psoriasis

TNF inhibitor use in juvenile idiopathic arthritis triples risk for psoriasis

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Exposure to TNF inhibitors nearly triples the risk for psoriasis among children with juvenile idiopathic arthritis, according to data published in the Annals of the Rheumatic Diseases.

“Previous studies have reported the increased risk for new-onset of psoriasis in children with JIA, inflammatory bowel disease and non-bacterial osteomyelitis (CNO) from a single Children’s Hospital, as well as a prevalence of nearly 3% in these children from another tertiary children’s hospital,” Yongdong Zhao, MD, PhD, RhMSUS, of the Seattle Children’s Research Institute, told Healio.

RH0222Zhao_Graphic_01
Exposure to TNF inhibitors nearly triples the risk for psoriasis among children with JIA, according to data derived from Zhao Y, et al. Ann Rheum Dis. 2022;doi:10.1136/annrheumdis-2021-221694.

“However, the association between TNF inhibitors and subsequent psoriasis in JIA has not been systematically assessed using a large prospective clinic-based registry, such as the Childhood Arthritis and Rheumatology Research Alliance (CARRA),” he added. “This large-scale dataset offers the advantage of safety surveillance for pediatric rheumatic medications such as TNF inhibitors.”

To analyze the association between TNF inhibitors and new-onset psoriasis in children with JIA, Zhao and colleagues studied data from the CARRA Registry. According to Zhao, the CARRA Registry features data from more than 10,000 children with rheumatic disease, including more than 9,000 with JIA, across more than 70 sites in North America. The researchers included patients with JIA and follow-up data who were enrolled from June 30, 2015, to Jan. 1, 2020. Those with documented IBD or psoriasis on or before their JIA diagnosis, or with incomplete data, were excluded.

Zhao_Yongdong_2022

Yongdong Zhao

In all, the researchers included 8,225 patients, with a median follow-up of 3.9 years, in their analysis. Among these, 4,437 received TNF inhibitors. Exposure to TNF inhibitors was characterized as either “ever use,” recorded from first use until psoriasis outcome or more recent visit date irrespective of ongoing use or discontinuation; “current use,” recorded from first use and continued for as long as the patient received the drug; or “first use only,” recorded from first use and continues until first use ended.

The researchers determined adjusted HRs between exposed and unexposed groups, adjusting for methotrexate use, sex, race, family history of psoriasis and initial JIA category.

According to the researchers, the adjusted HR for new-onset psoriasis following ever exposure to TNF inhibitors was 2.93 (95% CI, 2.15-3.98). The psoriasis incidence rate was the highest among children who ever received, and were actively receiving, adalimumab (Humira, AbbVie). Meanwhile, ever concurrent MTX use (HR = 0.45; 95% CI, 0.29-0.69) was associated with lower risk for psoriasis.

“We observed a three-fold increased risk for psoriasis in children with JIA after TNF-inhibitor exposure and an adjusted HR of 5.6 in the non-psoriatic arthritis subset,” Zhao said. “There was no association between family history or race/ethnicity and psoriasis development.

“However, concurrent use of methotrexate was significantly associated with a lower risk for psoriasis in those without psoriatic subtype of JIA,” he added. “Clinicians should educate patients and families about potential unwanted side effects while taking medications and inquire about symptoms during regular visits. Concurrent methotrexate use can be considered to lower the risk.”

Psoriasis Response Falls as Comorbidities Rise

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Two-thirds of patients with moderate or severe plaque psoriasis had comorbid conditions at baseline, which appeared to blunt the effect of treatment, according to a study reported here.

Overall, 64% of patients had one or more comorbid conditions at the start of treatment, and some of the patients had new comorbid diagnoses during follow-up. The proportion of patients who achieved disease clearance decreased as the number of comorbidities increased, as reported at the European Academy of Dermatology and Venereology congress.

“Patients with no comorbidities at baseline reported almost double the clearance rate of those patients with three or more comorbidities at baseline,” said Finn Ziegler, of LEO Pharma in Ballerup, Denmark. “More insights are needed on how different treatments can influence skin clearance in patients with comorbidities.”

Numerous studies have documented a high prevalence of comorbid conditions in patients with plaque psoriasis. However, the impact of comorbidities on treatment-induced disease clearance remained unclear, said Ziegler.

In an effort to clarify the relationship between comorbidities and clearance, an international team of investigators performed a 12-month observational study involving 846 patients with newly diagnosed moderate or severe psoriasis in the United States and Europe. All the patients were either initiating treatment with a biologic agent or switching from one biologic to another at the time of enrollment.

Patients self-reported baseline comorbidities by means of a questionnaire. Investigators also reported patients’ comorbidities at baseline and during the follow-up period by means of a separate questionnaire. The physician questionnaire had a checklist of selected conditions identified prior to the start of patient enrollment.

The study population had a mean age of 47.4, and men accounted for about two thirds of the population. The patients had a median psoriasis duration of 18.4 years, mean Psoriasis Area and Severity Index (PASI) score of 14.3, and 40% had prior exposure to a biologic agent. The mean body mass index for the study population was 29.4.

Ziegler said 541 patients had one or more comorbidities prior to starting or switching biologic treatment, including 60% of patients enrolled in Europe and 72.4% of patients from the U.S. The most commonly reported comorbid conditions were hypertension (33.5%), psoriatic arthritis (28.1%), hyperlipidemia (20.9%), diabetes (13.9%), and depression (13.7%). During follow-up, 31 patients developed new comorbid conditions, consisting of anxiety in five patients; hypertension in five; psoriatic arthritis in four; and depression, hyperlipidemia, and other rheumatologic conditions in three patients each.

The subgroup of patients with concomitant psoriatic arthritis consisted of 23.4% of patients with no prior biologic therapy and 35.3% of those previously treated with biologic therapy.

Comparison comorbidity burden and response to treatment, investigators found that 31% of patients with no comorbid conditions at baseline had disease clearance (PASI 100) at 6 months, as compared with 16.5% of patients who had three or more comorbid conditions at enrollment. A similar disparity was observed after 12 months of treatment.

Ziegler acknowledged several limitations of the study. The descriptive design precluded the possibility of assessing causality. Various confounding factors could have affected the results. Rates of psoriatic arthritis differed between the patient and investigator questionnaires, suggesting potential underreporting of that condition and the other comorbidities.

Patient’s psoriasis improves with initiation of hepatitis C therapy

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https://speciality.medicaldialogues.in/patients-psoriasis-improves-with-initiation-of-hepatitis-c-therapy/

Biologics Prove Best for Psoriasis Patients

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Although all major treatment classes reviewed in a Cochrane meta-analysis were more effective than placebo for moderate to severe psoriasis, biologic agents appeared to be the most efficacious.

With data from 109 studies, anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha drugs were superior for achieving PASI 90 status (that is, 90% reduction in Psoriasis Area and Severity Index score), reported Emilie Sbidian, of Hôpital Henri Mondor, Department of Dermatology, Créteil, France, and colleagues.

 “A selection of treatments from the class of biological medicines appear to be the most effective systemic medicines for achieving a chronic plaque psoriasis score of PASI 90,” stated the authors online in Cochrane Library. “We found no significant difference in serious adverse effects when comparing any of the assessed treatments with placebo. However, as the evidence was of very low to moderate quality, we cannot be sure of these results,” they continued.

Two-thirds of the included studies were placebo controlled; 23% were head-to-head studies, and 10% were multi-armed studies with both an active comparator and placebo. All of the trials evaluated outcomes at 12-16 weeks after randomization.

Among the 39,882 total patients, average age was 44 years, mean PASI score at the start of the study was 20 (range 9.5-39), and two-thirds were men.

The researchers found that all of the anti-IL17 drugs and guselkumab (Tremfya) were more effective than the anti-TNF alpha drugs infliximab (Remicade), adalimumab (Humira), and etanercept (Enbrel) for reaching PASI 90 status.

Ustekinumab (Stelara, an IL-12/23 inhibitor) was better than etanercept but there was no clear difference between infliximab, adalimumab, and etanercept. Tofacitinib (Xeljanz, a small molecule) was superior to methotrexate (a conventional systemic agent), but there was no difference between the other small molecules and conventional drugs.

 Sbidian and colleagues also reported that compared with placebo treatment, risk of serious side effects and major adverse cardiac events were similar among all of the systemic medicines. Methotrexate had the best safety profile (based on moderate-certainty evidence), followed by ciclosporin (very low-certainty evidence), certolizumab (Cimzia; moderate-certainty evidence), infliximab (very low-certainty evidence), alefacept (Amevive; low-certainty evidence), and fumaric acid esters (very low-certainty evidence).

Looking at both efficacy and acceptability, the researchers noted that most effective treatments had more serious adverse events compared with the other treatments. Additionally, ustekinumab, infliximab, and certolizumab appeared to have the better trade-off between efficacy and acceptability, they added.

Sbidian and colleagues noted that some of the interventions had low numbers of studies, suggesting that more research needs to be conducted to directly compare the systemic medicines with each other, rather than with placebo. They also called for longer-term studies to provide more evidence about the benefit and safety of systemic medicines and to compare safety profiles.

Links Between Atopic Dermatitis and Psoriasis

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Thinking of psoriasis and atopic dermatitis (AD) as a spectrum, rather than separate diseases, might lead to better understanding and potentially better treatments, two authors have proposed in Current Opinion in Immunology.

“A case can be made that psoriasis and AD exist across a spectrum where polar T-cell axes can be variably present and create some overlapping disease characteristics,” wrote Emma Guttman-Yassky, MD, PhD, of the Icahn School of Medicine at Mount Sinai Medical Center, and James G. Krueger, MD, PhD, of Rockefeller University, both in New York City.

When these T-cell mediated inflammatory skin diseases are studied in European-American populations, the differences between them are clear in both T-cell polarity and cytokine arrays, they noted.

Psoriasis is driven in large part by Th17 T-cells and the associated activation of IL-17, they said. In contrast, a strong driver of AD is Th2, which is associated with overproduction of IL-4 and IL-13.

However, subtypes, including Asian-origin, pediatric, and intrinsic AD have a prominent IL-17 component. That, along with tissue patterning that overlaps with psoriasis histopathology, starts to build the case for a spectrum of immune disease, which is depicted graphically in the article.

“We used to think that atopic dermatitis was a purely Th2 disease,” Guttman-Yassky said in an interview. “We now know that it’s much more complex, and instead of being a homogeneous disease, it actually has different phenotypes. While Th2 activation is common to these phenotypes, they differ in activation of Th17 and Th22 T-cell axes, which show for example significant increases in Asians with AD.”

“So, we need to think about it as a continuum, and for different patient subsets with different phenotypes of atopic dermatitis, we need to think that maybe some treatments from the psoriasis arena may actually qualify,” she added.

Where this mindset may be most useful now is in the development of targeted treatments, particularly for AD, the authors suggested. Targeting Th2 and IL-4/IL-13 with dupilumab (Dupixent) has proven to be a very effective strategy for atopic dermatitis.

However, the presence and influence of the Th17 cytokine axis in certain AD subtypes suggest treatment might be optimized by targeting multiple cytokines; in particular, targeting Th17/IL-23 has proven to be an effective treatment strategy for psoriasis, they noted.

Targeted treatment of AD is generally more complicated than that of psoriasis because multiple immune axes may contribute to AD disease pathogenesis, Guttman-Yassky said.

The approval of dupilumab for moderate-to-severe AD represented a major step forward in the targeted treatment of this disease, according to the authors. In particular, studies showed that approximately 60% of patients attained an EASI75 response on dupilumab, and 35% attain an EASI90 response.

However, studies of agents targeting IL-17, ixekizumab (Taltz) and brodalumab (Siliq), suggested PASI75 and PASI90 responses of 90% and 60%, respectively.

“We do not see these results in atopic dermatitis yet, even with very good drugs like dupilumab,” Guttman-Yassky said in an interview. “So we may need to think that we need to target several axes in atopic dermatitis for complete disease resolution in AD because of differences between different cytokine axes in different AD phenotypes.”

While the outcome of dupilumab treatment argues for a primary Th2-centered pathogenesis of AD, some investigations have shown that the drug also modulates the IL-23/Th17/Th22 axes, the authors wrote.

As a result, it might be best to think about AD not only as a Th2-predominant disease, but as a “multi-axis” immune disease to which Th22 and potentially Th17 are contributors; that would mean that combinations of targeted therapy could be required to achieve maximum therapeutic success, Guttman-Yassky and Krueger wrote.

In particular, Th22 is also commonly present and activated across major AD subtypes, and clinical efficacy has been recently reported for the experimental anti-IL-22 antibody, fezakinumab, according to results of a 60-patient placebo controlled trial in the Journal of Investigative Dermatology.

Future studies need to determine whether subsets of patients, such as Asian AD patients, can benefit from targeted treatments that are effective in psoriasis, according to the authors. Also, the emergence of bi-specific and tri-specific antibodies could represent an opportunity to improve on single-cytokine targeting approaches in this disease.

“Psoriasis is about 10 years, if not 12 years, ahead of atopic dermatitis” in development of targeted therapeutics, Guttman-Yassky said in the interview. “I think we’ll need to still have single targeting in atopic dermatitis with all these agents to really understand their contribution for the disease. And then we may need to also think about dual targeting to really achieve maximum disease control.”

RNA therapy has shown real promise against psoriasis in its first human trial

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A phase 1 trial involving a new type of RNA therapy has shown that the treatment could be used to fight psoriasis, a debilitating skin condition that affects nearly 3 percent of the world’s population.

At the American Chemical Society (ACS) meeting in Philadelphia last week, researchers announced that AST-005, a type of RNA therapy, is safe to use in humans, and were optimistic about the drug’s dose-dependent response in psoriasis patients.

Psoriasis is an auto-immune disease, triggered when the body creates too much of a normally healthy protein, tumour necrosis factor-α (TNF-α). The immune system attacks this protein, causing red, itchy, and scaly skin patches.

Right now, there is no cure, and very limited treatments, but RNA could be the key to controlling it.

In every one of your cells, RNA acts as a messenger between your DNA and protein. Although DNA stays in the nucleus at all times, RNA moves around the cell, directing the creation of various proteins.

One of the ways scientists have been able to limit protein creation – such as the overproduction of TNF- α – is by destroying RNA genes using a relatively new technique called RNA interference, or RNAi. RNAi enters the cell, destroys the regular RNA, and less protein is created.

While we’ve been able to use RNAi in animal models pretty effectively, as Robert Service explains at Science Magazine, this has been difficult to get right in humans:

“The trouble is that traditional antisense RNA drugs [synthetic RNAi] usually don’t work. To date, only two antisense RNA therapies have been approved in the United States, despite decades of effort and dozens of clinical trials.

Among other problems, most introduced RNA snippets get chopped up before they reach their target by enzymes that patrol the cell for foreign material.”

But there’s renewed hope that this technique could work in humans, with the development of a new type of RNAi, called spherical nucleic acid (SNA).

Developed by researchers at US-based company, Exicure, AST-005 is a gel made up of SNAs, which has been shown in the past to lower the amount of TNF-α in animal trials. And unlike previous synthetic RNAis, the SNA’s structure is not chopped up by enzymes in the cell.

Back in April, researchers from Exicure announced treatment of its first patients for a phase 1 clinical trial for the AST-005 gel, which they hoped would lower the amount of TNF-α protein produced by the corresponding gene, and therefore limit patients’ symptoms.

“This clinical trial will enable our team to study safety and tolerability of AST-005 while demonstrating that the SNA technology can be used to treat diseases locally using a nucleic acid therapy. We are excited to bring this approach to patients in need,” said David Giljohann, CEO at Exicure, when the trial was first announced.

The results are looking promising. At the ASC meeting, one of the team, Chad Mirkin, explained that AST-005 has been found to be safe in humans, and shows a dose-dependent response to TNF-α.

This means that although there is more work to do in finding the correct dose, the researchers are hoping that a treatment could be on the way for those suffering psoriasis.

The researchers didn’t go into much detail, as it is still very early days yet. The initial observations have only been discussed at the ASC meeting, there has been no paper published in a peer reviewed journal, so unfortunately we can’t explain much more about the trial, or get too excited just yet.

But if the treatment continues to show promise in this and other follow-up trials, it’s just the beginning for similar SNA therapies, with the potential for more new drugs based on this technique to target cancer-causing genes, and a number of auto-immune diseases.

Although this is just an initial observation, we’re looking forward to seeing the final results.

This MAN Healed 5000 People from Cancer: This Is a Recipe That Kills Tumors in 90 Days – See more at: http://www.choiceandtruth.com/2016/08/this-man-healed-5000-people-from-cancer.html#sthash.6q55okXx.dpuf

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Hemp or cannabis oil was used by numerous people for centuries, but it was banned in the second half of the 20th century, as a result of the rise of the billion-dollar pharmaceutical industry.

Rick Simpson is a mechanical engineer and a self-taught doctor, who was diagnosed with skin cancer in 2002 and fought this disease using this miraculous oil. Nowadays, he is one of the greatest world activists for legalization of hemp oil. Using this treatment, he has cured over 5,000 people.

He attended a debate organized in Belgrade, the capital of Serbia, on this topic. He states that hemp or cannabis oil can cure a vast variety of serious health issues, like diabetes, arteriosclerosis, multiple sclerosis, epilepsy, asthma, psoriasis, as well as some of the deadliest forms of cancer.

Rick recounted his story to the Serbian magazine Telegraph “I always tell people – Cannabis will cure you, and you will see that at present, it is the best cure there is in the world!”

He began his story: “It was 2002. The doctors had given up on me because I’d had more than one unsuccessful operation on three pigmented lesions on my face’s skin. As soon as these were removed, they would reappear even more infected! Since I had been studying plants as a hobby for years, one day as I was looking at my wounds in the mirror, I remembered a study from the University of Virginia that said that THC, an active component of cannabis could cure cancer. I took some cannabis oil I had prepared beforehand from the cabinet and dripped a few drops directly on the wound.”
No significant results could be noticed at first. He bandaged his wounds again after applying the oil and waited for few days.

Then, he went on: “After four days I removed the bandages and I couldn’t believe my eyes! The wound was no longer there, and my skin was regenerated! I immediately started talking to people about how I had cured skin cancer with cannabis oil… Everyone laughed at me, but then eleven and a half years have passed, and the cancer still hasn’t returned.”

From then on, Simpson decided to help people in need for this cure, and his work resulted in thousands of cases effectively solved. His last case was an 80-year-old man who was dying from lung cancer.

“The man was all swollen from chemotherapy, open wounds on his legs and was barely breathing! After the doctors had given him no more than 48 hours, his son brought him to me. As I had recommended cannabis oil therapy, the young man had also consulted his father’s doctor. The doctor, of course, rejected such treatment, so in the end the young man took the oil from me, soaked a small cracker in it and gave it to his father.”

In less than thirty minutes, the old man finally started breathing normally again and his breathing completely stabilized during the night.

“Although the doctors “explained” that before death, his vital functions would return briefly, his son didn’t want to wait any longer so he checked his father out of the hospital the next morning. He also stopped all of his father’s prescribed therapy. After six weeks of cannabis oil treatment, the old man no longer needed insulin, and after three months he was completely cured from cancer,”says Rick/
Moreover, he stated that cannabis oil therapy is equally effective in all cases, for it knows no age limit. It can even be given to babies.

In order to supply fresh raw ingredients for his hemp oil, Rick soon started growing marijuana, but his field was raided four times in three years by the police. People who publicly claim to cure cancer are threatened 5-40-year imprisonment, according to laws in North America.

So, Jack was imprisoned for four days in Canada in 2005, for cultivating, owning and selling marijuana. However, at one point he was liable for 12 year imprisonment. He was fined 2,000 dollars.
“The worst of all was that the jurors were people whose dearest I had cured with cannabis oil. Even the judge knew it was all a farce! At one point he even told me that I should be rewarded, instead of tried! All knew, and no one could do anything! They didn’t even allow ten patients I have cured to testify! They also didn’t allow the doctors to come out on the bench, nor me to show a pile of medical documents about the effects of my oil. If you don’t know the meaning of a “coward court,” go to Canada and you will see what I mean,” claims Jack.

Rick claims that he has never sold weed, but only hemp oil, and as he was deeply disappointed by the Canadian government and corrupted doctors, he even put the recipe for hemp oil on the web page phoenixtears.ca.

According to him, the preparation of this miraculous oil is extremely easy. Simpson’s treatment starts with several drops of hemp oil three times a day.

“The usual dose I give to cancer patients is 60 grams within 90 days. And, it is never too late for the patient to start cannabis oil therapy. There isn’t such an excuse as, “It is late”… If you ask me, if I approve of smoking marijuana, I will tell you it isn’t as effective as cannabis oil, but it is scientifically proven that people who smoke marijuana live six years longer than those who don’t.”
Moreover, he adds that as opposed to Europe, North America still puts a blind eye when it comes to legalization of cannabis. He believes that every country in the world should allow their citizens to cultivate and use cannabis for medical purposes. He also points out that pharmacies should be opened for those who can’t cultivate it.

“Little is known that cannabis has been used as one of the most healing remedies hundreds of years before Christ. In the ancient Persian religious scripts, which among other things describe the most healing herbs, cannabis takes the first place,” concludes Rick.
His biggest wish and goal is to live in a world without cancer. – See more at: http://www.choiceandtruth.com/2016/08/this-man-healed-5000-people-from-cancer.html#sthash.6q55okXx.dpuf

Combination methotrexate, pioglitazone therapy offers no added quality-of-life benefits

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In patients with chronic plaque-type psoriasis, pioglitazone therapy taken with methotrexate caused greater reductions in psoriasis area and severity index scores than methotrexate alone but did not significantly improve quality of life, according to study findings.

For the controlled, assessor-blinded, parallel-group study, patients with plaque-type psoriasis were randomly assigned to treatment with methotrexate only (group A) or methotrexate plus 30 mg/daily of oral pioglitazone (group B).Methotrexate (MTX) dosage commenced at 7.5 mg weekly and was adjusted, if necessary, for body mass index.

At week 16, the difference in reduction of mean psoriasis area and severity index (PASI) scores between the groups was statistically significant, according to the researchers, with group B at a 70.3% reduction and group A at a 60.2% reduction.

Fourteen patients in group B achieved PASI 75 by week 16 compared with only two in group A, which was also considered statistically significant.

At week 16, complete clearance of the disease (PASI 100) was achieved by four patients in group B compared with one patient from group A.

Differences between the groups in terms of dermatology life quality index were not significant, however, according to the researchers. In group B, a 63.6% decrease was seen at week 16, and a 56.9% decrease was seen for group A.

Study finds overlap between psoriasis, diabetes, and obesity

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Psoriasis is significantly associated with type 2 diabetes mellitus (T2D) and obesity, based on a population-based study involving Danish twins.

After adjusting for age, sex, smoking, and body mass index (BMI), there was a higher incidence of psoriasis in individuals with T2D compared to those without (7.6 vs 4.1 percent; odds ratio [OR], 1.53, 95 percent confidence interval [CI], 1.03-2.27; p=0.04). Individuals with a BMI≥35.0 had almost twice the risk of psoriasis (OR, 1.81, 95 percent CI, 1.28-2.55; p=0.001). [JAMA Dermatol2016;doi:10.1001/jamadermatol.2015.6262]

Mean BMI was higher among those with psoriasis compared to those without (25 vs 24.4 percent; p<0.001), as was the risk for obesity (BMI>30; 10.8 vs 7.9 percent; p<0.001).

Twins with psoriasis had a higher mean BMI than co-twins without psoriasis (25.1 vs 24.7 percent). Twins with psoriasis also had a higher likelihood for obesity (11.6 vs 8.1 percent; OR, 1.92, 95 percent CI, 1.06-3.46; p=0.03) with a higher risk observed in dizygotic twin pairs (OR, 2.13, 95 percent CI, 1.03-4.39; p=0.04) compared to monozygotic twin pairs (OR, 1.43, 95 percent CI, 0.50-4.07; p=0.50). The prevalence of T2D was similar in twins regardless of psoriasis status.

The study authors believe that the “dilution of the risk estimate” in monozygotic versus dizygotic twins suggests genetic confounding between psoriasis and obesity.

In this same-sex twin study examining the association between psoriasis, T2D, and obesity (based on BMI), researchers looked at 34,781 twins aged 20-71 years born between 1931 and 1982. Also investigated was the role played by genetic and environmental factors in this association. The prevalence of psoriasis and T2D was 4.2 (n=1,401) and 1.4 percent (n=459), respectively, while the prevalence of BMI≥30 was 8 percent.

Due to the cross-sectional nature of the study, directionality of the association could not be established. “Psoriasis may predispose to a more sedentary lifestyle, leading to behaviours that predispose to obesity and T2D, or these conditions could be causative of psoriasis,” said the authors, who recommended that further studies focus on identifying the genes and epigenetic factors that may be responsible for the link between psoriasis, obesity, and T2D.

“[The study’s] careful control for BMI, which most large population-based studies are unable to capture, adds to the weight of evidence suggesting psoriasis as a risk factor for diabetes,” said Dr. Joel Gelfand of the Department of Dermatology and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, US, who wrote the accompanying editorial to the study.

Psoriasis affects an estimated 0.5 to 1 percent of the Singapore population, and the close link between psoriasis, T2D, and obesity is commonly observed, said Adjunct Associate Professor Chong Wei Sheng, senior consultant dermatologist and head of the psoriasis unit at the National Skin Centre, Singapore.

“Treatment strategies of psoriasis often depend largely on whether patients have obesity and/or diabetes as the strategies used are aimed at reducing the overall cardiovascular risks of psoriasis especially when there is concomitant obesity and diabetes. On the other hand, such strategies are also employed not to worsen obesity and diabetes and also not to interact with medications used to treat [these two conditions],” said Chong.

“It is now well known that psoriasis is strongly associated with metabolic syndrome [ie, obesity, T2D, hyperlipidaemia and hypertension] and thus, our approach to psoriasis treatment is now holistic rather than just purely dermatological. In our practice, it is routine to offer screening for metabolic syndrome in patients with psoriasis for early detection of such associated diseases and to treat them early if found. We always encourage weight loss, a healthy lifestyle, and healthy eating as losing weight has been associated with an improvement of psoriasis and glycaemic control,” he said.

Previous studies have highlighted a possible association between psoriasis and metabolic syndrome, leading to the suggestion that appropriate management of metabolic syndrome may be integral to psoriasis management.

Study finds overlap between psoriasis, diabetes, and obesity

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Psoriasis is significantly associated with type 2 diabetes mellitus (T2D) and obesity, based on a population-based study involving Danish twins.

After adjusting for age, sex, smoking, and body mass index (BMI), there was a higher incidence of psoriasis in individuals with T2D compared to those without (7.6 vs 4.1 percent; odds ratio [OR], 1.53, 95 percent confidence interval [CI], 1.03-2.27; p=0.04). Individuals with a BMI≥35.0 had almost twice the risk of psoriasis (OR, 1.81, 95 percent CI, 1.28-2.55; p=0.001). [JAMA Dermatol2016;doi:10.1001/jamadermatol.2015.6262]

Mean BMI was higher among those with psoriasis compared to those without (25 vs 24.4 percent; p<0.001), as was the risk for obesity (BMI>30; 10.8 vs 7.9 percent; p<0.001).

Twins with psoriasis had a higher mean BMI than co-twins without psoriasis (25.1 vs 24.7 percent). Twins with psoriasis also had a higher likelihood for obesity (11.6 vs 8.1 percent; OR, 1.92, 95 percent CI, 1.06-3.46; p=0.03) with a higher risk observed in dizygotic twin pairs (OR, 2.13, 95 percent CI, 1.03-4.39; p=0.04) compared to monozygotic twin pairs (OR, 1.43, 95 percent CI, 0.50-4.07; p=0.50). The prevalence of T2D was similar in twins regardless of psoriasis status.

The study authors believe that the “dilution of the risk estimate” in monozygotic versus dizygotic twins suggests genetic confounding between psoriasis and obesity.

In this same-sex twin study examining the association between psoriasis, T2D, and obesity (based on BMI), researchers looked at 34,781 twins aged 20-71 years born between 1931 and 1982. Also investigated was the role played by genetic and environmental factors in this association. The prevalence of psoriasis and T2D was 4.2 (n=1,401) and 1.4 percent (n=459), respectively, while the prevalence of BMI≥30 was 8 percent.

Due to the cross-sectional nature of the study, directionality of the association could not be established. “Psoriasis may predispose to a more sedentary lifestyle, leading to behaviours that predispose to obesity and T2D, or these conditions could be causative of psoriasis,” said the authors, who recommended that further studies focus on identifying the genes and epigenetic factors that may be responsible for the link between psoriasis, obesity, and T2D.

“[The study’s] careful control for BMI, which most large population-based studies are unable to capture, adds to the weight of evidence suggesting psoriasis as a risk factor for diabetes,” said Dr. Joel Gelfand of the Department of Dermatology and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, US, who wrote the accompanying editorial to the study.

Psoriasis affects an estimated 0.5 to 1 percent of the Singapore population, and the close link between psoriasis, T2D, and obesity is commonly observed, said Adjunct Associate Professor Chong Wei Sheng, senior consultant dermatologist and head of the psoriasis unit at the National Skin Centre, Singapore.

“Treatment strategies of psoriasis often depend largely on whether patients have obesity and/or diabetes as the strategies used are aimed at reducing the overall cardiovascular risks of psoriasis especially when there is concomitant obesity and diabetes. On the other hand, such strategies are also employed not to worsen obesity and diabetes and also not to interact with medications used to treat [these two conditions],” said Chong.

“It is now well known that psoriasis is strongly associated with metabolic syndrome [ie, obesity, T2D, hyperlipidaemia and hypertension] and thus, our approach to psoriasis treatment is now holistic rather than just purely dermatological. In our practice, it is routine to offer screening for metabolic syndrome in patients with psoriasis for early detection of such associated diseases and to treat them early if found. We always encourage weight loss, a healthy lifestyle, and healthy eating as losing weight has been associated with an improvement of psoriasis and glycaemic control,” he said.

Previous studies have highlighted a possible association between psoriasis and metabolic syndrome, leading to the suggestion that appropriate management of metabolic syndrome may be integral to psoriasis management.