Patients with inflammatory disorders, especially psoriasis and psoriatic arthritis, had an elevated risk for severe liver disease such as nonalcoholic fatty liver disease and cirrhosis, according to a recently published study.
“As a rheumatologist, I prescribe methotrexate a lot, and what we see in clinic often is that our patients with psoriatic arthritis tend to have a lot of liver function test abnormalities somewhat quickly after starting methotrexate. It happens in a large proportion of patients, anecdotally, in my clinic,” Alexis Ogdie, MD, MSCE, from the Perelman School of Medicine at the University of Pennsylvania, told Healio.com/Hepatology. “So, one of the things we were interested in was: are these patients already set up for liver disease even before methotrexate?”
To determine the correlation between inflammatory diseases and the risk for liver disease, Ogdie and colleagues performed a population-based cohort study with data from The Health Improvement Network, or THIN.
The researchers identified 197,130 patients with psoriasis, 12,308 with psoriatic arthritis, 54,251 with rheumatoid arthritis and 1,279,754 controls. Those who had undergone systemic therapy included 6% of those with psoriasis, 53% of those with psoriatic arthritis and 61% of those with rheumatoid arthritis.
After adjusting for age and sex, all patients had a higher risk for incident liver disease compared with controls, ranging from a hazard ratio of 1.19 (95%, 1.04-1.36) in patients with rheumatoid arthritis and systemic therapy to a hazard ratio of 2.32 (95% CI, 1.95-2.75) in those with psoriasis with systemic therapy.
In a fully adjusted model, all patients except for those with rheumatoid arthritis had a higher risk for incident liver disease compared with controls. The hazard ratios ranged from 1.37 (95%, 1.29-1.45) for those with psoriasis and no systemic therapy to 1.97 (95% CI, 1.63-2.38) in those with psoriasis and systemic therapy.
Among patients with psoriasis and psoriatic arthritis, those who received systemic therapy had overall increased risk for liver disease compared with those who did not and compared with controls.
The most common incident liver disease was NAFLD (37.85%), followed by alcoholic liver disease (18.53%), viral etiologies (7.76%), biliary disease (4.33%), autoimmune liver disease (0.6%) and unknown causes (10.35%). Of those diagnosed with liver disease, 10% of patients also received a diagnosis of cirrhosis during follow-up.
The researchers also analyzed the prevalence of liver disease by severity of psoriasis based on body surface area in a separate cohort. After adjusting for age, sex and BMI, psoriasis severity significantly correlated with increased risk for liver disease from mild psoriasis (2% or less body surface area; OR = 1.13; 95% CI, 0.94-1.36), to moderate (3-10% body surface area; OR = 1.19; 95% CI, 0.96-1.48), to severe psoriasis (more than 10% body surface area; OR = 1.67; 95% CI, 1.22-2.3).
“There's a difference between dermatologists and rheumatologists in terms of prescribing methotrexate — dermatologists for a long time have had in their treatment recommendations that people, after a certain amount of methotrexate, should get a liver biopsy to make sure there's no liver toxicity from the methotrexate,” Ogdie said, adding that it is not a standard recommendation for rheumatologists. “I think it's very important among methotrexate users to follow with liver function tests.” – by Talitha Bennett
Disclosure: Ogdie reports he is a consultant to Bristol-Myers Squibb, Lilly, Novartis, Pfizer and Takeda and is a co-investigator on a research grant from Pfizer.