Ryan Haumschild, PharmD, MS, MBA: Let me transition now to another topic that I think is really important for us to hit on. It was something that many of you brought up. I think Dr Groves, you and Dr Lebwohl really hit on this. It’s the association of chronic plaque psoriasis and this immune-mediated inflammatory skin disease, but also its strong association with metabolic syndrome. We see this increased risk of metabolic syndrome with patients with psoriasis, and I believe that can be up to even 20% to 50%. Thus, for those in the audience that aren’t familiar, maybe Dr Lebwohl and then Dr Groves, I’d like to hear you chime in on this. Please provide an overview of metabolic syndrome. Why do we see such a high association specifically within this patient population? How do we identify it? What are those confounding disease states? Because we know metabolic syndrome is growing across the country, it’s a chronic disease. Hopefully Dr Groves, you can chime in a little bit on that as we look at total claims. But now as we try to identify this, in this unique high-cost patient population, we’re seeing it continue to grow. Why is that, and what can we do to identify it and treat it?

Mark Lebwohl, MD: Years ago, the question was asked, are patients with psoriasis on average obese and does the psoriasis cause the obesity? Patients are less active; they stay at home. Or does obesity predispose to psoriasis? I think when you look at both conditions, they are multifactorial in terms of their inheritance patterns and the way they develop. It’s a combination of genes you inherit from both parents combined with environmental factors. Thus, there’s no question that the average patients with psoriasis weigh more, and of course, obesity and abdominal girth are parts of the metabolic syndrome. I don’t think there’s any question that patients with psoriasis in the United States weigh more. In fact, in our typical biologic trial for psoriasis, the average weight is often between 90 and 100 kg. They are a lot bigger than the average American population.

The other features that are clearly associated, I think again, I would say they’re multifactorial, and it’s a combination of genes you inherit from both parents in addition to environmental factors. There’s Hyperlipidemia. Now we can control hyperlipidemia to some extent with diet, but we can’t control it completely. Hypertension is associated with psoriasis, all of these features of the metabolic syndrome. Diabetes mellitus is associated with psoriasis. Again, it’s another feature of the metabolic syndrome. I think the explanation for all of those is they’re multifactorial, but it’s combinations of genes that patients have inherited from their parents. They are not to blame for them. They don’t have full control over those. It even gets to cases of discrimination. Patients are truly discriminated against when they’re obese, but they don’t control that. A lot of that is genetic. The same holds true, of course, for psoriasis. We see that a lot of our patients are discriminated against in terms of jobs and other things. That’s something that’s out of their control. It’s combinations of genes that they inherit from their parents.

Robert Groves, MD: I would echo that sentiment; however, I think it’s important to remember that even a 5% weight loss can have a dramatic impact on the disease course in both psoriasis and coronary disease, etc. What is metabolic syndrome? Well, it’s a combination of signs and symptoms that include things like a beer belly in guys. The cutoff is a waist greater than 40 in. I think in women it may be 35 in, or something along those lines. It’s the presence of hypertension, for example. It’s the presence of resistance to insulin. That may manifest not at all in early metabolic syndrome, or it may manifest as prediabetes. It’s now estimated that 1 in 3 of us in this country as adults have prediabetes. What that means is the system is out of whack, it’s already starting to fail. There are estimates that metabolic syndrome may drive as much as half of all the costs of chronic care in this country. Why? Because it increases the risk for so many other problems, not just cardiovascular disease, heart attack, stroke, but also kidney disease and renal failure if you go down the diabetic continuum. It’s also associated with something that has become an epidemic and will soon be the No. 1 cause for liver transplant, something called nonalcoholic fatty liver disease. Also, it is not just a United States problem, this is a worldwide problem. It’s particularly prevalent in nations that have fewer resources to do something about it, unfortunately.

One could ask about the root causes and a variety of strategies that we might undertake to address this problem. But the bottom line is that diet is important; it’s notoriously difficult to parse through all the literature on this. But again, let’s not forget that even a 5% weight loss can have a dramatic impact on not only the risk of coronary disease but on psoriasis itself. Thus, I don’t want to discount that. You’re right, absolutely correct in that we inherit a predisposition for our ability to manage and metabolize carbohydrates. When you think about the metabolic syndrome, you have to think about carbohydrates and that our ability to manage that, and I’m talking about breads, pastas, and of course, straight up sugar: sucrose, high-fructose corn syrup. I would have no qualms about saying the latter is toxic in high quantities. In this country, almost all of us are getting high quantities in our diet. Knowing how well one tolerates carbohydrates and what one can do to manage that is an integral part of a comprehensive approach to managing these inflammatory diseases of metabolic syndrome.

Thus, I don’t discount the great advances in science that we’ve made, but I also want to emphasize that we can’t discount diet. Also, it gets past just willpower. It’s not about willpower, it’s about policy, for example, how we reimburse nationally the food industry, what we have on our shelves in the grocery stores. There’s a whole host of things that we can do to manage this. We should because it really is not about willpower. It’s about the system within which we find ourselves and the habits that we have come to acquire.

This transcript has been edited for clarity.