Rheumatology News

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Cardiovascular risk factors in psoriatic diseases are
common, often go untreated
BY AMY KARON
Frontline Medical News
At the American College of Rheumatology
annual meeting, San Francisco
Despite their frequent contact
with the health care system,
patients with psoriasis and
psoriatic arthritis often receive no
treatment for major cardiovascular
risk factors, according to two large
multicentre studies.
“We identified a gap in quality of
care in terms of the primary preven-
tion of cardiovascular risk factors in
psoriatic arthritis and psoriasis. The
next step will be to develop strategies
to increase awareness and imple-
ment treatment recommendations
among primary care physicians, der-
matologists, and rheumatologists,”
Dr Lihi Eder of the University of
Toronto said in an interview at the
annual meeting of the American
College of Rheumatology.
Psoriatic and cardiovascular
diseases share an inflammatory ae-
tiology and often co-occur. In past
studies, patients with psoriasis and
psoriatic arthritis were about 50%
more likely than average to have
dyslipidaemia and ischaemic heart
disease, and about 80–90% more
likely than usual to have hyperten-
sion and diabetes, Dr Eder said.
She and her associates studied
dyslipidaemia and hypertension
among 1327 patients with psori-
atic arthritis and 927 patients with
psoriasis at eight sites in Canada,
the US, and Israel as part of the
International Psoriasis & Arthritis
Research Team (IPART). Based on
medical and laboratory reports and
self-reported data, the investiga-
tors assessed these comorbidities
and whether treatment adhered
to cholesterol and hypertension
guidelines from the American Col-
lege of Cardiology and the Ameri-
can Heart Association (Circulation
2014;129:S1–45), and the Eighth
Joint National Committee (JAMA
20145;311:507–20), respectively.
More than 80% of patients in the
cohort had at least one modifiable
cardiovascular risk factor, Dr Eder
said. While 6% had ischaemic heart
disease, 45% had hypertension,
71% had dyslipidaemia, 13% had
diabetes, 54% had central obesity,
and 17% were current smokers. Fur-
thermore, close to half of patients
who had been diagnosed with hy-
pertension had uncontrolled high
blood pressure, and 57% were not
receiving antihypertensive medica-
tions. Likewise, 58% of patients
with dyslipidaemia met criteria for
statins, but only a third of these
patients were receiving them.
Undertreatment was associated
with having psoriatic arthritis or se-
vere psoriasis and with having a high
school or lower level of education,
Dr Eder added. “You have to remem-
ber that this study was conducted
among specialists – these are sup-
posed to be experts in the field,” she
said. “If the treatment adherence is
relatively low in these centres, then
I would expect that for patients who
are being followed in centres that do
not specialise in psoriatic disease,
adherence would be even lower.”
The second study detected signifi-
cantly higher rates of cardiovascular
risk factors among patients with
psoriatic diseases, compared with
controls from the Health Improve-
ment Network, a medical records
database that covers more than 9
million individuals in the United
Kingdom. Patients with psoriatic
arthritis or severe psoriasis were
significantly more likely than were
controls to develop hypertension,
hyperlipidaemia, obesity, or diabe-
tes, with odds ratios ranging from
1.22 to 1.78, reported Dr Kashif A.
Jafri, who led the study while he
was an internal medicine resident
at the University of Pennsylvania in
Philadelphia.
But despite their disproportionate
risk, patients were treated at about
the same rate as controls, Dr Jafri
said. About 15% of individuals with
hypertension received no treatment,
30–40% with hyperlipidaemia went
untreated, and nearly 60% with
diabetes received no documented
therapy. “The absence of a significant
difference in receipt of appropriate
therapy among the groups reflects a
need for more careful attention to
the management of cardiovascular
risk factors in patients with inflam-
matory diseases,” Dr Jafri empha-
sised. Because these risk factors can
be successfully treated, it is “critical”
to educate primary care providers
about the need to do so, he said.
Rheumatologists also should peri-
odically discuss cardiovascular risk
factors with their patients as part
of routine care, Dr Jafri advised.
“Although there are obviously time
constraints during each office visit,
this is a topic that dramatically influ-
ences the morbidity and mortality
of our patient population, and rheu-
matologists have the unique ability
to address this issue in the context
of their long-term relationships with
their patients,” he said.
Dr Jafri is now a fellow in rheumatol-
ogy at the University of California,
San Francisco. His was supported by
an Ephraim P. Engleman Endowed
Resident Research Preceptorship
Award from the Rheumatology Re-
search Foundation. IPART is spon-
sored by the Krembil Foundation and
the Canadian Institutes of Health
Research. Dr Jafri and Dr Eder had
no disclosures.
Cryoglobulinemic vasculitis in Sjögren’s linked to lymphoma, mortality
BY AMY KARON
Frontline Medical News
At the American College of Rheumatology
annual meeting, San Francisco
Patients with primary Sjögren’s
syndrome who met criteria for
cryoglobulinemic vasculitis were
significantly more likely to develop
B-cell lymphoma and to die during
follow-up, compared with patients
who did not have cryoglobulins, in
a large multicentre study.
The study’s findings reveal one
subset of Sjögren’s patients who
need more frequent and intensive
follow-up, said Dr Soledad Reta-
mozo, who led the study while she
was at the rheumatology unit at
Hospital Privado Centro Médico
de Córdoba in Córdoba, Argentina.
She is now with the department of
autoimmune diseases at CELLEX
Biomedical Research Centre, part
of the University of Barcelona’s In-
stitut d’Investigacions Biomèdiques
August Pi i Sunyer.
Patients with primary Sjögren’s
syndrome can have cryoglobulins
and several other kinds of autoan-
tibodies, including anti-SSA/Ro,
anti-SSB/La, rheumatoid factor,
and antinuclear antibodies. That
diversity helps explain why patients
have such varying clinical presen-
tations and long-term outcomes,
as researchers have noted. Cryo-
globulinemic vasculitis is known
to precede lymphoma in primary
Sjögren’s syndrome, but few stud-
ies have examined the association
or effects on mortality.
To explore those questions,
Dr Retamozo and her colleagues
at rheumatology centres in Spain
and Italy performed cryocrit testing
in 515 consecutive patients with
primary Sjögren’s syndrome. A total
of 94% of patients were female,
and they averaged 54 years of age
at diagnosis. In all, 65 (12%) of the
patients tested positive for cryoglo-
bulins, resembling the prevalence in
a prior report.
About one in every three patients
with cryoglobulinemia also fulfilled
the classification criteria for cryo-
globulinemic vasculitis that were
published in 2011 and validated
last year. Patients who met the vas-
culitis criteria were “sicker” than
other cryoglobulinemic patients
by many measures, according to
Dr Retamozo. They had about twice
the rate of type II cryoglobulinemia
(86% vs 43%), a fivefold higher aver-
age cryocrit level (6.6% vs 1.25%), a
more than twofold higher cumula-
tive mean score (35.3 vs 16.2), and
significantly higher rates of hypoc-
omplementemia, monoclonality,
lymphadenopathy, peripheral neu-
ropathy, and renal, skin, and joint
disease.
Over an average follow-up pe-
riod of 9.1 years, 9% of the entire
cohort developed B-cell lymphoma,
and 6% of the cohort died, Dr Re-
tamozo and her associates found.
Cryoglobulinemic patients with pri-
mary Sjögren’s syndrome were more
likely than test-negative patients to
develop B-cell lymphoma (hazard
ratio, 2.56; 95% confidence inter-
val, 1.03–6.35), and the association
was even stronger for patients with
cryoglobulinaemic vasculitis (HR,
7.47; 95% CI, 3.38–16.53). Patients
with vasculitis also were significantly
more likely to die during follow-up
in a Kaplan-Meier survival analysis
(HR, 4.36; 95% CI, 1.32–14.47),
Dr Retamozo reported.
The findings reflect a recent sys-
temic review and meta-analysis by
researchers from the Mayo Clinic
(Rheumatology [Oxford] 2015 Sep
27. doi: 10.1093/rheumatol-
ogy/kev354) that separately linked
vasculitis and cryoglobulinaemia
to mortality in primary Sjögren’s
syndrome. “We measure cryocrit
every 3–6 months in our Sjögren’s
patients, and it helps us catch pa-
tients at greater risk of developing
B-cell lymphoma,” Dr Retamozo
said. “For us it has been very helpful,
in addition to tests for hypocomple-
mentaemia and monoclonality.”
The findings have been accepted
for publication in the journal Rheu-
matology, she added.
Dr Retamozo had no disclosures. One
coauthor reported receiving research
funding from Bristol-Myers Squibb.
The absence of a significant difference in receipt of appropriate
therapy among the groups reflects a need for more careful
attention to the management of cardiovascular risk factors in
patients with inflammatory diseases. Because these risk factors
can be successfully treated, it is “critical” to educate primary
care providers about the need to do so.
Rheumatology News • Vol. 4 • No. 1 • 2016 14
SPONDYLOARTHROPATHIES