Cardiovascular Risk Factors Associated with Psoriatic Arthritis Complicate Treatment Decisions

In the article “Managing Comorbid Disease in Patients with Psoriatic Arthritis,” published in the August 2010 issue of Current Rheumatology Reports, Cleveland Clinic rheumatologist Elaine Husni, MD, MPH, examined several comorbidities that are frequently present in people with psoriatic arthritis (PsA), including cardiovascular disease, which she says is most concerning.

Why psoriatic arthritis puts people at greater risk of developing premature atherosclerosis or heart disease is still unclear, but researchers have proposed several theories.

In the report, Husni and colleagues proposed that “Systemic inflammation, involving low-grade inflammatory activity in the vascular wall, may be pivotal in the pathogenesis of atherosclerosis. Many of the same inflammatory cells and cytokines, including tumor necrosis factor (TNF)-α, play an active role.”

Researchers say age, gender, smoking, and diabetes are contributing risk factors associated with heart disease. The problem is that some people present few of these risk factors, making it difficult for physicians to assess these patients. Instead, Husni says people may have “novel risk factors like low-grade inflammation.”

In the report by Husni, et al, “Recent studies have found that up to 30% to 50% of PsA patients with atherosclerosis do not have these traditional CV risk factors.”

The study goes on to say that obesity and smoking may be to blame for the higher rates of heart disease among people with psoriasis.

Husni also cited findings from a study of 648 people with PsA, in which researchers reported “an increased standardized prevalence ratio for myocardial infarction and hypertension.” The report noted that as psoriasis worsens, it could be a “predictor” associated with worsening heart disease and premature death.

According to Arthur Kavanaugh, MD, professor of medicine at University California San Diego, while corticosteroids are sometimes prescribed to people with severe cases of PsA, there are some risks physicians might want to keep in mind. “There is a concern using steroids, particularly high doses, with acute withdrawal, which can cause serious flares of skin disease. But as in rheumatoid arthritis, for patients with bad peripheral arthritis (eg, hands) they may be used.”

While one drug therapy alleviates symptoms for one disease, it may potentially raise concerns or risks for patients with other underlying diseases.

According to Husni’s report, 50% of patients in one study were prescribed corticosteroids, which are proatherogenic drugs, known to increase cardiac events in some people.

“Corticosteroids also may be more commonly used in the high disease severity group, making the relationship between prednisone and endothelial dysfunction biased,” said the authors.

Kavanaugh says variables like these make it difficult to sort out the true cause and effect. Physicians accept the idea that it’s difficult to separate the disease path in patients, especially those with multiple diseases.

That’s why treating the patient properly takes careful consideration of many factors says Kavanaugh, especially considering the higher incidence of metabolic syndrome in people with psoriatic arthritis, for example.

“Steroids can be proatherogenic for example, raising lipids and blood pressure. However, they can also decrease inflammation,” he says, also noting that inflammation itself is proatherogenic.

The relationship between heart disease and medications used to treat people with psoriatic arthritis continues to present many questions. Husni says often the scientific literature is “very complex and sometimes contradictory.”

She adds, “For now, there is a trend that methotrexate and anti-TNF medications appear to reduce cardiovascular risks in our patients; however, more studies are needed to confirm these results.”

To read more on this topic, review a recent paper published in the Journal of American Academy of Dermatology.