Position statement for the management of comorbidities in psoriasis.

BACKGROUND: The association between psoriasis and some diseases has become relevant in recent years. Providing appropriate management of psoriasis from an early stage requires prompt diagnosis and treatment of concomitant diseases and to prevent any potential comorbidity. This approach should consider the adverse events of the drugs used to treat psoriasis potentially related to the onset of comorbidities. OBJECTIVE: To provide the dermatologist with an accurate and friendly tool for systematizing the diagnosis of psoriasis-associated comorbidities, which generally escapes the scope of the dermatology setting, and to facilitate decision-making about the referral and treatment of patients with comorbidities. METHODS: These position statement recommendations were developed by a working group composed of ten experts (four dermatologists, one cardiologist, one rheumatologist, one gastroenterologist, one nephrologist, one endocrinologist and one psychiatrist) and two health services researchers. The expert group selected the psoriasis comorbidities considered according to their relevance in the dermatology setting. The recommendations on diagnostic criteria are based on the current clinical practice guidelines for each of the comorbidities. The information regarding the repercussion of psoriasis medical treatments on associated comorbid diseases was obtained from the summary of product characteristics of each drug. RESULTS: Recommendations were developed to detect and refer the following psoriasis comorbidities: psoriatic arthritis, cardiovascular risk factors (diabetes, dyslipidaemia, obesity, hypertension and metabolic syndrome), non-alcoholic fatty liver disease, inflammatory bowel disease, kidney disease and psychological disorders (anxiety and depression). In addition, alcohol consumption and tobacco consumption were included. The tables and figures are precise, easy-to-use tools to systematize the diagnosis of comorbidities in patients with psoriasis and facilitate the decision-making process regarding referral and treatment of patients with an associated disease. CONCLUSION: The application of these position statement recommendations will facilitate the dermatologist practice, and benefit psoriasis patients' health and quality of life.

Psoriasis and Nonalcoholic Fatty Liver Disease. / Psoriasis e hígado graso no alcohólico.

Nonalcoholic fatty liver disease (NAFLD) is the most prevalent liver condition in the West. The prevalence and severity of NAFLD is higher and the prognosis worse in patients with psoriasis. The pathogenic link between psoriasis and NAFLD is chronic inflammation and peripheral insulin resistance, a common finding in diseases associated with psoriasis. NAFLD should therefore be ruled out during the initial evaluation of patients with psoriasis, in particular if they show signs of metabolic syndrome and require systemic treatment. Concomitant psoriasis and NAFLD and the likelihood of synergy between them place limitations on general recommendations and treatment for these patients given the potential for liver toxicity. As hepatotoxic risk is associated with some of the conventional drugs used in this setting (e.g., acitretin, methotrexate, and ciclosporin), patients prescribed these treatments should be monitored as appropriate. Anti-tumor necrosis factor agents hold the promise of potential benefits based on their effects on the inflammatory process and improving peripheral insulin resistance. However, cases of liver toxicity have also been reported in relation to these biologics. No evidence has emerged to suggest that anti-p40 or anti-interleukin 17 agents provide benefits or have adverse effects.

Clinical, Diagnostic, and Therapeutic Implications in Psoriasis Associated With Cardiovascular Disease. / Implicaciones clínicas, diagnósticas y terapéuticas de la psoriasis y enfermedad cardiovascular.

In recent years the concept of psoriasis as a systemic disease has gained acceptance due to its association with numerous comorbid conditions, particularly atherosclerosis and cardiovascular disease. Several studies have shown that patients with psoriasis, especially younger patients and those with more severe forms of psoriasis or with psoriatic arthritis, have a higher prevalence of risk factors and metabolic syndrome, as well as an increased risk of major cardiovascular events such as myocardial infarction, cerebrovascular disease, and peripheral arterial disease. Furthermore, it remains unclear which of the current treatments might be more effective in reducing cardiovascular risk in these patients. It is therefore important for dermatologists to be aware of this increased risk, to be able to detect modifiable risk factors early and, when appropriate, refer patients to other specialists for the prevention of major cardiovascular events.

Kidney Disease and Psoriasis. A New Comorbidity? / Enfermedad renal y psoriasis. ¿Una nueva comorbilidad?

Psoriasis is a chronic inflammatory disease that has been associated with cardiovascular and metabolic comorbidities, particularly in young patients and patients with more severe forms of the disease. Recent studies have also linked psoriasis to kidney disease, and this would seem only logical, as the kidney is both a target of classic cardiovascular risk factors and susceptible to the toxic effects of some of the traditional drugs used to control psoriasis. In this article, we would like to draw readers' attention to this recently described comorbidity and stress the importance of early detection, as once chronic kidney disease develops, it cannot be reversed. When evaluating patients with psoriasis, particularly when they are candidates for systemic therapy, we believe it is important to order laboratory tests including glomerular filtration rate and a simple urine test to screen for albuminuria (albumin/creatinine ratio).

Impact of Diabetes Mellitus and Frailty on Long-Term Outcomes in Elderly Patients with Acute Coronary Syndromes.

OBJECTIVES: Diabetes mellitus (DM) and frailty are common in older patients with acute coronary syndromes (ACS). No data exists about its prognostic impact on long-term outcomes and their possible interaction in this setting. DESIGN: Observational prospective study. SETTING: Multicenter registry conducted in 44 hospitals in Spain. PARTICIPANTS: Consecutive patients with ACS aged 80≥years. MEASUREMENTS: A comprehensive geriatric evaluation was performed during hospitalization, including frailty assessment by the FRAIL score. The impact of DM and frailty on the incidence of mortality/readmission at 24 months was analysed by a Cox regression model. RESULTS: A total of 498 patients were included (mean age 84.3 years). Prevalence of previous DM was 199/498 (40.0%). The rate of frail patients was 135/498 (27.1%). The incidence of mortality/readmission was higher frail patients (HR 2.49) (both p<0.001). In contrast, DM was not significantly associated to a higher rate of outcomes (HR 1.23, p=0.060) in the whole cohort. Among non-frail patients, patients with DM had a similar incidence of mortality or readmission (p=0.959). In contrast, among frail patients, DM was significantly associated with a higher incidence of events (HR 1.51, p=0.034). CONCLUSIONS: Unlike frailty status, DM was not associated to poorer long-term outcome in elderly patients with ACS. Among frail patients the presence of DM seems to provide additional prognostic information.

Resonancia magnética cardiaca de estrés para predecir mortalidad y toma de decisiones: registro de 2.496 pacientes mayores con síndrome coronario crónico / Stress cardiac magnetic resonance for mortality prediction and decision-making: registry of 2496 elderly patients with chronic coronary syndrome

Introducción y objetivos: El tratamiento del paciente mayor con síndrome coronario crónico (SCC) es un reto. Se exploró el valor pronóstico y la utilidad para la toma de decisiones de la carga isquémica determinada mediante resonancia magnética cardiaca (RMC) de estrés con vasodilatador en pacientes mayores con SCC. Métodos: Se incluyó a 2.496 pacientes mayores de 70 años estudiados con una RMC de estrés con vasodilatador por SCC conocido o sospechado. La carga isquémica (número de segmentos con déficit de perfusión inducido por el estrés) se calculó siguiendo el modelo de 17 segmentos. Posteriormente se analizó de manera retrospectiva su asociación con la mortalidad por cualquier causa y el efecto de la revascularización guiada por la RMC. Resultados: Durante una mediana de seguimiento de 4,58 años, se registraron 430 muertes (17,2%). Una mayor carga isquémica fue un predictor independiente de mortalidad: razón de riesgos, 1,04; intervalos de confianza del 95%, 1,01-1,07 por cada segmento adicional isquémico; p=0,006). Esta asociación también ocurrió en los mayores de 80 años y en las mujeres (p<0,001). Se detectó una interacción entre la revascularización y la mortalidad hacia un efecto deletéreo a baja carga isquémica y un efecto protector en caso de isquemia grave. Conclusiones: La RMC de estrés es un valioso instrumento para la estratificación del riesgo de los pacientes de edad avanzada con SCC y puede contribuir a guiar la toma de decisiones en este contexto (AU)

Introduction and objectives: The management of elderly patients with chronic coronary syndrome (CCS) is challenging. We explored the prognostic value and usefulness for decision-making of ischemic burden determined by vasodilator stress cardiac magnetic resonance (CMR) imaging in elderly patients with known or suspected CCS. Methods: The study group comprised 2496 patients older than 70 years who underwent vasodilator stress CMR for known or suspected CCS. The ischemic burden (number of segments with stress-induced perfusion deficit) was calculated following the 17-segment model. Subsequently, we retrospectively analyzed its association with all-cause mortality and the effect of CMR-guided revascularization. Results: During a median follow-up of 4.58 years, there were 430 deaths (17.2%). A higher ischemic burden was an independent predictor of mortality (HR, 1.04; 95%CI, 1.01-1.07 for each additional ischemic segment; P=.006). This association was also found in patients older than 80 years and in women (P <.001). An interaction between revascularization and mortality was detected toward deleterious consequences at low ischemic burden and a protective effect in patients with extensive ischemia. Conclusions: Vasodilator stress CMR is a valuable tool to stratify risk in elderly patients with CCS and might be helpful to guide decision-making in this scenario (AU)

Implicaciones clínicas, diagnósticas y terapéuticas de la psoriasis y enfermedad cardiovascular / Clinical, Diagnostic, and Therapeutic Implications in Psoriasis Associated With Cardiovascular Disease

En los últimos años el concepto de psoriasis como enfermedad sistémica se ha ido extendiendo debido a su asociación con múltiples comorbilidades, entre las que destaca la arterioesclerosis y la enfermedad cardiovascular. En diferentes estudios a lo largo de los años se ha demostrado que en los pacientes con psoriasis, sobre todo en aquellos más jóvenes, con formas más graves y/o artritis psoriásica, existe una mayor prevalencia de factores de riesgo y síndrome metabólico, así como un mayor riesgo de presentar eventos cardiovasculares mayores, como el infarto de miocardio, la enfermedad cerebrovascular y la arteriopatía periférica. Además, aún no queda claro cuáles de los tratamientos actuales podrían ser más beneficiosos en cuanto a reducción del riesgo cardiovascular en estos pacientes. Por eso, es importante la difusión entre dermatólogos de este riesgo aumentado, con el fin de diagnosticar precozmente aquellos factores de riesgo modificables, y derivar al paciente a otros especialistas en el momento oportuno para prevenir el desarrollo de eventos cardiovasculares mayores (AU)

In recent years the concept of psoriasis as a systemic disease has gained acceptance due to its association with numerous comorbid conditions, particularly atherosclerosis and cardiovascular disease. Several studies have shown that patients with psoriasis, especially younger patients and those with more severe forms of psoriasis or with psoriatic arthritis, have a higher prevalence of risk factors and metabolic syndrome, as well as an increased risk of major cardiovascular events such as myocardial infarction, cerebrovascular disease, and peripheral arterial disease. Furthermore, it remains unclear which of the current treatments might be more effective in reducing cardiovascular risk in these patients. It is therefore important for dermatologists to be aware of this increased risk, to be able to detect modifiable risk factors early and, when appropriate, refer patients to other specialists for the prevention of major cardiovascular events (AU)

Psoriasis e hígado graso no alcohólico / Psoriasis and Nonalcoholic Fatty Liver Disease

El hígado graso no alcohólico es la principal causa de enfermedad hepática en nuestro medio. Los pacientes con psoriasis presentan mayor prevalencia y gravedad y peor pronóstico de esta hepatopatía. El vínculo patogénico entre ambas es el estado de inflamación crónica y la resistencia periférica a la insulina, habitual en las comorbilidades asociadas a la psoriasis. Por este motivo, en la evaluación de los pacientes con psoriasis, en particular si existen componentes del síndrome metabólico y se requiere tratamiento sistémico, se recomienda descartar esta posibilidad. La coexistencia de psoriasis e hígado graso no alcohólico, con probable sinergia entre ambos, condiciona las medidas generales que deben recomendarse en estos pacientes y también la estrategia terapéutica, por la potencial hepatotoxicidad de algunos de ellos. En este sentido, algunos de los fármacos convencionales habituales como acitretino, metotrexato o ciclosporina presentan potenciales efectos hepatotóxicos cuya repercusión en cada paciente debe evaluarse de forma individualizada. Los fármacos anti-TNF podrían tener efectos beneficiosos fundamentados en el buen control del proceso inflamatorio y de una mejoría de la resistencia periférica a la insulina. Sin embargo, se han descrito casos de hepatotoxicidad en algunos pacientes. No existe evidencia de efectos beneficiosos o perjudiciales de los fármacos anti p40 o anti IL-17 (AU)

Nonalcoholic fatty liver disease (NAFLD) is the most prevalent liver condition in the West. The prevalence and severity of NAFLD is higher and the prognosis worse in patients with psoriasis. The pathogenic link between psoriasis and NAFLD is chronic inflammation and peripheral insulin resistance, a common finding in diseases associated with psoriasis. NAFLD should therefore be ruled out during the initial evaluation of patients with psoriasis, in particular if they show signs of metabolic syndrome and require systemic treatment. Concomitant psoriasis and NAFLD and the likelihood of synergy between them place limitations on general recommendations and treatment for these patients given the potential for liver toxicity. As hepatotoxic risk is associated with some of the conventional drugs used in this setting (e.g., acitretin, methotrexate, and ciclosporin), patients prescribed these treatments should be monitored as appropriate. Anti-tumor necrosis factor agents hold the promise of potential benefits based on their effects on the inflammatory process and improving peripheral insulin resistance. However, cases of liver toxicity have also been reported in relation to these biologics. No evidence has emerged to suggest that anti-p40 or anti-interleukin 17 agents provide benefits or have adverse effects (AU)

Enfermedad renal y psoriasis. ¿Una nueva comorbilidad? / Kidney disease and psoriasis. A new comorbidity?

La psoriasis es un proceso inflamatorio crónico que se ha asociado con comorbilidades cardiovasculares y metabólicas, especialmente las formas más graves y en pacientes jóvenes. Estudios recientes relacionan también la psoriasis con enfermedad renal, y parece lógico que sea así porque, por un lado, el riñón es un órgano diana de los factores de riesgo cardiovascular clásicos, y además, algunos de los tratamientos clásicos empleados para controlar la psoriasis tienen toxicidad renal. Con este artículo queremos hacer una llamada de atención sobre esta comorbilidad recientemente descrita; es fundamental su detección precoz porque una vez instaurada, la enfermedad renal crónica es irreversible. Consideramos importante que en el estudio basal de todo paciente con psoriasis, especialmente aquellos que van a recibir terapia sistémica, se analice la función renal con una analítica de sangre con filtrado glomerular y un análisis sencillo de orina para estudiar la albuminuria (relación albúmina/creatinina)

Psoriasis is a chronic inflammatory disease that has been associated with cardiovascular and metabolic comorbidities, particularly in young patients and patients with more severe forms of the disease. Recent studies have also linked psoriasis to kidney disease, and this would seem only logical, as the kidney is both a target of classic cardiovascular risk factors and susceptible to the toxic effects of some of the traditional drugs used to control psoriasis. In this article, we would like to draw readers’ attention to this recently described comorbidity and stress the importance of early detection, as once chronic kidney disease develops, it cannot be reversed. When evaluating patients with psoriasis, particularly when they are candidates for systemic therapy, we believe it is important to order laboratory tests including glomerular filtration rate and a simple urine test to screen for albuminuria (albumin/creatinine ratio)