Rheumatology News

R heumatology N ews • Vol. 4 • No. 1 • 2016 14 SPONDYLOARTHROPATHIES

Cardiovascular risk factors in psoriatic diseases are common, often go untreated

BY AMY KARON Frontline Medical News At the American College of Rheumatology annual meeting, San Francisco D espite their frequent contact with the health care system, patients with psoriasis and psoriatic arthritis often receive no treatment for major cardiovascular risk factors, according to two large multicentre studies. “We identified a gap in quality of care in terms of the primary preven- tion of cardiovascular risk factors in psoriatic arthritis and psoriasis. The next step will be to develop strategies to increase awareness and imple- ment treatment recommendations among primary care physicians, der- matologists, and rheumatologists,” Dr Lihi Eder of the University of Toronto said in an interview at the annual meeting of the American College of Rheumatology. Psoriatic and cardiovascular diseases share an inflammatory ae- tiology and often co-occur. In past studies, patients with psoriasis and psoriatic arthritis were about 50% more likely than average to have dyslipidaemia and ischaemic heart disease, and about 80–90% more likely than usual to have hyperten- sion and diabetes, Dr Eder said. She and her associates studied dyslipidaemia and hypertension among 1327 patients with psori- atic arthritis and 927 patients with psoriasis at eight sites in Canada, the US, and Israel as part of the International Psoriasis & Arthritis BY AMY KARON Frontline Medical News At the American College of Rheumatology annual meeting, San Francisco P atients with primary Sjögren’s syndrome who met criteria for cryoglobulinemic vasculitis were significantly more likely to develop B-cell lymphoma and to die during follow-up, compared with patients who did not have cryoglobulins, in a large multicentre study. The study’s findings reveal one subset of Sjögren’s patients who need more frequent and intensive follow-up, said Dr Soledad Reta- mozo, who led the study while she was at the rheumatology unit at Hospital Privado Centro Médico de Córdoba in Córdoba, Argentina. She is now with the department of autoimmune diseases at CELLEX Biomedical Research Centre, part of the University of Barcelona’s In- stitut d’Investigacions Biomèdiques August Pi i Sunyer. Patients with primary Sjögren’s syndrome can have cryoglobulins and several other kinds of autoan- tibodies, including anti-SSA/Ro, anti-SSB/La, rheumatoid factor, and antinuclear antibodies. That

The absence of a significant difference in receipt of appropriate therapy among the groups reflects a need for more careful attention to the management of cardiovascular risk factors in patients with inflammatory diseases. Because these risk factors can be successfully treated, it is “critical” to educate primary care providers about the need to do so.

adherence would be even lower.” The second study detected signifi- cantly higher rates of cardiovascular risk factors among patients with psoriatic diseases, compared with controls from the Health Improve- ment Network, a medical records database that covers more than 9 million individuals in the United Kingdom. Patients with psoriatic arthritis or severe psoriasis were significantly more likely than were controls to develop hypertension, hyperlipidaemia, obesity, or diabe- tes, with odds ratios ranging from 1.22 to 1.78, reported Dr Kashif A. Jafri, who led the study while he was an internal medicine resident at the University of Pennsylvania in Philadelphia. But despite their disproportionate risk, patients were treated at about the same rate as controls, Dr Jafri said. About 15% of individuals with hypertension received no treatment, 30–40% with hyperlipidaemia went untreated, and nearly 60% with diabetes received no documented therapy. “The absence of a significant difference in receipt of appropriate therapy among the groups reflects a need for more careful attention to

the management of cardiovascular risk factors in patients with inflam- matory diseases,” Dr Jafri empha- sised. Because these risk factors can be successfully treated, it is “critical” to educate primary care providers about the need to do so, he said. Rheumatologists also should peri- odically discuss cardiovascular risk factors with their patients as part of routine care, Dr Jafri advised. “Although there are obviously time constraints during each office visit, this is a topic that dramatically influ- ences the morbidity and mortality of our patient population, and rheu- matologists have the unique ability to address this issue in the context of their long-term relationships with their patients,” he said. Dr Jafri is now a fellow in rheumatol- ogy at the University of California, San Francisco. His was supported by an Ephraim P. Engleman Endowed Resident Research Preceptorship Award from the Rheumatology Re- search Foundation. IPART is spon- sored by the Krembil Foundation and the Canadian Institutes of Health Research. Dr Jafri and Dr Eder had no disclosures. likely than test-negative patients to develop B-cell lymphoma (hazard ratio, 2.56; 95% confidence inter- val, 1.03–6.35), and the association was even stronger for patients with cryoglobulinaemic vasculitis (HR, 7.47; 95% CI, 3.38–16.53). Patients with vasculitis also were significantly more likely to die during follow-up in a Kaplan-Meier survival analysis (HR, 4.36; 95% CI, 1.32–14.47), Dr Retamozo reported. The findings reflect a recent sys- temic review and meta-analysis by researchers from the Mayo Clinic ( Rheumatology [Oxford ] 2015 Sep 27. doi: 10.1093/rheumatol- ogy/kev354) that separately linked vasculitis and cryoglobulinaemia to mortality in primary Sjögren’s syndrome. “We measure cryocrit every 3–6 months in our Sjögren’s patients, and it helps us catch pa- tients at greater risk of developing B-cell lymphoma,” Dr Retamozo said. “For us it has been very helpful, in addition to tests for hypocomple- mentaemia and monoclonality.” The findings have been accepted for publication in the journal Rheu- matology , she added. Dr Retamozo had no disclosures. One coauthor reported receiving research funding from Bristol-Myers Squibb.

who had been diagnosed with hy- pertension had uncontrolled high blood pressure, and 57% were not receiving antihypertensive medica- tions. Likewise, 58% of patients with dyslipidaemia met criteria for statins, but only a third of these patients were receiving them. Undertreatment was associated with having psoriatic arthritis or se- vere psoriasis and with having a high school or lower level of education, Dr Eder added. “You have to remem- ber that this study was conducted among specialists – these are sup- posed to be experts in the field,” she said. “If the treatment adherence is relatively low in these centres, then I would expect that for patients who are being followed in centres that do not specialise in psoriatic disease,

Research Team (IPART). Based on medical and laboratory reports and self-reported data, the investiga- tors assessed these comorbidities and whether treatment adhered to cholesterol and hypertension guidelines from the American Col- lege of Cardiology and the Ameri- can Heart Association ( Circulation 2014;129:S1–45), and the Eighth Joint National Committee ( JAMA 20145;311:507–20), respectively. More than 80% of patients in the cohort had at least one modifiable cardiovascular risk factor, Dr Eder said. While 6% had ischaemic heart disease, 45% had hypertension, 71% had dyslipidaemia, 13% had diabetes, 54% had central obesity, and 17% were current smokers. Fur- thermore, close to half of patients diversity helps explain why patients have such varying clinical presen- tations and long-term outcomes, as researchers have noted. Cryo- globulinemic vasculitis is known to precede lymphoma in primary Sjögren’s syndrome, but few stud- ies have examined the association or effects on mortality. To explore those questions, Dr Retamozo and her colleagues at rheumatology centres in Spain and Italy performed cryocrit testing in 515 consecutive patients with primary Sjögren’s syndrome. A total of 94% of patients were female, and they averaged 54 years of age at diagnosis. In all, 65 (12%) of the patients tested positive for cryoglo- bulins, resembling the prevalence in a prior report. About one in every three patients with cryoglobulinemia also fulfilled the classification criteria for cryo- globulinemic vasculitis that were published in 2011 and validated last year. Patients who met the vas- culitis criteria were “sicker” than other cryoglobulinemic patients by many measures, according to Dr Retamozo. They had about twice the rate of type II cryoglobulinemia

Cryoglobulinemic vasculitis in Sjögren’s linked to lymphoma, mortality

disease. Over an average follow-up pe- riod of 9.1 years, 9% of the entire cohort developed B-cell lymphoma, and 6% of the cohort died, Dr Re- tamozo and her associates found. Cryoglobulinemic patients with pri- mary Sjögren’s syndrome were more

(86% vs 43%), a fivefold higher aver- age cryocrit level (6.6% vs 1.25%), a more than twofold higher cumula- tive mean score (35.3 vs 16.2), and significantly higher rates of hypoc- omplementemia, monoclonality, lymphadenopathy, peripheral neu- ropathy, and renal, skin, and joint