Published in Dermatology

Journal Scan / Research · June 18, 2019

Prevalence of Advanced Liver Fibrosis in Patients With Severe Psoriasis

JAMA Dermatology

TAKE-HOME MESSAGE

• Among the 333 participants with severe psoriasis treated with transient elastography, 47 (14.1%) demonstrated advanced liver fibrosis. The majority of participants were overweight (37%) or obese (37.2%) and had insulin resistance (53%). The highest risk for liver fibrosis was observed in those people with central obesity and insulin resistance. While many of the participants reported current or past treatment with methotrexate, this exposure was not significantly associated with liver fibrosis.

• This study indicated that the prevalence of advanced liver fibrosis in patients with severe psoriasis was higher than that previously reported for overweight (2%) or obese (9%) patients in the general population.

– Caitlyn T. Reed, MD

Written by

 

 

James F Libecco MD

This intriguing paper supports several ideas I have had over the last decade, but then opens an entirely new set of questions regarding treatment choices and dogmatic training regarding the use of methotrexate and psoriatic therapy. Many years ago, I saw data suggesting that the risk factors for hepatic fibrosis were more likely to be based on risk factors for nonalcoholic fatty liver disease (NALFD) rather than alcohol consumption, despite our continual reminders that patients on methotrexate should not consume alcohol.

This paper brings forth the idea that patients at risk of NAFLD might not only be better off avoiding liver-toxic medications but also may see benefit from IL-17 inhibitors, as this is apparently a key factor in the development of liver fibrosis, not only psoriatic disease (or that maybe we should consider NAFLD as just another component of the psoriatic inflammatory cascade). There was actually a slight tendency toward worse liver fibrosis with lesser alcohol consumption, warranting a thought that there may be some benefits that are yet unexplored with alcohol, liver fibrosis, and alcohol.

In the end, this brings to the forefront that increased abdominal circumference and insulin resistance are key factors not just in NAFLD, but these are features seen through the psoriatic comorbidity literature. I will continue to emphasize exercise, diet, weight loss, lipid control, and avoiding liver-toxic medications in my at-risk population. In the future, I also may think that specific therapeutic targeting with medications, such as IL-17 inhibitors, may be key to long-term success.

IMPORTANCE

Advanced liver fibrosis is a precursor to cirrhosis, a leading cause of mortality. People with severe psoriasis are at risk for liver disease, but our understanding of advanced fibrosis in individuals with psoriasis is limited.

OBJECTIVES

To describe the prevalence of and evaluate the clinical factors associated with advanced liver fibrosis in people with severe psoriasis.

DESIGN, SETTING, AND PARTICIPANTS

The Co-morbidities in Severe Psoriasis study, a prospective observational cohort study in a large center serving London and Southeast England, was conducted from October 18, 2012, to April 2, 2015; 400 adults with severe psoriasis (Psoriasis Area Severity Index score, ≥10) were recruited from outpatient clinics. Statistical analysis was conducted from October 2, 2016, to March 3, 2017.

MAIN OUTCOMES AND MEASURES

The primary outcome was a diagnosis of advanced liver fibrosis determined by transient elastography, a noninvasive criterion standard test. Clinical factors evaluated included psoriasis-specific and metabolic indices, alcohol use, and methotrexate exposure.

RESULTS

Of 400 patients recruited (108 women and 289 men; mean [SD] age, 49.5 [13] years), 333 had a successful transient elastography scan and were included in final analysis. Forty-seven patients (14.1%; 95% CI, 10.4%-17.9%) had advanced liver fibrosis as diagnosed by transient elastography. The clinical factors that produced the best-fit model for advanced fibrosis were central obesity (waist circumference), insulin resistance, aspartate aminotransferase level, platelet count, psoriasis disease severity, and reduced alcohol use (R2 = 0.54).

CONCLUSIONS AND RELEVANCE

Findings from this study suggest that advanced fibrosis is common in severe psoriasis. Abdominal obesity (by waist circumference) and insulin resistance were associated with the presence of advanced fibrosis. Longitudinal work to characterize the hepatic sequelae of central obesity, insulin resistance, and inflammation as well as the influence of systemic drugs (methotrexate and biologics) will inform future personalized therapeutic decision-making.

JAMA Dermatology

Prevalence of Advanced Liver Fibrosis in Patients With Severe Psoriasis

JAMA Dermatol 2019 Jun 05;[EPub Ahead of Print], CM Maybury, HF Porter, E Kloczko, M Duckworth, A Cotton, K Thornberry, T Dew, M Crook, S Natas, R Miquel, CM Lewis, T Wong, CH Smith, JN Barker

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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