Advertisement

Underdiagnosis and undertreatment of cardiovascular risk factors in patients with moderate to severe psoriasis

Published:October 24, 2011DOI:https://doi.org/10.1016/j.jaad.2011.06.035

      Background

      Patients with psoriasis are known to have an increased number of cardiovascular (CV) risk factors and be at increased risk for CV events.

      Objectives

      We sought to describe and characterize the underdiagnosis and undertreatment of CV risk factors in patients with moderate to severe psoriasis.

      Methods

      Medical histories including diabetes, hypertension, and hyperlipidemia were obtained from 2899 patients in 3 phase III ustekinumab trials, a therapeutic anti-interleukin (IL)-12/IL-23p40 monoclonal antibody. Reported history was compared with measured fasting glucose, fasting lipids, and blood pressure. Ten-year Framingham risk scores and the proportion of patients achieving glycemic, lipid, and blood pressure targets were evaluated.

      Results

      Significant risk factors existed in patients with moderate to severe psoriasis (58.6% and 28.8% of patients had ≥2 and ≥3 established CV risk factors, respectively). Based on Framingham risk score, 18.6% of patients were at high risk and 12.3% were at intermediate risk for CV events. At baseline, a small proportion of patients with diabetes (2.3%), hypertension (9.1%), or hyperlipidemia (4.9%) were previously without a diagnosis. However, 19.1%, 21.8%, and 38.6% of patients with diabetes, hypertension, or hyperlipidemia, respectively, were untreated at baseline, and the proportion at treatment goal was not ideal (hypertension 59.6% and hyperlipidemia 69.7%), especially for diabetes (36.7%).

      Limitations

      Results are based on a clinical trial population and findings may not be generalizable to the general psoriasis population.

      Conclusions

      In this moderate to severe psoriasis population, a high prevalence of undiagnosed and undertreated CV risk factors existed, emphasizing the importance of screening patients with psoriasis for CV risk factors.

      Key words

      Abbreviations used:

      ADA (American Diabetes Association), ASCVD (atherosclerotic cardiovascular disease), BMI (body mass index), CHD (coronary heart disease), CI (confidence interval), CRP (C-reactive protein), CV (cardiovascular), DBP (diastolic blood pressure), FRS (Framingham risk score), HbA1c (hemoglobin A1c), HDL-C (high-density lipoprotein cholesterol), IL (interleukin), NCEP (National Cholesterol Education Program), RA (rheumatoid arthritis), SBP (systolic blood pressure)
      To read this article in full you will need to make a payment
      AAD Member Login
      AAD Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Koo J.
        Population-based epidemiologic study of psoriasis with emphasis on quality of life assessment.
        Dermatol Clin. 1996; 14: 485-496
        • Schon M.P.
        • Boehncke W.H.
        Psoriasis.
        N Engl J Med. 2005; 352: 1899-1912
        • Nestle F.O.
        • Kaplan D.H.
        • Barker J.
        Psoriasis.
        N Engl J Med. 2009; 361: 496-509
        • Langley R.G.
        • Feldman S.R.
        • Han C.
        • Schenkel B.
        • Szapary P.
        • Hsu M.C.
        • et al.
        Ustekinumab significantly improves symptoms of anxiety, depression, and skin-related quality of life in patients with moderate-to-severe psoriasis: results from a randomized, double-blind, placebo-controlled phase III trial.
        J Am Acad Dermatol. 2009; 63: 457-465
        • Hong J.
        • Koo B.
        • Koo J.
        The psychosocial and occupational impact of chronic skin disease.
        Dermatol Ther. 2008; 21: 54-59
      1. National Psoriasis Foundation. Home page. Available from: URL:http://www.psoriasis.org. Accessed October 20, 2010.

        • Henseler T.
        • Christophers E.
        Disease concomitance in psoriasis.
        J Am Acad Dermatol. 1995; 32: 982-986
        • Mrowietz U.
        • Elder J.T.
        • Barker J.
        The importance of disease associations and concomitant therapy for the long-term management of psoriasis patients.
        Arch Dermatol Res. 2006; 298: 309-319
        • Neimann A.L.
        • Shin D.B.
        • Wang X.
        • Margolis D.J.
        • Troxel A.B.
        • Gelfand J.M.
        Prevalence of cardiovascular risk factors in patients with psoriasis.
        J Am Acad Dermatol. 2006; 55: 829-835
        • Gelfand J.M.
        • Neimann A.L.
        • Shin D.B.
        • Wang X.
        • Margolis D.J.
        • Troxel A.B.
        Risk of myocardial infarction in patients with psoriasis.
        JAMA. 2006; 296: 1735-1741
        • Gelfand J.M.
        • Dommasch E.D.
        • Shin D.B.
        • Azfar R.S.
        • Kurd S.K.
        • Wang X.
        • et al.
        The risk of stroke in patients with psoriasis.
        J Invest Dermatol. 2009; 129: 2411-2418
        • Mehta N.N.
        • Azfar R.S.
        • Shin D.B.
        • Neimann A.L.
        • Troxel A.B.
        • Gelfand J.M.
        Patients with severe psoriasis are at increased risk of cardiovascular mortality: cohort study using the General Practice Research Database.
        Eur Heart J. 2010; 31: 1000-1006
        • Gelfand J.M.
        • Troxel A.B.
        • Lewis J.D.
        • Kurd S.K.
        • Shin D.B.
        • Wang X.
        • et al.
        The risk of mortality in patients with psoriasis: results from a population-based study.
        Arch Dermatol. 2007; 143: 1493-1499
        • Abuabara K.
        • Azfar R.S.
        • Shin D.B.
        • Neimann A.L.
        • Troxel A.B.
        • Gelfand J.M.
        Cause-specific mortality in patients with severe psoriasis: a population-based cohort study in the United Kingdom.
        Br J Dermatol. 2010; 163: 586-592
        • Gerdes S.
        • Zahl V.A.
        • Knopf H.
        • Weichenthal M.
        • Mrowietz U.
        Comedication related to comorbidities: a study in 1203 hospitalized patients with severe psoriasis.
        Br J Dermatol. 2008; 159: 1116-1123
        • Grundy S.M.
        • Cleeman J.I.
        • Merz C.N.
        • Brewer Jr., H.B.
        • Clark L.T.
        • Hunninglake D.B.
        • et al.
        Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines.
        Circulation. 2004; 110: 227-239
        • Bairey Merz C.N.
        • Alberts M.J.
        • Balady G.J.
        • Ballantyne C.M.
        • Berra K.
        • Black H.R.
        • et al.
        ACCF/AHA/ACP 2009 competence and training statement: a curriculum on prevention of cardiovascular disease.
        J Am Coll Cardiol. 2009; 54: 1336-1363
        • Leonardi C.L.
        • Kimball A.B.
        • Papp K.A.
        • Yeilding N.
        • Guzzo C.
        • Wang Y.
        • et al.
        PHOENIX 1 Study Investigators. Efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 76-week results from a randomised, double-blind, placebo-controlled trial (PHOENIX 1).
        Lancet. 2008; 371: 1665-1674
        • Papp K.A.
        • Langley R.G.
        • Lebwohl M.
        • Krueger G.G.
        • Szapary P.
        • Yeilding N.
        • et al.
        PHOENIX 2 Study Investigators. Efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 52-week results from a randomised, double-blind, placebo-controlled trial (PHOENIX 2).
        Lancet. 2008; 371: 1675-1684
        • Griffiths C.E.M.
        • Strober B.E.
        • van de Kerkhof P.
        • Ho V.
        • Fidelus-Gort R.
        • Yeilding N.
        • et al.
        Comparison of ustekinumab and etanercept for moderate-to-severe psoriasis.
        N Engl J Med. 2010; 362: 118-128
        • Cleeman J.I.
        Executive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III).
        JAMA. 2001; 285: 2486-2497
      2. World Health Organization, Department of Noncommunicable Disease Surveillance, Geneva. Report of a WHO Consultation. Definition, diagnosis and classification of diabetes mellitus and its complications, part 1: diagnosis and classification of diabetes mellitus. 1999;1-59.

        • Chobanian A.V.
        • Bakris G.L.
        • Black H.R.
        • Cushman W.C.
        • Green L.A.
        • Izzo J.L.
        • et al.
        Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
        Hypertension. 2003; 42: 1206-1252
        • American Diabetes Association
        Standards of medical care in diabetes-2009.
        Diabetes Care. 2009; 32: S13-S61
        • Rosendorff C.
        • Black H.R.
        • Cannon C.P.
        • Gersh B.J.
        • Gore J.
        • Izzo J.L.
        • et al.
        American Heart Association Council for High Blood Pressure Research; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Epidemiology and Prevention. Treatment of hypertension in the prevention and management of ischemic heart disease: a scientific statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention.
        Circulation. 2007; 115: 2761-2788
        • Wilson P.W.
        • D’Agostino R.B.
        • Levy D.
        • Belanger A.M.
        • Silbershatz H.
        • Kannel W.B.
        Prediction of coronary heart disease using risk factor categories.
        Circulation. 1998; 97: 1837-1847
        • Gelfand J.M.
        • Stern R.S.
        • Nijsten T.
        • Feldman S.R.
        • Thomas J.
        • Kist J.
        • et al.
        The prevalence of psoriasis in African Americans: results from a population-based study.
        J Am Acad Dermatol. 2005; 52: 23-26
        • Chang Y.T.
        • Chen T.J.
        • Liu P.C.
        • Chen Y.C.
        • Chen Y.J.
        • Huang Y.L.
        • et al.
        Epidemiological study of psoriasis in the national health insurance database in Taiwan.
        Acta Derm Venereol. 2009; 89: 262-266
        • American Heart Association
        Heart disease and stroke statistics–2010 update.
        American Heart Association, Dallas (TX)2010 (p. 1-36)
        • Brown J.R.
        • O’Connor G.T.
        Coronary heart disease and prevention in the United States.
        N Engl J Med. 2010; 362: 2150-2153
        • Mottillo S.
        • Filion K.B.
        • Genest J.
        • Joseph L.
        • Pilote L.
        • Poirier P.
        • et al.
        The metabolic syndrome and cardiovascular risk a systematic review and meta-analysis.
        J Am Coll Cardiol. 2010; 56: 1113-1132
        • Centers for Disease Control and Prevention
        Cigarette smoking among adults and trends in smoking cessation–United States, 2008.
        Morb Mortal Wkly Rep. 2009; 58: 1227-1232
        • Kimball A.B.
        • Guerin A.
        • Latremouille-Viau D.
        • Yu A.P.
        • Gupta S.
        • Bao Y.
        • et al.
        Coronary heart disease and stroke risk in patients with psoriasis: retrospective analysis.
        Am J Med. 2010; 123: 350-357
        • Peters M.J.
        • Symmons D.P.
        • McCarey D.
        • Dijkmans B.A.C.
        • Nicola P.
        • Kvien T.K.
        • et al.
        EULAR evidence-based recommendations for cardiovascular risk management in patients with rheumatoid arthritis and other forms of inflammatory arthritis.
        Ann Rheum Dis. 2010; 69: 325-331
        • Kaye J.A.
        • Li L.
        • Jick S.S.
        Incidence of risk factors for myocardial infarction and other vascular diseases in patients with psoriasis.
        Br J Dermatol. 2008; 159: 895-902
        • Elliott J.R.
        • Manzi S.
        Cardiovascular risk assessment and treatment in systemic lupus erythematosus.
        Best Pract Res Clin Rheumatol. 2009; 23: 481-494
        • Agarwal S.
        • Elliott J.R.
        • Manzi S.
        Atherosclerosis risk factors in systemic lupus erythematosus.
        Curr Rheumatol Rep. 2009; 11: 241-247
        • Han C.
        • Robinson Jr., D.W.
        • Hackett M.V.
        • Paramore L.C.
        • Fraeman K.H.
        • Bala M.V.
        Cardiovascular disease and risk factors in patients with rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis.
        J Rheumatol. 2006; 33: 2167-2172
        • Reilly M.P.
        • Wolfe M.L.
        • Rhodes T.
        • Girman C.
        • Mehta N.
        • Rader D.J.
        Measures of insulin resistance add incremental value to the clinical diagnosis of metabolic syndrome in association with coronary atherosclerosis.
        Circulation. 2004; 110: 803-809
        • Dekker J.M.
        • Girman C.
        • Rhodes T.
        • Nijpels G.
        • Stehouwer C.D.
        • Bouter L.M.
        • et al.
        Metabolic syndrome and 10-year cardiovascular disease risk in the Hoorn study.
        Circulation. 2005; 112: 666-673
        • Friedewald Jr., V.E.
        • Cather J.C.
        • Gordon K.B.
        • Kavanaugh A.
        • Ridker P.M.
        • Roberts W.C.
        The editor’s roundtable: psoriasis, inflammation, and coronary artery disease.
        Am J Cardiol. 2008; 101: 1119-1126
        • Triplitt C.
        Improving treatment success rates for type 2 diabetes: recommendations for a changing environment.
        Am J Manag Care. 2010; 16: S195-S200
        • Malik S.
        • Lopez V.
        • Chen R.
        • Wu W.
        • Wong N.D.
        Undertreatment of cardiovascular risk factors among persons with diabetes in the United States.
        Diabetes Res Clin Pract. 2007; 77: 126-133
        • Zafrir B.
        • Cohen S.
        Primary prevention in high-risk dyslipidemic patients without an established cardiovascular disease: undertreatment and rationale for lipid-lowering therapy.
        Eur J Intern Med. 2006; 17: 495-499
        • Chapman R.H.
        • Petrilla A.A.
        • Berman L.
        • Benner J.S.
        • Tang S.S.
        Are high-risk hypertensive patients being prescribed concomitant statin therapy? A retrospective cohort study.
        Am J Cardiovasc Drugs. 2009; 9: 299-308
        • MacDonald T.M.
        • Morant S.V.
        • Mozaffari E.
        Treatment patterns of hypertension and dyslipidaemia in hypertensive patients at higher and lower risk of cardiovascular disease in primary care in the United Kingdom.
        J Hum Hypertens. 2007; 21: 925-933
        • Costenbader K.H.
        • Wright E.
        • Liang M.H.
        • Karlson E.W.
        Cardiac risk factor awareness and management in patients with systemic lupus erythematosus.
        Arthritis Rheum. 2004; 51: 983-988
        • Maksimowicz-McKinnon K.
        • Selzer F.
        • Manzi S.
        • Kip K.E.
        • Mulukutla S.R.
        • Marroquin O.C.
        • et al.
        Poor 1-year outcomes after percutaneous coronary interventions in systemic lupus erythematosus: report from the National Heart, Lung, and Blood Institute Dynamic Registry.
        Circ Cardiovasc Interv. 2008; 1: 201-208
        • Toms T.E.
        • Panoulas V.F.
        • Douglas K.M.
        • Griffiths H.
        • Sattar N.
        • Smith J.P.
        • et al.
        Statin use in rheumatoid arthritis in relation to actual cardiovascular risk: evidence for substantial undertreatment of lipid-associated cardiovascular risk?.
        Ann Rheum Dis. 2010; 69: 683-688
        • Chung C.P.
        • Oeser A.
        • Avalos I.
        • Raggi P.
        • Stein C.M.
        Cardiovascular risk scores and the presence of subclinical coronary artery atherosclerosis in women with systemic lupus erythematosus.
        Lupus. 2006; 15: 562-569
        • Chung C.P.
        • Oeser A.
        • Avalos I.
        • Gebretsadik T.
        • Shintani A.
        • Raggi P.
        • et al.
        Utility of the Framingham risk score to predict the presence of coronary atherosclerosis in patients with rheumatoid arthritis.
        Arthritis Res Ther. 2006; 8: R186
        • Marma A.K.
        • Berry J.D.
        • Ning H.
        • Persell S.D.
        • Lloyd-Jones D.M.
        Distribution of 10-year and lifetime predicted risks for cardiovascular disease in US adults: findings from the National Health and Nutrition Examination Survey 2003 to 2006.
        Circ Cardiovasc Qual Outcomes. 2010; 3: 8-14
        • Nijsten T.
        • Wakkee M.
        Complexity of the association between psoriasis and comorbidities.
        J Invest Dermatol. 2009; 129: 1601-1603
        • Mosenifar Z.
        Population issues in clinical trials.
        Proc Am Thorac Soc. 2007; 4: 185-188
        • Ding E.L.
        • Powe N.R.
        • Manson J.E.
        • Sherber N.S.
        • Braunstein J.B.
        Sex differences in perceived risks, distrust, and willingness to participate in clinical trials: a randomized study of cardiovascular prevention trials.
        Arch Intern Med. 2007; 167: 905-912
        • Braunstein J.B.
        • Sherber N.S.
        • Schulman S.P.
        • Ding E.L.
        • Powe N.R.
        Race, medical researcher distrust, perceived harm, and willingness to participate in cardiovascular prevention trials.
        Medicine (Baltimore). 2008; 87: 1-9