Studying the effectiveness of the combined use of methotrexate and metformin on psoriasis concomitant with metabolic syndrome

, parakeratosis and vascular dilation. - Other tests: Mild anemia is commonly reported among psoriasis patients. There is an increase in the risk of arthritis due to Gout. Nitrogen balance is negative, presenting low albumin in the serum. The level of C- reactive protein, α2-macroglobulin and erythrocyte sedimentation rate rises, which indicates systemic inflammation. 1.2. Psoriasis and metabolic syndrome: A number of recent research studies on lipid disorders showed ununiformed results across geographies and races. These studies showed a strong correlation between psoriasis and lipid disorder. A systemic review from literature on “Psoriasis and metabolic syndrome” by Rita Sales, Tiago Torres from 5 Portal university, Portugal pinpointed that psoriasis is positively correlated to metabolic disorder. Psoriasis should not be considered as a simple skin condition but a systemic inflammatory illness concomitant with some diseases, e.g. an increased likelihood of cardiovascular illness. Doctors should be alerted to this syndrome and find it beside skin condition. It is important to screen for the proofs of metabolic disease and control them tightly. All psoriasis patients are advised to change their lifestyles and do exercise more frequently. With the objective to evaluate the serum lipid in psoriasis patients, Nguyen Trong Hao and Tran Hau Khang conducted a case-control study on 80 psoriasis patients and 80 healthy people. Diagnosis of psoriasis was based on clinical and pathological features. Both group had lipid profile calculated (triglyceride, cholesterol, HDLc, LDLc). The results showed that patients had a higher triglyceride (p = 0.03) and lower HDLc (p = 0.0009) in comparison to that of healthy people. The authors concluded that it is necessary to 6 screen and treat lipid disorder as soon as possible to prevent atherosclerosis and its complications. 1.3. Methotrexate and Metformin in the treatment of psoriasis with metabolic syndrome: 1.3.1. Methotrexate - Effect on DNA synthesis: MTX competitively and reversibly binds to dihydrofolate reductase within 1 hour, with an affinity greater than that of folic acid. This prevents the conversion of dihydrofolate to tetrahydrofolate. Tetrahydrofolate is a necessary co- factor in the production of 1-carbon units, which are critical for the synthesis of thymidylate and purine nucleotides needed for DNA and RNA synthesis. A less rapid, but partially reversible, competitive inhibition of thymidylate synthetase also occurs within 24 hours after administration of MTX - Effect on T lymphocytes: Jeffes et al. demonstrated in an in vitro experiment that the effect of MTX on the proliferation of lymphoid cells is 1000 times greater than its effect on human keratinocytes. Not only does 7 MTX affect the proliferation of lymphocytes, it also blocks migration of activated T cells into certain tissues. - Immunosuppression: The effect probably occurs because of inhibition of DNA synthesis in immunologically competent cells. The drug can suppress primary and secondary antibody responses. - Anti-inflammatory effect: the anti-inflammatory effects are predominantly mediated by adenosine. This increased adenosine production is the result of a complex interaction with AICAR transformylase and ecto 5′ nucleotidase. 1.3.2. Metformin Metformin is an oral diabetes medicine in biguanide group that helps control blood sugar levels. It cannot decrease sugar level in normal person. In diabetes patients, metformin improves blood sugar control but do not cause hypoglycemia (unless the patients starve themselves or using other drugs for diabetes treatment). Metformin act through activation of adenosine monophosphate-activated protein kinase 8 (AMPK) in extracellular signal-related kinase (ERK1/2) signaling pathway leading to cell cycle arrest and therefore inhibition of cell proliferation, hallmark of psoriasis. AMPK activation not only inhibits iNOS, dendritic, and T cell and monocyte/macrophage activation but also activates IL-10 and TGF-β, thereby exerting its anti-inflammatory action. The anti- proliferative and anti-inflammatory effects of metformin might have resulted in reduction of psoriasis. 1.3.3. Using Metformin and Methotrexate on psoriasis patients. Hartmut Glossmann et al highlighted that Metformin is a good therapy in combination with methotrexate in the treatment of male patients with psoriasis concomitant with obesity and metabolic syndrome. Scientists have the evidence supporting the theory in which the anti-inflammatory effect of metformin can combine with methotrexate and reduce its hepatotoxicity in experimented animals. This 9 suggests for the doctors that using metformin can protect the liver from methotrexate in psoriasis patients 10 Chapter 2 MATERIALS AND METHODS 2.1. Objectives and materials 2.1.1. Objectives: From 6/2016 to10/2018, we chose 66 patients with plaque psoriasis diagnosis being treated in Ho Chi Minh city Hospital of Dermatology and Venereology. All of them have enough criteria to participate in the research. 2.1.1.1. Diagnostic criteria: - Psoriasis diagnostic criteria: The diagnosis is based on clinical features. To be specific, the lesions are erythematous plaques with scales on the surface and some suggestive characteristics: circumscribed border, non-inflitration, sites of predilection, mild or severe priritus and silvery scales. - Metabolic syndrome diagnostic criteria: According to the criteria of NCEP ATP III and SAM-NCEP, the diagnosis is establised when 3 on 5 factors appear. Table 2.1: Risk factors of metabolic syndrome: 11 Factors Values Waist circumference ≥ 90cm in males and ≥ 80cm in females Triglyceride ≥ 150mg/dl (1,7mmol/L) HDL-C  40mg/dl (0,9mmol/L) in males and  50mg/dl (1,0mmol/L) in females Hypertension Systolic pressure ≥ 130mmHg or diastolic pressure ≥ 85mmHg Fasting glucose ≥ 100mg/dl (5,55 mmol/L) 2.1.1.2. Inclusion criteria: - Patient with psoriasis vulgaris and metabolic syndrome with the age between 18 and 70. - Patients are non-alcoholic and liver, kidney function tests are normal. - Accept to participate in the research. 12 2.1.1.3. Exclusion criteria: - Pregnancy and lactation. - Patient have been using systemic drug to treat psoriasis such as: cyclosporine, retinoid, or immunologic therapy for one month. - Having acute or chronic infection. - Contraindication to use metformin and methotrexate. 2.1.2. Materials: - Drugs: +Metformin: tablet, proprietery name is Fodia, the dosage is 500mg/1 pill, manufactured by United International Pharma CO. LTD. Drug lot 617551, expired in 11/2019. +Methrotrexate: tablet, proprietery name is Unitrexate, the dosage is 2.5mg/1 pill, manufactured by Korea United Pharm.Inc, distributed by Song Việt Pharmacy. Drug lot E736615, expired in 04/2019. + Axit folic: proprietery name is Folacid, the dosage is 5mg/1 pill. Manufactured and distributed by Pharmadic 13 ( Drug lot 0080716, 0090716, expiration day 7/2019. - Test forms: Cholesterol, Triglyceride, Glucose. - Tape measure for waist circumference, height chart wall sticker for height - Camera (to take picture typical psoriasis patient). 2.2. Methods: 2.2.1. Study design - Objective 1: Prospecive, cross-sectional study to describe some relating factors and clinical features of psoriasis with metabolic syndrome - Objective 2: Prospecive, cross-sectional study to evaluate the metabolic syndrome in psoriasis vulgaris patient and its relationship to the clinical features. - Objective 3: Prospective, randomized placebo control study to evaluate effectiveness of the combination between methotrexate and metformin. 2.2.2. Sample size: - Convenient sampling for 3 objectives: Choosing every patient that meets the including creteria attended to 14 HCMC Hospital of Dermatology and Venereology from 6/2016 to 2/2018. - Choosing method: every psoriasis vulgaris patient that meets the including creteria attended to HCMC Hospital of Dermatology and Venereology. Objective 3: devided patients into 2 groups acccording to their odd and even order but there was no difference in age, sex and disease severity. 2.2.3. Steps: - Building sample clinical record (Data collection form) Objective 1 and 2: - Choosing qualified patients: examing, liver, kidney function test, lipid profile, fasting blood sugar. - 66 psoriasis patients met the including criteria were asked for history, examined, PASI evaluated, measured height, weight, waist circumference, blood pressure and lipid profile. Objective 3: - Psoriasis patients with metabolic syndrome chosen were devided into 2 groups: 15 Treatment group: 33 psoriasis vulgaris patients with metabolic syndrome were treated by metformin + methotrexate, and Control group: 33 psoriasis vulgaris patients with metabolic syndrome were treated by methotrexate only. - Treatment procedure: + Treatment group: Methotrexate: start with 10 mg/week, 15 mg in second week, and sustain in three months (12 weeks). drug is used weekly, devided into 2 doses q12hr. Metformin: 500mg/day after meal. + Control group: Methotrexate only with the same dosage and usage - Result evaluation: both groups were evaluated: + Treatment results were evaluated by PASI before treatment, after treatment 1 month, 2 months, 3 months. + Blood samples were taken to test full blood count, ure, creatinin, AST, ALT, GGT, cholesterol, triglyceride, fasting glucose before and 3 months after treatment. The indexes of AST, ALT, GGT, triglyceride, total 16 cholesterol, HDL-C were measured by HumaStar 600 machine with Enzyme kenetic. The tests were conducted in the laboratory of HCMC Hospital of Dermatology and Venereology. + To evaluate side effects through clinical features, test indexes and cutanous eruption. 2.2.4. Techniques and evaluation criteria 2.2.4.1. Evaluating the severity through PASI Evaluating the severity through PASI (Psoriasis area and severity index). Mild: PASI: < 10, Moderate: PASI: 10 - < 20, Severe: PASI: ≥ 20. - PASI calculating: the area and intensity of psoriasis: PASI=0,1(E+D+I)Ah+0,2(E+D+I)Au+0,3(E+D+I)At+ 0,4(E+D+I)Al In which: + Area: 0,1+0,2+0,3+0,4 = 1 To be specific: Head: 0,1, upper limbs: 0,2, trunk: 0,3, lower limbs: 0,4 + Intensity: Erythema (E); Desquamation (D); Infitration (I). 17 Every criteria (E, D, I) was divided into 5 levels (0 - 4). Very severe: 4; Severe: 3; Moderate: 2; Mild: 1; Absent: 0. + Area - A: Head (H); Trunk (T); Upper limds (U); Lower limds (L). Every area was devided into 5 levels (0-6): 0: 0%; 1: 1- 9%; 2: 10-29%; 3: 30-49%; 4: 50-69%; 5: 70-89%; 6: 90-100%. 2.2.4.2. Evaluating the treatment result: Clinical effects were measured by % PASI reduction according to equation of Heng-Leong Chan in 1993: % PASI reduction = PASI before treatment - PASI after treatment/PASI before treatment x 100 Based on PASI reduction, there are 4 levels: Very good : PASI reduces100% Good : PASI reduction ≥ 75% Moderate : PASI reduction 50 - < 75% 18 Medium : PASI reduction 25 – 50% Bad, no effectiveness : PASI reduction < 25% 2.2.5.3. Evaluating side effects: - Noting side effects such as fatique, headache, anorexia,... - Urticaria, pruritus, petachie,... - Test result AST, ALT, ure, creatinin, HC, BC, TC before and 3 months after treatment. 2.3. Data analysis: Entering and analysing data with Stata 12 software. The data was demonstrated by frequency, percentage, medium, standard deviation, median. Using χ2 to identify the relationship for qualitative variables or Fisher’s exact test when > 20% expected frequency in the table < 5, counted OR with 95% interval and analysed variance by ANOVA test. 19 For quantitative variables with normal distribution, we used t-Test to compare 2 average values and ANOVA variance analysis to compare more average values. For quantitative variables with abnormal distribution, we used Wilcoxon Two-Sample Test. 2.4. Location and duration: - Location: HCMC hospital of Dermatology and Venereology. - Duration: From 6/2016 to 2/2018. 20 Chapter 3: RESULT 3.1. Some relating factors and the clinical characteristics of psoriasis vulgaris and metabolic syndrome. - Sex distribution: Chart 3.1. Sex distribution (n = 66) Note: The proportion of male was 59,1%, higher than that of female, with 40,9%. - Age distribution: 21 Chart 3.2. Age distribution (n = 66) Note: In psoriasis patients with metabolic syndrome, the age 40 – 59 took the highest percentage, with 54,5%, followed by that of ≥ 60 with 30%. At the lowest percentage was the age < 40, with the figure being 15,2%. - Age of onset and duration: 22 Chart 3.4. Age of onset distribution (n = 66) Note: The age of onset below 40 was higher than that above 40, with 54.5% compared to 45.5% Chart 3.5. Duration distribution (n = 66) Note: At the top percentage was the 11-20 years duration, with 40.9%. The percentages ≤ 10-year 23 duration and > 20-year duration were relatively equal, at roughly 30% each. - Severity distribution: Chart 3.7. Severity distribution (n = 66) Note: The figure for moderate psoriasis was higher than that for severe ones, 53% and 47% respectively. - The relationship between the age of onset and some factors: Table 3.5: The relationship between the age of onset and some factors: (n = 66) The age of onset p < 40 n (%) ≥ 40 n (%) Gender p < 0,05 24 The age of onset p < 40 n (%) ≥ 40 n (%) Male 27 (69.2) 12 (30.8) (p = 0,013) Female 9 (33.3) 18 (66.7) Family history p > 0,05 (p = 0,381) Yes 4 (40.0) 6 (60.0) No 32 (57.1) 24 (42.9) Smoking p < 0,05 (p = 0,010) Yes 16 (76.2) 5 (23.8) No 20 (44.4) 25 (55.6) Drinking p < 0,05 (p = 0,000) Yes 17 (89.5) 2 (10.5) No 19 (40.4) 28 (59.6) Doing exercise p > 0,05 (p = 0,948) Not frequent 18 (56.2) 14 (43.8) 1 time/week 5 (55.6) 4 (44.4) > 1 time/week 13 (52.0) 12 (48.0) 25 Note: The result in table 3.5 showed that there was a significant difference in the relationship between gender, smoking, drinking history and the age of onset with p < 0,05. 3.2. Metabolic syndrome in psoriasis vulgaris patients and its relationship to clinical features - Metabolic syndrome in psoriasis vulgaris patients: 26 Chart 3.8. Percentage of risk factors in psoriasis vulgaris patient with metabolic syndrome. (n = 66) Note: Abdominal obesity the highest correlation at 93.9%. high blood pressure came second at 86.4%. Low HDL-cholesterol, was the lowest correlation at 33.3%. Chart 3.9. Distribution of risk factors (RF) in psoriasis vulgaris patient with metabolic syndrome. (n = 66) Note: Patients with 3-risk factors have the leading figures with 57.6%. 7.6% of patients had 5 risk factors, which was the lowest number. 27 - The relationship between obesity and some clinical features: Table 3.7: The relationship between abdominal obesity and some clinical features (n = 66) Abdominal obesity p Yes [n (%)] No [n (%)] Age of onset p < 0,05 (p = 0.047) < 40 32 (88.9) 4 (11.1) ≥ 40 30 (100) 0 Duration p > 0,05 (p = 0,091) ≤ 10 years 21 (100) 0 11 – 20 years 26 (96.3) 1 (3.7) > 20 years 15 (83.3) 3 (16.7) Severity p > 0,05 (p = 0,901) Severe 29 (93.6) 2 (6.4) Moderate 33 (94.3) 2 (5.7) 28 Note: There was a significant correlation between abdominal obesity and age of onset with p < 0.05. In contrast, abdominal obesity was not associated with duration and severity, with p > 0.05. 3.3. The effectiveness in the treatment of moderate and severe psoriasis vulgaris by methotrexate combined with metformin - Comparison in the characteristics of both groups: Table 3.14: Comparison in the characteristics of both group (n = 66) Treatment n (%) Control n (%) p Gender Male 23 (69.7) 16 (48.5) p > 0,05 (p = 0,08) Female 10 (30.3) 17 (51.5) Age 0,05 (p = 0,856) 40 – 59 17 (51.5) 19 (57.5) ≥ 60 11 (33.3) 9 (27.3) 29 Treatment n (%) Control n (%) p Severity p > 0,05 (p = 0,218) Moderate 20 (60.6) 15 (45.5) Severe 13 (39.4) 18 (54.5) - The comparison in treatment results between 2 groups Chart 3.20. The comparison in treatment results between 2 groups based on PASI Note: The statistics of PASI in both groups move downwards and these results had no statistical difference, with p > 0.05. 30 Chart 3.21. The comparison in fasting glucose of 2 groups Note: After 3 months of therapy, the fasting glucose level in the treatment group began the period with a number of 9.2 and this reduced to 6.1. By contrast, the control group had the fasting glucose level being 5.5. This figure then climbed to 6.6. 31 Chart 3.24. The comparison in total cholesterol of 2 groups Note: After proceducing, total cholesterol in treatment group was lower than that in control group and this difference is statistical with p < 0,05. - Side effects in clinical features: Table 3.21: Side effects in clinical features of both groups Symptoms Treatment Control P Anorexia, nausea 3 2 > 0,05 Fatique 2 2 Urticaria 4 0 32 Note: The side effects in clinical features of both groups had no statistical difference with p > 0,05. - Side effects in subclinical features: Table 3.22: Cases with abnormal blood test (MTX+MET) (n = 33) Before treatment n (%) 1 month n (%) 2 month n (%) 3 months n (%) Hemoglobin (12 – 16g/dL) below 2g/dL 0 0 0 0 Number of WBC (5 – 10 x 109/L) Below 5 x 109/L 0 0 0 0 33 Below 3 x 109/L 0 0 0 0 Number of RBC (4 – 6,13M/µL) Below 4M/µL 0 4 (12,1) 4 (12,1) 3 (9,1) Number of platelet (140 – 440 x 103/L) Below 140 x 103/L 0 0 0 0 Below 100 x 103/L 0 0 0 0 Note: The results showed that after 3 months, there were 3 patients (9.1%) with RBC below < 4M/µL. 34 CHAPTER 4: DISCUSSION 4.1. Some relating factors and the clinical features of psoriasi vulgaris along with metabolic - Age of onset and duration: Patient had the mean age of onset being 36 years old. The mean duration was 16 years with the longest one being 47 years (chart 3.5), which is compatible to the research of Ngo Minh Vinh (37,1 ± 14,4 years) and the youngest patient was 16 years old. Our results are also equivalent to Reich and Ruiz’s research with the mean age of onset being 35 and 36.2 years old, respectively. In conclusion, the proportion of cases having the age of onset before 40 was 54.5%. In term of duration, at the top position was <15 years duration, with 40.9%. The figure for 15-20 years and > 20 years duration were very similar, at roughly 27.3% each. This figure shows that psoriasis is a chronic disease which can last for years, not to mention the complicated progression affecting petients’ quality of life. 35 - Severity distribution: The figure for moderate psoriasis was higher than that for severe ones, 53% compared to 47% respectively, which was supported by the results of Truong Le Anh Tuan’s study in which the percentage of moderate and severe psoriasis patient with metabolic syndrome were 68.42% and 31.58%, respectively. - The relationship between the age of onset and some relating factors: The research showed that there is a statistical correlation between smoking, drinking and the age of onset in which the proportion of smoking and drinking patients had the age of onset before 40 were 1.71 and 2.21 times as high as that of non smoking and drinking ones, respectively. The research also found a connection between drinking and type of disease in which the statistics of drinking patients having type 1 psoriasis were 1.86 times higher than that of non alcoholic ones. As we mentioned before, drinking and smoking play an important role in the pathogenesis of psoriasis. 36 Therefore, psoriasis patients are strongly advised to quit smoking and drinking. 4.2. The matabolic syndrome in psoriasis vulgaris and its relationship to clinical features The matabolic syndrome in psoriasis vulgaris patient Among five risk factors in psoriasis vulgaris patients with metabolic syndrome, abdominal obesity has the highest correlation at 93,9%. high blood pressure came second at 86,4%. Standing in the least correction was low HDL-cholesterol, with the percentage of 33,3%. Patients with 3 risk factors have the highest percentage, accounting for 57.6% of the samples. 7.6% of patients had 5 risk factors, which was the lowest number. Based on PASI, dermatologists can evaluate the severity of psoriasis. Psoriasis should not be considered as a simple skin condition but a systemic inflammatory illness concomitant with the increased risk of cardiovascular illness and other diseases. Compared with the study, of Joel M. et al operated in Americac 37 concluded that the percentage of metabolic syndrome in psoriasis patient was higher than that in population. The connection between severe psoriasis and risk factors of metabolic syndome has been proven recently. Doctor should alert to this syndrome, find it beside skin condition and notice the effectiveness and safety of the treatment in order to manage psoriasis comprehensively. More studies are needed to investigate the pathogenesis and evaluate the effectiveness of psoriasis treatment on metabolic syndrome. - The relationship between abdominal obesity and some relating factors: There are an association between the age of onset, type of psoriasis and abdominal obesity feature in which patients with the age of onset before 40 or type 1 psoriasis have the rate of abdominal obesity being 0.89 and 0.9 time higher than that in late onset or type 2 patients. Waist circumference in Asian male and female ≥ 90cm and 80cm, respectively, a creteria of NCEP ATP III, is a risk factor of metabolic syndrome. The result in 38 table 3.12 showed the percentage of high waist circumference in patient and control groups were 39,39% and 25,76%, respectively. However there was no significant difference in high waist circumference between two groups, which was inconsistent with Al- Mutairi’s study result in which the figure of abdominal obesity in psoriasis and control groups were 47,7% and 19%, respectively, as well as Gisondi P.’s research (57.1% in psoriasis group and 47.6% in control group). The reasons this differnce could be explained that our sample size was not as large as that in studies conducted before and all patients had metabolic syndrome. However, many research have confirmed psoriasis induces high waist circumference. According to Katarina Wolk et al, one unit increase in BMI will make the risk of psoriasis onset rise 9% and PASI go up 7%. Obesity (BMI ≥ 30) also increases the threat of psoriasis, almost doubling that in patients. 39 4.3. Effectiveness of treating mild and moderate psoriasis with metabolic syndrome by the combination of Metformin and Methotrexate - Comparing treatment effectiveness between 2 groups After treatment, there was a fall in PASI of both group but the difference was not statiscal. We have not found any research comparing these 2 medicines, resulting in no data for us to compare and discuss. Fasting glucose monitoring showed that: fasting glucose in MET+MTX group was control tightly, in constrast, not much change in that of MTX group. This result is consistent after 3 months monitoring, which is easy to explain because metformin is highly effective in controlling fasting glucose in diabetes patients, noy MTX. However, the difference between two groups was not statistical, with p>0.05. No patient had hypoglycemia, proving the safety of metformin in the treatment of psoriasis. Fasting Cholesterol monitoring showed that: Cholesterol in MTX+MET group was reduced after 1- 40 weeks monitoring but no statistical difference was shown, with p>0.05. Meanwhile, the decrease of cholesterol in MTX group after 12 weeks was statistical different, with p<0.001. However, the comparison between two groups show no statistical difference, with p>0.05. The explanation c