Gastrointestinal Signs and Symptoms Related to Inflammatory Bowel Disease in Patients With Moderate-to-Severe Psoriasis
December 2018 | Volume 17 | Issue 12 | Original Article | 1298 | Copyright © 2018
Steven R. Feldman MD PhD,a Bhaskar Srivastava MD PhD,bJill Abell MPH PhD,b Timothy Hoops MD,b Steve Fakharzadeh MD,c Soumya D. Chakravarty MD PhD,b,d Erik Muser PharmD MPH,b Danielle Dungee BA,b Sean T. Quinn BSc,b Megan Leone-Perkins PhD,e Michael D. Kappelman MD MPHf
aDepartment of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC bJanssen Scientific Affairs, LLC, Horsham, PA cJanssen Global Services, LLC, Titusville, NJ dDivision of Rheumatology, Drexel University College of Medicine, Philadelphia, PA eHealthiVibe, LLC, Arlington, VA fDivision of Pediatric Gastroenterology, University of North Carolina Chapel Hill, Chapel Hill, NC
BACKGROUND: Psoriasis (PsO) is a chronic inflammatory skin disorder that may be associated with comorbidities, including inflammatory bowel disease (IBD), given common immunopathogenic mechanisms. Whether PsO patients are more likely to suffer from gastrointestinal (GI) signs and symptoms has not been well-characterized. Understanding their prevalence in PsO patients may inform strategies to evaluate for GI signs and symptoms, screen for those at risk for IBD, and guide choice of therapy. OBJECTIVE: To assess the prevalence of GI signs and symptoms in patients with moderate-to-severe PsO. METHODS: An Internet-based survey was conducted to evaluate GI signs and symptoms in patients with self-reported moderate-to-severe PsO and non-PsO controls. The impact of PsO severity and presence of psoriatic arthritis (PsA) [self-reported and/or screened positive on the Psoriatic Arthritis Screening and Evaluation (PASE) questionnaire] on prevalence of GI signs and symptoms was also assessed. The survey included questions about PsO, comorbidities, demographics, and GI signs and symptoms. Questions related to GI signs and symptoms were used to calculate a modified CalproQuest* score to identify patients at increased risk for IBD. RESULTS: Survey responses were collected from 740 PsO patients and 1411 non-PsO controls. With the exception of age, demographics were generally comparable between groups. All six GI signs and symptoms assessed (belly pain, feeling full/bloated, diarrhea, mucus in stool, blood in stool, and unintentional weight loss) were more prevalent in PsO patients compared with non-PsO controls, and a higher proportion of PsO patients also had a positive CalproQuest* result. In addition, both more severe PsO and concomitant PsA were associated with a higher prevalence of GI signs and symptoms and a positive CalproQuest*. CONCLUSIONS: This study suggests that PsO patients, including those with PsA, have a higher prevalence of GI signs and symptoms. Physicians should recognize and consider this concern in PsO patient management. J Drugs Dermatol. 2018;17(12):1298-1308.
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Psoriasis (PsO) is a chronic immune-mediated skin disorder characterized by erythematous, scaling plaques, which are often pruritic or painful. The prevalence of PsO in the United States is approximately 3.2% or about 7.2 million adults.1 The T-helper cell (Th)17/interleukin (IL)-23 axis has been implicated as a key immune mediator of PsO. Genetic and environmental factors also play a role.2 Psoriasis is associated with a number of comorbidities, including the inflammatory bowel diseases (IBD), Crohn’s disease (CD) and ulcerative colitis (UC) as well as psoriatic arthritis (PsA).3,4,5 PsO, IBD, and PsA also share genetic determinants that involve the Th17/IL-23 pathway.6,7 PsO patients have an increased risk of developing CD (relative risk, 3.49), and PsO patients with concomitant PsA have an even higher risk of developing CD (relative risk, 6.54).3 Patients with severe PsO (defined as requiring treatment with systemic therapy) have an increased rate of developing CD and UC [incidence rate ratio (IRR), 2.85 and 1.96, respectively] than patients with mild PsO (IRR, 1.28 and 1.49, respectively). Meanwhile, PsO patients with concomitant PsA have a higher rate of developing CD and UC (IRR, 3.42 and 2.43, respectively) than patients with severe PsO.5 Conversely, patients with IBD have an increased risk (odds ratio, 1.8) of developing PsO.8 Together, these studies indicate a strong association between PsO and risk of developing IBD, and that greater severity of PsO and the presence of PsA further increase this risk. Given that similar mechanisms drive PsO, PsA, and bowel inflammation, PsO patients may be at risk of developing features of subclinical and/or undiagnosed IBD. However, PsO patients