Tumor Necrosis Factor Inhibitor Therapy and Myocardial Infarction Risk in Patients With Psoriasis, Psoriatic Arthritis, or Both

August 2014 | Volume 13 | Issue 8 | Original Article | 932 | Copyright © August 2014


Jashin J. Wu MDa and Kwun-Yee T. Poon MSb

aDepartment of Dermatology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
bDepartment of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA

Abstract
OBJECTIVES: To stratify MI risk reduction in those treated with a TNF inhibitor for psoriasis only, psoriatic arthritis only, or both psoriasis and psoriatic arthritis.
DESIGN: Retrospective cohort study
SETTING: Between January 1, 2004 and November 30, 2010
PARTICIPANTS: At least 3 ICD9 codes for psoriasis (696.1) or psoriatic arthritis (696.0) (without antecedent MI.
INTERVENTION: None
MAIN OUTCOME MEASURE: Incident MI
RESULTS: When comparing to those not treated with TNF inhibitors (reference group), of those treated with TNF inhibitors: those with psoriasis only (N= 846) had a significant decrease in MI risk (hazard ratio (HR), 0.26; 95% CI, 0.12-0.56); those with psoriatic arthritis only (N= 112) had a non-significant decrease in MI risk (HR, 0.86; 95% CI, 0.28-2.70); those with both psoriasis and psoriatic arthritis (N= 715) had a non-significant decrease in MI risk (HR, 0.76; 95% CI, 0.47-1.24).
CONCLUSIONS: In the TNF inhibitor cohort, those with psoriasis only have the strongest association with MI risk reduction, followed by those with psoriatic arthritis only, and then followed by those with both psoriasis and psoriatic arthritis.

J Drugs Dermatol. 2014;13(8):932-934.

INTRODUCTION

Psoriasis is a chronic skin condition affecting approximately 2-3% of the U.S. population and worldwide.1 About 15-40% of those with psoriasis also have psoriatic arthritis. Those with psoriatic arthritis have an overall higher level of inflammation compared to those with psoriasis only, and those with both psoriasis and psoriatic arthritis have an overall higher level of inflammation compared to those with either condition.23 Those with psoriasis only had a median baseline hsCRP of 2.7 or 3.2 mg/L, and those with both psoriasis and psoriatic arthritis had a baseline median hsCRP of 5.0 or 5.5 mg/L.2 Those with psoriatic arthritis only had a median baseline hsCRP of 4.8 mg/L.3 Chandran V et al4 recently showed that 26 patients with both psoriasis and psoriatic arthritis when compared to 26 patients with psoriasis only had elevated levels of highly sensitive CRP as well as other potential markers of inflammation such as MMP-3, osteoprotegerin, and ratio of C-propeptide of Type II collagen and collagen fragment neoepitopes Col2-3/4 (long mono).
Our group has recently shown that the use of tumor necrosis factor (TNF) inhibitor therapy for psoriasis and/or psoriatic arthritis is associated with a 50% reduction in risk of myocardial infarction (MI) compared to psoriasis and/or psoriatic arthritis treated with only topical therapy.5 For this secondary analysis, the study objective was to stratify MI risk reduction in those treated with a TNF inhibitor based on International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9) codes for psoriasis only (696.1), psoriatic arthritis only (696.0), or both psoriasis and psoriatic arthritis. Our hypothesis was that, in the TNF inhibitor cohort, those with psoriasis only would have the greatest association with MI risk reduction, and that those with both psoriasis and psoriatic arthritis would have the weakest association of MI risk reduction.

METHODS

The full methods are listed in the primary manuscript,5 but a brief summary follows. This is a retrospective cohort study conducted within the Kaiser Permanente Southern California (KPSC) Health Plan, which serves approximately 15% of the region’s population. All data were extracted from HealthConnect, the electronic databases of KPSC. The study protocol was approved by the local Institutional Review Board at KPSC.
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