Issue 33 / 27 August 2012

A US study demonstrating that aggressive therapies for psoriasis can slash the risk of myocardial infarction has been welcomed by specialists who say this could justify wider use of expensive new therapies.

The research, published in the Archives of Dermatology, is the first large study to show that the use of tumour necrosis factor (TNF) inhibitors for psoriasis is associated with a clinically and statistically significant reduction in MI risk and incident rate compared with topical agents. (1)

Of 8845 patients with psoriasis or psoriatic arthritis who were enrolled in a large US health maintenance organisation, 1673 had been treated with a TNF inhibitor, 2097 received other systemic agents or phototherapy, and 5075 were treated with topical agents only.

The researchers found that the use of TNF inhibitors or older systemic treatments such as oral agents and phototherapy for psoriasis was associated with statistically significant reductions in MI risk of 50% and 46% respectively. The 4% difference between these risk reductions is not statistically significant, indicating that aggressive therapy of either type is the key.

“It seems that controlling psoriasis with aggressive therapy and, thus, lowering inflammation leads to a reduction in MI risk”, the authors concluded.

Sydney dermatologist Dr Stephen Shumack said the study confirmed what was already suspected and might help to justify higher funding under the Pharmaceutical Benefits Scheme (PBS) for new biological agents such as TNF inhibitors.

He said though biological agents like TNF inhibitors were expensive (around $15 000 per patient per year), they had fewer side-effects than oral agents and phototherapy.

“The bottom line is that if you’ve got bad psoriasis, it needs to be treated, and if it’s treated appropriately, the risk of other conditions is going to be less. From a cost-effectiveness point of view, expensive medications like TNF inhibitors may, in the longer term, be cheaper than we thought”, he said.

Currently only patients with the most extreme cases of psoriasis can receive TNF inhibitors under the PBS because of the high cost, said Professor Alan Cooper, clinical professor of dermatology at the Northern Clinical School of the University of Sydney.

“It is free for those on the PBS but the criteria around patient access are so incredibly strict, not many can be subsidised”, he said.

Gastroenterologist Professor Timothy Florin from the University of Queensland School of Medicine, who is involved in research into TNF inhibitors, said it was interesting that TNF inhibitors appeared to result in improved MI risk given that the literature is “possibly unnecessarily controversial and divided about whether to use anti-TNF where there is heart failure”.

“[The new US research is] a good study but it gives the wrong message that anti-TNF provides the benefit. In fact, the real message should be that any of the aggressive treatment modalities provided benefit”, Professor Florin said.

– Amanda Bryan

1. Arch Dermatol 2012; Online 20 August

Posted 27 August 2012

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