What You Need to Know About Comorbidities in Psoriatic Arthritis

People with psoriatic arthritis (PsA) are at higher risk for other diseases, called comorbidities. In medicine, comorbidity is defined as the presence of one or more conditions co-existing with a primary condition. Some of the comorbid conditions associated with PsA include inflammatory bowel disorders, cardiovascular disease, diabetes, and metabolic syndrome.

Prevalence studies show people with PsA are at risk for numerous comorbidities. Comorbidities of PsA tend to be associated with worse prognosis, decreased quality of life, and increased risk for mood disorders.

Here is what you need to know about comorbidities associated with PsA, their effect, and reducing your risk.

Arthritis and psoriasis are inflammatory diseases.

• Arthritis is known for causing joint pain, stiffness, and swelling.
• Psoriasis causes skin cells to renew too quickly, leading to a buildup of red, scaly, and silvery-looking skin patches, called plaques.

According to the National Psoriasis Foundation, up to 30% of people with psoriasis will eventually go on to develop psoriatic arthritis (PsA), with both sets of symptoms. Sometimes the arthritis symptoms develop before skin involvement.

Cardiovascular Disease

PsA and other types of inflammatory arthritis are systemic, which means they affect the entire body, including the heart. There is a strong link between the risk of heart disease and PsA. One 2016 study reported in the journal Arthritis Care & Research finds people with PsA are 43% more likely than others in the general population to develop cardiovascular disease. The study also found that people with PsA also have a 22% higher risk for cerebrovascular disease, which may lead to a stroke.

Inflammation can also cause blood vessels to harden and become damaged, a condition called atherosclerosis, which increases the risk for a stroke or a heart attack. And having other comorbidities, including diabetes, can increase further increase a person’s risk for cardiovascular disease.

Because of the increased risk for cardiovascular disease, it is important to know the warning signs of a heart attack and stroke.

• Signs of a heart attack include shortness of breath, pain in the upper part of the body, extreme discomfort or pain in the chest.
• Signs of a stroke include trouble speaking, numbness or weakness in the face, arm, or leg, usually on one side of the body.

Ask your healthcare provider about which screening tests you should get. It is also a good idea to get regular activity/exercise, consider an anti-inflammatory diet, and quit smoking.

Metabolic Syndrome        

Metabolic syndrome is defined as having a combination of central obesity (fat around the waist), high blood pressure, insulin resistance, and dyslipidemia (high triglycerides, high bad cholesterol, low good cholesterol).

The risk for metabolic syndrome tends to be higher in people with PsA in comparison to those who only have psoriasis or neither condition. And people with both PsA and metabolic syndrome tend to have more severe PSA.

Diabetes

People with a PsA have an increased risk for type 2 diabetes, a metabolic disease. Type 2 diabetes results when a person’s body is unable to use insulin properly and blood sugar levels become elevated. The prevalence of diabetes mellitus (DM) is significantly higher in people with PsA who experience high PsA disease activity, according to a study reported in 2017 by The Journal of Rheumatology.

DM refers to a group of diseases that cause high blood sugar, including pre-diabetes, types 1 and 2 diabetes, and gestational diabetes. The PsA-DM researchers found a 43% higher risk of developing DM with PsA, compared to others in the general population.

Diabetes and PsA have similar risk factors, including genetics, obesity, and metabolic causes. Talk to your healthcare provider if you experience signs of type 2 diabetes, including thirst, hunger, blurred vision, and extreme fatigue. Additionally, tell your healthcare provider if diabetes runs in your family so your blood sugar can be monitored for pre-diabetes.

Osteoporosis

Osteoporosis—a condition that cause bones to become weak, fragile, and prone to fractures—is linked to PsA. A study reported in 2014 from researchers out of the University of Rome "Sapienza" found a high prevalence of osteopenia in people with psoriatic disease.

Osteopenia is a condition where the body isn’t making new bone as quickly it is reabsorbing old bone. Osteopenia is considered an early form of osteoporosis. In the study, researchers were looking for signs of osteoporosis and osteopenia in 43 people with PsA. What they found was 60% had osteopenia and 18% had osteoporosis.

The PsA-osteoporosis connection has several possible contributing factors. One is that inflammation causes both PsA and osteoporosis. A second possible explanation is that corticosteroid medications used to control PsA inflammation can also cause bone thinning. Additionally, joint pain and stiffness can cause a person to be less active and lack of movement can cause bones to become weak.

Osteoporosis is an asymptotic condition—that means it doesn’t cause symptoms so you may not know you have it until you experience a fracture. If you have other risk factors for osteoporosis, including family history, talk to your healthcare provider about bone density screening to check for signs of osteoporosis before you experience a fracture.

Gout

Gout is a type of inflammatory arthritis that is caused by uric acid buildup in the blood. Uric acid is a normal waste product in the body. When uric acid levels are elevated, they build up and accumulate in a joint and cause inflammation, triggering pain and swelling. Excess uric acid can be caused by rapid cell turnover, a feature of psoriasis.

One study reported in 2015 by the Journal of Rheumatic Diseases finds a connection between high uric levels and psoriasis, and a strong connection with PsA. For both men and women with PsA and psoriasis, their risk is five times higher than their peers who do not have psoriasis or PsA.  

Inflammatory Bowel Disease

Inflammatory bowel disease (IBD), which includes Crohn’s disease and ulcerative colitis (UC), is known for co-occurring with PsA. IBD causes the body to overact and attack the walls and tissues of the intestines.

A review of studies in the journal JAMA Dermatology found people with PsA had a 1.7-fold increased risk for UC and a 2.5-fold increased risk for Crohn’s disease. This is likely due to the fact that some of the same genetic variations associated with PsA are also associated with IBD.

Depression

Mood disorders, such as depression, are more common in people with arthritis conditions, but people with PsA have an even higher risk. A study reported in 2014 by the Journal of Rheumatology found people with both PsA and psoriasis experience higher levels of anxiety and depression than people living with psoriasis alone.

PsA can severely affect a person’s life. For example, psoriasis skin problems affect appearance and self-esteem, while joint pain, reduced mobility, and fatigue can make it harder to be social and active, resulting in isolation. These factors all play a part in causing emotional distress and contributing to the development of depression.

Additionally, it has been shown that Inflammation can create brain changes that affect emotional states.

Symptoms of depression include:

• Loss of interest in activities once enjoyed
• Feeling sad, helpless, and hopeless often
• Sleep problems
• Problems with concentration and focus
• Withdrawing from friends and family

Vision Problems

PsA has been liked to the eye disease uveitis, which causes inflammation of the uvea—the middle layer of the eye. Symptoms of uveitis include redness, eye pain and swelling, watery eyes, sensitivity to light, and blurred and impaired vision.

Uveitis is known for becoming severe quickly and, if left untreated, can cause vision loss. If you think you may have it, talk to your rheumatologist or other treating healthcare provider about what you can do to treat it and reduce the risk of complications.

You should also visit an ophthalmologist at least once a year to get your eyes checked and see an eye healthcare provider right away if experience vision changes or severe eye symptoms.

Non-Alcoholic Fatty Liver Disease

Non-alcoholic fatty liver disease (NAFLD) is the result of fat accumulating in liver cells and deposits. It has nothing to do with alcohol abuse. Having inflammatory arthritis can increase your risk of NAFLD.

This disease has few symptoms early on so it is likely once you are diagnosed, the disease has already advanced. This is why healthcare providers monitor liver function with blood work in people with PsA. Weight loss and exercise can reduce your risk for NAFLD.

Arthritis Mutilans

Arthritis mutilans (AM) is a severe form of PsA,, affecting around 5% of people with PsA. Despite its rarity, it is a comorbidity of PsA known for damaging and destroying bones.

In people with AM, once destroyed, bones cannot be rebuilt, and soft tissues of bones end up collapsing. AM mainly impacts the fingers, hands, wrists, and feet. The good news is that it is rare in people with PsA who are treated with biologics. And even if a person develops the condition, early treatment can prevent further bone loss and slow down bone destruction.

A Word From Verywell

There are things you can do to reduce your risk of developing a comorbid condition with PsA. Make sure you are seeing your primary care healthcare provider annually to screen for cardiovascular risk factors, check blood pressure and blood sugar levels, and to perform other relevant screenings. If you smoke, it is a good idea to quit. Reducing alcohol intake can also help, as will regular exercise and eating a healthy diet.

Making sure that PsA is well-managed can also reduce the risk of comorbidities. And because depression is so common in PsA, don’t be afraid to ask for help from loved ones, through a support group, or by talking with a mental health professional.

If you have already been diagnosed with a comorbidity, make sure you are seeking care from a specialist for your condition. Seeing the right healthcare providers makes a big difference in your overall health and treatment outcomes.