Coronary Plaques in Psoriasis Patients Change After Treatment With Biologics

SAN DIEGO, CA—Biologic therapies used to treat psoriasis show potential for decreasing both the volume and the burden of inflammation in atherosclerotic plaques, providing extra ammunition to combat the increased risk of MI that is associated with having psoriasis, according to data presented at the Society for Cardiovascular Angiography and Interventions 2018 Scientific Sessions.

Middle-age patients at low cardiovascular risk who had been taking US Food and Drug Administration-approved immunomodulatory therapy to treat their psoriasis had a decrease in coronary plaque volume of 40% after 1 year, reported Youssef Elnabawi (National Institutes of Health, Bethesda, MD).

“This is the [first study in humans] to show that biologic therapy was associated with regression of coronary plaque burden over 1 year, and this may potentially be due to modulation of proinflammatory cytokines . . . and it may serve as a basis of future randomized controlled trials,” Elnabawi said. “While this is too early to be adopted clinically, it does provide us with a novel way of looking at inflammation and inflammatory risk in coronary artery disease.”

The data build on previous evidence indicating that a 40-year old patient with severe psoriasis has about a 200% increased risk of early MI. Additionally, Elnabawi’s group published a paper in Circulation last year showing that psoriasis patients have a coronary plaque burden equivalent to that of CAD patients 10 years their senior.

Elnabawi’s findings are the latest in a spate of studies trying to connect the dots linking atherosclerosis and inflammation and looking at whether immune-modulating therapies could play a role in preventing coronary disease and acute events. Last year, the large, randomized CANTOS trial demonstrated a reduction in cardiovascular events among patients with high C-reactive protein (CRP) and prior MI using a monoclonal antibody, canakinumab (Novartis).

Coronary Parameters Worsen Without Biologics

As part of the Psoriasis, Atherosclerosis and Cardiometabolic Disease Initiative (PACI), Elnabawi’s group recruited patients who were receiving either some form of biologic therapy (n = 57) or topical or UV light therapy (n = 27). All underwent coronary CTA at their initial visit and again 1 year later.

Patients had a mean age of 51 years, were predominantly male, and had low Framingham risk scores. Clinical and laboratory changes indicated a significant reduction in CRP as well as in a proinflammatory, proatherosclerotic molecule, interleukin-1 beta (IL-1β), in the biologics group versus the nonbiologics group at 1 year. While the latter group also had decreases in CRP, they actually showed increases in IL-1β.

Elnabawi said the most surprising aspect of the findings was the morphological changes in plaque seen on coronary CTA. The vivid images in his presentation show the necrotic core changing and taking on a more atheroprotective, fibrous appearance.

Noncalcified plaque index decreased by about 10% in the group treated with biologics, from a mean of 1.29 mm2 to 1.17 mm2 (P = 0.03), while increasing in those on other therapies. Similarly, plaque volume decreased dramatically with biologics, from a mean of 2.5 mm3 to 1.5 mm3 (P = 0.002), and nearly doubled over the same time in the group on nonbiologic therapies.

“We saw that the change in plaque volume were associated with a change in interleukin-1 beta, a proinflammatory cytokine, over this 1 year, even after adjustment for traditional cardiovascular risk factors,” Elnabawi added.

‘Exciting’ Use of Coronary CTA

In an interview with TCTMD, Elnabawi said it is difficult to say for sure if the decreases in IL-1β are responsible for the plaque regression that was seen.

“It’s in one of the pathways of interest and maybe there is something going on there,” he noted. “But we can’t definitely say without more in vivo studies that IL-1 beta was directly involved.”

Following his presentation, panelist John McB. Hodgson, MD (MetroHealth Medical Center, Cleveland, OH), congratulated Elnabawi on the study and said it represents “a great use of cardiac CT to investigate new therapies” and opens up “very exciting possibilities.”

To TCTMD, Elnabawi said the PACI group will continue to be studied and will receive their final imaging again at 4 years, hopefully shedding more light on whether the differences between those on biologics vs nonbiologics continue to be seen over time.

“We’re just starting to get patients trickling in for their 4-year follow-up, and that’s the extent of the protocol that we have to follow them,” he added.