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
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.
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
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.
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.