Alcohol-related mortality in patients with

psoriasis: a population-based cohort study

Rosa Parisi, PhD1; Roger T Webb, PhD2; Matthew J Carr, PhD2; Kieran J Moriarty, MD3; C Elise Kleyn,

MD4; Christopher EM Griffiths, MD4,5; Darren M Ashcroft, PhD1,5,6

1Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, University of

Manchester, Manchester Academic Health Science Centre, Manchester, UK; 2Centre for Mental

Health and Safety, School of Health Sciences, University of Manchester, Manchester Academic

Health Science Centre, Manchester, UK; 3Bolton NHS Foundation Trust, Bolton, UK; 4Dermatology

Centre, Salford Royal NHS Foundation Trust, University of Manchester, Manchester Academic Health

Science Centre, Manchester, UK; 5NIHR Manchester Biomedical Research Centre, Faculty of Biology,

Medicine and Health, University of Manchester, Manchester Academic Health Science Centre,

Manchester, UK; 6NIHR Greater Manchester Patient Safety Translational Research Centre, University

of Manchester, Manchester Academic Health Science Centre, Manchester, UK

Corresponding author: Professor Darren Ashcroft

Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry

University of Manchester

Stopford Building, Oxford Road, Manchester, M13 9PT, UK

+44(0)161 2754299

darren.ashcroft@manchester.ac.uk

Revised on June 27, 2017

Word count: 2954; Number of figures: 1; Number of tables: 4; Number of online figures: 3

1

Key points

Question: Do people with psoriasis have an elevated risk of alcohol-related mortality?

Findings: In this population-based cohort study, the adjusted hazard ratio of alcohol-related

mortality for patients with psoriasis was 1.58 (95% CI 1.31-1.91), compared to patients without

psoriasis.

Meaning: The elevated risk of alcohol-related mortality found in people with psoriasis calls for

routine screening, identification and treatment, using the simple, Alcohol Use Disorders

Identification Test (AUDIT-C), in both primary and secondary healthcare, to detect alcohol

consumption and misuse amongst people diagnosed with psoriasis.

2

ABSTRACT

Importance: People diagnosed with psoriasis have an increased risk of premature mortality, but the

underlying reasons for this mortality gap are unclear.

Objective: Our objective was to investigate whether psoriasis patients have an elevated risk of

alcohol-related mortality.

Design: Population-based incident cohort study of patients with and without psoriasis.

Setting: 398 general practices in England, contributing to the Clinical Practice Research Datalink, with

linkage to Hospital Episode Statistics and Office for National Statistics mortality records.

Participants: Patients with a first diagnosis of psoriasis between 1998 and 2014, who were 18 years

or older at diagnosis, were matched with up to 20 comparison patients without psoriasis on age,

gender, and general practice.

Main outcome and Measure: Alcohol-related deaths were ascertained via the Office for National

Statistics mortality records. A stratified Cox proportional hazard model was used to estimate the

cause-specific hazard ratio for alcohol-related death, with adjustment for socioeconomic status.

Results: The cohort included 55,537 and 854,314 patients, with and without psoriasis respectively.

Median (interquartile) age at index date was 47 (27) years; 44.9% were male. During a median (IQR)

of 4.4 (6.2) years of follow-up, the alcohol-related mortality rate was 4.8 per 10,000 person-years

(95% CI 4.1-5.6; n=152) for the psoriasis cohort, versus 2.5 per 10,000 (95% CI 2.4-2.7; n=1,118) for

the comparison cohort. The hazard ratio for alcohol-related death in patients with psoriasis was 1.58

(95% CI 1.31 to 1.91) and the predominant causes of alcohol-related deaths were alcoholic liver

disease (65.1%), fibrosis and cirrhosis of the liver (23.7%), and mental and behavioural disorders due

to alcohol (7.9%).

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Conclusions and Relevance: People with psoriasis have approximately a sixty percent greater risk of

dying due to alcohol-related causes, compared to peers of the same age and gender in the general

population. This appears to be a key contributor to the premature mortality gap. These findings call

for routine screening, identification and treatment, using the Alcohol Use Disorders Identification

Test (AUDIT-C), in both primary and secondary care, to detect alcohol consumption and misuse

amongst people diagnosed with psoriasis.

4

INTRODUCTION

Psoriasis is a common, currently incurable, immune-mediated skin disease, with a prevalence of

between 0.9% and 8.5% in Western countries1. Recently, we have shown that, despite an overall

decrease in mortality over the last fifteen years, people with psoriasis nonetheless still die

prematurely versus individuals without the disease2. These findings call for a greater understanding

of excess mortality linked with psoriasis3. Excessive alcohol consumption is recognized in as many as

a third of patients with moderate to severe psoriasis4-6. Furthermore, there is a correlation between

increased alcohol intake and extent of body surface area involvement by psoriasis5,7. Patients with

increased alcohol intake may also report significantly higher levels of anxiety, depression and

psychosocial challenges5. Consequently, alcohol misuse may be considered as a maladaptive

behaviour, used by affected individuals to manage their psychological distress.

Earlier studies found that people affected by severe psoriasis had a greater prevalence of, and

elevated risk of dying from liver disease8,9 and from gastrointestinal disease10. However, only two

studies from the USA and Finland specifically examined death due to cirrhosis or alcohol-related

mortality in people with psoriasis11,12. These studies are at least two decades old and they examined

patients with severe psoriasis identified from hospital settings11,12.

No study has specifically investigated the relative risk of dying from alcohol-related causes among

people with psoriasis in the general population.

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MATERIAL AND METHODS

Data Source and Study Design

This cohort study was carried out using the UK Clinical Practice Research Datalink (CPRD). The CPRD

contains complete patient information from 711 participating general practices in the UK, with

diagnoses, test results, prescriptions and hospital referrals recorded. Read coding is used to record

diagnoses within CPRD13. We examined the 398 CPRD practices in England that were also linked to

the national Hospital Episode Statistics (HES) and the Office for National Statistics (ONS) mortality

records. Linkage is available at individual-level for those patients registered at practices that have

consented to data linkage. Linkage between datasets is undertaken using a deterministic linkage

algorithm, based on a patient’s exact National Health Service (NHS) identification number, gender,

date of birth and residential postcode. The study was approved by the Independent Scientific

Advisory Committee (ISAC) for Medicines and Healthcare products Regulatory Agency database

research (ISAC approval 15_033R) and is reported in line with the recommendations of the RECORD

statement14. This population-based study was conducted using anonymized electronic health records

that were extracted by a third party and de-identified before they were made available for research

purposes. Hence, patient consent was not required.

The psoriasis cohort comprised adult patients (18 years and older), identified in the CPRD, with their

first diagnosis of psoriasis between January 1, 1998 and March 3, 2014. Patients were eligible for

linkage to the HES and ONS mortality records and were registered in the practice for at least 1 year

prior to being diagnosed with psoriasis. The index date was set as the first diagnosis recorded during

the study window. Up to 20 comparison patients, without a diagnosis of psoriasis, were matched by

age, gender and general practice on index date. The reason for matching with this number of

unaffected comparison patients was the rarity of alcohol-related death as an outcome, to thereby

maximize statistical power and precision and to preclude the occurrence of very small cell values

among the comparison cohort. The comparison patients were required to have been in contact with

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the general practice within six months of the index date of the psoriasis patients, to whom they were

matched. The selection of patients, with and without psoriasis, from the same population at risk, and

identifying them from the same general practice and during the same time-window, was

implemented to thereby avoid potential selection, information and detection biases. All patients

included in the study were followed up from the index date to the end of the study observation

period (March 3, 2014), or to the last date of data collection from the practice, the date the patient

transferred out of the practice or died, whichever came first.

Area-level Socioeconomic Status

The residential postcodes of patients were linked to the Index of Multiple Deprivation (IMD) 201015.

The IMD is an area-level weighted combination of the following seven domains of deprivation:

income, employment, health and disability, education skills and training, barriers to housing and

services, living environment, and crime. It is calculated at the Lower-layer Super Output Areas (LSOA)

level covering approximately 1,500 residents. The IMD scores were aggregated into quintiles, where

1 corresponded to the least deprived area and 5 to the most deprived area.

Measurement of Alcohol Consumption

Information on alcohol consumption was extracted using an existing algorithm16 modified for this

study (e-Figure 1). In summary, the most recent record, prior to or recorded on the index date, was

used to determine the alcohol consumption level. If no information on alcohol consumption was

available, this was set to ‘missing’. Alcohol consumption level was categorized as follows: non-

drinkers, former drinkers, occasional drinkers, moderate drinkers and heavy drinkers, according to

UK guidelines on alcohol consumption that were in place during the study’s observation period17.

Alcohol-related Mortality and Clinical Management

Cause-specific mortality was determined via linkage of patients’ electronic health records (primary

care: CPRD; secondary care: HES) with ONS mortality records. In the UK, death certificates are

completed by an attending registered medical practitioner, and this information is captured

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nationally by the ONS. Death certificates are divided into two parts, containing the underlying cause

of death (part 1) and diseases that may have contributed to the death (part 2). We identified

alcohol-related deaths via the underlying cause of death code, according to International

Classification of Diseases, 9th (ICD-9) and 10th (ICD-10) revisions, as recommended by the ONS18.

The ONS definition of alcohol-related deaths only includes those causes regarded as resulting

directly from harmful alcohol consumption (as presented in e-Figure 2) and does not include other

diseases, where alcohol has been shown to make some aetiological contribution, such as cancers of

the mouth, oesophagus and liver and suicide18.

Amongst those who died from alcohol-related causes, the proportion of people, who had previously:

i) been classified as heavy drinkers; ii) prescribed treatment for alcohol dependence (acamprosate,

disulfiram, nalmefene and naltrexone); iii) coded for being offered psychological support for alcohol

dependence in primary care; or iv) had an admission to hospital for chronic causes, directly

attributable to alcohol, were calculated.

All of the code lists used are available from www.clinicalcodes.org 19 .

Statistical Analysis

For the descriptive analysis, continuous variables were summarized using the median and

interquartile range (IQR), whereas discrete variables were reported as percentages per exposure

group. All-person and gender-specific alcohol-related death rates per 10,000 person-years, with 95%

confidence intervals (CI) and median age at death (IQR), were calculated for patients with and

without psoriasis. Cumulative incidence functions were calculated for alcohol-related deaths, and

deaths due to all other causes combined (‘other causes of death’). A stratified Cox proportional

hazard model was fitted to estimate the cause-specific hazard ratio and 95% CI. The model was

adjusted for socioeconomic status, measured according to IMD quintile. Additionally, the following

three models were fitted separately: interactions between psoriasis and age, gender and IMD

quintile. A sensitivity analysis was performed to assess the robustness of the results, by restricting

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the analysis to patients not prescribed methotrexate (MTX) as this could be a potential confounder,

given the hepatotoxicity of this drug. All statistical analyses were performed using Stata v14

(StataCorp, College Station, TX).

RESULTS

In all, 55,537 patients with incident psoriasis, and 854,314 patients in the matched comparison

cohort, met the eligibility criteria and were included in the analysis (e-Figure 3). Median (IQR) age at

index date was 47 (27) years (Table 1). Patient postcode-level IMD was similarly distributed. At

baseline, there was a higher prevalence of being recorded as a heavy drinker in the psoriasis cohort

(9.3%) versus the comparison cohort (7.0%) (p-value < 0.001, Table 1). During a median (IQR) of 4.4

(6.2) years of follow-up, 152 alcohol-related deaths occurred in the psoriasis cohort and 1,118 in the

matched comparison cohort. As shown in Table 2, the alcohol-related death rate per 10,000 person-

years was higher for the psoriasis cohort (4.8, 95% CI 4.1-5.6) versus the comparison cohort (2.5,

95% CI 2.4-2.7). People with psoriasis died from alcohol-related causes on average three years

younger versus those without psoriasis who died from these causes: median (IQR) age at death 55

(16) years versus 58 (17) years, respectively (Table 2). Furthermore, women with psoriasis died from

alcohol-related causes at approximately 5 years younger than women without psoriasis who died

from these causes. Three diagnostic codes were predominant among the alcohol-related deaths in

the psoriasis cohort: alcoholic liver disease (99 cases, 65.1%), fibrosis and cirrhosis of the liver

excluding biliary cirrhosis (36 cases, 23.7%), and mental and behavioural disorders due to alcohol

misuse (12 cases, 7.9%). These three causes together accounted for 147 (96.7%) of the 152 deaths

among the individuals diagnosed with psoriasis. The equivalent percentage (92.1 %; 1,030/1,118)

was lower in the comparison cohort, but the same three types of alcohol-related death

predominated.

9

The electronic health records revealed that most patients, who died from alcohol-related causes in

the psoriasis cohort, or in the comparison cohort, had at least one lifetime hospital admission for a

chronic alcohol-related condition (85.5% and 79.0% respectively). Amongst those patients, who died

due to alcohol-related disease, 82.2% in the psoriasis group and 75.5% in the comparison group had

been classified as heavy drinkers in their primary care medical records. However, 17.8% of patients,

who died from alcohol-related causes in the psoriasis cohort, and 24.3% in the comparison cohort,

never received a lifetime diagnosis of excessive alcohol consumption, or a prescription in primary

care for alcohol dependence. Only a small proportion of these patients received pharmacotherapy

for alcohol dependence or was coded as being offered psychological support (Table 3).

The cause-specific hazard of alcohol-related death was increased by 58% (HR 1.58, 95% CI 1.31-1.91)

in the psoriasis cohort versus the comparison cohort, and the cause-specific hazard of ‘other causes

of death’ was lower by 19% (HR 0.81, 95% CI 0.78-0.83), as reported in Table 4. For patients with

psoriasis, the cumulative incidence of alcohol-related death tended to increase much more rapidly

than in the comparison group across the follow-up period. The 16 year cumulative incidence of

alcohol-related death in the psoriasis and comparison cohorts were 0.007% (95% CI 0.005-0.009)

and 0.005% (95% CI 0.003-0.005), respectively (Figure 1). There was no evidence of variability in

relative risk by age (p = 0.45), gender (p = 0.59) or IMD quintile (p= 0.28). The sensitivity analysis,

excluding people prescribed methotrexate, confirmed that psoriasis was associated with an elevated

alcohol-related mortality risk: HR 1.66 (95% CI 1.37-2.01).

DISCUSSION

Main Findings

People diagnosed with psoriasis had a greater risk of dying, on average three years younger, due to

alcohol-related causes, compared to the general population. Moreover, although there was no

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evidence of a variation in relative risk by gender, women with psoriasis died of alcohol-related

causes at considerably younger age (by approximately 5 years) than women without psoriasis, who

died from these causes. The cumulative incidence functions also showed that the incidence of

alcohol-related mortality increased much more rapidly during follow-up in patients with psoriasis.

Similar findings were evident after excluding patients, who were prescribed methotrexate in primary

care.

Comparison to Other Studies

Consistent with other studies, we found a raised prevalence of alcohol misuse in the psoriasis

cohort7. Our results are also consistent with those that found an increased mortality risk due to liver

disease in patients with psoriasis9,10,20. In examining cause-specific mortality, these earlier studies

found that people affected by psoriasis had a greater risk of dying from liver disease, with a standard

mortality ratio (SMR) of 4.04 (95% CI 2.76–5.70) if they had the most severe form of the disease9, or

with a HR of 2.00 (95% CI 1.34-2.99) for mild psoriasis, and 4.26 (95% CI 1.87-9.73) for severe

psoriasis10. Higher mortality rates from gastrointestinal diseases have also been reported amongst

patients with mild (0.9 per 1,000 person-years, 95% CI 0.9-1.0) and severe (1.8 per 1,000 person-

years, 95% CI 1.6-2.0) psoriasis, compared to 0.4 per 1,000 person-years (95% CI 0.4-0.4) in the

general population20. Similar to findings reported by Stern and Lange (1988)11 and Poikolainen et al.

(1999)12, we found that the risk of death, due to cirrhosis and other causes, directly attributable to

alcohol misuse, is greater in people with psoriasis than it is in those without the condition. The first

study, using a cohort of 1,380 people with moderate-to-severe psoriasis, exposed to

Photochemotherapy (PUVA), and which investigated specific causes of death, found that psoriasis

was positively associated with death due to cirrhosis (SMR 4.7, 95% CI 3.1-6.8)11.The second study,

analysing more than 5,000 patients hospitalized for psoriasis, reported elevated mortality, directly

attributable to alcohol: SMR 4.46 (95% CI 3.60-5.45) for men and 5.60 (95% CI 2.98-8.65) for

women12.

11

Strengths and Limitations of the Study

Major strengths of this study included the linkage of primary care electronic health records to

national mortality records, in order to ascertain causes of death, and also the adoption of a stringent

definition to identify alcohol-related mortality. The use of the ONS definition included only those

causes of death directly attributable to chronic or acute alcohol misuse18. Earlier studies are likely to

have misclassified the outcome by using broader definitions, including diagnoses, which are

associated with alcohol, but not directly attributable to acute or chronic excessive alcohol

consumption12. In contrast to Stern and Lange11 and Poikolainen et al.12, we examined risk within a

population-based cohort of people with psoriasis, rather than within those with just the most severe

form of the disease11, or in cases hospitalized for psoriasis12. In a sensitivity analysis, we examined

whether the observed elevated alcohol-related death risk might be explained by hepatotoxicity due

to methotrexate use, rather than excessive alcohol consumption, by excluding patients prescribed

methotrexate. A further strength of our study was the size and coverage of the data source, which

yielded a cohort broadly representative of all patients, registered in primary care in England. This

provided abundant statistical power to examine this relatively rare cause-specific mortality outcome.

Only one variable in our cohort study was affected by missing data: specifically, socioeconomic

status (IMD score) contained a negligible amount of missing data (0.1%). Nonetheless, some

limitations of the study should be acknowledged. These include the fact that information on

methotrexate use was identified from prescriptions issued in primary care, as no information on

hospital prescribing was available. However, patients receiving low-dose methotrexate for psoriasis

are commonly managed through shared-care arrangements between hospital and primary care

healthcare providers. Secondly, we were unable to examine risk of alcohol-related mortality by

severity of psoriasis, as validated measures of disease severity are not routinely recorded in patients’

electronic health records in primary care.

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Interpretation of the Findings

Individuals with psoriasis face psychological distress and psychosocial challenges, often as a

consequence of the stigmatising nature of the disease, and these in turn can lead to chronic alcohol

misuse and dependence. Highlighting the dual stigma of psoriasis and problem drinking is important.

Alcohol misuse is perceived as a self-inflicted lifestyle choice, rather than a disease. Hence, patients

are often reticent to acknowledge the problem5. People affected by psoriasis have a higher

prevalence of excessive alcohol consumption and an elevated risk of dying due to alcohol-related

causes, compared to the general population of the same age and gender, independent of

socioeconomic status. Our findings also highlight that alcohol misuse often remains unidentified and

undertreated in primary care.

Only a very small proportion of individuals, who died from alcohol-related causes, was prescribed

pharmacotherapy, or was coded as being offered psychological support. Nonetheless, the majority

of these patients had previously been hospitalized for alcohol-related problems. These findings

concur with those from a recent study on prescribing patterns for alcohol dependence in the UK,

which concluded that only 12% of people with alcohol dependence were prescribed treatment in

primary care21. In recent years, the National Institute for Health and Care Excellence (NICE)

guidelines in England22 and systematic reviews of the evidence-base23 have recommended a

combination of pharmacotherapy and psychological counselling, neither of which is regularly

deployed for people with alcohol dependence.

Alcohol Treatment Services and Implications for Clinicians

There is also a need to detect and intervene earlier in liver disease and the main determinant of long

term survival for these patients is to abstain from drinking24. Screening and Brief Interventions, in

both primary and secondary healthcare, and hospital Alcohol Care Teams help patients achieve

abstinence, improve health harms and prognosis, and remove the stigma of self-inflicted disease25,26.

Our study has reinforced the findings from the National Confidential Enquiry into Patient Outcome

13

and Death (NCEPOD) report, highlighting the long-term nature of missed opportunities, such as

delays in referral of patients for specialist alcohol and liver care, and missed opportunities for brief

interventions during previous admissions27.

Our findings also indicate that healthcare practitioners, with responsibility for the care of patients

with psoriasis, should be more aware of the psychological difficulties that this group faces. Routine

screening, identification and treatment, using the simple, shortened form (AUDIT-C) of the Alcohol

Use Disorders Identification Test (AUDIT) screening tool, developed by the World Health

Organisation to detect the early signs of hazardous, harmful and dependent alcohol consumption28,

should be implemented in both primary and secondary care, to detect alcohol misuse amongst all

people diagnosed with psoriasis28. This is critical in hospital dermatology departments, where the

most severe cases of psoriasis, in whom alcohol consumption is highest, are cared for6. Moreover,

there is also an urgent need for effective alcohol and addiction treatment services to be developed,

so as to address both health harms and to overcome the stigma experienced by patients with both

psoriasis and alcohol problems24.

ACKNOWLEDGMENTS

Author Contributions

Dr Parisi 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. Study concept and design: Parisi, Webb, Ashcroft.

Acquisition, analysis, and interpretation of data: Parisi, Webb, Ashcroft. Drafting of the manuscript:

Parisi. Critical revision of the manuscript for important intellectual content: Parisi, Webb, Moriarty,

Kleyn, Griffiths, Ashcroft. Statistical analysis: Parisi, Carr. Obtained funding: Parisi, Griffiths, Ashcroft.

Administrative, technical, or material support: Parisi. Study supervision: Webb, Ashcroft.

14

Funding/Support

This study was supported in part by Salford Royal NHS Foundation Trust in conjunction with the

National Institute for Health Research (NIHR) Programme Grant: Identification and Management of

Psoriasis Associated ComorbidiTy (IMPACT) (RP-PG-0608-10163). CEMG and DMA are funded in part

by the Medical Research Council (MR/L011808/1). CEMG is an NIHR Senior Investigator.

Role of the Funder/Support:

The funders had no role in the design and conduct of the study; collection, management, analysis,

and interpretation of the data; preparation, review, or approval of the manuscript; or decision to

submit the manuscript for publication.

Conflict of Interests Disclosure

No specific conflicts of interest relevant to this study.

CEK has received honoraria and/or research funding from Pfizer, Janssen, Johnson & Johnson and

honoraria from Abbvie, Amgen, Galderma, Leo Pharma and GSK-Stiefel, Eli Lilly. DMA has received

grant funding from Abbvie and served on advisory boards for Pfizer and GSK. CEMG has received

honoraria and/or research grants from Abbvie, Actelion, Almirall, Amgen, Celgene, Galderma, LEO

Pharma, Eli Lilly, GSK-Stiefel, Janssen, MSD, Novartis, Pfizer, Sandoz, Sun Pharmaceuticals and USB

Pharma.

15

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Figure 1 - Cumulative Incidence Functions for alcohol-induced death and ‘other causes of death’. The

figure shows the cumulative incidence functions for alcohol-induced death and ‘other causes of

death’ in the psoriasis and comparison cohort, across the maximum 16 years of follow-up.

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Table 1 Comparison of patient characteristics at baseline for the psoriasis vs. comparison cohorts

Psoriasis Cohort Comparison CohortNo. 55,537 854,314Men (%) 26,795 (48.2) 381,435 (44.6)Women (%) 28,742 (51.7) 472,879 (55.3)Median age (IQR) 48 (28) 47 (28)IMD score quintile1 (%)

1 (least deprived) 12,887 (23.2) 206,121 (24.1)2 12,608 (22.7) 197,246 (23.1)3 11,107 (20.0) 170,642 (20.0)4 10,598 (19.1) 156,342 (18.3)

5 (most deprived) 8,277 (14.9) 122,936 (14.4)Missing (%) 60 (0.1) 1027 (0.1)

Alcohol consumption2

Non-drinker 5,463 (9.8) 91,739 (10.7) Former drinker 2,582 (4.6) 36,102 (4.2) Occasional drinkers 6,512 (11.7) 102,646 (12.0) Moderate drinkers 22,714 (40.9) 349,182 (40.9) Heavy drinkers 5,146 (9.3) 60,054 (7.0) Missing 13,117 (23.6) 214,591 (25.1)1 Index of Multiple Deprivation (IMD), which measures socioeconomic status at area level, and is divided into quintiles. 1 corresponds to the least deprived area; 5 to the most deprived area.

2 The variable includes the most recent record of alcohol consumption prior to or on the index date.

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Table 2 Event counts and crude incidence rates of alcohol-related death in the psoriasis and comparison cohorts

Characteristics Psoriasis Cohort Comparison Cohort

Number of patients per cohort 55,537 854,314

Follow-up in years, median (IQR) 5.0 (6.4) 4.3 (6.1)

Person-years 318,435 4,455,669

Number of alcohol-relateddeaths (%)

152 (0.3) 1,118 (0.1)

Alcohol-relatedmortality rate (95% CI)1

4.8 (4.1-5.6) 2.5 (2.4-2.7)

Female 3.9 (3.1-5.0) 1.9 (1.7-2.1)

Male 5.7 (4.6-7.0) 3.3 (3.0-3.5)

Median age at death foralcohol-related death (IQR)

55 (16) 58 (17)

Female 55 (18) 60 (18) Male 56 (14) 57 (16)

1 Crude mortality rates per 10,000 person-years

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Table 3 Proportion of alcohol-related deaths in the psoriasis and comparison cohorts with history of alcohol misuse indicated in their primary (CPRD) or secondary care (HES) records

History of alcohol misuse indicators

Psoriasis Cohort (N=152) Comparison Cohort (N=1,118)

Coded as being a heavy drinker 125 (82.2) 844 (75.5)

Prescription for alcohol dependence

16 (10.5) 122 (10.9)

Coded as being offered psychological support in primary care

30 (19.7) 161 (14.4)

Hospital admission for chronic causes entirely attributable to alcohol

130 (85.5) 883 (79.0)

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Table 4 Cause-specific hazard ratios (95% confidence intervals) for alcohol-related death and ‘other causes of death’

Alcohol-related death

p-value Other causes of death

p-value

Unadjusted analysis

1.60 (1.33-1.93) <0.001 0.81 (0.78-0.83) <0.001

Primary analysis1 1.58 (1.31-1.91) <0.001 0.81 (0.78-0.83) <0.001

Excluding people who were prescribed MTX1,2

1.66 (1.37-2.01) <0.001 0.78 (0.75-0.80) <0.001

1 Adjusted for Index of Multiple Deprivation (IMD) quintile

2 MTX: methotrexate

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