Impact of Biologics on Comorbidities in Patients with Psoriasis or Psoriatic Arthritis

Abstract

Background/Objectives: Psoriasis and psoriatic arthritis are associated with various comorbidities, particularly cardiovascular conditions. Although biologics are increasingly used to manage moderate-to-severe disease, their effect on comorbidity risk remains unclear. This study aimed to assess the association between biologics and the risk of comorbid diseases compared to conventional systemic immunosuppressants. Methods: A retrospective cohort study was conducted using the Korean National Health Insurance Service database from 2002 to 2021. Patients with a principal diagnosis of psoriasis or psoriatic arthritis were included. Overall, 8173 biologics users (TNF-α, IL-12/23, IL-23, or IL-17 inhibitors) were compared to 41,598 patients treated exclusively with cyclosporine A or methotrexate. Adjusted hazard ratios (aHRs) for incident comorbid diseases were calculated using Cox proportional hazard models, with follow-up through 31 December 2021. Results: Biologics use was associated with a decreased risk of rheumatoid arthritis (aHR, 0.37; 95% CI, 0.17-0.79), mood disorders (aHR, 0.72; 95% CI, 0.53-0.97), and solid tumors (aHR, 0.63; 95% CI, 0.47-0.84). Subgroup analyses revealed that IL-23 inhibitors were linked to reduced risk of solid tumors (aHR, 0.31; 95% CI, 0.12-0.83), whereas IL-17 inhibitors were associated with increased risk of chronic obstructive pulmonary disease (aHR, 2.96; 95% CI, 1.08-8.14). No significant differences were found for major cardiovascular events. Conclusions: Biologics appear relatively safe with respect to cardiovascular disease and may reduce the risk of certain comorbidities such as mood disorders and solid tumors in patients with psoriasis or psoriatic arthritis. Clinicians should consider comorbidity profiles when selecting biologic agents for individual patients.

Keywords: biologics; comorbidity; immunotherapy; psoriasis; psoriatic arthritis; risk.

Figure 1

Flowchart of study population selection. We identified 353,409 individuals with psoriasis or psoriatic arthritis from the National Health Insurance Database of Korea. A biologics cohort of 8173 patients who were prescribed any biologics at least once and a control cohort of 41,598 patients who were treated exclusively with conventional systemic immunosuppressants without biologics were selected. Among them, 6932 patients in the biologics cohort and 35,096 patients in the control cohort underwent a general health examination.

Figure 2

Comorbid disease risk associated with biologics in the biologics cohort compared with that in the control cohort. The forest plot depicts adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of comorbid diseases in the biologics and control cohorts. Statistical estimates were adjusted for age, sex, insurance type, income level, and location. Abbreviations: aHRs, adjusted hazard ratios; CI, confidence interval.

Figure 3

Stratified analysis of comorbid disease risks in biologics cohorts by biologic class. The forest plot depicts adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of comorbid diseases in the biologics and control cohorts. Statistical estimates were adjusted for age, sex, insurance type, income level, and location. The risks of comorbid disease outcomes were stratified by class of biologics [(a) TNF-α inhibitor, (b) IL-12/23 inhibitor, (c) IL-23 inhibitor, and (d) IL-17 inhibitor]. Abbreviations: aHRs, adjusted hazard ratios; CI, confidence interval; IL, interleukin; TNF, tumor necrosis factor.

Figure 4

Subgroup analyses according to class of biologics and cardiovascular risk. Subgroup analyses were conducted to investigate potential differences in terms of class of biologics and CV risk: (a) TNF-α inhibitor cohort of the high CV risk group, (b) TNF-α inhibitor cohort of the low CV risk group, (c) IL inhibitor cohort of the high CV risk group, and (d) IL inhibitor cohort of the low CV risk group. The forest plot shows the aHRs and 95% CIs of comorbid disease outcomes in the biologics and control cohorts. Statistical estimates were adjusted for age, sex, insurance type, income level, and location. Abbreviations: aHRs, adjusted hazard ratios; CI, confidence interval; CV, cardiovascular; IL, interleukin; TNF, tumor necrosis factor.