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Psoriasis, Rheumatoid Arthritis, Primary Care……….

Psoriasis, Rheumatoid Arthritis, Primary Care………. What do they have to do with each other?. Psoriasis. Classically described Development of chronic inflammatory plaques of the skin

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Psoriasis, Rheumatoid Arthritis, Primary Care……….

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  1. Psoriasis, Rheumatoid Arthritis, Primary Care………. What do they have to do with each other?

  2. Psoriasis • Classically described • Development of chronic inflammatory plaques of the skin • Prevalence: ~2 % population; 125 million people world-wide, 7.5 million in US; ~ 4 year reduction in average life expectancy • Increasing evidence that psoriasis • Multisystem, chronic inflammatory disorder • Multiple associated comorbidities • European studies (United Kingdom, Scandinavia, Italy) University of New England Physician Assistant Program

  3. Chronic Plaque Psoriasis University of New England Physician Assistant Program

  4. Chronic Plaque Psoriasis University of New England Physician Assistant Program

  5. Chronic Plaque Psoriasis University of New England Physician Assistant Program

  6. Comorbidities • Psoriatic Arthritis • Obesity • Metabolic syndrome • Vascular disease (CVD, CeVD, PVD) • Malignancy • Autoimmune disease • Nonalcoholic Fatty Liver Disease (NAFLD) • COPD • OSA • Parkinsonism • Psychiatric Disorders • Alcohol abuse University of New England Physician Assistant Program

  7. Psoriatic Comorbidities & Primary Care • Psoriatic Arthritis • Obesity • Metabolic syndrome • Vascular disease (CVD, CeVD, PVD) • Malignancy • Autoimmune disease • Nonalcoholic Fatty Liver Disease (NAFLD) • COPD • OSA • Parkinsonism • Psychiatric Disorders • Alcohol abuse University of New England Physician Assistant Program

  8. Comorbidities: Obesity (BMI ≥ 30kg/m2) • Armstrong (2012) • Increased prevalence of obesity in people with psoriasis • OR for obesity 1.66 • Langan(2012) • Risk for obesity increases directly with severity of psoriasis • Mild (≤ 2%BSA)  prevalence 14% • Moderate (3 to 10% BSA)  “ 34% • Severe (>10% BSA)  “ 66% • Impact of weight loss on psoriasis variable • Reduced PASI score reduction, QoL index improvement, improved response to treatment • Psoriasis may also worsen after weight loss University of New England Physician Assistant Program

  9. Comorbidities: Metabolic Syndrome • NCEP ATP III • Presence of three or more of • Elevated waist circumference (F ≥ 88cm, M ≥ 102cm) • Elevated BP (≥ 130mm/Hg systolic or ≥ 85mg/Hg diastolic) or Rx • Elevated FG (≥100mg/dL) or Rx • Elevated Triglycerides (≥ 150mg/dL) or Rx • Reduced HDL (F ≤ 50mg/dL, M ≤ 40mg/dL) or Rx • Armstrong (2013) • OR for metabolic syndrome in psoriasis 2.26 • Severity of psoriasis correlates with prevalence of metab syndrome • Impact of treatment on psoriasis uncertain University of New England Physician Assistant Program

  10. Comorbidities: Hypertension & Diabetes Mellitus • Hypertension • In addition to, and independent of, metabolic syndrome • OR for HTN 1.58, OR 16.5 for needing three drugs to control • Trends with severity of psoriasis • Rationale: ? Angiotensin II production in adipose tissue; increased serum endothilium-1 • Diabetes, Type 2 • In addition to, and independent of, metabolic syndrome • OR for Diabetes 1.59 • Trends with severity of psoriasis University of New England Physician Assistant Program

  11. Comorbidities: Vascular Disease(Cardiovascular, Cerbrovascular, Peripheral vascular disease) • Atherosclerosis • UK Study: psoriasis independent risk factor for MI • Incidence MI: controls 3.58/1000 person-years, 4.04 mild psoriasis, 5.13 severe psoriasis (Gelfand: 130,000 pts with psoriasis & 550,000 controls) • Independent of age, sex, smoking, prior MI, diabetes, HTN, elevated lipids, BMI • US Study: OR ischemic vascular disease 1.78, CeVD 1.70, PVD 1.98, increased mortality risk 1.86 (Prodanovich: 3236 pts with psoriasis, 2500 controls) • Correlation strongest with severe psoriasis • Severe psoriasis 3 to 4 year decrease in average life expectancy; CAD most common cause of mortality • Treatment psoriasis: methotrexate, TNF-α Inhibitors appear to reduce risk for CV events University of New England Physician Assistant Program

  12. Comorbidities: Malignancy • Increased risk for • Lymphoma (IRR 1.81) • Pancreatic cancer (IRR 2.20) • Cutaneous malignancy • Increased risk only following PUVA therapy University of New England Physician Assistant Program

  13. Comorbidities: Other Autoimmune Disease • Crohn’s disease (Cohen, 2008) OR 1.54 to 6.05 • ~10% co-incidence with psoriasis • Ulcerative colitis (Cohen, 2008) OR 1.36 to 5.78 • Rheumatoid arthritis (Cohen, 2008) OR 1.2 w/ psoriasis, 33 w/ psoriatic arthritis • Shared susceptibility loci chromosome ??? University of New England Physician Assistant Program

  14. Comorbidities: Nonalcoholic Fatty Liver Disease (NAFLD) • NAFLD frequently associated with metabolic syndrome • Gisondi(2009) 47% rate NAFLD in patients with psoriasis • Miele(2009) 59% rate NAFLD in patients with psoriasis • Severity NAFLD (fibrosis) correlated with severity of psoriasis University of New England Physician Assistant Program

  15. Comorbidities: Psychiatric Disorders • Depression: Schmitt (2010) OR 1.49 • Esposito (2006):Prevalence of depression 62% • Personality and behavioral disorders: Schmitt (2010) OR 1.58 University of New England Physician Assistant Program

  16. Recommendations • 2008 American Journal of Cardiology Editor’s Consensus on Psoriasis and Coronary Artery Disease: • Inform patients of increased risk CAD • Assess personal and family history of CAD • Monitor BP • Screen lipids and fasting glucose • Treat risk factors for CAD University of New England Physician Assistant Program

  17. Recommendations • 2008 National Psoriasis Foundation • Identify and reduce life style risks for CVD • Recognize and control depression • Moderation of alcohol intake • Vigilance for signs of malignancy • Monitor for onset of psoriatic arthritis • Specialist referral as needed: cardiology, gastroenterology, hepatology, nephrology, psychiatry, pulmonology University of New England Physician Assistant Program

  18. Rheumatoid Arthritis • Prevalence: ~1% in Caucasian population • Reduction in average life expectancy: ~3 to 10 years • Systemic manifestations of RA • Ostopenia(Kanis, 2008):40% increased risk hip fracture • Sarcopenia • CAD, CVD, CeVD, PVD: ~50-60% increased mortality risk from CVD • Heart failure • Atrial fibrillation (IRR 1.41) • PVD risk increases with severity of RA (extra-articular manifestations) University of New England Physician Assistant Program

  19. Psoriasis, Rheumatoid Arthritis & Primary Care Psoriasis Rheumatoid Arthritis • ~1-2 % population • Systemic inflammatory condition • T-cell involvement • Multiple comorbidities • Increased mortality sec to CVD linked to severity of psoriasis • DMARDs and bDMARDs decrease mortality, CVD • ~1% population • Systemic inflammatory condition • T-cell involvement • Multiple systemic manifestations • Increased mortality sec to CVD linked to severity of RA • DMARDs and bDMARDs decrease mortality, CVD University of New England Physician Assistant Program

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