Psoriasis comorbidities in Germany: A population-based study on spatiotemporal variations

Real-world psoriasis treatment patterns and disease burden in Germany, with a focus on biologics and apremilast: data from a German statutory health insurance database

BACKGROUND

Psoriasis is a chronic, systemic, inflammatory skin disease, with increasing prevalence; however, few studies have reported real-world prescription patterns and healthcare burden.

OBJECTIVES

This retrospective, observational cohort study used statutory health insurance claims data (January 2014-December 2019) to estimate prevalence/incidence of moderate-to-severe psoriasis in Germany. Patient characteristics, treatment patterns/compliance, and healthcare resource utilization (HCRU)/costs were evaluated, focusing on apremilast and anti-interleukin (IL), and anti-tumor necrosis factor (TNF) biologics.

METHODS

The epidemiology population included adults with psoriasis; 1-year prevalence/incidence rates were extrapolated to the statutory health insurance population. The HCRU/costs population included adults with psoriasis and a first prescription for a drug of interest (index date). Baseline periods were 12 or 48 months before the index date, with 12‑month follow-up.

RESULTS

In 2019, the estimated psoriasis prevalence/incidence was 2,672.9 per 100,000 individuals/508.7 per 100,000 person-years. Of 2,809 patients in the HCRU/costs population, 3.6% (n = 101) received index drug apremilast, 10.2% (n = 287) anti-IL, 6.8% (n = 191) anti-TNF, and 79.4% (n = 2,230) traditional/other systemic therapy. Patients initiating apremilast were older and were more often biologic-naïve than those initiating anti-IL/TNF biologics. Twelve months after treatment initiation, drug adherence (medication possession rate >80%) and persistence (<60 days between prescriptions/no switch) were lower for apremilast vs. anti-IL and anti-TNF groups (24.8% vs. 59.6% and 53.9%; 36.6% vs. 66.9% and 57.6%, respectively). During a 12-month baseline period, psoriasis-related hospitalization was lower for apremilast vs. anti-IL and anti-TNF groups (4.95% vs. 15.68% and 14.14%) and higher during 12 months' follow-up (5.94% vs. 2.44% and 3.14%). Adjusted index drug costs during follow-up were €4,105, €3,498, and €13,777 higher for adalimumab, other anti-TNF and anti-IL biologics vs. apremilast, respectively, and the main driver for lower overall apremilast costs.

CONCLUSION

Given variation in treatment adherence/persistence, HCRU, and costs between apremilast and biologics, these findings could be key considerations during treatment selection.

Unraveling Multimorbidity Patterns of Psoriasis Using Network Analysis

BACKGROUND

Psoriasis is a chronic disease with a prevalence of 3% in the general population. The high prevalence of psoriasis has prompted the study of its comorbidities in recent decades. However, no studies have ever analyzed comorbidity patterns including all chronic diseases in psoriatic patients.

OBJECTIVES

To identify comorbidity patterns in psoriatic patients using network analysis and describe them from a clinical point of view.

METHODS

We conducted an observational and retrospective study with individuals of the EpiChron Cohort (Aragón, Spain) diagnosed with psoriasis from January 1st, 2010 through December 31st, 2019. The population was stratified by sex and age intervals (0-11, 12-17, 18-44, 45-64, ≥65). We built a network for each stratum (i.e., 5 for each sex), calculating the tetrachoric correlations of each pair of diseases. We used a cut-off threshold for statistical significance of p-value <0.01. We applied the Louvain community detection algorithm to identify clusters of diseases.

RESULTS

The prevalence of psoriasis in Aragón was found to be 2.84%. We identified a total of 31,178 psoriatic patients (54% men, 61% from metropolitan areas). The most common comorbidities were respiratory diseases, cardiometabolic conditions (such as hypertension and dyslipidemia), and mental health disorders (including anxiety and mood disorders). A total of 21 comorbidity patterns were identified, varying by sex and age group.

CONCLUSIONS

This is the first study ever conducted with a comprehensive analysis of the disease patterns of psoriatic patients. Our results are a comprehensive map of possible psoriasis-related comorbidities. Further studies should confirm these associations and their pathophysiological relationship with psoriasis, which could help to detect and prevent comorbidities and modifiable risk factors.

Treatment adjustment in biologic therapies for moderate-to-severe plaque psoriasis: a German retrospective chart review (TABU)

BACKGROUND AND OBJECTIVES

Flexible biologic therapy dosing regimens in psoriasis management are common, but data from routine care in Germany are scarce. This study evaluated treatment adjustments for biologic therapies commonly prescribed in Germany.

PATIENTS AND METHODS

Charts for up to 100 consecutive patients treated at 29 centers were reviewed. Data were extracted for adults (aged 18-65 years) with moderate-to-severe plaque psoriasis treated with adalimumab, guselkumab, ixekizumab, secukinumab, or ustekinumab for ≥ 36 weeks. The primary endpoint was time to first treatment adjustment. Secondary endpoints included frequency of and reasons for treatment adjustments. Time to treatment adjustment was analyzed using Kaplan-Meier methods.

RESULTS

Among 982 patients, 297 treatment adjustments in 240 (24.4%) patients were identified. The mean (median; interquartile range) time to first treatment adjustment (n = 223) was 8.4 (4.0; 2.0-12.0) months (secukinumab: 14.1 [10.0; 4.0-21.0], adalimumab: 11.0 [7.0; 3.0-14.5], ustekinumab: 11.0 [6.0; 2.0-16.0], ixekizumab: 5.8 [3.0; 2.0-8.5], guselkumab: 5.1 [3.0; 2.0-7.0]). The most frequent adjustment type was starting concomitant treatment(s) (10.4% of patients); insufficient skin effectiveness was the most frequent reason for adjustment.

CONCLUSIONS

Biological treatment adjustments are frequent in moderate-to-severe psoriasis; flexible dosing regimens would support optimal management.

Epidemiology of alopecia areata and population-wide comorbidities in Germany: analysis of longitudinal claims data

BACKGROUND

Alopecia areata (AA) is a chronic, immune-mediated disease characterized by acute-onset hair loss. The hair loss can range from small, circumscribed hairless areas on the scalp to complete loss of hair on the head and body hair. However, data on the epidemiology of AA are limited. Current evaluations are lacking in Germany. The aim of this study was to evaluate the epidemiology and comorbidity of AA in Germany based on claims data.

METHODS

A representative 40% sample of all adults who were insured with a German statutory health insurance company (DAK-Gesundheit) between 2016 and 2020 was evaluated (n = 2.88 million). Based on at least one relevant outpatient or inpatient diagnosis of International Classification of Diseases (ICD)-10 L63, the annual AA prevalence and incidence (ICD-10 L63) were calculated for 2016 to 2020. Different case definitions were used for diagnosis validation. In addition, the occurrence of comorbidities in patients with AA was investigated.

RESULTS

In 2020, AA prevalence was 210 cases per 100 000 and incidence 72 cases per 100 000. Compared with persons without AA, those with AA significantly more often had atopic dermatitis [rate ratio (RR) 2.9], pruritus (RR 2.7), lupus erythematosus (RR 2.4), urticaria (RR 2.3) and psoriasis (RR 2.2). Women were affected slightly more often than men (0.2% vs. 0.1%). On a regional level, higher prevalence and incidence rates were found in Brandenburg (prevalence 332 cases per 100 000; incidence 116 cases per 100 000), Hesse (prevalence 344 cases per 100 000; incidence 124 cases per 100 000) and Mecklenburg-Western Pomerania (prevalence 303 cases per 100 000; incidence 111 per 100 000).

CONCLUSIONS

AA is a common immune-mediated skin condition with marked regional variations in Germany. For a complete understanding of epidemiology, complementary population-based studies including clinical characteristics of AA are useful.

A Familial Novel Putative-Pathogenic Mutation Identified in Plaque-Psoriasis by a Multigene Panel Analysis

Psoriasis is a chronic multifactorial skin disorder with an immune basis. It is characterized by patches of skin that are usually red, flaky and crusty, and that often release silvery scales. The patches appear predominantly on the elbows, knees, scalp and lower back, although they may also appear on other body areas and severity may be variable. The majority of patients (about 90%) present small patches known as "plaque psoriasis". The roles of environmental triggers such as stress, mechanical trauma and streptococcal infections are well described in psoriasis onset, but much effort is still needed to unravel the genetic component. The principal aim of this study was to use a next-generation sequencing technologies-based approach together with a 96 customized multigene panel in the attempt to determine if there are germline alterations that can explain the onset of the disease, and thus to find associations between genotypes and phenotypes. To this aim, we analyzed a family in which the mother showed mild psoriasis, and her 31-year-old daughter had suffered from psoriasis for several years, whereas an unaffected sister served as a negative control. We found variants already associated directly to psoriasis in the TRAF3IP2 gene, and interestingly we found a missense variant in the NAT9 gene. The use of multigene panels in such a complex pathology such as psoriasis can be of great help in identifying new susceptibility genes, and in being able to make early diagnoses especially in families with affected subjects.

Associations between a Subjective Living Environment and Quality of Life among People with Arterial Hypertension-Results from the Hamburg City Health Study

Hypertension is a global public health concern and an important contributor to cardiovascular disease. It remains disputed how important life circumstances are for the etiology of hypertension. Thus, the aim of this study is to assess the spatial variation of hypertension within an urban population and to investigate the association with the quality of life of city dwellers and their subjective evaluation of their residential district, as well as their home environment, using the example of Hamburg, Germany. In this cross-sectional study, the first 10,000 participants from the Hamburg City Health Study (HCHS) were analysed. Only participants who had resided at the current address for a minimum of five years were considered. In the descriptive analysis, participants with and without arterial hypertension were compared considering various parameters. The subjective quality of the living environment was obtained using an appropriate subjective living environment index. Quality of life was mapped using the EuroQol Group quality of life questionnaire (EQ-5D) score and the two (mental and physical health) scores of the Short Form Health Questionnaire SF-8. The Gini-coefficient was used to quantify the regional economic variation within Hamburg. Linear and logistic regression analyses were performed. Regional levels were 68 city district clusters in Hamburg. The analysis included n = 8192 participants living at least five years in Hamburg at the time of participation in the HCHS. There was a spatial variation in the prevalence of arterial hypertension within Hamburg. Prevalence rates between city district clusters ranged from 50.0% to 88.5%. The results showed that city district clusters with a worse subjective perception of the living environment were partly associated with an increased prevalence of arterial hypertension. Furthermore, a negative association was observed between arterial hypertension prevalence and the sociodemographic status of participants in the city district clusters. Thus, participants with a high level of education suffered less frequently from arterial hypertension than participants with a rather low level of education. The subjective living environment index and quality of life were significantly related to the occurrence of arterial hypertension; however, more extensive and detailed studies are necessary to derive possible clinical implications.