What is the best approach to manage a psoriasis patient with hypercholesterolemia and elevated LDL, who is a chronic tobacco chewer?

Management of Psoriasis with Hypercholesterolemia and Tobacco Use

Initiate high-potency statin therapy (atorvastatin or rosuvastatin) immediately to target LDL-C <70 mg/dL, counsel on tobacco cessation as a priority cardiovascular risk factor, and select TNF-alpha inhibitor biologics over traditional systemic agents for psoriasis treatment given the cardiovascular risk profile. 1, 2

Cardiovascular Risk Assessment and Lipid Management

Your patient requires aggressive cardiovascular risk reduction given the convergence of multiple high-risk factors:

• Psoriasis itself is an ASCVD risk-enhancing factor that warrants a 1.5 multiplication factor when calculating cardiovascular risk, particularly for patients requiring systemic therapy 1

• With TC 265 mg/dL and LDL 165 mg/dL, combined with psoriasis and tobacco use, this patient meets criteria for high-intensity statin therapy 1

• Target LDL-C should be <70 mg/dL (<1.8 mmol/L) given the presence of multiple major ASCVD risk factors (psoriasis, hyperlipidemia, tobacco use) 1

• Initiate maximally tolerated high-potency statin (atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily) 1, 3

• If LDL-C goal is not achieved after 6-12 weeks, add ezetimibe 10 mg daily 1

• Consider PCSK9 inhibitor therapy if goals remain unmet despite maximally tolerated statin plus ezetimibe 1

Tobacco Cessation as Priority Intervention

• Tobacco cessation counseling must be provided at every visit as smoking is a modifiable cardiovascular risk factor that compounds the already elevated risk from psoriasis 1

• Chronic tobacco use may worsen psoriasis severity and reduce treatment response, making cessation doubly important 1

Psoriasis Treatment Selection

TNF-alpha inhibitors (adalimumab, etanercept, or infliximab) are the preferred systemic therapy for this patient over traditional agents for the following reasons: 1, 2

Why TNF-Alpha Inhibitors Are Optimal:

• No known drug interactions with statins or other cardiovascular medications 1, 2

• No deleterious effects on renal function or blood pressure, unlike cyclosporine 1, 2

• No adverse effects on lipid profiles in psoriasis patients (unlike acitretin which elevates triglycerides in 25-50% and cholesterol in patients) 1

• Fewer significant safety issues compared to traditional systemic agents 1, 2

Why Traditional Systemic Agents Should Be Avoided:

Acitretin is contraindicated in this patient because: 1

• Elevates serum transaminases in up to 16% of patients
• Elevates triglycerides in 25-50% of patients
• Would worsen existing dyslipidemia

Cyclosporine should be avoided because: 1, 4

• Commonly causes or exacerbates hypertension (occurred in 27.5% of psoriasis patients in trials)
• Elevates serum triglycerides and cholesterol in many patients
• Increases cardiovascular risk in patients already at high risk
• Best used only as short-term "rescue" therapy, not maintenance treatment

Methotrexate is less favorable given potential hepatotoxicity concerns, though it remains an option if biologics are unavailable 2

Monitoring Protocol

Lipid monitoring: 1

• Fasting lipid panel at 6-12 weeks after statin initiation
• Repeat every 3-6 months until LDL-C goal achieved
• Then annually if stable

Cardiovascular screening: 1

• Blood pressure measurement every visit (at minimum every 3 months)
• Fasting glucose or HbA1c every 6-12 months to screen for diabetes
• Calculate 10-year ASCVD risk using pooled cohort equations with 1.5 multiplication factor for psoriasis

Psoriasis treatment monitoring: 2

• Assess treatment response at 12-16 weeks
• Monitor for infections given immunosuppressive therapy
• Screen for tuberculosis before initiating biologic therapy

Critical Pitfalls to Avoid

• Do not delay statin therapy - this patient has clear indication for immediate high-intensity statin treatment given LDL 165 mg/dL with multiple risk factors 1

• Do not use cyclosporine as first-line therapy despite its efficacy for psoriasis, given the cardiovascular and metabolic profile 1, 4

• Do not assume statins will worsen psoriasis - evidence suggests statins may actually improve psoriasis through anti-inflammatory effects and are safe to use 5, 6

• Do not ignore the systemic inflammatory burden - psoriasis is an immunometabolic disease with systemic effects beyond the skin 7, 8

• Statins can be used safely in psoriasis patients and may provide dual benefit for both cardiovascular risk reduction and potential psoriasis improvement through immunomodulatory effects 5, 6