PracticeUpdate Dermatology May 2019

EXPERT OPINION 16

Biologics and Psoriatic Disease: Have We Finally Detected a Mechanism Linking Treatment to Cardiovascular Risk Improvement? By Anthony Fernandez MD, PhD

F ollowing a hallmark study revealing that psoriasis is an individual risk fac- tor for future myocardial infarction (MI), an explosion of research has solidified an association between moderate to severe psoriasis and increased risk of cardiovas- cular disease. 1,2 More recently, imaging studies using FDG-PET/CT have shown that patients with psoriasis have inflammation in numerous organs, including the aorta and other vascular beds, compared with healthy individuals without psoriasis. 3 Thus, a funda- mental hypothesis has been that adequately treatingmoderate to severe psoriasis should decrease vascular inflammation, and thus, future risk of cardiovascular events. Unfortunately, results of studies explor- ing the relationship between adequately treating psoriasis and decreasing future cardiovascular events have been conflict- ing. Epidemiologic studies using claims databases suggest that treating psoriasis with biologics decreases cardiovascular events compared with treating psoriasis with phototherapy and methotrexate. 4,5 However, several relatively well-designed, prospective studies have recently failed to show that biologic therapy decreases aor- tic vascular inflammation in moderate to severe psoriasis patients. 6–8 These studies do, however, show a trend in decreased

biomarkers of vascular inflammation, such as hsCRP, with biologic treatment. Although lack of positive impact on vas- cular inflammation may be surprising, trends in decreased biomarkers suggest that study designs with more patients fol- lowed for longer time periods may allow detection of positive results. Nevertheless, this remains to be seen. Results of this study by Elnabawi et al suggest that researchers may have found a mechanism alternative to direct effect on vascular inflammation that links biologic therapy to decreased risk of cardiovascular events. 9 In a prospective, observational study, 215 patients were followed for 1 year, with 121 biologic- and systemic therapy-naive patients initiated on biologic therapy. The other patients were treated with topical medications and phototherapy. After following patients with serial coronary computed tomography angiography (CCTA) over 1 year, the patients treated with biologics (anti-TNF, anti-IL12/23, or anti-23 therapies) demonstrated significant decreases in noncalcified coronary plaque burden and reduction in necrotic core, with no effect on fibrous burden, compared with the nonbiologic-treated cohort. The decrease in noncalcified plaque burden was significant even after adjustment

Dr. Fernandez is Director of Medical and Inpatient Dermatology, Assistant Professor in Dermatopathology and Staff Physician at Cleveland Clinic in Cleveland, Ohio.

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