Tumor Necrosis Factor Inhibitors May Decrease MI Risk in Psoriasis

Fran Lowry

February 11, 2011

February 11, 2011 (New Orleans, Louisiana) — A retrospective review of a large database shows that treatment of severe psoriasis with tumor necrosis factor alfa (TNF-α) inhibitors is associated with a reduced risk for myocardial infarction (MI), according to Jashin Wu, MD, from Kaiser Permanente Los Angeles Medical Center in California.

Dr. Wu presented the results here at the American Academy of Dermatology 69th Annual Meeting.

Psoriasis is one of the most common chronic skin conditions in the United States and worldwide, affecting approximately 2% to 3% of people, Dr. Wu said. Recently, people with psoriasis have been shown to be at increased risk for cardiovascular disease, including MI and stroke.

In this study, Dr. Wu and his colleagues sought to determine whether patients with psoriasis treated with TNF-α inhibitors have a decreased risk for MI, compared with those not treated with TNF-α inhibitors.

They used data from the Kaiser Permanente Southern California group of members between January 2004 and December 31, 2008. The cohort consisted of 21,081 patients, 48% of whom were men, with a mean age of 50 years. The patients were followed until November 30, 2010 for the occurrence of MI, and the median follow-up was 3.6 years.

Among the cohort, 22% had type 2 diabetes mellitus, more than half had dyslipidemia and hypertension, and slightly less than half had psoriatic arthritis, Dr. Wu noted.

The researchers found that treatment with TNF-α inhibitors was associated with a significantly reduced risk for MI, compared with other treatments. The hazard ratio was 0.52 (P < .05), Dr. Wu reported.

"This is the first large-scale retrospective cohort to show that the use of [TNF-α] inhibitors for psoriasis is associated with a significant reduction in risk of MI, compared with psoriasis patients not treated with [TNF-α] inhibitors," Dr. Wu told Medscape Medical News in an interview after his presentation.

"Dermatologists should be aware that patients with severe psoriasis are at risk for myocardial infarction and that treatment with [TNF-α] inhibitors may be associated with a reduction in MI risk," he said.

Dr. Wu added that his study cannot show causality. However, "future studies may show that treatment with [TNF-α] inhibitors does reduce MI risk."

One explanation for this reduced risk might be the decrease in overall inflammation, he suggested. "C-reactive protein [CRP] is a marker for inflammation, and elevated CRP levels are associated with an increased risk for MI. A study in 2008 showed that after 12 weeks of etanercept therapy, CRP was significantly reduced in those with psoriasis and psoriatic arthritis."

The results of this review raise the possibility that TNF-α inhibitors reduce the risk for stroke and other cardiovascular events, he said.

Commenting on this study for Medscape Medical News, Paolo Romanelli, MD, from the University of Miami Miller School of Medicine in Florida, noted that some issues were not very well explained in the study.

"They did not tell us what the average treatment duration of [TNF-α] was, but this is important to know. Do we need continuous treatment to get this effect? Also, homocysteine is a risk factor, especially if you are comparing etanercept with methotrexate, so I believe that homocysteine should have been part of the risk factor criteria," he said.

On a positive note, this was a large, strong, epidemiologic study, "so it definitely has some input for future strategies, perhaps even a clinical trial," Dr. Romanelli said.

Dr. Wu and Dr. Romanelli have disclosed no relevant financial relationships.

American Academy of Dermatology (AAD) 69th Annual Meeting. Abstract P400. Presented February 6, 2011.

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