From the Medical Board of the National Psoriasis Foundation: The risk of cardiovascular disease in individuals with psoriasis and the potential impact of current therapies

Abstract

Background: Many studies have identified cardiovascular risk factors in patients with psoriasis. Some psoriasis therapies may increase cardiovascular disease (CVD) and others may decrease CVD.

Objective: We reviewed the literature to define the impact of common psoriasis therapies on cardiovascular measures and outcomes.

Results: Phototherapy has no major cardiovascular impact and may reduce levels of proinflammatory cytokines. Acitretin increases serum lipids and triglycerides, but has not been shown to increase cardiovascular risk. Cyclosporine A increases blood pressure, serum triglycerides, and total cholesterol. Methotrexate is associated with a decreased risk of CVD morbidity and mortality. Among the biologics, data for tumor necrosis factor inhibitors suggest an overall reduction in cardiovascular events. Most data on short-term ustekinumab use suggest no effect on major adverse cardiovascular events, however some authorities remain concerned. Nevertheless, ustekinumab use over a 4-year period shows a decrease in major adverse cardiovascular events when compared both with the general US population and with psoriatics in Great Britain.

Limitations: Most studies lack the power and randomization of large clinical trials and long-term follow-up periods. In addition, the increased risk of CVD associated with psoriasis itself is a confounding factor.

Conclusion: Some therapies for moderate to severe psoriasis, including methotrexate and tumor necrosis factor inhibitors, may reduce cardiovascular events in psoriatic patients. Ustekinumab appears to be neutral but there may be a long-term benefit. Appropriate patient counseling and selection and clinical follow-up are necessary to maximize safety with these agents. Further long-term study is necessary to quantify the benefits and risks associated with biologic therapies.

Keywords: CHF; CVD; DM; HTN; IL; MACE; MI; MTX; PUVA; PsA; RA; TNF; TNFi; UV; VEGF; adalimumab; biologic therapies; cardiovascular; cardiovascular disease; congestive heart failure; cyclosporine; diabetes mellitus; etanercept; hypertension; infliximab; interleukin; major adverse cardiovascular events; methotrexate; mycophenolate mofetil; myocardial infarction; psoralen plus ultraviolet A; psoriasis; psoriatic arthritis; rheumatoid arthritis; tumor necrosis factor; tumor necrosis factor inhibitor; ultraviolet; ultraviolet therapy; ustekinumab; vascular endothelial growth factor.