John Kraft

The effects of tumour necrosis factor inhibitors, methotrexate, non-steroidal anti-inflammatory drugs and corticosteroids on cardiovascular events in rheumatoid arthritis, psoriasis and psoriatic arthritis: a systematic review and meta-analysis

The objective of this systematic literature review was to determine the association between cardiovascular events (CVEs) and antirheumatic drugs in rheumatoid arthritis (RA) and psoriatic arthritis (PsA)/psoriasis (Pso). Systematic searches were performed of MEDLINE, EMBASE and Cochrane databases (1960 to December 2012) and proceedings from major relevant congresses (2010-2012) for controlled studies and randomised trials reporting confirmed CVEs in patients with RA or PsA/Pso treated with antirheumatic drugs. Random-effects meta-analyses were performed on extracted data. Out of 2630 references screened, 34 studies were included: 28 in RA and 6 in PsA/Pso. In RA, a reduced risk of all CVEs was reported with tumour necrosis factor inhibitors (relative risk (RR), 0.70; 95% CI 0.54 to 0.90; p=0.005) and methotrexate (RR, 0.72; 95% CI 0.57 to 0.91; p=0.007). Non-steroidal anti-inflammatory drugs (NSAIDs) increased the risk of all CVEs (RR, 1.18; 95% CI 1.01 to 1.38; p=0.04), which may have been specifically related to the effects of rofecoxib. Corticosteroids increased the risk of all CVEs (RR, 1.47; 95% CI 1.34 to 1.60; p<0.001). In PsA/Pso, systemic therapy decreased the risk of all CVEs (RR, 0.75; 95% CI 0.63 to 0.91; p=0.003). In RA, tumour necrosis factor inhibitors and methotrexate are associated with a decreased risk of all CVEs while corticosteroids and NSAIDs are associated with an increased risk. Targeting inflammation with tumour necrosis factor inhibitors or methotrexate may have positive cardiovascular effects in RA. In PsA/Pso, limited evidence suggests that systemic therapies are associated with a decrease in all CVE risk.

Hidradenitis Suppurativa in 64 Female Patients: Retrospective Study Comparing Oral Antibiotics and Antiandrogen Therapy

Background: Hidradenitis suppurativa (HS) is a recurrent disease confined to apocrine gland-bearing areas causing painful, deep-seated lesions and draining sinus tracts. Uniformly effective therapy is lacking. Improvements in current medical management strategies are needed. Objective: We sought to determine the success rate for a variety of treatments in our female HS patients and whether androgen-related tests can predict a response to antiandrogen therapy. As HS has been linked to a hyperandrogen state, we sought to determine if it is also associated with polycystic ovary syndrome (PCOS). Methods: A retrospective chart review was performed examining hormonal profiles and the response to a variety of treatments in female patients with HS. Results: Sixty-four female HS patients were identified (mean age 33 years). Antiandrogen therapy was superior to oral antibiotic therapy (55% vs 26%) based on a two-sample, two-sided, t-test statistic (p < .04). The prevalence of PCOS among our study patients in whom androgen markers were available was 8 of 21 (38.1%), and even if taken over all study patients, not necessarily investigated for PCOS, the prevalence was 8 of 64 (12.5%). This reflects a greater than expected prevalence among all women (10%). Conclusion: As a proof-of-concept study, despite limitations inherent in a retrospective chart review, there is sufficient signal to suggest that a hormonal manipulation approach to therapy should be considered in all women presenting with HS. Female patients presenting with HS should prompt investigations for underlying PCOS and insulin resistance.

Evidence-based Recommendations for the Management of Comorbidities in Rheumatoid Arthritis, Psoriasis, and Psoriatic Arthritis: Expert Opinion of the Canadian Dermatology-Rheumatology Comorbidity Initiative

Objective. Comorbidities such as cardiovascular diseases (CVD), cancer, osteoporosis, and depression are often underrecognized in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), or psoriasis (PsO). Recommendations may improve identification and treatment of comorbidities. The Canadian Dermatology-Rheumatology Comorbidity Initiative reviewed the literature to develop practical evidence-based recommendations for management of comorbidities in patients with RA, PsA, and PsO. Methods. Eight main topics regarding comorbidities in RA, PsA, and PsO were developed. MEDLINE, EMBASE, and the Cochrane Library (1960–12/2012), together with abstracts from major rheumatology and dermatology congresses (2010–2012), were searched for relevant publications. Selected articles were analyzed and metaanalyses performed whenever possible. A meeting including rheumatologists, dermatologists, trainees/fellows, and invited experts was held to develop consensus-based recommendations using a Delphi process with prespecified cutoff agreement. Level of agreement was measured using a 10-point Likert scale (1 = no agreement, 10 = full agreement) and the potential effect of recommendations on daily clinical practice was considered. Grade of recommendation (ranging from A to D) was determined according to the Oxford Centre for Evidence-Based Medicine evidence levels. Results. A total of 17,575 articles were identified, of which 407 were reviewed. Recommendations were synthesized into 19 final recommendations ranging mainly from grade C to D, and relating to a large spectrum of comorbidities observed in clinical practice: CVD, obesity, osteoporosis, depression, infections, and cancer. Level of agreement ranged from 80.9% to 95.8%. Conclusion. These practical evidence-based recommendations can guide management of comorbidities in patients with RA, PsA, and PsO and optimize outcomes.

Effect of biologics on depressive symptoms in patients with psoriasis: a systematic review.

Twenty to fifty percent of patients with psoriasis have depressive symptoms.

The Relationship of Obesity With the Severity of Psoriasis A Systematic Review

Background: Psoriasis is a chronic inflammatory disease associated with obesity. The increased production of adipocytokines in central adiposity contributes to the systemic inflammation of obesity and perhaps to psoriasis. Objective: The objective of this systematic review is to determine the association of obesity with psoriasis severity. Methods: We searched PubMed, EMBASE, and Cochrane Database for English-language papers involving human subjects for all years. We extracted data on age, sex, body mass index (BMI), proportion obese, and psoriasis severity index score (PASI). Results: We identified 254 articles in our search and included 9. The sample size was 134 823 psoriasis patients. Seven of the 9 studies found a statistically significant association of increased psoriasis severity with higher BMI. Conclusion: Increased severity of psoriasis appears to be associated with increased BMI. Most studies were cross-sectional or case-control, making it difficult to determine temporality. Dermatologists should consider recording BMI for psoriasis patients and offering them lifestyle counseling.

Meta-analysis of tumor necrosis factor inhibitors and glucocorticoids on bone density in rheumatoid arthritis and ankylosing spondylitis trials.

To examine the impact of antirheumatic drugs on bone mineral density (BMD) in rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), and psoriasis using a systematic review.

Psoriasis and Smoking A Systematic Literature Review and Meta-Analysis With Qualitative Analysis of Effect of Smoking on Psoriasis Severity

Background: Smoking has been associated with psoriasis prevalence and severity. Objective: To evaluate prevalence of smoking in patients with psoriasis and to examine the relationship between smoking and psoriasis severity. Methods: MEDLINE, EMBASE, and Cochrane databases (1960-2012) and conference proceedings (2010-2012) were systematically searched using keywords relevant to psoriasis and smoking. Controlled studies addressing psoriasis and smoking status were included. A meta-analysis for the relative risk of smoking in psoriasis patients was performed. Results: Meta-analysis identified a significant association between smoking and psoriasis with a relative risk of 1.88 (95% CI, 1.66-2.13) for smoking in patients with psoriasis versus patients without psoriasis. Eight articles of 11 with data on smoking and psoriasis severity suggested that severity increases with smoking status. Conclusions: This literature review is in favor of a positive association between the prevalence of smoking and psoriasis as well as an association between smoking and severity of psoriasis.

Response to: ‘Drugs and cardiovascular risk in inflammatory arthritis: another case of glucocorticoid-bashing?’ by Dr Boers

We thank Dr Boers for the interesting comments1 on our paper2. First, the decision to exclude studies reporting less than 400 patients was made after noticing that most of these studies had less than 1 year of follow-up or had large drop-outs with few remaining patients at or beyond 1 year. We also reviewed the abstract by Tarp et al .3 Among a total of 4831 subjects, 1944 were specifically analysed for …

Henry Vandyke Carter: A Physician Worthy of Recognition

To the Editor: No. 2 Belgrave Crescent in Scarborough, England, is distinguished by an English Heritage plaque honoring Henry Vandyke Carter. It acknowledges him as a pathologist and illustrator of Gray’s Anatomy. However, Carter should also be recognised for his important contributions to dermatology research. Born in Yorkshire in 1831 to a renowned watercolorist and named after the Flemish painter, Anthony Van Dyck, Henry Vandyke Carter had a natural talent for drawing. He chose to apply his skills in the field of medicine. Carter trained as an apothecary and later studied medicine at the University of London. While working as a demonstrator in anatomy at St George’s Hospital in London, his anatomical artistry was noticed by Henry Gray. Together, for almost 2 years, Carter and Gray dissected corpses from the hospital and workhouses to better understand and record anatomical structure. Their collaboration resulted in the publication of the acclaimed book Anatomy: Descriptive and Surgical (original title of Gray’s Anatomy) in 1858. Despite Carter’s noteworthy illustrations, his contribution was obscured, and he did not receive financial or appropriate personal credit. Richardson writes in The Making of Mr. Gray’s Anatomy, “Although the book’s famous selling point has always been its illustrations, the name of the man who drew them is hardly known.” His conflict with Gray spurred Carter to join the Indian Medical Service. Interestingly, the private lifestyle that he had sought in England escaped Carter in India. He married Harriet Bushell, who was actually Amelia Adams pretending to be a widow after her first marriage had ended because of adultery. This caused a dramatic scandal, drawing Carter much unwelcomed attention. Carter became a professor of anatomy and physiology at Grant Medical College, and he moved through the ranks of the Indian Medical Service to brigade-surgeon. Carter was appointed by the British government to investigate skin diseases in India. He developed an interest in leprosy and had several publications on the subject. Carter visited Norway to learn about its segregation and treatment of patients with leprosy. A proponent of the contagion theory, he advised the government about segregating people afflicted with leprosy in India. His epidemiologic study was published in 1876 as “Notes by Vandyke Carter.” This was the first publication of dermatological literature from India. In 1883, Carter was the first to demonstrate lepra bacilli in India. He was a pioneer in leprosy research. In addition, Carter investigated “bouton de Briska” (Sind sore, Delhi boil), elephantiasis, and lymphscrotum. He also named mycetoma as a “fungal tumour” and described its clinical presentation. After spending 30 years in India, Carter returned to England. He was appointed Honorary Surgeon to Queen Victoria in 1890. Carter died in 1897 of tuberculosis. Ironically, he was the first to confirm the presence in India of the organism causing tuberculosis. Henry Vandyke Carter deserves to be recognised not only for his remarkable medical illustrations but also for advancing dermatology, especially the study of leprosy.

Dr. Roubille, et al reply

To the Editor: We thank Castaneda, et al 1 for their comments on our article2. We do support comorbidity management in rheumatoid arthritis (RA), psoriatic arthritis (PsA), and psoriasis (PsO) in daily practice to ensure optimal care and outcomes, and completely agree with the recently published Spanish recommendations3. Given that patients with RA have increased risk of cardiovascular (CV) morbidity and mortality4, CV monitoring appears critical. In the CARMA (CARdiovascular in rheuMAtology) study, Castaneda, et al 5 reported that patients with RA, PsA, and PsO had higher prevalence of CV events while receiving biological therapy despite being in low disease activity for almost half of the patients. Notably, almost half of the patients also received nonsteroidal antiinflammatory drugs and/or glucocorticoids (patients with RA), which may have increased CV risk6. Regardless of the other confounding factors, these data reinforce the importance of CV monitoring and … Address correspondence to Dr. C. Roubille, University of Montreal Hospital Research Center (CRCHUM), Notre-Dame Hospital, Montreal, Quebec H2L 1S6, Canada. E-mail: camille.roubille{at}gmail.com