MACE and VTE: Which Psoriasis Treatment is Safest?

Original Article:  Risk of major adverse cardiovascular events and venous thromboembolic events between patients with psoriasis or psoriatic arthritis on tumor necrosis factor inhibitors, interleukin 17 inhibitors, interleukin 12/23 inhibitors, and interleukin 23 inhibitors: An emulated target trial analysis

What are the key takeaways of this article?

Psoriasis and psoriatic arthritis, collectively referred to as psoriatic disease, are chronic inflammatory conditions that not only affect the skin and the joints but are also associated with an increased risk of comorbidities, particularly cardiometabolic diseases. Recent studies have highlighted that patients with psoriatic disease face a higher incidence of major adverse cardiovascular events (MACEs) and venous thromboembolic events (VTEs), likely due to systemic inflammation and underlying metabolic dysfunction. As a result, the cardiovascular safety profile of systemic treatments, especially biologic therapies, is a growing concern in clinical decision-making. 

In this emulated target trial, Chen et al. used multicenter electronic medical records from 59 healthcare organizations across the United States to evaluate whether the choice of biologic therapy influences the risk of MACE and VTE in biologic-naive patients with newly diagnosed psoriatic disease.

The study included 32,098 patients over the age of 18 who were initiating treatment with one of four classes of biologics: tumor necrosis factor inhibitors (TNFi), interleukin-17 inhibitors (IL-17i), interleukin-12/23 inhibitors (IL-12/23i), and interleukin-23 inhibitors (IL-23i). Patients were categorized into cohorts based on their first prescribed biologic, and the primary outcomes measured were the incidence of MACE and VTE from treatment initiation to either the event or the last recorded follow-up.

This study revealed no significant differences in the risks of MACE and VTE between different biologics among patients with psoriatic disease. Similarly, subgroup analyses specifically comparing psoriasis and psoriatic arthritis did not demonstrate significant differences in the risks of MACE or VTE. These results suggest that, for the average patient, the cardiovascular and thromboembolic risks associated with these biologics are broadly comparable.

However, more nuanced differences emerged when stratifying the cohort by the presence of preexisting cardiometabolic risk factors (i.e., hyperlipidemia and diabetes mellitus). Among this higher risk subgroup, patients treated with newer biologics (namely IL-17i, IL-12/23i and IL-23i) demonstrated a lower incidence of MACE and VTE compared to those using TNF-alpha inhibitors. This finding points to a potential advantage of newer biologic classes in patients with elevated baseline cardiovascular risk.

In Summary, this study is particularly important because it offers large-scale, real-world evidence addressing a key safety concern in the management of psoriatic disease. While prior literature has supported the anti-inflammatory benefits of biologics in reducing systemic risk, Chen et al.'s study adds granularity by suggesting that certain classes may be more favourable in specific patient populations. These insights can support shared decision-making between clinicians and patients, emphasizing that while no class of biologics shows a universal advantage, patient-specific risk profiles, particularly related to cardiometabolic disease, should inform treatment selection.

Publication Date: October 30th 2025

Reference: Chen TL, Huang JY, Lin HY, Chang YT, Li CY, Wei JC. Risk of major adverse cardiovascular events and venous thromboembolic events between patients with psoriasis or psoriatic arthritis on tumor necrosis factor inhibitors, interleukin 17 inhibitors, interleukin 12/23 inhibitors, and interleukin 23 inhibitors: An emulated target trial analysis. J Am Acad Dermatol. 2025 May;92(5):1015-1023. doi: 10.1016/j.jaad.2024.12.025. Epub 2024 Dec 28. PMID: 39736358.

Summary By: Nicholas Chiang