA. Lipid-lowering therapy consisted of an intensive regimen of atorvastatin 80 mg or a conventional/low-dose regimen of atorvastatin 10 mg or simvastatin 20-40 mg. The median duration of followup was nearly 5 years. Changes in lipid levels were examined by analyses of covariance. The effect on CVD was examined by Cox regression analyses, and heterogeneity tests were performed.

RESULTS

Patients with RA and those with AS had lower baseline cholesterol levels than patients without inflammatory joint disease (least squares mean ± SEM 180.7 ± 2.3 mg/dl and 176.5 ± 4.7 mg/dl, respectively, versus 185.6 ± 0.2 mg/dl; P = 0.03 and P = 0.05, respectively). Statin treatment led to a comparable decrease in lipid levels and a 20% reduction in overall risk of CVD in both patients with and those without inflammatory joint disease.

CONCLUSION

Our findings indicate that patients with and those without inflammatory joint disease experience comparable lipid-lowering effects and CVD risk reduction after intensive treatment with statins.

Prediction of cardiovascular events in patients with ankylosing spondylitis and psoriatic arthritis: role of lipoproteins in a high-risk population

OBJECTIVE

To evaluate lipids and apolipoproteins as predictors of cardiovascular mortality and morbidity (CVD) in patients with spondyloarthritis (SpA).

METHODS

In the pooled cohort of participants in the IDEAL, TNT, and CARDS trials, 50 had ankylosing spondylitis (AS), 36 had psoriatic arthritis (PsA), and 21,641 did not have AS or PsA (non-SpA). We compared lipid levels at baseline between AS or PsA and non-SpA, and hazard ratios (HR) for CVD were calculated in a Cox proportional hazard model.

RESULTS

Atherogenic lipids were lower in samples from AS, but not in PsA, compared to non-SpA. The HR for 1 SD increase in baseline lipids for future CVD was for total cholesterol 1.39 (95% CI 0.82, 2.36) in AS, 1.01 (95% CI 0.44, 2.31) in PsA, and 1.10 (95% CI 1.07, 1.14) in non-SpA. Both high-density lipoprotein (HDL) and apolipoprotein (ApoA-1) were significantly associated with CVD in AS (HR 3.67, 95% CI 1.47, 9.06, and HR 1.89, 95% CI 1.02, 3.54, respectively), in contrast to PsA (HDL: HR 1.03, 95% CI 0.49, 2.15; ApoA-1: HR 0.79, 95% CI 0.34, 1.89) and non-SpA (HDL: HR 0.86, 95% CI 0.84, 0.89; ApoA-1: HR 0.88, 95% CI 0.85, 0.91).

CONCLUSION

HDL and ApoA-1 were surprisingly associated with increased risk of future CVD in patients with AS, whereas these lipids were protective in non-SpA.

Cardiovascular risk in patients with psoriatic arthritis

Psoriatic arthritis (PsA) is an inflammatory arthritis associated with psoriasis. In addition to skin and joint involvement, there is increasing evidence suggesting that patients with PsA also have an increase in risk of clinical and subclinical cardiovascular diseases, mostly due to accelerating atherosclerosis. Both conventional and nonconventional cardiovascular risk factors contribute to the increased cardiovascular risk in PsA. Chronic inflammation plays a pivotal role in the pathogenesis of atherosclerosis in PsA, acting independently and/or synergistically with the conventional risk factors. In this paper, we discuss the current literature indicating that patients with PsA are at risk of cardiovascular diseases.

Psoriasis and vascular disease-risk factors and outcomes: a systematic review of the literature

BACKGROUND

Psoriasis afflicts 2-3% of the world's population. Affected patients commonly have risk factors for cardiovascular disease (CVD). In addition, psoriasis is independently associated with CVD and mortality.

PURPOSE

To determine which CVD risk factors are associated with psoriasis independent of confounders, whether psoriasis is associated with CVD independent of CVD risk factors, and whether there is increased mortality among patients with psoriasis.

DATA SOURCES

MEDLINE, Embase, and Cochrane Collaborations from inception through October 2009. We reviewed bibliographies of retrieved articles for additional references.

STUDY SELECTION

Cross-sectional, cohort-based, case-control, and randomized controlled trials which involved patients with psoriasis.

DATA EXTRACTION

Two investigators independently reviewed studies and resolved any discrepancies by consensus.

DATA SYNTHESIS

Of the 2,303 articles identified by literature search, 90 studies met inclusion criteria for this review; 15 were cohort-based studies, 45 were case-control, and 30 were cross-sectional.

LIMITATIONS

The quality of evidence was limited by study heterogeneity and lack of large scale prospective studies with long-term follow-up.

CONCLUSIONS

Patients with psoriasis demonstrate a higher prevalence of cardiovascular risk factors and appear to be at increased risk for ischemic heart disease, cerebrovascular disease, and peripheral arterial disease. This increase in vascular disease may be independent of shared risk factors and may contribute to the increase in all-cause mortality. Future research should aim to more confidently distinguish between a true causal relationship or merely an association resulting from multiple shared risk factors. Physicians should screen for and aggressively treat modifiable risk factors for CVD in patients with psoriasis.

Atherosclerosis in psoriatic arthritis

The atherosclerotic process is accelerated in several autoimmune rheumatic diseases. Effector cells of innate and adaptive immunity along with pro-inflammatory cytokines and other immune mediators are found in atherosclerotic lesions, where they play an important role in induction, progression and rupture of plaques. Psoriatic arthritis (PsA) is a chronic inflammatory disease, characterized by arthritis, enthesitis, dactilytis, osteitis, and axial involvement, along with skin manifestations. PsA is frequently associated with obesity, diabetes, dyslipidemia, hypertension, accelerated atherosclerosis and with increased cardiovascular morbidity and mortality. Disease-specific and traditional risk factors seem to account for the atherosclerotic burden in PsA patients. Some immunological factors which are involved in PsA can also contribute to atherosclerosis including C reactive protein (CRP), TNF-α, IFN-γ, IL-1, Il 6, IL23, and Th17.

Heart rate variability in patients with psoriatic arthritis: associations with systemic inflammation and traditional cardiovascular risk factors

Aim. To identify the disturbances of vegetative heart regulation and their associations with systemic inflammation activity in patients with psoriatic arthritic (PsA). Material and methods. The main group (MG) included 32 PsA patients without cardiovascular disease, CVD (mean age 44,62±11,6 years; mean PsA duration 10,32±10,2 years; 52,3% men). The control group (CG) included 25 healthy volunteers (mean age 40,33±11,8 years; 49,1% men). Time and spectral parameters of heart rate variability (HRV) were assessed. PsA activity was assessed by DAS index, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and fibrinogen (FG) levels. Cardiovascular risk (CVR) was calculated, based on the following parameters: lipid spectr arterial hypertension, body mass index, and family history of CVD. Results. Compared to CG, all HRV parameters were affected in MG patients (p<0,01). HRV parameters were associated with PsA activity (ESR, CRP, FG, enthesitis), as well as with CVD risk factors (dyslipidemia, age). Conclusion. In PsA patients, disturbed vegetative heart regulation was manifested in reduced HRV and activated sympathetic HRV component. These disturbances were associated with traditional CVD risk factors and systemic inflammation activity.

Mortality in Psoriatic Arthritis – A Single-center Study from the UK

Objective.

To determine whether the mortality in a cohort of patients with psoriatic arthritis (PsA) from a single center in the UK is significantly different from the general UK population.

Methods.

Patients who were entered onto the PsA database at the Royal National Hospital for Rheumatic Diseases, Bath, between 1985 and 2007 were included in this study. Information on patient deaths was collected retrospectively. The National Health Service (NHS) Strategic Tracing Service was used to establish which patients were alive and which had died. Date and cause of death were confirmed by death certificates from the Registry of Births, Marriages and Deaths. A standardized mortality ratio (SMR) was calculated by matching the patient data to single-year, 5-year age-banded England and Wales data from the Office of National Statistics.

Results.

In this cohort of 453 patients with PsA (232 men, 221 women), there were 37 deaths. Sixteen men and 21 women died. The SMR for the men was 67.87% (95% CI 38.79, 110.22), and for the women, 97.01% (95% CI 60.05, 148.92) and the overall SMR for the PsA cohort was 81.82% (95% CI 57.61, 112.78). The leading causes of death in this cohort were cardiovascular disease (38%), diseases of the respiratory system (27%), and malignancy (14%).

Conclusion.

These results suggest that mortality in our single-center PsA cohort is not significantly different from the general UK population. No increased risk of death was observed in this cohort.

Energy regulation and neuroendocrine-immune control in chronic inflammatory diseases

Energy regulation (EnR) is most important for homoeostatic regulation of physiological processes. Neuroendocrine pathways are involved in EnR. We can separate factors that provide energy-rich fuels to stores [parasympathetic nervous system (PSNS), insulin, insulin-like growth factor-1, oestrogens, androgens and osteocalcin] and those that provide energy-rich substrates to consumers [sympathetic nervous system (SNS), hypothalamic-pituitary-adrenal axis, thyroid hormones, glucagon and growth hormone]. In chronic inflammatory diseases (CIDs), balanced energy-rich fuel allocation to stores and consumers, normally aligned with circadian rhythms, is largely disturbed due to the vast fuel consumption of an activated immune system (up to 2000 kJ day(-1)). Proinflammatory cytokines such as tumour necrosis factor or interleukins 1beta and 6, circulating activated immune cells and sensory nerve fibres signal immune activation to the rest of the body. This signal is an appeal for energy-rich fuels as regulators are switched on to supply energy-rich fuels ('energy appeal reaction'). During evolution, adequate EnR evolved to cope with nonlife-threatening diseases, not with CIDs (huge negative selection pressure and reduced reproduction). Thus, EnR is inadequate in CIDs leading to many abnormalities, including sickness behaviour, anorexia, hypovitaminosis D, cachexia, cachectic obesity, insulin resistance, hyperinsulinaemia, dyslipidaemia, fat deposits near inflamed tissue, hypoandrogenaemia, mild hypercortisolaemia, activation of the SNS (hypertension), CID-related anaemia and osteopenia. Many of these conditions can contribute to the metabolic syndrome. These signs and symptoms become comprehensible in the context of an exaggerated call for energy-rich fuels by the immune system. We propose that the presented pathophysiological framework may lead to new therapeutical approaches and to a better understanding of CID sequence.

Cardiovascular Disease and Risk Factors in Patients with Psoriasis and Psoriatic Arthritis

Objective.

Patients with psoriasis and psoriatic arthritis (PsA) have an increased incidence of cardiovascular disease (CVD) and cardiovascular risk factors such as smoking, hypertension, and metabolic syndrome compared to the normal population. Patients with psoriasis and PsA may also have increased risk from nonconventional risk factors such as raised levels of homocysteine and excessive alcohol consumption. We conducted a comprehensive review of the literature on CVD and all cardiovascular risk factors in patients with psoriasis and PsA.

Methods.

Data sources: All studies identified from a Medline (www.ncbi.nlm.nih.gov) search pertaining to CVD, individual risk factors in psoriasis, and PsA were included. Study selection: Studies included a healthy reference population, were published between 1975 and 2009, and were written in English.

Results.

Our search yielded 14 studies that documented rates of CVD in patients with psoriasis and PsA compared to controls. Substantial evidence points to elevated risk of CVD in patients with psoriasis and PsA.

Conclusion.

It remains difficult to conclude if risk factors are caused by psoriasis or share a common pathogenesis. Physicians treating patients with psoriasis and PsA must be aware of all potential cardiovascular risk factors in their patients.

Effects of 14 weeks of TNF alpha blockade treatment on lipid profile in ankylosing spondylitis

OBJECTIVE

Cardiovascular morbidity and mortality seem to be increased in ankylosing spondylitis, perhaps as the result of biological inflammation and consecutive dyslipidemia. This study aims to investigate the impact of TNF alpha-inhibitors, an effective treatment, on lipid profile.

METHODS

Thirty-four ankylosing spondylitis (AS) patients with active disease undergoing anti-TNF alpha therapy (n=20, infliximab; n=7, etanercept; n=7, adalimumab) were recruited. Disease activity parameters, total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides were assessed at baseline and after 14 weeks of treatment.

RESULTS

After 14 weeks of TNF alpha blockade treatment, there was a significant increase in levels of total cholesterol (5.08+/-1.20 vs. 4.73+/-1.12 mmol/l; p=0.01) and HDL-cholesterol (1.61+/-0.47 vs. 1.47+/-0.35 mmol/l; p=0.008), but no resulting change in the atherogenic index (3.43+/-1.13 vs. 3.35+/-0.93; p=0.87). There was also no change in concentrations of triglycerides (1.33+/-1.22 vs. 1.27+/-0.98 mmol/l; p=0.794) and LDL-cholesterol (3.15+/-0.99 vs. 2.91+/-0.93 mmol/l; p=0.24). TNF alpha inhibitor treatment was followed by a significant improvement in all disease activity parameters: VAS pain or VAS disease activity, BASDAI or BASFI and systemic inflammation. Sub-group analysis showed that monoclonal antibodies increased total and LDL-cholesterol levels but did not change the atherogenic index. Conversely, 14 weeks of etanercept treatment was followed by no change in lipid profile.

CONCLUSION

TNF alpha inhibitors may be successful in reducing cardiovascular risk in AS, as in RA, but not by affecting lipid profile. However, there is insufficient documented evidence, and long-term investigations are needed to define the possible protective mechanisms of TNFalpha inhibitor treatment in spondylarthropathies.

Lipoprotein (a) in patients with psoriasis: associations with lipid profiles and disease severity

BACKGROUND

Lipoprotein (a) [Lp(a)] is a genetically determined molecule whose role has been implied in cardiovascular pathology, and whose levels have been reported to be elevated in patients with psoriasis. Aim To assess the serum levels of Lp(a) in patients with psoriasis, and to investigate the associations of Lp(a) with other lipids and with psoriasis severity.

METHODS

Thirty-four patients with psoriasis and 26 healthy control subjects took part in the study. Serum levels of Lp(a) and total, high density lipoprotein (HDL), low density lipoprotein (LDL), and very low density lipoprotein (VLDL) cholesterol fractions were measured in all participants. The levels of triglycerides and total cholesterol were measured using enzymatic colorimetric tests; HDL and LDL cholesterol concentrations were determined by precipitation methods; the VLDL concentration was calculated according to the formula: VLDL cholesterol = triglycerides/5.

RESULTS

Patients with psoriasis showed significantly higher serum levels of Lp(a) relative to controls. Even when controlling for normolipidemic vs. hyperlipidemic status, abnormal levels of Lp(a) (> 30 mg/dL) were observed significantly more often in patients than in controls. In both patients and controls, Lp(a) levels correlated positively with total and HDL cholesterol levels. In patients, Lp(a) levels correlated positively with psoriasis severity.

CONCLUSIONS

Lp(a) may be a factor contributing to an increased cardiovascular risk in patients with psoriasis. A pathogenetic link may exist between this lipoprotein and psoriatic pathophysiology.

Clinical characteristics of psoriatic arthritis and psoriasis in dermatologists' offices

OBJECTIVE

To describe the skin and joint disease of patients with psoriatic arthritis being treated in dermatology clinics.

METHODS

A total of 1122 patients who had active psoriatic arthritis were enrolled in a Phase 4, non-randomized, open-label, single-arm, 24-week study. They were treated at 108 community and 17 academic dermatology centers. These patients experienced clinically stable, plaque psoriasis involving > or =10% body surface area and joint disease (either > or = two swollen and > or = two tender/painful joints for > or =3 months, or > or = one joint with sacroiliitis or spondylitis).

RESULTS

In general, patient demographics and disease characteristics did not appear to differ between academic and community dermatology sites. Based on patient-reported assessments, patients rated the severity of their baseline joint symptoms lower than the severity of their skin disease. Baseline skin and joint disease measures were not correlated. Psoriatic arthritis was newly diagnosed in 23% of the patients. Most had received prior therapy for psoriasis, but only half had received systemic therapy for psoriatic arthritis.

CONCLUSION

Assessment for joint disease in psoriasis patients being treated at dermatology clinics may facilitate earlier psoriatic arthritis diagnosis and treatment initiation, which may prevent disability and other negative impacts.

Psoriasis comorbidities

Psoriasis is a chronic and debilitating inflammatory disease associated with serious comorbidities. Psoriasis can have a significant impact on a patient's quality of life and is associated with loss of productivity, depression, and an increased prevalence of malignancy. Emerging comorbidities of psoriasis include cardiovascular disease and metabolic syndrome. Psoriasis patients have an increased prevalence of the core components of metabolic syndrome, including obesity, dyslipidemia, and insulin resistance. The relationship between psoriasis and comorbidities such as metabolic syndrome and cardiovascular disease is likely linked to the underlying chronic inflammatory nature of psoriasis. The molecular mechanisms involved in psoriasis-associated dysregulation of metabolic function are believed to be due, in large part, to the action of increased levels of proinflammatory factors, such as tumor necrosis factor-alpha, that are central to the pathogenesis of psoriasis. Recent studies investigating the effects of tumor necrosis factor antagonists on the treatment of cardiovascular disease and metabolic syndrome support this concept.

Prevalence and Risk Factors of Atherosclerosis in Patients with Psoriatic Arthritis

OBJECTIVES

To evaluate the extent of subclinical atherosclerosis by measuring the intima-media wall thickness (IMT) of the common carotid artery in patients with psoriatic arthritis (PsA) and to identify vascular risk factors associated with PsA.

METHODS

Forty-seven patients with PsA were compared with 100 allegedly healthy subjects. Carotid duplex scanning was used to measure common carotid artery IMT. Traditional risk factors, such as gender, age, body mass index (BMI), hypertension, smoking, and lipids were checked. Assessment of PsA activity included clinical patterns of involvement, degree of severity, duration of morning stiffness, number of tender and swollen joints, degree of pain and fatigue, the Bath Ankylosing Spondylitis Disease Activity Index, the Psoriasis Area and Severity Index, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and fibrinogen.

RESULTS

The average IMT (mean +/- standard deviation) for PsA patients was significantly higher compared with controls (0.76 +/- 0.11 versus 0.64 +/- 0.27, respectively, P < 0.00001) for the whole group and after adjustment for age, gender, BMI, hypertension, and hyperlipidemia. The PsA subjects had significantly higher levels of hypertension, hyperlipidemia, ESR, CRP, and fibrinogen, and their average IMT significantly correlated with age, BMI, duration of skin and joint disease, spine involvement, ESR, and fibrinogen. IMT did not correlate with the presence of oligo- or polyarthritis but was increased in patients with clinical spinal involvement. IMT was not associated with the degree of severity or the use of different therapies for PsA, including methotrexate or tumor necrosis factor-alpha-blocking agents.

CONCLUSIONS

PsA patients exhibited greater IMT than healthy controls. Increased IMT independently correlated with parameters of disease activity and conventional risk factors of atherosclerosis.

Metabolic disorders in patients with psoriasis and psoriatic arthritis

Psoriasis is one of the common complex disorders in Western world, affecting 2% to 3% of the population. Recent studies indicate that psoriasis is associated with an increased risk of comorbidity and mortality compared to the general population. It appears that patients with psoriasis have a higher prevalence of metabolic disorders such as diabetes, hypertension, obesity, and hyperlipidemia, as well as a higher frequency of cigarette smoking. These concomitant diseases can complicate the treatment of psoriasis. Even though the etiology of these associations is elusive, physicians should be aware of them and take active steps to reduce the risk profiles of patients with psoriasis and psoriatic arthritis, in order to lessen mortality and comorbidity.

The importance of disease associations and concomitant therapy for the long-term management of psoriasis patients

It is well established that several inflammatory-type conditions, such as arthritis, diabetes, cardiovascular disease, and irritable bowel disease exist comorbidly and at an increased incidence in patients with psoriasis. Psoriasis and other associated diseases are thought to share common inflammatory pathways. Conditions such as these, with similar pathogenic mechanisms involving cytokine dysregulation, are referred to as immune-mediated inflammatory diseases (IMIDs). Considerable evidence for the genetic basis of comorbidities in psoriasis exists. The WHO has reported that the occurrence of chronic diseases, including IMIDs, are a rising global burden. In addition, conditions linked with psoriasis have been associated with increasing rates of considerable morbidity and mortality. The presence of comorbid conditions in psoriasis patients has important implications for clinical management. QoL, direct health care expenditures and pharmacokinetics of concomitant therapies are impacted by the presence of comorbid conditions. For example, methotrexate is contraindicated in hepatic impairment, while patients on cyclosporin should be monitored for kidney function. In addition, some agents, such as beta blockers, lithium, synthetic antimalarial drugs, NSAIDs and tetracycline antibiotics, have been implicated in the initiation or exacerbation of psoriasis. Consequently, collaboration between physicians in different specialties is essential to ensuring that psoriasis treatment benefits the patient without exacerbating associated conditions.