Seminars in Arthritis and Rheumatism 50 (2020) 571 575

Contents lists available at ScienceDirect

Seminars in Arthritis and Rheumatism

journal homepage: www.elsevier.com/locate/semarthrit

Mortality in psoriatic arthritis: Risk, causes of death, predictors for death

Ofir Elaloufa,b, Anastasiya Muntyanua, Ari Polachekb, Daniel Pereiraa, Justine Y. Yea,
Ker-Ai Leec, Vinod Chandrana,d,e, Richard J. Cookc, Dafna D. Gladmana,e,*
a
Centre for Prognostic Studies in the Rheumatic Diseases, Toronto Western Hospital, University of Toronto, Toronto, ON Canada
b
Department of Rheumatology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
c
Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, ON Canada
d
Departments of Medicine, Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON Canada
e
Institute of Medical Science, University of Toronto, Toronto, ON Canada

A R T I C L E I N F O A B S T R A C T

Keywords: Background/Objectives: Mortality studies in psoriatic arthritis (PsA) have provided inconsistent results. This
Psoriatic arthritis study aimed to: 1) Estimate trends in mortality rates among PsA patients over calendar time; 2) Evaluate
Mortality cause-specific mortality rates in patients with PsA compared to the general population; 3) Identify predictors
Standardized mortality ratios for mortality in PsA.
Cause specific mortality
Methods: The study was carried out at the University of Toronto Psoriatic Arthritis Clinic where patients are
followed prospectively according to a standard protocol at 6- to 12- month intervals. Standardized mortality
ratios (SMRs) were calculated overall, by age, and by sex with reference to the Ontario population. Causes of
death were recorded by ICD9 and ICD10 codes and cause-specific SMRs were computed. Cox regression mod-
els were used to identify predictors for mortality among PsA patients.
Results: Among 1490 patients followed over 15062.8 patient-years, 225 (15%) confirmed deaths were
recorded (111 females, 114 males). The overall SMR was 0.92 (95% CI: 0.81-1.05), the sex-specific SMRs were
1.08 (95% CI: 0.89-1.30) for females and 0.81 (95% CI: 0.66-0.97) for males. The age-specific SMRs were 3.36
(95% CI: 1.61-6.18), 0.97 (95% CI: 0.68-1.34), 0.88 (95% CI: 0.73-1.06) and 0.86 (95% CI: 0.66-1.11) for 20-39,
40-59, 60-79 and above 80 years of age, respectively. Major causes of death included malignant neoplasms
(n=61; SMR=0.97, 95% CI: 0.72-1.28), acute myocardial infarction (n=32; SMR=1.11, 95% CI: 0.74-1.58), and
pneumonia (n=14; SMR=2.46, 95% CI: 1.27-4.31). Factors found to be associated with increased mortality
include elevated acute phase reactants, presence of comorbidities such as heart disease and cancer, and
lower education level.
Conclusion: Young patients with PsA are at increased mortality risk. Better control of comorbidities may
reduce this risk.
© 2020 Published by Elsevier Inc.

Introduction (SMR) of 1.62 (95% confidence interval (CI): 1.21-2.12) in PsA

Psoriasis is a chronic inflammatory skin disease, affecting 2-3% of
the world's population. Psoriatic arthritis (PsA) is an inflammatory
musculoskeletal disease that affects 20-30% of psoriasis patients and
can lead to significant joint damage and disability. PsA is considered
a systemic disease with well-established comorbidities such as
depression, obesity, type 2 diabetes, hypertension, metabolic syn-
drome, fatty liver, and cardiovascular events. [1]
Data regarding mortality in psoriatic disease have been pub-
lished since the end of the last century, with inconsistent results.
Wong et al. [2] reported an increased standardized mortality ratio
* Corresponding author: Institute of Medical Science, University of Toronto, Toronto,
ON Canada
E-mail address: dafna.gladman@utoronto.ca (D.D. Gladman).
patients compared to the general population, in a longitudinal
observational cohort study conducted at the University of Toronto
between 1978 and 1993. A follow up study from the same centre
10 years later, reported overall increased SMR of 1.36 (95% CI: 1.12-
1.64) for the period of 1978-2004, and an estimated life-years loss
of 2.99 (95% CI: 1.14 -4.77). An improved trend in mortality risk was
observed in patients entering the cohort in a later calendar period,
[3] with SMRs of 1.89, 1.83, and 1.21 for follow-up periods
1978 1986, 1987 1995, and 1996 2004, respectively. The
improved survival was attributed to earlier diagnosis and more
aggressive treatment in the more recent follow up period. Others
have reported conflicting results about mortality risk in patients
with PsA. [4, 5]
The aims of this study were to: 1. Estimate the mortality over a
40-year period; 2. Estimate the risk for different causes of death, and

https://doi.org/10.1016/j.semarthrit.2020.04.001
0049-0172/© 2020 Published by Elsevier Inc.
572 O. Elalouf et al. / Seminars in Arthritis and Rheumatism 50 (2020) 571 575

for age- and sex-specific SMRs among these patients; 3. Identify fac- Descriptive tables were constructed using SAS (version 9.3; SAS
tors associated with mortality. Institute, Cary, NC, USA) while SMR calculations and Cox regression
analysis were performed using R version 3.5.1 (2018).
Patients and methods

Setting Results

Patients who were enrolled into the University of Toronto PsA During the period of January 1, 1978 through December 31, 2017,
Clinic between January 1, 1978 and December 31, 2017 were 1490 patients were enrolled into the University of Toronto PsA clinic. Of
included in the study. these 1490 patients, 830 (56%) were males and 660 (44%) were females.
Patients are referred from family doctors, rheumatologists, der- There were 225 (15%) confirmed deaths among 111 female and 114
matologists and other medical specialists. The clinic serves as a pri- male individuals. Patients’ characteristics are presented in Table 1.
mary, secondary, and tertiary referral center and provides clinical Assuming these lost to follow up patients were still alive at the end
care to patients with a broad spectrum of disease severity. of 2017, the number of years of follow-up was 15062.8 (8482.6 for
men, and 6580.2 for women). The mean age of the patients entering
Assessments the clinic was 44.5 years (SD 13.2). Mean age at psoriasis onset was
28.7 years (SD 14.7), while mean age at PsA onset was 38.2 years (SD
Patients are evaluated at the initial clinic visit and subsequently 13.7). Mean PsA duration at entry to the clinic was 6.3 years (SD 7.9).
every 6-12 months according to a standard protocol. [6] The prospec- Causes of death are presented in Table 2. The leading causes were
tively collected data are stored in a web-based database that include malignant neoplasm (n=61), acute myocardial infarction (n=32) and
demographics, personal and family medical history, smoking and pneumonia (n=14). The cause of death could not be retrieved in 25
alcohol drinking habits, medications, skin and musculoskeletal dis- cases. The overall SMR comparing the mortality of the PsA cohort to
ease activity, imaging, and laboratory findings. [7] Most of the the general population of Ontario for the study period between 1978
patients (98%) fulfill the ClASsification for Psoriatic ARthritis (CAS- and 2017 was 0.92 (95% CI: 0.80-1.05). The sex-specific SMRs for the
PAR) criteria for classification of PsA. [8, 9] same period were 1.08 (95% CI: 0.89-1.30) for females, and 0.81 (95%
CI: 0.66-0.97) for males. Overall SMRs throughout the years as pre-
Death and Causes of Death sented by 10-year rolling SMRs (Fig. 1A) show a declining trend from
the 1980s until the present time. A similar trend is seen for the male
Information on patient deaths and causes of death was collected population, while the female population displayed an initial
prospectively through notifications by family members and physi- increased mortality risk, which later decreased as well. Fig. 1B dis-
cians, daily checks of death notices in the newspaper, through linkage plays the 5-year rolled SMRs which show similar patterns for the
with the provincial cancer registry and death registry, and through overall, male and female populations.
telephone interviews and correspondence with family physicians Looking at age-specific SMRs, there is a significant increased mor-
and patients’ relatives. Death certificates, and hospital admission tality in the 20-39 year group with SMR of 3.36 (95% CI: 1.61-6.18),
records were used, where possible, to verify patient death and to while in the other age groups of 40-59 (SMR=0.97, 95% CI: 0.68-1.34),
identify the primary cause of death. 60-79 (SMR=0.88, 95% CI: 0.73-1.06), and above 80 (SMR=0.86, 95%
CI: 0.66-1.11), the rates are similar to the mortality rate of the general
Statistical Analysis
Table 1
Characteristics of the study patients at first presentation.
A descriptive table was constructed of demographic, disease fea-
tures, drug intake and comorbidities for both the deceased and sur- Overall Alive Deceased (n=225)
viving individuals. Crude mortality rates (reported per 1000 person), (n=1490) (n=1265)
as well as SMRs, were computed by comparing the mortality rate in Age in years, mean (SD) 44.5 (13.2) 42.8 (12.5) 54.3 (12.6)
the diseased individuals with the mortality rate in the general popu- Age at Psoriasis onset in 28.7 (14.7) 27.5 (13.9) 35.4 (17.2)
lation of Ontario, Canada. The mortality data of the general popula- years, mean (SD)
Age at PsA onset in years, 38.2 (13.7) 37.1 (13.3) 44.2 (14.5)
tion after 2013 could not be obtained from Statistics Canada.
mean (SD)
Mortality data for the general population of Ontario, stratified by 5- PsA duration in years, mean 6.3 (7.9) 5.6 (7.1) 10.2 (10.6)
year age bands, sex, and calendar year (from 1978 to 2013), were (SD)
used to calculate the reference mortality rates. Our cohort was Follow up duration in years, 10.4 (9.7) 10.4 (9.7) 8.7 (8.7)
divided into four age groups by 20-year age bands: 20-39, 40-59, 60- mean (SD)
Smoking ever, n (%) 663 (44%) 579 (46%) 84 (37%)
79, and above 80 years of age. Overall SMRs were calculated by Sex, n (%)
adjusting for age, sex, and calendar year, and SMRs were also * Female 660 (44%) 549 (43%) 111 (49%)
reported by sex, by age, as well as by cause-specific SMRs. In addition, Alcohol consumption, n (%)
we performed a trend analysis by using 5-year “rolling-average” * None 510 (41%) 456 (40%) 54 (50%)
* Social 630 (50%) 592 (52%) 38 (35%)
SMRs analysis from 1981 to 2017. All analyses performed were based
* Daily 109 (9%) 93 (8%) 16 (15%)
on the assumption that any patient lost to follow-up was still alive at Ethnicity, n (%)
the end of 2017. * Caucasian 1281 (87%) 1070 (85%) 211 (94%)
Cox regression models with time-dependent covariates were used Marital status, n (%)
to identify factors associated with increased risk of death among * Single 285 (23%) 269 (24%) 16 (14%)
* Married/Common law 824 (66%) 751 (66%) 73 (65%)
patients with PsA while adjusting for two fixed covariates such as * Divorced and other 134 (11%) 111 (10%) 23 (21%)
duration of PsA at clinic entry and sex. Time-dependent covariates Decade of entry, n (%)
included marital status, education level (college or above), actively * 1978-1987 326 (22%) 185 (15%) 141 (63%)
inflamed joint count, dactylitis count, enthesitis count, psoriasis area * 1988-1997 238 (16%) 199 (16%) 39 (17%)
* 1998-2007 427 (29%) 389 (31%) 38 (17%)
severity index (PASI) score, nail lesions, acute phase reactants, pres-
* 2008-2016 499 (33%) 492 (39%) 7 (3%)
ence of comorbidities such as diabetes, heart disease, depression and
PsA = Psoriatic arthritis.
cancer, medications, radiographic damage and axial disease.
 O. Elalouf et al. / Seminars in Arthritis and Rheumatism 50 (2020) 571 575 573

Table 2 Table 3
Causes of death. Standardized mortality ratios along with
age- and sex-specific mortality ratios.
Cause of Death Cases
SMR (95% CI)
Malignant neoplasm 61
Acute myocardial infarction 32 Overall SMR 0.92 (0.80,1.05)
Pneumonia 14 Age specific SMR
Injuries / Poisoning 13 * 20-39 3.36 (1.61,8.18)
Cirrhosis / liver failure 10 * 40-59 0.97 (0.68,1.34)
Stroke 9 * 60-79 0.88 (0.73,1.06)
Respiratory diseases 8 * 80 + 0.86 (0.66,1.10)
Alzheimer’s disease 8 Sex specific SMR
Congestive heart failure 7 * Female 1.08 (0.89,1.30)
Renal failure 6 * Male 0.80 (0.66,0.97)
Infections 5
Atherosclerosis 5
Gastrointestinal bleeding 4
Other 17
Unknown 25 Table 4
Total 224 Cause specific SMRs.

Cause of death Cause specific SMR (95% CI)

population (Table 3). When analyzing age- and sex-specific SMRs, the
Alzheimer’s disease 0.43 (0.01,2.44)
male population showed increased mortality for the 20-39-year-old
Atherosclerosis 1.01 (0.27,2.58)
patients (SMR 3.3, 95% CI: 1.32-6.80), while the older groups of 60-79 CHF 2.57 (0.94,5.59)
and above 80 showed better survival (SMR=0.75, 95% CI: 0.57-0.97 Cirrhosis* 3.62 (1.65,6.88)
and SMR=0.56, 95% CI: 0.32-0.90, respectively). For the female popu- CVA* 0.38 (0.10,0.97)
GIB 5.01 (0.60,18.11)
lation, increased mortality was seen for young patients, that later
Infections* 5.32 (2.13,10.96)
decreased, and this trend was similar to the general population. Injury/Poisoning 0.82 (0.4,1.4)
Malignant neoplasm (Table 4) was the leading cause of death with Malignancy 0.97 (0.72,1.28)
61 cases (27%), although the rate was similar to the general population MI 1.11 (0.74,1.58)
(SMR=0.97, 95% CI: 0.72-1.28). Thirty-two patients (14.3% with Pneumonia* 2.46 (1.27,4.31)
Renal Diseases* 11.88 (7.53,17.8)
SMR=1.11, 95% CI: 0.74-1.58) died from acute myocardial infarctions.
Respiratory Disease* 98.5 (36.1,214.4)
The cause of death could not be identified for 25 deceased patients
*significant increase in mortality.

although it is known that they did not die of malignancy. Although

there was no increase in overall mortality, cause- specific SMRs dem-
onstrated increase rates for liver cirrhosis (SMR=3.62, 95% CI: 1.65-
6.88), infections (SMR=5.32, 95% CI: 2.13-10.96), particularly pneumo-
nia (SMR=2.46, 95% CI: 1.27-4.31), renal disease (SMR=11.88, 95% CI:
7.53-17.8), and respiratory disease (SMR=98.5, 95% CI: 36.1-214.4).

Factor associated with mortality

The Cox regression analysis included 1398 patients who had com-
plete covariate information among whom there were 212 deaths. This
analysis revealed that elevated acute phase reactants, presence of
heart disease and presence of cancer increased the risk of death,
whereas higher education was “protective” (Table 5). Sensitivity analy-
ses (results not shown in tables) which included only those patients
who had all covariates available, including smoking, provided broadly
similar findings. When HLA alleles known to be associated with PsA
were included, the modeling identified similar prognostic factors.

Discussion

In our first mortality study in PsA patients, which reflected the

Fig. 1. (A) Unadjusted standardized mortality ratios. Overall rates in 1490 study
patients, as well as sex-specific rates (B) SMR over 5 years gap.
period from 1978 to 1994, we demonstrated an increased risk of mor-
tality in patients with PsA compared to the general population. [2]
We subsequently demonstrated improved survival among PsA
patients in the 1990s compared to previous decades but still found
an increased mortality risk with SMR of 1.36. [3] Subsequent studies
also found lower mortality risk in more recent decades. [5]
Comparing mortality data between different studies might be
problematic from several aspects. First, studies based on national reg-
istries or medical record registries as opposed to clinical databases do
not define precisely the disease phenotype, for instance, patient
selection based only on medical record diagnosis might misclassify
PsA patients as psoriasis patients and vice versa, and as a
574 O. Elalouf et al. / Seminars in Arthritis and Rheumatism 50 (2020) 571 575

Table 5
Factors associated with mortality in patients with PsA.

Covariate Univariate Multivariate

Full model Reduced model

HR (95% CI) P value HR (95% CI) P value HR (95% CI) P value

Fixed Covariates
PsA duration (per 1 year)
Gender (Male vs female)
Time-dependent covariates
Married
College or above
Active joint counts
Dactylitis counts
Enthesitis counts
PASI score
Nail lesions (yes vs. no)
High acute phase reactant
Axial disease (yes vs no)
Arthritis mutilans (yes vs no)
Damage joints (yes vs no)
Diabetes (yes vs no)
Heart disease (yes vs. no)
Depression (yes vs. no)
Cancer (yes vs. no)
Strongest medication
NSAIDs vs. none
csDMARDs vs none
Biologics vs none
HR hazard ratio; CI confidence interval, PASI psoriasis area severity index, NSAIDs
csDMARD conventional synthetic disease modifying anti-rheumatic drugs.
1.00 (0.99, 1,02) 0.51 1.00 (0.99, 1.02) 0.31
1.19 (0.89, 1.59) 0.25 1.13 (0.86, 1.50) 0.38
0.65 (0.48, 0.89) 0.006 0.75 (0.53, 1.06) 0.10
0.54 (0.39, 0.75) 0.0002 0.53 (0.37, 0.77) 0.0007 0.46 (0.34, 0.64) <0.0001
1.01 (1.00, 1.03) 0.11 1.00 (0.98, 1.02) 0.96
1.11 (1.00, 1.23) 0.05 1.03 (0.92, 1.16) 0.61
0.89 (0.60, 1.31) 0.54 0.90 (0.61, 1.35) 0.62
1.00 (0.98, 1.02) 0.94 1.00 (0.97, 1.02) 0.67
1.35 (0.99, 1.84) 0.06 1.34 (0.95, 1.89) 0.10
1.60 (1.17, 2.17) 0.003 1.53 (1.11, 2.11) 0.009 1.56 (1.14, 2.13) 0.005
0.94 (0.70, 1.26) 0.67 0.88 (0.65, 1.20) 0.43
1.08 (0.77, 1.50) 0.66 1.06 (0.75, 1.49) 0.76
1.21 (0.83, 1.77) 0.32 1.19 (0.81, 1.75) 0.38
1.51 (0.98, 2.33) 0.07 1.54 (0.96, 2.47) 0.07
1.79 (1.23, 2.50) 0.002 1.64 (1.07, 2.51) 0.02 1.67 (1.12, 2.49) 0.01
1.30 (0.87, 1.95) 0.20 1.19 (0.76, 1.87) 0.44
1.75 (1.22, 2.50) 0.002 1.84 (1.24, 2.72) 0.002 1.79 (1.22, 2.61) 0.003
0.82 (0.44, 1.52) 0.53 0.83 (0.44, 1.55) 0.43
0.90 (0.51, 1.60) 0.72 0.85 (0.47, 1.54) 0.59
0.75 (0.39, 1.49) 0.42 0.84 (0.41, 1.73) 0.64
nonsteroidal anti-inflammatory drugs,

consequence, the rates might be affected. Second, comparing mortal-
ity from different centers and different geographical areas might
reflect many differences such as disease severity, frequency of comor-
bidities and treatment, access to effective therapies and its usage. The
advantage of our study is that the same methodology was used dur-
ing 3 consecutive studies for patient follow up and for mortality data
retrieval. Reports from other studies showed inconsistent results and
do not fully support a chronologic association with improved survival
as was observed in our cohort (Fig. 2). While two earlier studies from
Olmsted County assessing patients in the period of 1970-1999 could
not establish a correlation between PsA and increased mortality,
[10, 11] a more recent hospital registry-based study from Hong-Kong
describing 778 PsA patients between 1999-2008 reported an
Fig. 2. SMRs from PsA mortality studies.
increased mortality with SMR of 1.59 (95% CI: 1.16 2.03). [4] PsA
SMR was comparable to rheumatoid arthritis (1.68) and ankylosing
spondylitis (1.87), and also comparable to our initial study. [2]
Some other recent studies did not find increased mortality. Buck-
ley et al. assessed survival in a hospital-based cohort of 453 PsA
patients between 1985-2007 in Bath, UK and reported SMR of 0.82
(95% CI: 0.57-1.5). [5] Ogdie et al. conducted a large medical record
database longitudinal cohort study in the UK, assessing the mortality
of PsA (n=8706), psoriasis (n=138,424) and RA (n=41,742) patients
compared to matched controls (n=81 573). [12] PsA patients did not
have an increased risk of mortality (HR=1.06, 95% CI: 0.80-1.10) after
controlling for sex and age (even without controlling for common
cardiovascular risk factors which are more common in PsA), while RA
and severe psoriasis (cDMARDs users) patients had a pronounced
increased mortality risk (HR=1.59, 95% CI: 1.52-1.64 and HR=1.75,
95% CI: 1.56-1.95, respectively). Mild psoriasis (no cDMARDs users)
had a mildly elevated mortality risk (HR=1.08, 95% CI: 1.04-1.12).
Fig. 2 summarizes the mortality ratios in the leading studies.
The literature on mortality in psoriasis provides conflicting find-
ings. Gelfand et al. [13] conducted a retrospective cohort study on pso-
riasis patients between 1987-2002, using the General Practice
Research Database which is a medical records databases in the UK.
Hazard ratios of time to death were comparable to the general popula-
tion for patients with mild psoriasis (defined as no systemic therapy)
(HR=1.0; 95% CI: 0.97-1.02), whereas patients with severe psoriasis
(defined as current or past use of any systemic therapy including pho-
totherapy or PUVA) had an increased hazard ratio of 1.5 (95% CI: 1.3-
1.7). The increased risk persisted after controlling for common mortal-
ity risk factors. The authors suggested that severe but not mild psoria-
sis imparts an increased risk of death. Svedbom et al. [14] assessed the
mortality risk as well as cause-specific mortality risk for mild and
severe psoriasis patients in Sweden. The study was based on data from
Swedish administrative registers and reported increased crude risk of
death both for mild psoriasis defined as no psoriasis related admission
and no systemic therapy (HR=1.15, 95% CI: 1.10-1.21) and for severe
disease (HR=1.56, 95% CI: 1.36-1.79). A recent large study from the
Danish National Patient Registry assessed the mortality risk in
 O. Elalouf et al. / Seminars in Arthritis and Rheumatism 50 (2020) 571 575
psoriasis and PsA as well as cause mortality risk. [15] Psoriasis patients
had lower survival compared to the general population (HR=1.74;
p<0.001), while this correlation was not demonstrated for PsA
patients (HR=1.06; p=0.19).
Causes of death
Wong et al. [2] reported a total of 53 deaths among 428 patients,
28% were attributable to cardiovascular reasons, followed by respira-
tory, cancer, and injuries/poisoning at 21%, 17%, and 15%, respectively.
SMR was elevated from diseases of the respiratory system and from
injuries or poisoning (SMR=5.14, 95% CI: 1.67-12.01 and SMR=1.36,
95% CI: 1.62-9.62, respectively). Mortality was not increased from dis-
eases of the circulatory system, cancer or from other reasons. In the
subsequent report by Ali et al. [3] cause-specific SMRs were not calcu-
lated, however the main causes of death were similar with diseases of
the circulatory system (24.5%) and cancer (23%) as the leading causes.
In the hospital-based registry study by Mok et al, [4], cause-specific
SMRs were not reported, however in this study reporting patients
from 1999-2008 infection was the leading cause accounting for 33% of
the deaths in PsA, while cancer and cardiovascular causes were
responsible for 20% each. Odgie et al. [12], reported cause-specific
mortality rates of psoriasis, PsA and RA patients of the same medical
record database from UK. Leading causes were cardiovascular, fol-
lowed by malignancy, respiratory and infections, while none of the
above was found to be increased compared to the general population.
Deaths from suicide were reported to be elevated in PsA patients with
hazard ratio of 3.03 (95% CI: 1.56- 5.90). As opposed to PsA, RA patients
had increased cause-specific mortality related to cardiovascular dis-
eases (HR = 1.55, 95% CI: 1.44- 1.66), respiratory diseases (HR = 1.85,
95% CI: 1.72- 2.01), infectious diseases (HR = 2.21, 95% CI: 2.00- 2.44)
and cancer (HR=1.18, 95% CI: 1.08-1.28).
In our cohort, male patients were found to have slightly better
survival than females. This finding was noted in the previous study,
but others have not found the same results. Since SMRs reflect mor-
tality in the general population it is possible that males with PsA
actually survive better than males with other conditions. It is possible
that the reduced mortality risk noted among the males with PsA in
our clinic has resulted from the close observation as well as the spe-
cific attention to comorbidities in our Clinic.
Another interesting finding is the markedly increased mortality
(SMR=3.36, 95% CI: 1.61-6.18) observed in the young population. This
was also demonstrated in a study in psoriasis and may be explained by
few factors. [13] First, mortality in the young general population is
very low; hence every PsA death has a very high impact on the SMR.
Second, it is well known that psoriatic disease correlates with depres-
sion, anxiety and suicide, [16] increased suicide death was reported as
well, [12] these conditions often affect the young PsA population.
Third, it might be that active disease in its early stages poses a higher
mortality risk, as opposed to a long-standing and most likely treated
and controlled disease seen in the older age groups. Acute phase reac-
tants did impart a higher mortality risk in our patient population and
may support this hypothesis. These hypotheses need to be confirmed
in further mortality and morbidity studies; meanwhile one needs to
be aware of this risk when managing the young PsA population.
Although the overall risk of death was not elevated in our PsA pop-
ulation, we identified increased acute phase reactants, and presence of
comorbidities such as heart disease and cancer as risk factors for mor-
tality in these patients. Interestingly higher education conferred a sur-
vival advantage, although the reason for this is not clear from our data.
Conclusions
The current study supports the trend of improved survival of PsA
patients seen in the previous studies from the same center in Tor-
onto. The reasons for this trend are not yet known, but cumulative
575
evidence from several studies from different geographical areas
mostly showing comparable mortality rates of PsA patients to the
general population, further support our findings. These encouraging
findings might be attributable to instituting therapy in earlier stages
of the disease, improved therapeutic options, and better awareness
of the importance of treating comorbidities. However, the comorbid-
ities and active disease remain predictors of mortality in patients
with PsA suggesting that we need to do better in controlling the dis-
ease and preventing the comorbidities.
Declaration of Competing Interests
None.
Acknowledgments
The University of Toronto Psoriatic Arthritis Program is supported
by a grant from The Krembil Foundation. Dr. Ofir Elalouf was
supported by a Psoriatic Disease Research Fellowship from the
National Psoriasis Foundation/USA. This work was presented as a
poster at the American College of Rheumatology Annual meeting
October 2018.
All authors were involved in drafting the article or revising it criti-
cally for important intellectual content, and all authors approved the
final version to be published. All authors were likewise involved in
the study conception and design, acquisition of data as well as analy-
sis and interpretation of data. Dr. Gladman had full access to all of the
data in the study and takes responsibility for the integrity of the data
and the accuracy of the data analysis.
Role of funding source
None.
References
[1] Ritchlin CT, Colbert RA, Gladman DD. Psoriatic Arthritis. N Engl J Med
2017;376:2095–6.
[2] Wong K, Gladman DD, Husted J. Mortality studies in psoriatic arthritis: results
from a single outpatient clinic. I. Causes and risk of death. Arthritis Rheum
1997;40:1868–72.
[3] Ali Y, Tom BD, Schentag CT. Improved survival in psoriatic arthritis with calendar
time. Arthritis Rheum 2007;56:2708–14.
[4] Mok CC, Kwok CL, Ho LY. Life expectancy, standardized mortality ratios, and
causes of death in six rheumatic diseases in Hong Kong. China. Arthritis Rheum
2011;63:1182–9.
[5] Buckley C, Cavill C, Taylor G. Mortality in psoriatic arthritis - a single-center study
from the UK. J Rheumatol 2010;37:2141–4.
[6] Gladman DD, Shuckett R, Russell ML. Psoriatic arthritis (PSA) an analysis of 220
patients. Q J Med 1987;62:127–41.
[7] Gladman DD, Chandran V. Review of clinical registries of psoriatic arthritis: les-
sons learned?: value for the future? Curr Rheumatol Rep 2011;13:346–52.
[8] Chandran V, Schentag CT, Gladman DD. Sensitivity and specificity of the CASPAR
criteria for psoriatic arthritis in a family medicine clinic setting. J Rheumatol
2008;35:2069–70 author reply 70.
[9] Taylor W, Gladman D, Helliwell P. Classification criteria for psoriatic arthritis:
development of new criteria from a large international study. Arthritis Rheum
2006;54:2665–73.
[10] Shbeeb M, Uramoto KM, Gibson LE. The epidemiology of psoriatic arthritis in
Olmsted County, Minnesota, USA, 1982-1991. J Rheumatol 2000;27:1247–50.
[11] Wilson FC, Icen M, Crowson CS. Time trends in epidemiology and characteristics
of psoriatic arthritis over 3 decades: a population-based study. J Rheumatol
2009;36:361–7.
[12] Ogdie A, Maliha S, Shin D. Cause-specific mortality in patients with psoriatic
arthritis and rheumatoid arthritis. Rheumatology (Oxford) 2017;56:907–11.
[13] Gelfand JM, Troxel AB, Lewis JD. The risk of mortality in patients with psoriasis:
results from a population-based study. Arch Dermatol 2007;143:1493–9.
[14] Svedbom A, Dalen J, Mamolo C. Increased cause-specific mortality in patients
with mild and severe psoriasis: a population-based Swedish register study. Acta
dermato-venereologica 2015;95:809–15.
[15] Skov L, Thomsen SF, Kristensen LE, et al.Cause-specific mortality in patients with
psoriasis and psoriatic arthritis. Br J Dermatol2018
[16] Olivier C, Robert P, Daihung D. The risk of depression, anxiety, and suicidality in
patients with psoriasis: a population-based cohort study. Arch. Dermatol.
2010;146:891–5.