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Comorbidities and Changes in Treatment Plan


Experts delve into their treatment plan based on additional comorbidities patients may have.


Peter L. Salgo, MD: What about comorbidities here? Do the patients with comorbidities actually require more intensive care early on? Is that an obvious fact? Am I asking a silly question?

Joel Gelfand, MD, MSCE, FAAD: Well, I think that when they have more health problems, that’s one of the challenges for payers, as well. We know that comorbidity in general in the United States is a major problem. People don’t have 1 chronic condition but 2 or 3 chronic conditions, and that ends up increasing cost dramatically. Psoriasis patients often have other psychiatric comorbidities—anxiety, depression—that comingle with the disease as you can imagine. Those are also things that end up being costly to the healthcare system.

Peter Dehnel, MD: Just 1 question, and I don’t know this information. Say somebody comes in with a significant outbreak of psoriasis and they have metabolic syndrome, if you aggressively treat the psoriasis, will it also positively impact their metabolic syndrome?

Peter L. Salgo, MD: I was going to ask that next, darn it! I’m glad you did.

Peter Dehnel, MD: Pete or Peter, you take your pick.

Steven Feldman, MD, PhD: We need somebody to devote their life to that. Oh, we have somebody.

Joel Gelfand, MD, MSCE, FAAD: Yes. Well, I think that certainly, in the cardiovascular field, inflammation as a causal risk factor for cardiovascular events has been a matter of intense study. Recently, Paul Ridker MD, MPH, had a seminal finding showing that a biologic that targets interleukin-1-beta, called canakinumab, can lower the risk of major cardiovascular events in patients who already have coronary disease. We now know that it’s targeting certain immune pathways, and people at high risk for cardiovascular disease can causally lower risks of events. In psoriasis, it’s more challenging to figure out because you’d have to do a randomized controlled trial in 10,000 people and follow them for 5 years. We just don’t have that type of data. What we know so far is that, from observational data with TNF [tumor necrosis factor] inhibitors, which have been around for 20 years now, that patients who go on TNF inhibitors tend to have lower rates of major cardiovascular events over time compared to patients treated with other agents. It will take longer term for that same data to emerge with therapies like IL-17 [interleukin-17] inhibitors, IL-23 inhibitors, IL-12/23 inhibitors, looking at these events.

Peter L. Salgo, MD: So the short answer of: “Do you take into consideration metabolic syndrome when dealing with psoriasis?” is yes?

Joel Gelfand, MD, MSCE, FAAD: Absolutely, particularly when it relates to other therapies. Methotrexate is often more complicated to use in people who are overweight or have metabolic syndrome. They get into more trouble with the liver function issues.

Peter L. Salgo, MD: From your perspective, do people with comorbidities fit into a different strata in terms of their reimbursement plan? Do you carve out for them differently?

Peter Dehnel, MD: I don’t think most of the time we get that kind of data, nor do most of the, if you will, medical policies account for this. For example, if you’re looking at the treatment options for psoriasis, I don’t remember seeing that there’s a significant pathway down if they have metabolic syndrome, that you’re going to consider them in a different bucket, if you will.

Peter L. Salgo, MD: OK, does that surprise you?

Steven Feldman, MD, PhD: No. Very little surprises me. You know, I have a questioning attitude about things, even with the improvement you see with TNF inhibitors, or those associated with TNF inhibitors. TNF inhibitors, at least 1 of them, are thought to worsen congestive heart failure. Is it possible that the observational data are a little biased by physicians being afraid to put the patients who are at high risk of cardiovascular disease on a TNF inhibitor, so that when you look at the final results, you have the CAR [cardiovascular risk] TNF group performing better?

Joel Gelfand, MD, MSCE, FAAD: Right. And I think it’s a very possible issue going on, especially due to the fact we have an enormous amount of undertreatment of psoriasis in the broader population. And so there may be some strong selection pressure. Really, only the healthy patients—the compliant or adherent patients, well educated, motivated patients—are getting these therapies. To some extent, these data have been shown in rheumatoid arthritis [RA] as well. Maybe that might be a little bit more reassuring, where the use of biologics is much higher in the patient population, and you see the same cardioprotective effects in RA that you see in psoriasis.

Peter L. Salgo, MD: So boots on the ground here. In the office, patients coming in, what are the challenges that healthcare providers face when they’re dealing with these 2 comorbidities, psoriasis and metabolic syndrome?

Joel Gelfand, MD, MSCE, FAAD: Well, I think the biggest challenge is really thinking about how well we can manage both. How we can help a patient changes their health behavior, while working with their primary care team to be as healthy as possible, then have the best outcomes related to their psoriasis. When people are heavy, they don’t respond as well to systemic agents, they tend to lose response more quickly over time. They may do well but then have to cycle through multiple biologics. I often talk to my patients about weight loss. I’ve had some patients who have BMI [body mass index] over 40, and we see a fair number of those in our practice, and go with bariatric surgery. And it tends to be life changing for them, and oftentimes will modulate their psoriasis down.

There have been a couple of really fascinating reports out there of patients experiencing big improvements in their psoriasis when they go through bariatric surgery. There’s one study from Denmark showing that patients who had bariatric surgery had a lower frequency in developing psoriasis in the future. As we’re knowing that weight loss in people who were obese lowers the risk of diabetes and cardiovascular disease, it also probably benefits them with inflammatory skin disease.

Peter L. Salgo, MD: Now, you just said something really interesting, and I’m not going to let this slide by. We were talking about the chicken and the egg philosophy earlier. And we weren’t really sure whether metabolic syndrome predisposes you to psoriasis or vice-versa. But you just said that obese patients who have bariatric surgery have a smaller chance of having psoriasis.

Joel Gelfand, MD, MSCE, FAAD: In the future, yes.

Peter L. Salgo, MD: So didn’t you just answer my question?

Joel Gelfand, MD, MSCE, FAAD: Well the chicken and the egg are walking in the room at the same time.

Peter L. Salgo, MD: But in this case I got an egg and you operated on it, and that chicken never showed up.

Joel Gelfand, MD, MSCE, FAAD: That’s exactly right. But I think both sides of the coin can be going on, both issues can be at play.

Peter L. Salgo, MD: If you perform bariatric surgery so that they lose weight, and then psoriasis doesn’t show up as frequently, doesn’t that imply causation?

Joel Gelfand, MD, MSCE, FAAD: Well, yes. I think that there’s a lot of evidence to suggest that obesity is an important risk factor in developing psoriasis. But there are also data suggesting that when you have psoriasis, you develop complications related to metabolic disease, diabetes, things of that nature.

Steven Feldman, MD, PhD: I think the evidence would be strong if you randomized the patients to get the bariatric surgery or not.

Joel Gelfand, MD, MSCE, FAAD: Exactly.

Peter L. Salgo, MD: OK.

Steven Feldman, MD, PhD: If you didn’t randomize, then you have the issue of whether there is anything different about the people that you operate on. Now, I don’t operate on people for bariatric surgery. But I’ve talked to surgeons and they tell me they’re very particular about who they operate on.

Peter L. Salgo, MD: Sure they are. That’s why I brought it up; I didn’t want this issue to slide by here.

Joel Gelfand, MD, MSCE, FAAD: Right. But the point is, when patients who have multiple comorbid states are often overwhelmed by the healthcare system, they may not know what things are available to help them in these conditions. And so the goal is to make sure the patients get access to evidence-based interventions that can better fit their overall health. And so we know bariatric surgery will be helpful to people with a BMI over 40—there are good data on that.

Steven Feldman, MD, PhD: And they don’t have to have psoriasis to recommend it.

Joel Gelfand, MD, MSCE, FAAD: That’s true, that’s exactly right.

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