Psoriasis Patients, Docs Want to Do More to Prevent Heart Problems

More attention to statin therapy and other ways to reduce cardiovascular (CV) risks associated with psoriatic diseases would be welcomed by both patients and the doctors who treat them, survey results indicated.

Among 322 U.S. patients completing an electronic questionnaire, a large majority agreed that they "would like it if my dermatologist/rheumatologist educated me about my risk of heart disease" and that it would help "to have my cholesterol checked by my dermatologist/rheumatologist," according to John S. Barbieri, MD, MBA, of Brigham and Women's Hospital in Boston, and colleagues.

Similarly, about two-thirds of the 183 dermatologists queried thought it was feasible for them to check blood lipid levels and assess their patients' CV risk, to determine if statin therapy is warranted, they reported in JAMA Dermatology.

These physicians appeared more reluctant, however, to actually prescribe statins. Only about 36% "agreed or strongly agreed" with the statement, "I think prescribing statins when they are indicated based on guidelines for primary prevention of cardiovascular disease seems doable," Barbieri and colleagues indicated.

But the figure rose to 68% when asked whether "they would change their practice to screen and manage CVD [disease] risk," including writing statin prescriptions, if a clinical trial showed improved patient outcomes with such a strategy.

The researchers noted that, currently, management of CV risk in psoriatic disease patients -- i.e., those with psoriasis or psoriatic arthritis (PsA) -- is far short of optimal. Despite ample evidence that these patients are at markedly greater risk of early death, most patients with elevated blood lipids are not on statin therapy. They cited a 2012 study showing that just 24% of patients with moderate-to-severe psoriasis, and for whom statins would be recommended, were actually using them (statin uptake is also low in the general population, Barbieri's group wrote, but the figure for psoriasis patients was substantially lower).

One reason for the low rates, they hypothesized, is that many psoriatic disease patients receive most of their care from dermatologists and rheumatologists, seeing primary care physicians (PCP) infrequently if at all. The result is "that the current model in which the patient is referred back to their primary care physician for screening and management of CVD risk factors may not be useful for many patients with psoriatic disease," they stated.

In an accompanying editorial, Michael S. Garshick, MD, MS, and Jeffrey S. Berger, MD, MS, both at NYU Langone Health in New York City, agreed that CV risk management is largely lacking in this patient population, and that specialists could do more to address this gap.

The question then becomes, how much responsibility are specialists willing and able to take? They noted that "CVD risk reduction in patients with psoriasis should expand beyond lipid management to include blood pressure, glucose lowering, obesity management, and antiplatelet therapy. It is almost impossible to address all of these concepts in a single visit, especially when one also has to address skin and joint manifestations."

And would patients be amenable to even part of this discussion?

Barbieri's group devised two parallel surveys, one for patients and one for dermatologists and rheumatologists. Besides the primary questions on the overall acceptability of specialist-led management of CV risk, the survey also asked about particular strategies. For clinicians, this included preferences around the degree of their involvement (e.g., telemedicine consults with their patients versus electronic reminders that they should seek CV risk screening).

Patients were asked about their willingness to accept particular preventive steps, including statins but also lifestyle changes.

Barbieri's group set participant targets of 160 each for patients with psoriasis and PsA, and also for dermatologists and rheumatologists. In the end, the latter had to be abandoned, as only 27 rheumatologists completed the survey, although participation by dermatologists exceeded the goal. Totals for patients with psoriasis and PsA reached 160 and 162, respectively.

Contrary to what the researchers may have expected from prior studies, most patients in both groups said they had seen a PCP at least once in the past year. However, for those with PsA, their interactions with specialists were considerably more frequent, with 56% saying they had seen one more than twice, whereas only 26% had visited a PCP more than twice.

Across both patient groups, more than 80% indicated that they would accept physician recommendations to have their lipids checked, whether from primary care or specialist physicians. Acceptance of statin therapy if recommended was a bit less, at about 60%, again irrespective of provider type.

Notably, despite the widely held notion that Americans prefer pills to lifestyle alterations, both diet modifications and exercise programs scored higher than statins. About 75%-80% of patients said they would be "likely" to engage in both when recommended by physicians.

Responses among dermatologists showed that their most-preferred strategy regarding CV risk was, by a wide margin, to see it highlighted in their electronic health records systems, followed by "physician education outreach" and education materials to give to patients. The least-preferred approaches were comparisons with peers, financial incentives based on patient records, and electronic patient reminders.

Barbieri and colleagues suggested that specialty clinics would benefit from use of care coordinators along with physician-led patient education.

"In this model," the authors explained, "the specialist educates the patient regarding psoriasis and cardiovascular risk, measures blood pressure, checks a lipid panel, and refers the patient to the care coordinator," who then delves deeper into the patient's history to calculate a CV risk score. The coordinator then makes recommendations back to physicians about further care, including whether statins and/or hypertension treatment is needed, and also circles back to the patient to reinforce the educational aspects and advise on lifestyle approaches.

As in any survey study, limitations included the response rate, which the researchers conceded was low, and the fact that respondents' stated intentions in hypothetical scenarios often don't match up with actual performance. Also, the survey could not address every potential management approach.

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