Complications
Older patients with psoriatic arthritis are at a higher risk of developing venous thromboembolism, deep vein thrombosis, and pulmonary embolism.[130]
Patients with psoriatic disease are at increased risk of myocardial infarction, angina, and hypertension. Factors increasing the risk include diabetes, hyperlipidaemia, and severe skin disease.[115] These patients tend to have a higher prevalence of obesity and dyslipidaemia than the general population. Reduction of cardiovascular risk should address individual risk factors for the metabolic syndrome, as well as cigarette smoking.[116][117][118][119] Cardiovascular risk assessment is recommended at least every 5 years and following major changes in treatment.[116] In patients with cardiovascular disease or risk factors, NSAIDs and corticosteroids should be used cautiously.[116]
Patients with psoriatic arthritis have a higher occurrence of diabetes, which may be caused by insulin resistance associated with chronic inflammation and common gene loci.[51]
A frequent comorbidity of psoriatic arthritis with a large impact on quality of life.[60]
Hepatic fibrosis from long-term methotrexate therapy occurs 3 times as frequently in psoriatic arthritis (PsA) as in rheumatoid arthritis. The reasons for this increased risk are yet to be determined but are likely to include fatty liver disease related to obesity and type 2 diabetes, as well as increased alcohol abuse in persons with psoriatic disease. The best method for monitoring hepatic toxicity is uncertain. Routine liver biopsy is not recommended. A recent prospective study demonstrated that PsA patients taking methotrexate for up to 6 years may be monitored effectively using standard American College of Rheumatology guidelines.[120] Liver biopsy should be considered in patients with persistently elevated LFTs.[120][121]
It is not known how much alcohol consumption is safe with long-term methotrexate use. To reduce the risk of hepatotoxicity, minimising alcohol consumption and aggressive treatment of metabolic syndrome is recommended.[122][123]
PsA patients receiving methotrexate, ciclosporin, or tumour necrosis factor-alpha inhibitor immunosuppressive therapy may have a greater risk of malignancy, but this has not been quantified.[118] There is an increased risk of skin cancers associated with these agents, and patients receiving them for arthritis should have periodic skin checks by a dermatologist.[124][125] Risk is highest in people who have received previous ultraviolet therapy.
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