Anti-inflammatory biologic therapies used to treat psoriasis reduce coronary inflammation

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Researchers have found that anti-inflammatory biologic therapies used to treat moderate to severe psoriasis can significantly reduce coronary inflammation in patients with the chronic skin condition.

Scientists said the findings are particularly notable because of the use of a novel imaging biomarker, the perivascular fat attenuation index (FAI), that was able to measure the effect of the therapy in reducing the inflammation.

The study published online in JAMA Cardiology, has implications not just for people with psoriasis, but for those with other chronic inflammatory diseases, such as lupus and rheumatoid arthritis.

These conditions are known to increase the risk for heart attacks and strokes.

The study was funded by the National Heart, Lung, and Blood Institute (NHLBI), part of the National Institutes of Health.

“Coronary inflammation offers important clues about the risk of developing heart artery disease,” said study’s senior author Nehal N. Mehta, M.D., a cardiologist and head of the Lab of Inflammation and Cardiometabolic Diseases at NHLBI.

“Our findings add to the growing body of research that shows treating underlying inflammatory conditions may reduce the risk of cardiovascular diseases.”

The researchers analyzed 134 patients who suffered moderate to severe psoriasis and had not received biologic treatment for at least three months before starting on the study’s therapy.

Fifty-two of these patients who chose not to receive the biologic therapy, were treated with topical or light therapies only and served as the control group.

The participants are from an ongoing, prospective cohort study, the Psoriasis Atherosclerosis Cardiometabolic Initiative cohort at NIH.

Coronary artery inflammation particularly affects perivascular fat – the fat tissue surrounding arteries – by changing its composition, making it attenuated, or less fatty, as captured by the perivascular fat attenuation index (FAI), which researchers in the current study used to measure the effects of the biologics on coronary inflammation.

“FAI is a new method of analyzing CT scans that can predict a patient’s risk of fatal heart attacks and other cardiac events years in advance, and independent of other traditional risk factors for heart disease,” explained study co-author Charalambos Antoniades, M.D., professor of cardiovascular medicine at Oxford University.

“In fact, our research has found that an abnormal perivascular FAI was linked to a six- to nine-fold increased risk of major adverse cardiovascular events.”

The 134 patients, all of whom had low cardiovascular risk, underwent CT scans at the start of the study and again a year later to assess coronary inflammation using the perivascular FAI.

Researchers found a significant reduction in coronary inflammation among those receiving biologic therapy, but there was no change in the control group.

Coronary CT angiography image of the coronary arteries depicting the perivascular fat attenuation index before and after biologic therapy at one-year follow-up for patients with excellent response to biologic therapy. FAI: Fat Attenuation Index, HU: Hounsfield Units. Credit: Antoniades Group: The Oxford Translational Cardiovascular Research Group and Lab of Inflammation and Cardiometabolic Diseases at NHLBI.

Even patients with preexisting coronary artery plaque saw a reduction in coronary inflammation following biologic therapy.

“After seeing the predicting value of the perivascular FAI for cardiac events, a key lingering question was if we could modify it using anti-inflammatory interventions.

As far as we know, our study is the first to assess potential effects of biologic therapy on coronary inflammation using the measure,” said Mehta.

The researchers believe that the strength of the perivascular FAI in predicting the risk of future cardiac events could guide therapeutic decisions for individual patients, promoting a more personalized medicine approach to care.

Psoriasis, a common skin disease affecting 3% to 5% of the U.S. population, is associated with heightened systemic inflammation, which elevates risk of blood vessel disease and diabetes.

Inflammation occurs when the body’s defensive mechanism kicks in to ward off infection or disease, but this mechanism can turn against itself when triggered, for instance, by excess low-density lipoproteins (LDLs) that seep into the lining of the arteries.

The resulting inflammatory response can increase formation of blood clots, which block arteries leading to heart attack and stroke. Inflammation puts 20% to 30% of the U.S. population at risk for these kinds of events.


Anti-inflammatory biologic drugs used to treat severe psoriasis have the potential to prevent heart disease in patients with the skin condition. During one year of treatment, biologic therapy improved coronary artery plaque similar to the effect of a low-dose statin.

“Psoriasis severity is related to the burden of coronary disease – our findings suggest treating the psoriasis may potentially benefit coronary heart disease,” said study author Dr Nehal Mehta, Chief of Inflammation and Cardiometabolic Diseases at the National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, Maryland, US.

Psoriasis causes scaly skin patches, often on the elbows, knees, scalp, and lower back. Patients with the skin condition have an elevated risk of heart disease – young patients with severe psoriasis are at twice the risk of having a first heart attack at 40-50 years of age.

Psoriasis patients often have inflammation throughout the body and may be treated with anti-inflammatory biologic therapy when their skin condition is severe and topical treatments or phototherapy have failed.

This study investigated whether treating severe psoriasis with a biologic could improve the health of the coronary arteries.

The study found that patients with severe psoriasis who took biologic therapy for one year had an 8 percent reduction in total and non-calcified coronary plaque burden, a frequent cause of heart attacks (see figure) – similar to the effect of a low dose statin.

The make-up of coronary plaques also improved in those taking biologics, making them less risky. Coronary plaque burden increased by 2 percent in patients who did not take a biologic.

Dr Mehta said: “We found that these anti-inflammatory drugs  commonly used to treat severe psoriasis also improve plaque in the coronary artery making them more stable and less likely to cause a heart attack.

This occurred in the absence of changes in traditional cardiovascular risk factors including blood pressure and blood lipids.”

During the one-year study, systemic inflammation assessed by blood markers reduced only in the group taking biologic therapy. Dr Mehta said it is too early to say whether biologics exert their effects on coronary plaques directly or by reducing systemic inflammation.

He said: “This preliminary study provides the first evidence that biologic therapy is associated with coronary plaque reduction and stabilisation,and provides strong rationale for conduct of a randomised trial testing the impact of biologic therapy on the progression of coronary disease in patients with psoriasis.”

Dr Mehta noted that some patients with severe psoriasis opt not to take a biologic medicine because they suppress the immune system and may increase the chance of infection. In addition, they must be injected.

Previous research has shown that in heart attack patients, anti-inflammatory biologic therapy reduces the risk of another cardiovascular event.

“With the results of that study and our current one, my message to patients with psoriasis is to take untreated inflammation seriously,” said Dr Mehta. “When someone has severe psoriasis, they are at higher risk of heart attack and treating the psoriasis may reduce that risk.”

The observational study included 121 patients with severe psoriasis who qualified for biologic treatment. Of those, 89 took biological therapy (one of three types) and 32 used topical treatment.

All patients underwent imaging of their coronary arteries with computed tomography angiography at baseline and one year later to assess the amount and characteristics of plaques such as the necrotic core which causes plaque rupture.

The research was published in the journal Cardiovascular Research.


More information: Association of Biologic Therapy with Coronary Inflammation in Patients with Psoriasis as Assessed by Perivascular Fat Attenuation Index. JAMA Cardiology (2019). DOI: 10.1001/jamacardio.2019.2589

Journal information: JAMA Cardiology
Provided by NIH/National Heart, Lung and Blood Institute

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