2015

1. 2015 PSORIATIC DISEASE COMORBIDITIES Presented by Ron Prussick, MD

2. Today’s talk Ron Prussick, MD Medical Director, Washington Dermatology Medical Center in Washington, D.C. Assistant Clinical Professor of Dermatology, George Washington University

3. Overview Introduction: what is a comorbidity? Established comorbidities for psoriasis and psoriatic arthritis Does treatment impact comorbidities? How to minimize your risks and work productively with your health care team Question and answer session

4. What is a comorbidity? Definition: a comorbidity is a disease or condition that coexists with a primary disease but also stands on its own as a specific disease For many comorbidities associated with psoriatic disease, the common thread is inflammation

5. Acute and chronic inflammation Inflammation can be acute (response to a paper cut, a sunburn) or chronic Acute inflammation is healthy and a sign your body is functioning normally Chronic, persistent inflammation can contribute to serious health risks

6. Psoriasis is a systemic disease The image at left shows increased inflammation:(A) in the patient's right knee joint and surrounding muscle and in the ankle;(B) throughout the liver;(C) in the wall of the aorta and arteries in both thighs that lead to the aorta; and(D) on the skin in the lower parts of the legs, consistent with inflammation of psoriasis plaques.

7. Inflammation and psoriasis FDG-PET/CT imaging of skin correlates with observed skin inflammation.

8. Comorbidities associated with psoriatic disease Psoriatic arthritis Cardiovascular disease/ increased mortality Obesity / metabolic syndrome Other autoimmune diseases Skin cancer / lymphoma Nonalcoholic fatty liver disease Psychiatric diseases COPD Sleep issues, sleep apnea Vitamin D deficiency Uveitis Pregnancy complications

9. Psoriatic arthritis It is estimated that up to 30 percent of people with psoriasis develop psoriatic arthritis Can cause swelling, stiffness and pain in/around the joints, nail changes and fatigue Early recognition, diagnosis and treatment of psoriatic arthritis are critical to relieve pain and inflammation and help prevent joint damage

10. Cardiovascular disease: what is it? Also called heart disease Issues are caused by atherosclerosis: plaque builds up in the walls of the arteries Includes: Heart valve problems Arrhythmia Heart attack Stroke

11. Cardiovascular disease People with severe psoriasis are 58% more likely to have a major cardiac event 43% more likely to have a stroke Some researchers report that the leading cause of death for people with severe psoriatic arthritis is cardiovascular disease

12. Metabolic syndrome What is it? A cluster of conditions that include increased blood pressure, a high blood sugar level, excess body fat around the waist and abnormal cholesterol levels Increases one’s risk of heart disease, stroke and diabetes

13. Metabolic syndrome A national sample of more than 6,500 people found that 40 percent of those with psoriasis had metabolic syndrome Compared with just 23 percent of the general population More women with psoriasis had metabolic syndrome than men People with severe psoriatic arthritis are at even higher risk, with 44 percent diagnosed with metabolic syndrome in a recent study

14. Obesity People with psoriatic disease are more likely to be obese than the normal population Children with psoriasis are at much greater risk of being obese Being overweight at 18 increases the risk of developing psoriatic arthritis Losing weight can improve psoriatic disease symptoms and help make treatments more effective

15. Type 2 diabetes Most common type of diabetes Blood glucose (sugar) levels to rise higher than normal Body does not use insulin properly Symptoms Increased thirst Hunger Blurred vision Fatigue

16. Diabetes People with severe psoriasis, in particular, are 30 percent more likely to have type 2 diabetes A drug called glucagon-like peptide-1 used to treat type 2 diabetes may help psoriasis, too

17. Nonalcoholic fatty liver disease Non-alcoholic fatty liver disease (NAFLD) is the build up of extra fat in liver cells that is not caused by alcohol People with psoriasis and psoriatic arthritis may be at greater risk for developing NAFLD NAFLD tends to develop in people who are overweight or obese or have diabetes, high cholesterol or high triglycerides

18. Symptoms of NAFLD Often has no symptoms Can include fatigue, weakness, weight loss, loss of appetite, nausea, abdominal pain, spider-like blood vessels, jaundice, edema, and mental confusion

19. Crohn’s disease: what is it? Chronic inflammatory condition of the gastrointestinal tract Autoimmune disease Common symptoms: Diarrhea Abdominal cramping, pain and tenderness Bloody stools Weight loss Fever Feeling of a mass or fullness in the abdomen Rectal bleeding

20. Crohn’s disease Connection between psoriasis, psoriatic arthritis and inflammatory bowel disease In a recent study of women with psoriasis, 10% developed a form of inflammatory bowel disease Those with both psoriasis and psoriatic arthritis are at a greater risk of developing Crohn's People with psoriatic disease and Crohn's share similar genetic mutations

21. Cancer People with psoriatic disease have an increased risk of certain types of cancer Lymphoma, nonmelanomaskin cancer No single treatment significantly raises the risk of cancer One study showed a the three-fold increased rate of lymphoma amongst people with psoriasis Translates to only 12 additional cases for every 10,000 people with psoriasis

22. Psychiatric disorders Emotional distress, low self-esteem, mood disorders, depression People with psoriatic arthritis are at greater risk of developing depression than those with psoriasis alone Studies show that treating your disease can alleviate symptoms of depression

23. Sleep issues with psoriatic disease People with psoriasis sleep 20 minutes less than controls Itching, arthritis pain or stiffness Sleep apnea Sleep disorder in which breathing repeatedly stops and starts Linked with snoring loudly and feeling tired even after a full night's sleep

24. Vitamin D: the sunshine vitamin Vitamin D has a role in regulation of the immune system Modulates dendritic cells, regulates keratinocytes/T cells Maintains normal blood levels of calcium and phosphorus May also protect against osteoporosis, high blood pressure, cancer, and other diseases

25. Vitamin D deficiency People with psoriatic disease often have low-levels of vitamin D Vitamin D topical ointments are successfully used treat psoriasis A 2012 study found that 57% people with psoriasis had vitamin D deficiency 80% in winter months Vitamin D deficiency is a risk factor for osteoporosis Studies have shown associations between low levels of vitamin D and increased risk of diabetes mellitus, metabolic syndrome and cardiovascular mortality

26. How to address vitamin D deficiency Food sources of vitamin D include: Cod liver oil Salmon (sockeye) Mackerel Tuna fish canned in water Milk, non-fat, reduced-fat, and whole, vitamin D-fortified Orange juice fortified with vitamin D Yogurt fortified with 20 percent of the daily value of vitamin D Eggs, vitamin D is found in the yolk Swiss cheese Fortified cereals A simple blood test can tell you whether you're deficient in vitamin D

27. Supplementation guidelines for vitamin D Optimal dosage regimens for vitamin D remain uncertain Guidelines between 400 and 1000 IU of Vitamin D daily Toxicity from vitamin D supplementation is very rare; usually results from doses that exceed 10 000 IU per day The tolerable upper level of daily vitamin D intake recently set by the Institute of Medicine is 600 IU

28. Uveitis Uveitis is an inflammatory disease of the eye About 7 percent of people with psoriatic arthritis will develop uveitis Systemic treatment for psoriatic disease can help with some of the symptoms, but uveitis usually requires specific treatment Rheumatologists also treat uveitis

29. Can treatment of Pso/PsA lower your risk of comorbidities? Limited studies have indicated yes, but more research is needed One study suggests treating your disease can reduce risk of heart attack and stroke Studies show that treating your psoriasis can alleviate symptoms of depression

30. Lowering your risk factors Maintain a healthy diet and weight Physical activity Get plenty of rest Keep stress low Don’t smoke Treat psoriasis and psoriatic arthritis symptoms to target level of severity

31. Wellness & primary care People with psoriatic disease should incorporate regular skin cancer screenings into their routine care Consider asking your doctor for a bone density scan

32. Diet recommendations Eating a low-fat diet rich in fruits, vegetables and lean protein, will lower your risk of developing associated comorbidities Coldwater fish, colorful fruits and vegetables, beans and legumes Limit alcohol, processed foods, refined sugars, trans-fats, and full-fat dairy products

33. Gluten intolerance & psoriasis It is estimated that up to 25% of people who have psoriasis also are sensitive to gluten Can be identified by the presence of anti-gliadin (AGA) and anti-endomysial (AEA) antibodies GF diets will not clear everyone's psoriasis But they do have a good chance of significantly reducing the psoriasis of people who test positive for the AGA antibody

34. Attempting a gluten-free or elimination diet It is recommended that you remain completely gluten-free for at least three months Beware of hidden sources of gluten, barley and their derivatives: includes malt flavoring, rye, MSG and soy sauce After three months, if you are unsure if you've seen a benefit from eliminating gluten, add it back into your diet Over the next three to four days be sure to make note of increased itching, joint pain, headaches etc. If you don't notice any benefit, you may choose to add gluten back into your diet Consult with a physician or dietician before starting

35. Exercise recommendations At least 150 minutes of moderate intensity aerobic physical activity (2 hours and 30 minutes) each week About 20 minutes a day Activities include: Walking briskly Water aerobics Muscle-strengthening activity provides additional benefits Talk with a physical therapist if you have concerns about how to be active safely

36. Tips for good sleep hygiene Make sure the room is dark Wake and fall asleep at the same times each day Eliminate noise and distractions Keep the room at a cool, comfortable temperature Avoid stimulants like caffeine close to bedtime Avoid using electronics, watching television in bed

37. Diabetes prevention and tips Healthy body weight, healthy diet Blood glucose screening if: Age 45 or older and overweight Younger than 45 and overweight with one or more additional risk factors for type 2 diabetes Such as a sedentary lifestyle or a family history of diabetes

38. Weight loss tips Keep a food diary Eat slowly, and intentionally Plan your meals ahead of time so you make healthy choices Eat when you're truly hungry rather than when you are tired, anxious, or stressed Stay hydrated-- Oftentimes people mistake thirst for hunger Eat breakfast

39. Working with your doctor Should you ask your doctor to test your inflammation levels? The C-reactive protein Screening for other risk factors Maintain open communication so you can adapt your psoriasis/psoriatic arthritis treatment plan as needed to keep symptoms under control Take medications as directed

40. Next steps in research Further research is needed on a larger scale Assess the effect of psoriatic disease treatments on inflammation Study the effect of psoriatic disease drugs on blood vessel diseases Further understand the relationship between psoriasis inflammation and vascular disease

41. Question and answer session