糖尿病+银屑病=血管风险更高

布拉格——根据在欧洲皮肤病与性病学会(EADV)2012年会上报告的一项大型研究结果，与无银屑病的糖尿病患者相比，糖尿病合并银屑病患者更易新发糖尿病相关微血管和大血管并发症。

这是首项评估银屑病合并糖尿病(两种疾病都是以全身性炎症为特征)对糖尿病血管并发症的影响的研究。

加州大学戴维斯卫生系统皮肤病科的April W. Armstrong博士及其同事从Thomson Reuters MarketScan医疗记录数据库中识别出6,164例成人银屑病合并糖尿病患者。研究者承认，该数据库的局限性在于缺乏关于糖尿病控制情况的信息。基于性别、糖尿病类型、既往糖尿病并发症、糖尿病并发症和血管并发症倾向性评分，将患者与人数相等的对照患者(无银屑病的糖尿病患者)相匹配。然后，研究者分析了之后1、3和5年内发生糖尿病相关微血管和大血管并发症的风险。

结果显示，在随访12个月时，18.3%的糖尿病合并银屑病患者新发糖尿病微血管并发症(即视网膜病变、神经病变或肾病)，而对照组的发生率为16.5%。相似的，在这一时间段内，18.6%的糖尿病合并银屑病患者发生大血管并发症，而对照组的发生率为15.9%。在整个为期5年的随访期间，糖尿病合并银屑病患者中有29.2%发生微血管并发症，28.6%发生大血管并发症，而对照患者的发生率则分别为26.0%和25.7%。糖尿病合并银屑病队列经校正的微血管并发症相对风险增加14%，大血管并发症(如MI、心力衰竭或卒中)发生率增加13%，有高度统计学意义。

基线时，研究者将6,164例银屑病合并糖尿病患者中的73%归类为轻度银屑病患者，依据是这些患者仅使用外用药治疗，其他27%的患者为中至重度银屑病患者，依据是这些患者使用全身药物或接受光疗。然后研究者试图了解，在糖尿病合并银屑病患者中，糖尿病血管并发症的风险是否随皮肤病的严重程度增加而增高，结果显示“在一定程度上是这样的”：糖尿病合并轻度银屑病患者的经校正5年糖尿病微血管并发症风险较无银屑病的糖尿病患者高13%，而糖尿病合并中至重度银屑病患者的风险较无银屑病的糖尿病患者高16%。这一结果与以下概念一致：银屑病越严重，全身炎症越严重，并预示血管风险越高。

但大血管并发症的风险并非如此明确。糖尿病合并轻度银屑病患者的糖尿病大血管并发症风险较无银屑病的糖尿病患者增加了16%，而糖尿病合并中至重度银屑病患者的的相对风险仅较无银屑病的糖尿病患者增加了10%，增高的幅度无统计学意义。对此结果的可能解释为，中至重度患者使用全身性治疗抑制了全身炎症，并因而降低了发生大血管并发症的风险，但其风险仍显著高于无糖尿病的一般人群。

Armstrong博士披露接受了由雅培公司提供的银屑病研究基金，这项研究是由雅培公司、安进公司和杨森公司共同资助的。

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By: BRUCE JANCIN, Cardiology News Digital Network

PRAGUE – Patients with diabetes and psoriasis are significantly more likely to develop new-onset, diabetes-related microvascular and macrovascular complications than are psoriasis-free patients with diabetes, according to the results of a large study.

"In view of this greater likelihood of developing microvascular and macrovascular complications, clinicians may wish to consider closer disease management of diabetic patients with psoriasis," said Dr. April W. Armstrong, director of clinical research and teledermatology for the department of dermatology at the University of California Davis Health System. The study is the first to examine the impact of comorbid psoriasis and diabetes – two diseases characterized by systemic inflammation – on the risk of diabetic vascular complications.

She and her coinvestigators identified 6,164 adult patients with psoriasis and diabetes in the Thomson Reuters MarketScan medical records database covering 2000-2006. A limitation of the database is its lack of information regarding how well the participants’ diabetes was controlled, Dr. Armstrong noted.

The patients were matched to an equal number of control patients (psoriasis-free patients with diabetes) based on sex, diabetes type, prior diabetic complications, diabetic complications, and a vascular complications propensity score. Then, the researchers analyzed the risk of incident diabetes-related microvascular and macrovascular complications over the subsequent 1, 3, and 5 years.

At 12 months’ follow-up, 18.3% of the patients with diabetes and psoriasis had developed new-onset diabetic microvascular complications – that is, retinopathy, neuropathy, or nephropathy – compared with 16.5% of controls. Similarly, 18.6% of patients with diabetes and psoriasis developed microvascular complications within this time frame, compared with 15.9% of controls.

Over the full 5 years of follow-up, 29.2% of the patients with diabetes and psoriasis experienced incident microvascular and 28.6% developed macrovascular complications, compared with 26.0% and 25.7% of control patients. This translated to a highly significant adjusted 14% increased relative risk of incident microvascular complications in the cohort with comorbid diabetes and psoriasis, as well as a 13% increased incidence of macrovascular complications such as MI, heart failure, or stroke, Dr. Armstrong reported at the annual congress of the European Academy of Dermatology and Venereology.

At baseline, investigators classified 73% of the 6,164 psoriasis patients who also had diabetes as having mild psoriasis based on their use of topical therapies only, while the remaining 27% had moderate to severe psoriasis defined by their use of systemic medications or phototherapy.

Next, the researchers sought to find out whether the risk of diabetic vascular complications in patients with comorbid psoriasis climbed with increasing severity of their dermatologic disease. The answer turned out to be "sort of," noted Dr. Armstrong.

That is, the adjusted 5-year risk of incident diabetic microvascular complications was 13% greater in patients with mild psoriasis than in psoriasis-free patients with diabetes, and 16% greater in those with moderate to severe psoriasis. The results were consistent with the notion that more severe psoriasis, with its greater attendant systemic inflammation, spells greater vascular risk.

However, the risk for macrovascular complications wasn’t as clear cut. While the risk of diabetic macrovascular complications was increased 16% in patients with diabetes and mild psoriasis, the relative risk in those with moderate to severe psoriasis was only 10% more than in psoriasis-free patients with diabetes – and that degree of elevation didn’t achieve statistical significance.

One plausible explanation for this discordant finding, according to Dr. Armstrong, is that the use of systemic therapies in the cohort with moderate to severe psoriasis quelled their systemic inflammation, which dampened their risk for macrovascular disease to a level similar to that seen in patients with diabetes without psoriasis, which, it must be emphasized, is still significantly greater than in the general population without diabetes.

Dr. Armstrong reported being the recipient of psoriasis research grants from Abbott Laboratories, which sponsored this study, as well as from Amgen and Janssen Pharmaceuticals.