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Original Investigation
June 5, 2019

Prevalence of Advanced Liver Fibrosis in Patients With Severe Psoriasis

Author Affiliations
  • 1St John’s Institute of Dermatology, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
  • 2Department of Dermatology, Guy’s and St Thomas’ National Health Service Foundation Trust, Great Maze Pond, London, United Kingdom
  • 3Department of Radiology, Guy’s and St Thomas’ National Health Service Foundation Trust, Great Maze Pond, London, United Kingdom
  • 4Department of Hepatology, Guy’s and St Thomas’ National Health Service Foundation Trust, Great Maze Pond, London, United Kingdom
  • 5Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
  • 6Contract Research Laboratory, Viapath, King’s College Hospital, Denmark Hill, London, United Kingdom
  • 7Affinity Biomarker Labs, London, United Kingdom
  • 8Department of Chemical Pathology, Guy’s and St Thomas’ National Health Service Foundation Trust, London, United Kingdom
  • 9Liver Histopathology Laboratory, Institute of Liver Studies, King’s College Hospital, London, United Kingdom
  • 10Department of Medical and Molecular Genetics, School of Basic and Medical Biosciences, King’s College London, London, United Kingdom
JAMA Dermatol. 2019;155(9):1028-1032. doi:10.1001/jamadermatol.2019.0721
Key Points

Question  Which clinical factors are associated with advanced liver fibrosis in severe psoriasis?

Finding  In a cohort study of 333 patients with severe psoriasis, results of cross-sectional analysis indicated that 14.1% (47 patients) of the cohort had advanced liver fibrosis. Clinical factors significantly associated with advanced fibrosis were increased central obesity, insulin resistance, and severity of psoriasis disease.

Meaning  This study suggests that people with severe psoriasis should be screened for advanced liver fibrosis irrespective of which systemic medication they are receiving; obesity and insulin resistance should be proactively managed to prevent the potential poor prognosis associated with advanced liver fibrosis in this population.

Abstract

Importance  Advanced liver fibrosis is a precursor to cirrhosis, a leading cause of mortality. People with severe psoriasis are at risk for liver disease, but our understanding of advanced fibrosis in individuals with psoriasis is limited.

Objectives  To describe the prevalence of and evaluate the clinical factors associated with advanced liver fibrosis in people with severe psoriasis.

Design, Setting, and Participants  The Co-morbidities in Severe Psoriasis study, a prospective observational cohort study in a large center serving London and Southeast England, was conducted from October 18, 2012, to April 2, 2015; 400 adults with severe psoriasis (Psoriasis Area Severity Index score, ≥10) were recruited from outpatient clinics. Statistical analysis was conducted from October 2, 2016, to March 3, 2017.

Main Outcomes and Measures  The primary outcome was a diagnosis of advanced liver fibrosis determined by transient elastography, a noninvasive criterion standard test. Clinical factors evaluated included psoriasis-specific and metabolic indices, alcohol use, and methotrexate exposure.

Results  Of 400 patients recruited (108 women and 289 men; mean [SD] age, 49.5 [13] years), 333 had a successful transient elastography scan and were included in final analysis. Forty-seven patients (14.1%; 95% CI, 10.4%-17.9%) had advanced liver fibrosis as diagnosed by transient elastography. The clinical factors that produced the best-fit model for advanced fibrosis were central obesity (waist circumference), insulin resistance, aspartate aminotransferase level, platelet count, psoriasis disease severity, and reduced alcohol use (R2 = 0.54).

Conclusions and Relevance  Findings from this study suggest that advanced fibrosis is common in severe psoriasis. Abdominal obesity (by waist circumference) and insulin resistance were associated with the presence of advanced fibrosis. Longitudinal work to characterize the hepatic sequelae of central obesity, insulin resistance, and inflammation as well as the influence of systemic drugs (methotrexate and biologics) will inform future personalized therapeutic decision-making.

Trial Registration  ClinicalTrials.gov identifier: NCT02174367

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