What is the best treatment approach for a patient with plaque psoriasis, heart failure, and diabetes?

Treatment for Plaque Psoriasis with Heart Failure and Diabetes

In patients with plaque psoriasis, heart failure, and diabetes, IL-17 inhibitors or IL-12/23 inhibitors (such as ustekinumab) are the preferred biologic options, as TNF inhibitors are relatively contraindicated in New York Heart Association class III or IV heart failure. 1

Critical Contraindications and Safety Considerations

TNF Inhibitor Restrictions in Heart Failure

• TNF inhibitors are relatively contraindicated in patients with New York Heart Association class III or IV congestive heart failure, as clinical trials showed no benefit and one trial demonstrated increased mortality compared with control therapy 1
• Population-based studies reveal that mortality is associated with increasing TNF use in heart failure patients, with 1-year mortality estimates of 16%, 18%, 23%, and 32% for patients in the lowest to highest TNF-α quartiles respectively 1
• If heart failure is NYHA class I or II, TNF inhibitors may be considered with extreme caution and close cardiac monitoring 1

Preferred Biologic Options for This Patient Population

• IL-17 inhibitors are conditionally recommended when TNF inhibitors are contraindicated due to congestive heart failure 1
• IL-12/23 inhibitors (ustekinumab) are conditionally recommended when TNF inhibitors are contraindicated due to congestive heart failure, with the additional benefit of less frequent drug administration 1
• Apremilast (oral small molecule) may be considered if the patient has contraindications to biologics, including cardiovascular disease, though biologics generally provide superior efficacy 1

Cardiovascular Risk Management Requirements

Mandatory Screening and Monitoring

• All patients with psoriasis should undergo cardiovascular risk assessment including screening for hypertension, diabetes, and hyperlipidemia according to national guidelines 1
• For patients requiring systemic therapy or with >10% body surface area involvement, consider early and more frequent screening for hypertension, diabetes, and hyperlipidemia 1
• Risk score models should be adapted by introducing a 1.5 multiplication factor when the patient has disease severity of BSA >10% or is a candidate for systemic or phototherapy 1

Diabetes Management Considerations

• The age-adjusted proportion of diabetes is significantly higher in psoriasis patients (OR 1.27,95% CI 1.1-1.48), and psoriasis severity correlates with diabetes risk 2
• Patients with psoriasis and diabetes have higher rates of microvascular conditions (retinopathy, nephropathy, neuropathy) and macrovascular complications 1
• Maintain close communication with the patient's primary care provider to ensure fasting blood glucose and/or hemoglobin A1C monitoring 1

Treatment Algorithm Based on Disease Severity

For Mild Psoriasis (<3% BSA)

• High-potency topical corticosteroids remain first-line, used for up to 4 weeks 3
• Vitamin D analogs (calcipotriene) can be combined with corticosteroids for enhanced efficacy 3
• Topical calcineurin inhibitors are particularly useful for facial and intertriginous areas 3

For Moderate-to-Severe Psoriasis (≥3% BSA)

• Phototherapy (narrowband UVB) can be considered as first-line for moderate disease, though requires multiple visits and time commitment 3
• For systemic therapy candidates, prioritize IL-17 inhibitors or IL-12/23 inhibitors given the heart failure contraindication to TNF inhibitors 1

Traditional Systemic Agents: Use with Extreme Caution

• Methotrexate requires careful consideration given potential hepatotoxicity and the patient's likely metabolic syndrome; requires baseline and regular monitoring of CBC, liver function tests, and serum creatinine 1, 3
• Cyclosporine poses significant nephrotoxicity risk and requires baseline and regular monitoring of serum creatinine and blood pressure; hypertension is already a concern in this population 1, 3
• Acitretin may worsen lipid profiles (elevations in triglycerides and cholesterol), though these can be managed with fibrates and statins; requires monitoring of lipids and liver function 1, 3

Specific Medication Considerations

IL-17 Inhibitors (Preferred Option)

• Effective for moderate-to-severe psoriasis without the cardiac contraindications of TNF inhibitors 1
• Particularly appropriate when severe psoriasis is present or when TNF inhibitors are contraindicated due to congestive heart failure 1

IL-12/23 Inhibitors (Preferred Option)

• Ustekinumab offers less frequent drug administration (every 12 weeks after loading) 1
• Appropriate when congestive heart failure contraindicates TNF inhibitors 1
• Meta-analysis data showed no statistically significant increased risk for major adverse cardiovascular events with ustekinumab, though one analysis using different statistical methods found OR 4.23 (P=0.04) 1

Adalimumab (TNF Inhibitor - Use Only if NYHA Class I-II)

• FDA-approved for moderate-to-severe chronic plaque psoriasis: 80 mg initial dose, followed by 40 mg every other week starting one week after initial dose 4
• Serious infections warning: increased risk of serious infections leading to hospitalization or death, including tuberculosis, bacterial sepsis, and invasive fungal infections 4
• Contraindicated or use with extreme caution in heart failure: particularly NYHA class III or IV 1, 4
• Requires tuberculosis testing before initiation and monitoring for active TB during treatment 4

Critical Pitfalls to Avoid

Systemic Corticosteroids

• Absolutely avoid systemic corticosteroids in psoriasis, as they can precipitate erythrodermic psoriasis or generalized pustular psoriasis upon discontinuation 5
• Systemic corticosteroids should only be used in rare specific conditions: persistent uncontrollable erythroderma causing metabolic complications, generalized pustular psoriasis when other drugs are contraindicated, or hyperacute psoriatic polyarthritis threatening severe irreversible joint damage 5

Drug Interactions and Metabolic Monitoring

• Co-morbidity necessitates co-medication; potential drug interactions must be considered when choosing systemic anti-psoriatic therapy 6
• When managing elevated lipids from retinoid therapy, exercise caution when combining statins and fibrates due to rhabdomyolysis risk 1
• Antihypertensives and statins may be used as in the general population for cardiovascular risk management 1

Lifestyle Modifications and Comprehensive Care

Essential Patient Counseling

• Psoriasis itself is an independent risk factor for cardiovascular mortality; patients must avoid other known risk factors such as obesity and smoking 1, 6
• Lifestyle modifications including dietary changes to achieve normal BMI, smoking cessation, and exercise regimen (3 times weekly for 30 minutes or more) are critical 1
• Effective continuous systemic therapy of severe psoriasis is accompanied by amelioration of biomarkers of cardiovascular risk 7

Multidisciplinary Coordination

• Cardiovascular risk management should be performed by either a primary care physician or other healthcare provider experienced in cardiovascular risk management, or the dermatologist 1
• Target blood pressure and lipid levels are based on risk calculated for psoriasis (with 1.5 multiplication factor) 1
• Regular consultation with cardiologists is necessary to confirm diagnoses and establish treatment plans 1