Effects of Systemic Treatment on the Risk for Cardiovascular Diseases in Psoriasis: A Nationwide Population-Based Study in South Korea

Psoriasis has been linked to various comorbidities including cardiovascular diseases. Recently, biologics have become widely used for their remarkable effectiveness and favorable safety profile. Nonetheless, many patients with moderate-to-severe psoriasis persist in using immunosuppressants, often driven by insurance-related constraints; the use of immunosuppressants, such as cyclosporine, may give rise to concerns regarding the additional cardiovascular burden attributed to the drug. Thus, we aimed to investigate the effect of systemic treatment on the risk of hypertension, dyslipidemia, and major cardiovascular events (MACE) in patients with psoriasis. A customized database from the National Health Insurance Service of South Korea spanning the years 2002 to 2019 served as the primary data source for this study. Propensity score matching was conducted in a 1:1 ratio between patients diagnosed with psoriasis who underwent systemic treatment and those who did not. The diagnoses of psoriasis and individual cardiovascular diseases were established using International Classification of Diseases, 10th Revision (ICD-10) codes. The systemic treatment group was divided into distinct and non-overlapping cohorts, including cyclosporine, methotrexate, mixed immunosuppressant, biologics, and phototherapy cohorts. We calculated the incidence rates of each cardiovascular disease and subsequently assessed the association between systemic treatment and the occurrence of cardiovascular diseases using a Cox proportional hazards model. Patients with psoriasis who received any systemic treatment had a significantly higher hazard ratio (HR) for hypertension, dyslipidemia and MACE than those who did not (HR 1.43, 1.60, 1.77). The mixed immunosuppressant cohort had the highest HRs for hypertension, dyslipidemia and MACE (HR 3.49, 4.08, 4.94), followed by methotrexate (HR 2.82, 2.73, 4.52), cyclosporine (HR 2.09, 2.36, 2.92), biologics (HR 1.46, 2.33, 1.98), and phototherapy cohorts (HR 1.00, 1.14, 0.96). In summary, our findings indicate that the mixed immunosuppressant cohort exhibited the highest risk of cardiovascular diseases, with methotrexate, cyclosporine, biologics, and phototherapy cohorts following in descending order. It remains unclear whether it is derived from the psoriasis itself or the treatment, as the disease severity could not be adjusted. Nevertheless, our results suggest that biologics may offer a more favorable choice for mitigating potential cardiovascular comorbidities in individuals with psoriasis when compared to immunosuppressant therapies.