Key clinical point: Signatures of circulating microRNA in patients with psoriatic arthritis (PsA) and patients with psoriasis were significantly different from those in control individuals, with some even being differentially regulated between PsA and psoriasis.

Major finding: Overall, 9 microRNA best differentiated patients with PsA and psoriasis from control individuals (area under the curve [AUC] ≥0.70; all P < .05) and 4 microRNA best differentiated patients with PsA from patients with psoriasis (all P < .05). A combination of 4 microRNA (miR-19b-3p, miR-21-5p, miR-92a-3p, and let-7b-5p) vs miR-92a-3p alone could better differentiate between patients with PsA and psoriasis (AUC 0.92 vs 0.82).

Study details: This cross-sectional study included 51 patients with PsA, 40 patients with psoriasis, and 50 control individuals.

Disclosures: This study did not receive any specific funding. Two authors declared being employees or shareholders of TAmiRNA GmbH or holding intellectual property for the diagnostic use of microRNA in bone diseases.

Source: Haschka J et al. Identification of circulating microRNA patterns in patients in psoriasis and psoriatic arthritis. Rheumatology (Oxford). 2023 (Feb 3). Doi: 10.1093/rheumatology/kead059

Key clinical point: Signatures of circulating microRNA in patients with psoriatic arthritis (PsA) and patients with psoriasis were significantly different from those in control individuals, with some even being differentially regulated between PsA and psoriasis.

Major finding: Overall, 9 microRNA best differentiated patients with PsA and psoriasis from control individuals (area under the curve [AUC] ≥0.70; all P < .05) and 4 microRNA best differentiated patients with PsA from patients with psoriasis (all P < .05). A combination of 4 microRNA (miR-19b-3p, miR-21-5p, miR-92a-3p, and let-7b-5p) vs miR-92a-3p alone could better differentiate between patients with PsA and psoriasis (AUC 0.92 vs 0.82).

Study details: This cross-sectional study included 51 patients with PsA, 40 patients with psoriasis, and 50 control individuals.

Disclosures: This study did not receive any specific funding. Two authors declared being employees or shareholders of TAmiRNA GmbH or holding intellectual property for the diagnostic use of microRNA in bone diseases.

Source: Haschka J et al. Identification of circulating microRNA patterns in patients in psoriasis and psoriatic arthritis. Rheumatology (Oxford). 2023 (Feb 3). Doi: 10.1093/rheumatology/kead059

Key clinical point: Signatures of circulating microRNA in patients with psoriatic arthritis (PsA) and patients with psoriasis were significantly different from those in control individuals, with some even being differentially regulated between PsA and psoriasis.

Major finding: Overall, 9 microRNA best differentiated patients with PsA and psoriasis from control individuals (area under the curve [AUC] ≥0.70; all P < .05) and 4 microRNA best differentiated patients with PsA from patients with psoriasis (all P < .05). A combination of 4 microRNA (miR-19b-3p, miR-21-5p, miR-92a-3p, and let-7b-5p) vs miR-92a-3p alone could better differentiate between patients with PsA and psoriasis (AUC 0.92 vs 0.82).

Study details: This cross-sectional study included 51 patients with PsA, 40 patients with psoriasis, and 50 control individuals.

Disclosures: This study did not receive any specific funding. Two authors declared being employees or shareholders of TAmiRNA GmbH or holding intellectual property for the diagnostic use of microRNA in bone diseases.

Source: Haschka J et al. Identification of circulating microRNA patterns in patients in psoriasis and psoriatic arthritis. Rheumatology (Oxford). 2023 (Feb 3). Doi: 10.1093/rheumatology/kead059

Key clinical point: The crude mortality rate increased by two-fold in patients with psoriatic arthritis (PsA) during the COVID-19 pandemic compared with the pre-pandemic era, with pulmonary reasons being the major risk factors for mortality.

Major finding: Although standard mortality rates were similar between patients with PsA and the general population during the pre-pandemic period (0.95; 95% CI 0.61-1.49), the crude mortality rate, which was 5.07 before the pandemic, increased by 2.12-fold during the pandemic in the PsA population. Interestingly, deaths due to pulmonary reasons increased from 6% during the pre-pandemic era to 66% during the pandemic.

Study details: Findings are from an international multicenter registry study including 1216 patients with PsA who were followed up for 7500 patient-years.

Disclosures: This study did not report the source of funding. Some authors declared receiving honoraria or research grants from several sources.

Source: Erden A et al. Mortality in psoriatic arthritis patients, changes over time, and the impact of COVID-19: Results from a multicenter Psoriatic Arthritis Registry (PsART-ID). Clin Rheumatol. 2023;42(2):385-390(Jan 13). Doi: 10.1007/s10067-022-06492-6

Key clinical point: The crude mortality rate increased by two-fold in patients with psoriatic arthritis (PsA) during the COVID-19 pandemic compared with the pre-pandemic era, with pulmonary reasons being the major risk factors for mortality.

Major finding: Although standard mortality rates were similar between patients with PsA and the general population during the pre-pandemic period (0.95; 95% CI 0.61-1.49), the crude mortality rate, which was 5.07 before the pandemic, increased by 2.12-fold during the pandemic in the PsA population. Interestingly, deaths due to pulmonary reasons increased from 6% during the pre-pandemic era to 66% during the pandemic.

Study details: Findings are from an international multicenter registry study including 1216 patients with PsA who were followed up for 7500 patient-years.

Disclosures: This study did not report the source of funding. Some authors declared receiving honoraria or research grants from several sources.

Source: Erden A et al. Mortality in psoriatic arthritis patients, changes over time, and the impact of COVID-19: Results from a multicenter Psoriatic Arthritis Registry (PsART-ID). Clin Rheumatol. 2023;42(2):385-390(Jan 13). Doi: 10.1007/s10067-022-06492-6

Key clinical point: The crude mortality rate increased by two-fold in patients with psoriatic arthritis (PsA) during the COVID-19 pandemic compared with the pre-pandemic era, with pulmonary reasons being the major risk factors for mortality.

Major finding: Although standard mortality rates were similar between patients with PsA and the general population during the pre-pandemic period (0.95; 95% CI 0.61-1.49), the crude mortality rate, which was 5.07 before the pandemic, increased by 2.12-fold during the pandemic in the PsA population. Interestingly, deaths due to pulmonary reasons increased from 6% during the pre-pandemic era to 66% during the pandemic.

Study details: Findings are from an international multicenter registry study including 1216 patients with PsA who were followed up for 7500 patient-years.

Disclosures: This study did not report the source of funding. Some authors declared receiving honoraria or research grants from several sources.

Source: Erden A et al. Mortality in psoriatic arthritis patients, changes over time, and the impact of COVID-19: Results from a multicenter Psoriatic Arthritis Registry (PsART-ID). Clin Rheumatol. 2023;42(2):385-390(Jan 13). Doi: 10.1007/s10067-022-06492-6

Key clinical point: All multiple manifestations of psoriatic arthritis (PsA) negatively affect quality of life (QoL), with dactylitis, peripheral joint disease, and psoriasis impairing functional status, whereas joint, skin, and periarticular symptoms independently impair work productivity.

Major finding: Presence vs absence of enthesitis, dactylitis, inflammatory back pain, and peripheral joint involvement was associated with worse QoL and self-rated health (all P < .05), whereas increasing number of affected joints and greater body surface area involvement significantly correlated with poorer functional state and greater work productivity impairment (all P < .05).

Study details: Findings are from a cross-sectional observational study including 2222 patients with physician-confirmed diagnosis of PsA.

Disclosures: This study did not receive any specific funding. Some authors declared receiving grants from, serving as a consultant for, being an employee of, or owning shares in different sources.

Source: Walsh JA et al. Impact of key manifestations of psoriatic arthritis on patient quality of life, functional status, and work productivity: Findings from a real-world study in the United States and Europe. Joint Bone Spine. 2023;105534 (Jan 25). Doi: 10.1016/j.jbspin.2023.105534

Key clinical point: All multiple manifestations of psoriatic arthritis (PsA) negatively affect quality of life (QoL), with dactylitis, peripheral joint disease, and psoriasis impairing functional status, whereas joint, skin, and periarticular symptoms independently impair work productivity.

Major finding: Presence vs absence of enthesitis, dactylitis, inflammatory back pain, and peripheral joint involvement was associated with worse QoL and self-rated health (all P < .05), whereas increasing number of affected joints and greater body surface area involvement significantly correlated with poorer functional state and greater work productivity impairment (all P < .05).

Study details: Findings are from a cross-sectional observational study including 2222 patients with physician-confirmed diagnosis of PsA.

Disclosures: This study did not receive any specific funding. Some authors declared receiving grants from, serving as a consultant for, being an employee of, or owning shares in different sources.

Source: Walsh JA et al. Impact of key manifestations of psoriatic arthritis on patient quality of life, functional status, and work productivity: Findings from a real-world study in the United States and Europe. Joint Bone Spine. 2023;105534 (Jan 25). Doi: 10.1016/j.jbspin.2023.105534

Key clinical point: All multiple manifestations of psoriatic arthritis (PsA) negatively affect quality of life (QoL), with dactylitis, peripheral joint disease, and psoriasis impairing functional status, whereas joint, skin, and periarticular symptoms independently impair work productivity.

Major finding: Presence vs absence of enthesitis, dactylitis, inflammatory back pain, and peripheral joint involvement was associated with worse QoL and self-rated health (all P < .05), whereas increasing number of affected joints and greater body surface area involvement significantly correlated with poorer functional state and greater work productivity impairment (all P < .05).

Study details: Findings are from a cross-sectional observational study including 2222 patients with physician-confirmed diagnosis of PsA.

Disclosures: This study did not receive any specific funding. Some authors declared receiving grants from, serving as a consultant for, being an employee of, or owning shares in different sources.

Source: Walsh JA et al. Impact of key manifestations of psoriatic arthritis on patient quality of life, functional status, and work productivity: Findings from a real-world study in the United States and Europe. Joint Bone Spine. 2023;105534 (Jan 25). Doi: 10.1016/j.jbspin.2023.105534

Key clinical point:  Patients with psoriasis and concomitant psoriatic arthritis (PsA) had a greater comorbidity burden compared with those with psoriasis alone, which negatively impacted treatment persistence.

Major finding: Among patients receiving ustekinumab, those with concomitant PsA vs psoriasis alone had higher comorbidity burden, including diabetes (odds ratio [OR] 1.52; 95% CI 1.16-1.97), hypertension (OR 1.55; 95% CI 1.27-1.89), and obesity (OR 1.33; 95% CI 1.1-1.61), and a shorter time to ustekinumab discontinuation (hazard ratio 1.98; P < .0001).

Study details: This was a retrospective study including 9057 patients with plaque psoriasis alone or with concomitant PsA who received either ustekinumab or conventional systemic disease-modifying antirheumatic drugs.

Disclosures: This study was funded by Janssen-Cilag Ltd. W Tillett and A Ogdie declared receiving fees and grants or research support from various sources, including Janssen. A Passey and P Gorecki declared being employees of Janssen-Cilag Ltd.

Source: Tillett W et al. Impact of psoriatic arthritis and comorbidities on ustekinumab outcomes in psoriasis: A retrospective, observational BADBIR cohort study. RMD Open. 2023;9(1):e002533 (Jan 17). Doi: 10.1136/rmdopen-2022-002533

Key clinical point:  Patients with psoriasis and concomitant psoriatic arthritis (PsA) had a greater comorbidity burden compared with those with psoriasis alone, which negatively impacted treatment persistence.

Major finding: Among patients receiving ustekinumab, those with concomitant PsA vs psoriasis alone had higher comorbidity burden, including diabetes (odds ratio [OR] 1.52; 95% CI 1.16-1.97), hypertension (OR 1.55; 95% CI 1.27-1.89), and obesity (OR 1.33; 95% CI 1.1-1.61), and a shorter time to ustekinumab discontinuation (hazard ratio 1.98; P < .0001).

Study details: This was a retrospective study including 9057 patients with plaque psoriasis alone or with concomitant PsA who received either ustekinumab or conventional systemic disease-modifying antirheumatic drugs.

Disclosures: This study was funded by Janssen-Cilag Ltd. W Tillett and A Ogdie declared receiving fees and grants or research support from various sources, including Janssen. A Passey and P Gorecki declared being employees of Janssen-Cilag Ltd.

Source: Tillett W et al. Impact of psoriatic arthritis and comorbidities on ustekinumab outcomes in psoriasis: A retrospective, observational BADBIR cohort study. RMD Open. 2023;9(1):e002533 (Jan 17). Doi: 10.1136/rmdopen-2022-002533

Key clinical point:  Patients with psoriasis and concomitant psoriatic arthritis (PsA) had a greater comorbidity burden compared with those with psoriasis alone, which negatively impacted treatment persistence.

Major finding: Among patients receiving ustekinumab, those with concomitant PsA vs psoriasis alone had higher comorbidity burden, including diabetes (odds ratio [OR] 1.52; 95% CI 1.16-1.97), hypertension (OR 1.55; 95% CI 1.27-1.89), and obesity (OR 1.33; 95% CI 1.1-1.61), and a shorter time to ustekinumab discontinuation (hazard ratio 1.98; P < .0001).

Study details: This was a retrospective study including 9057 patients with plaque psoriasis alone or with concomitant PsA who received either ustekinumab or conventional systemic disease-modifying antirheumatic drugs.

Disclosures: This study was funded by Janssen-Cilag Ltd. W Tillett and A Ogdie declared receiving fees and grants or research support from various sources, including Janssen. A Passey and P Gorecki declared being employees of Janssen-Cilag Ltd.

Source: Tillett W et al. Impact of psoriatic arthritis and comorbidities on ustekinumab outcomes in psoriasis: A retrospective, observational BADBIR cohort study. RMD Open. 2023;9(1):e002533 (Jan 17). Doi: 10.1136/rmdopen-2022-002533

Key clinical point: Nailfold capillaroscopy (NC) outcomes could not conclusively differentiate psoriasis from psoriatic arthritis (PsA).

Major finding: In addition to altered morphology, the density of capillaries at the nailfold was significantly lower in patients with psoriasis (standardized group difference [SMD] −0.91; P  =  .0058; area under curve [AUC] 0.740) and PsA (SMD −1.22; P  =  .0432; AUC, 0.806) compared with control individuals; however, no NC outcomes conclusively differentiated between psoriasis and PsA.

Study details: Findings are from a systematic review and meta-analysis of 22 studies investigating NC as a diagnostic tool for psoriasis or  PsA.

Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.

Source: Lazar LT et al. Nailfold capillaroscopy as diagnostic test in patients with psoriasis and psoriatic arthritis: A systematic review. Microvasc Res. 2023;147:104476 (Jan 16). Doi: 10.1016/j.mvr.2023.104476

Key clinical point: Nailfold capillaroscopy (NC) outcomes could not conclusively differentiate psoriasis from psoriatic arthritis (PsA).

Major finding: In addition to altered morphology, the density of capillaries at the nailfold was significantly lower in patients with psoriasis (standardized group difference [SMD] −0.91; P  =  .0058; area under curve [AUC] 0.740) and PsA (SMD −1.22; P  =  .0432; AUC, 0.806) compared with control individuals; however, no NC outcomes conclusively differentiated between psoriasis and PsA.

Study details: Findings are from a systematic review and meta-analysis of 22 studies investigating NC as a diagnostic tool for psoriasis or  PsA.

Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.

Source: Lazar LT et al. Nailfold capillaroscopy as diagnostic test in patients with psoriasis and psoriatic arthritis: A systematic review. Microvasc Res. 2023;147:104476 (Jan 16). Doi: 10.1016/j.mvr.2023.104476

Key clinical point: Nailfold capillaroscopy (NC) outcomes could not conclusively differentiate psoriasis from psoriatic arthritis (PsA).

Major finding: In addition to altered morphology, the density of capillaries at the nailfold was significantly lower in patients with psoriasis (standardized group difference [SMD] −0.91; P  =  .0058; area under curve [AUC] 0.740) and PsA (SMD −1.22; P  =  .0432; AUC, 0.806) compared with control individuals; however, no NC outcomes conclusively differentiated between psoriasis and PsA.

Study details: Findings are from a systematic review and meta-analysis of 22 studies investigating NC as a diagnostic tool for psoriasis or  PsA.

Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.

Source: Lazar LT et al. Nailfold capillaroscopy as diagnostic test in patients with psoriasis and psoriatic arthritis: A systematic review. Microvasc Res. 2023;147:104476 (Jan 16). Doi: 10.1016/j.mvr.2023.104476

Patients with psoriasis treated with interleukin-12/23 inhibitors or IL-23 inhibitors were less likely to develop inflammatory arthritis, compared with those treated with tumor necrosis factor (TNF) inhibitors, according to findings from a large retrospective study.

While previous retrospective cohort studies have found biologic therapies for psoriasis can reduce the risk of developing psoriatic arthritis when compared with other treatments such as phototherapy and oral nonbiologic disease-modifying antirheumatic drugs, this analysis is the first to compare classes of biologics, Shikha Singla, MD, of the Medical College of Wisconsin, Milwaukee, and colleagues wrote in The Lancet Rheumatology.

In the analysis, researchers used the TriNetX database, which contains deidentified data from electronic medical health records from health care organizations across the United States. The study included adults diagnosed with psoriasis who were newly prescribed a biologic approved by the Food and Drug Administration for the treatment of psoriasis. Biologics were defined by drug class: anti-TNF, anti-IL-17, anti-IL-23, and anti–IL-12/23. Any patient with a diagnosis of psoriatic arthritis or other inflammatory arthritis prior to receiving a biologic prescription or within 2 weeks of receiving the prescription were excluded.

The researchers identified 15,501 eligible patients diagnosed with psoriasis during Jan. 1, 2014, to June 1, 2022, with an average follow-up time of 2.4 years. The researchers chose to start the study period in 2014 because the first non–anti-TNF drug for psoriatic arthritis was approved by the FDA in 2013 – the anti–IL-12/23 drug ustekinumab. During the study period, 976 patients developed inflammatory arthritis and were diagnosed on average 528 days after their biologic prescription.

In a multivariable analysis, the researchers found that patients prescribed IL-23 inhibitors (guselkumab [Tremfya], risankizumab [Skyrizi], tildrakizumab [Ilumya]) were nearly 60% less likely (adjusted hazard ratio, 0.41; 95% confidence interval, 0.17–0.95) to develop inflammatory arthritis than were patients taking TNF inhibitors (infliximab [Remicade], adalimumab [Humira], etanercept [Enbrel], golimumab [Simponi], certolizumab pegol [Cimzia]). The risk of developing arthritis was 42% lower (aHR, 0.58; 95% CI, 0.43-0.76) with the IL-12/23 inhibitor ustekinumab (Stelara), but there was no difference in outcomes among patients taking with IL-17 inhibitors (secukinumab [Cosentyx], ixekizumab [Taltz], or brodalumab [Siliq]), compared with TNF inhibitors. For the IL-12/23 inhibitor ustekinumab, all sensitivity analyses did not change this association. For IL-23 inhibitors, the results persisted when excluding patients who developed arthritis within 3 or 6 months after first biologic prescription and when using a higher diagnostic threshold for incident arthritis.

“There is a lot of interest in understanding if treatment of psoriasis will prevent onset of psoriatic arthritis,” said Joel M. Gelfand, MD, MSCE, director of the Psoriasis and Phototherapy Treatment Center at the University of Pennsylvania, Philadelphia, who was asked to comment on the results.

“To date, the literature is inconclusive with some studies suggesting biologics reduce risk of PsA, whereas others suggest biologic use is associated with an increased risk of PsA,” he said. “The current study is unique in that it compares biologic classes to one another and suggests that IL-12/23 and IL-23 biologics are associated with a reduced risk of PsA compared to psoriasis patients treated with TNF inhibitors and no difference was found between TNF inhibitors and IL-17 inhibitors.”

While the study posed an interesting research question, “I wouldn’t use these results to actually change treatment patterns,” Alexis R. Ogdie-Beatty, MD, an associate professor of medicine at the University of Pennsylvania, Philadelphia, said in an interview. She coauthored a commentary on the analysis. Dr. Gelfand also emphasized that this bias may have influenced the results and that these findings “should not impact clinical practice at this time.”

Although the analyses were strong, Dr. Ogdie-Beatty noted, there are inherent biases in this type of observational data that cannot be overcome. For example, if a patient comes into a dermatologist’s office with psoriasis and also has joint pain, the dermatologist may suspect that a patient could also have psoriatic arthritis and would be more likely to choose a drug that will work well for both of these conditions.

“The drugs that are known to work best for psoriatic arthritis are the TNF inhibitors and the IL-17 inhibitors,” she said. So, while the analysis found these medications were associated with higher incidence of PsA, the dermatologist was possibly treating presumptive arthritis and the patient had yet to be referred to a rheumatologist to confirm the diagnosis.

The researchers noted that they attempted to mitigate these issues by requiring that patients have at least 1 year of follow-up before receiving biologic prescription “to capture only the patients with no previous codes for any type of arthritis,” as well as conducting six sensitivity analyses.

The authors, and Dr. Ogdie-Beatty and Dr. Gelfand agreed that more research is necessary to confirm these findings. A large randomized trial may be “prohibitively expensive,” the authors noted, but pooled analyses from previous clinical trials may help with this issue. “We identified 14 published randomized trials that did head-to-head comparisons of different biologic classes with regard to effect on psoriasis, and these trials collectively contained data on more than 13,000 patients. Pooled analyses of these data could confirm the findings of the present study and would be adequately powered.”

But that approach also has limitations, as psoriatic arthritis was not assessed an outcome in these studies, Dr. Ogdie-Beatty noted. Randomizing patients who are already at a higher risk of developing PsA to different biologics could be one approach to address these questions without needing such a large patient population.

The study was conducted without outside funding or industry involvement. Dr. Singla reported no relevant financial relationships with industry, but several coauthors reported financial relationships with pharmaceutical companies that market biologics for psoriasis and psoriatic arthritis. Dr. Ogdie-Beatty reported financial relationships with AbbVie, Amgen, Bristol-Myers Squibb, Celgene, CorEvitas, Gilead, Happify Health, Janssen, Lilly, Novartis, Pfizer, and UCB. Dr. Gelfand reported financial relationships with Abbvie, Amgen, BMS, Boehringer Ingelheim, FIDE, Lilly, Leo, Janssen Biologics, Novartis, Pfizer, and UCB. Dr. Gelfand is a deputy editor for the Journal of Investigative Dermatology.

This article was updated 3/15/23.

Patients with psoriasis treated with interleukin-12/23 inhibitors or IL-23 inhibitors were less likely to develop inflammatory arthritis, compared with those treated with tumor necrosis factor (TNF) inhibitors, according to findings from a large retrospective study.

While previous retrospective cohort studies have found biologic therapies for psoriasis can reduce the risk of developing psoriatic arthritis when compared with other treatments such as phototherapy and oral nonbiologic disease-modifying antirheumatic drugs, this analysis is the first to compare classes of biologics, Shikha Singla, MD, of the Medical College of Wisconsin, Milwaukee, and colleagues wrote in The Lancet Rheumatology.

In the analysis, researchers used the TriNetX database, which contains deidentified data from electronic medical health records from health care organizations across the United States. The study included adults diagnosed with psoriasis who were newly prescribed a biologic approved by the Food and Drug Administration for the treatment of psoriasis. Biologics were defined by drug class: anti-TNF, anti-IL-17, anti-IL-23, and anti–IL-12/23. Any patient with a diagnosis of psoriatic arthritis or other inflammatory arthritis prior to receiving a biologic prescription or within 2 weeks of receiving the prescription were excluded.

The researchers identified 15,501 eligible patients diagnosed with psoriasis during Jan. 1, 2014, to June 1, 2022, with an average follow-up time of 2.4 years. The researchers chose to start the study period in 2014 because the first non–anti-TNF drug for psoriatic arthritis was approved by the FDA in 2013 – the anti–IL-12/23 drug ustekinumab. During the study period, 976 patients developed inflammatory arthritis and were diagnosed on average 528 days after their biologic prescription.

In a multivariable analysis, the researchers found that patients prescribed IL-23 inhibitors (guselkumab [Tremfya], risankizumab [Skyrizi], tildrakizumab [Ilumya]) were nearly 60% less likely (adjusted hazard ratio, 0.41; 95% confidence interval, 0.17–0.95) to develop inflammatory arthritis than were patients taking TNF inhibitors (infliximab [Remicade], adalimumab [Humira], etanercept [Enbrel], golimumab [Simponi], certolizumab pegol [Cimzia]). The risk of developing arthritis was 42% lower (aHR, 0.58; 95% CI, 0.43-0.76) with the IL-12/23 inhibitor ustekinumab (Stelara), but there was no difference in outcomes among patients taking with IL-17 inhibitors (secukinumab [Cosentyx], ixekizumab [Taltz], or brodalumab [Siliq]), compared with TNF inhibitors. For the IL-12/23 inhibitor ustekinumab, all sensitivity analyses did not change this association. For IL-23 inhibitors, the results persisted when excluding patients who developed arthritis within 3 or 6 months after first biologic prescription and when using a higher diagnostic threshold for incident arthritis.

“There is a lot of interest in understanding if treatment of psoriasis will prevent onset of psoriatic arthritis,” said Joel M. Gelfand, MD, MSCE, director of the Psoriasis and Phototherapy Treatment Center at the University of Pennsylvania, Philadelphia, who was asked to comment on the results.

“To date, the literature is inconclusive with some studies suggesting biologics reduce risk of PsA, whereas others suggest biologic use is associated with an increased risk of PsA,” he said. “The current study is unique in that it compares biologic classes to one another and suggests that IL-12/23 and IL-23 biologics are associated with a reduced risk of PsA compared to psoriasis patients treated with TNF inhibitors and no difference was found between TNF inhibitors and IL-17 inhibitors.”

While the study posed an interesting research question, “I wouldn’t use these results to actually change treatment patterns,” Alexis R. Ogdie-Beatty, MD, an associate professor of medicine at the University of Pennsylvania, Philadelphia, said in an interview. She coauthored a commentary on the analysis. Dr. Gelfand also emphasized that this bias may have influenced the results and that these findings “should not impact clinical practice at this time.”

Although the analyses were strong, Dr. Ogdie-Beatty noted, there are inherent biases in this type of observational data that cannot be overcome. For example, if a patient comes into a dermatologist’s office with psoriasis and also has joint pain, the dermatologist may suspect that a patient could also have psoriatic arthritis and would be more likely to choose a drug that will work well for both of these conditions.

“The drugs that are known to work best for psoriatic arthritis are the TNF inhibitors and the IL-17 inhibitors,” she said. So, while the analysis found these medications were associated with higher incidence of PsA, the dermatologist was possibly treating presumptive arthritis and the patient had yet to be referred to a rheumatologist to confirm the diagnosis.

The researchers noted that they attempted to mitigate these issues by requiring that patients have at least 1 year of follow-up before receiving biologic prescription “to capture only the patients with no previous codes for any type of arthritis,” as well as conducting six sensitivity analyses.

The authors, and Dr. Ogdie-Beatty and Dr. Gelfand agreed that more research is necessary to confirm these findings. A large randomized trial may be “prohibitively expensive,” the authors noted, but pooled analyses from previous clinical trials may help with this issue. “We identified 14 published randomized trials that did head-to-head comparisons of different biologic classes with regard to effect on psoriasis, and these trials collectively contained data on more than 13,000 patients. Pooled analyses of these data could confirm the findings of the present study and would be adequately powered.”

But that approach also has limitations, as psoriatic arthritis was not assessed an outcome in these studies, Dr. Ogdie-Beatty noted. Randomizing patients who are already at a higher risk of developing PsA to different biologics could be one approach to address these questions without needing such a large patient population.

The study was conducted without outside funding or industry involvement. Dr. Singla reported no relevant financial relationships with industry, but several coauthors reported financial relationships with pharmaceutical companies that market biologics for psoriasis and psoriatic arthritis. Dr. Ogdie-Beatty reported financial relationships with AbbVie, Amgen, Bristol-Myers Squibb, Celgene, CorEvitas, Gilead, Happify Health, Janssen, Lilly, Novartis, Pfizer, and UCB. Dr. Gelfand reported financial relationships with Abbvie, Amgen, BMS, Boehringer Ingelheim, FIDE, Lilly, Leo, Janssen Biologics, Novartis, Pfizer, and UCB. Dr. Gelfand is a deputy editor for the Journal of Investigative Dermatology.

This article was updated 3/15/23.

Patients with psoriasis treated with interleukin-12/23 inhibitors or IL-23 inhibitors were less likely to develop inflammatory arthritis, compared with those treated with tumor necrosis factor (TNF) inhibitors, according to findings from a large retrospective study.

While previous retrospective cohort studies have found biologic therapies for psoriasis can reduce the risk of developing psoriatic arthritis when compared with other treatments such as phototherapy and oral nonbiologic disease-modifying antirheumatic drugs, this analysis is the first to compare classes of biologics, Shikha Singla, MD, of the Medical College of Wisconsin, Milwaukee, and colleagues wrote in The Lancet Rheumatology.

In the analysis, researchers used the TriNetX database, which contains deidentified data from electronic medical health records from health care organizations across the United States. The study included adults diagnosed with psoriasis who were newly prescribed a biologic approved by the Food and Drug Administration for the treatment of psoriasis. Biologics were defined by drug class: anti-TNF, anti-IL-17, anti-IL-23, and anti–IL-12/23. Any patient with a diagnosis of psoriatic arthritis or other inflammatory arthritis prior to receiving a biologic prescription or within 2 weeks of receiving the prescription were excluded.

The researchers identified 15,501 eligible patients diagnosed with psoriasis during Jan. 1, 2014, to June 1, 2022, with an average follow-up time of 2.4 years. The researchers chose to start the study period in 2014 because the first non–anti-TNF drug for psoriatic arthritis was approved by the FDA in 2013 – the anti–IL-12/23 drug ustekinumab. During the study period, 976 patients developed inflammatory arthritis and were diagnosed on average 528 days after their biologic prescription.

In a multivariable analysis, the researchers found that patients prescribed IL-23 inhibitors (guselkumab [Tremfya], risankizumab [Skyrizi], tildrakizumab [Ilumya]) were nearly 60% less likely (adjusted hazard ratio, 0.41; 95% confidence interval, 0.17–0.95) to develop inflammatory arthritis than were patients taking TNF inhibitors (infliximab [Remicade], adalimumab [Humira], etanercept [Enbrel], golimumab [Simponi], certolizumab pegol [Cimzia]). The risk of developing arthritis was 42% lower (aHR, 0.58; 95% CI, 0.43-0.76) with the IL-12/23 inhibitor ustekinumab (Stelara), but there was no difference in outcomes among patients taking with IL-17 inhibitors (secukinumab [Cosentyx], ixekizumab [Taltz], or brodalumab [Siliq]), compared with TNF inhibitors. For the IL-12/23 inhibitor ustekinumab, all sensitivity analyses did not change this association. For IL-23 inhibitors, the results persisted when excluding patients who developed arthritis within 3 or 6 months after first biologic prescription and when using a higher diagnostic threshold for incident arthritis.

“There is a lot of interest in understanding if treatment of psoriasis will prevent onset of psoriatic arthritis,” said Joel M. Gelfand, MD, MSCE, director of the Psoriasis and Phototherapy Treatment Center at the University of Pennsylvania, Philadelphia, who was asked to comment on the results.

“To date, the literature is inconclusive with some studies suggesting biologics reduce risk of PsA, whereas others suggest biologic use is associated with an increased risk of PsA,” he said. “The current study is unique in that it compares biologic classes to one another and suggests that IL-12/23 and IL-23 biologics are associated with a reduced risk of PsA compared to psoriasis patients treated with TNF inhibitors and no difference was found between TNF inhibitors and IL-17 inhibitors.”

While the study posed an interesting research question, “I wouldn’t use these results to actually change treatment patterns,” Alexis R. Ogdie-Beatty, MD, an associate professor of medicine at the University of Pennsylvania, Philadelphia, said in an interview. She coauthored a commentary on the analysis. Dr. Gelfand also emphasized that this bias may have influenced the results and that these findings “should not impact clinical practice at this time.”

Although the analyses were strong, Dr. Ogdie-Beatty noted, there are inherent biases in this type of observational data that cannot be overcome. For example, if a patient comes into a dermatologist’s office with psoriasis and also has joint pain, the dermatologist may suspect that a patient could also have psoriatic arthritis and would be more likely to choose a drug that will work well for both of these conditions.

“The drugs that are known to work best for psoriatic arthritis are the TNF inhibitors and the IL-17 inhibitors,” she said. So, while the analysis found these medications were associated with higher incidence of PsA, the dermatologist was possibly treating presumptive arthritis and the patient had yet to be referred to a rheumatologist to confirm the diagnosis.

The researchers noted that they attempted to mitigate these issues by requiring that patients have at least 1 year of follow-up before receiving biologic prescription “to capture only the patients with no previous codes for any type of arthritis,” as well as conducting six sensitivity analyses.

The authors, and Dr. Ogdie-Beatty and Dr. Gelfand agreed that more research is necessary to confirm these findings. A large randomized trial may be “prohibitively expensive,” the authors noted, but pooled analyses from previous clinical trials may help with this issue. “We identified 14 published randomized trials that did head-to-head comparisons of different biologic classes with regard to effect on psoriasis, and these trials collectively contained data on more than 13,000 patients. Pooled analyses of these data could confirm the findings of the present study and would be adequately powered.”

But that approach also has limitations, as psoriatic arthritis was not assessed an outcome in these studies, Dr. Ogdie-Beatty noted. Randomizing patients who are already at a higher risk of developing PsA to different biologics could be one approach to address these questions without needing such a large patient population.

The study was conducted without outside funding or industry involvement. Dr. Singla reported no relevant financial relationships with industry, but several coauthors reported financial relationships with pharmaceutical companies that market biologics for psoriasis and psoriatic arthritis. Dr. Ogdie-Beatty reported financial relationships with AbbVie, Amgen, Bristol-Myers Squibb, Celgene, CorEvitas, Gilead, Happify Health, Janssen, Lilly, Novartis, Pfizer, and UCB. Dr. Gelfand reported financial relationships with Abbvie, Amgen, BMS, Boehringer Ingelheim, FIDE, Lilly, Leo, Janssen Biologics, Novartis, Pfizer, and UCB. Dr. Gelfand is a deputy editor for the Journal of Investigative Dermatology.

This article was updated 3/15/23.

Key clinical point: Regular assessment of bone mineral density and initiation of primary prevention should be considered in patients with psoriatic arthritis (PsA) as they are predisposed to falls and fractures because of reduced bone density, particularly those with late-onset psoriasis involving scalp.

Major finding: Patients with PsA were at a significantly higher risk for osteopenia or osteoporosis (odds ratio [OR] 21.9; CI 7.1-67.7) and prevalent fractures (OR 3.42; P  =  .002) compared with control individuals, with scalp involvement (P  =  .0049) and late onset of psoriasis (P  =  .029) being significantly associated with greater number of prevalent fractures.

Study details: Findings are from an observational cohort study including 61 patients with PsA and 69 age-matched control individuals.

Disclosures: This study did not report the source of funding. The authors reported no conflicts of interest.

Source: Halasi A et al. Psoriatic arthritis and its special features predispose not only for osteoporosis but also for fractures and falls. J Dermatol. 2023 (Jan 17). Doi: 10.1111/1346-8138.16710

Key clinical point: Regular assessment of bone mineral density and initiation of primary prevention should be considered in patients with psoriatic arthritis (PsA) as they are predisposed to falls and fractures because of reduced bone density, particularly those with late-onset psoriasis involving scalp.

Major finding: Patients with PsA were at a significantly higher risk for osteopenia or osteoporosis (odds ratio [OR] 21.9; CI 7.1-67.7) and prevalent fractures (OR 3.42; P  =  .002) compared with control individuals, with scalp involvement (P  =  .0049) and late onset of psoriasis (P  =  .029) being significantly associated with greater number of prevalent fractures.

Study details: Findings are from an observational cohort study including 61 patients with PsA and 69 age-matched control individuals.

Disclosures: This study did not report the source of funding. The authors reported no conflicts of interest.

Source: Halasi A et al. Psoriatic arthritis and its special features predispose not only for osteoporosis but also for fractures and falls. J Dermatol. 2023 (Jan 17). Doi: 10.1111/1346-8138.16710

Key clinical point: Regular assessment of bone mineral density and initiation of primary prevention should be considered in patients with psoriatic arthritis (PsA) as they are predisposed to falls and fractures because of reduced bone density, particularly those with late-onset psoriasis involving scalp.

Major finding: Patients with PsA were at a significantly higher risk for osteopenia or osteoporosis (odds ratio [OR] 21.9; CI 7.1-67.7) and prevalent fractures (OR 3.42; P  =  .002) compared with control individuals, with scalp involvement (P  =  .0049) and late onset of psoriasis (P  =  .029) being significantly associated with greater number of prevalent fractures.

Study details: Findings are from an observational cohort study including 61 patients with PsA and 69 age-matched control individuals.

Disclosures: This study did not report the source of funding. The authors reported no conflicts of interest.

Source: Halasi A et al. Psoriatic arthritis and its special features predispose not only for osteoporosis but also for fractures and falls. J Dermatol. 2023 (Jan 17). Doi: 10.1111/1346-8138.16710

Key clinical point: A dose of 100 mg guselkumab every 4 or 8 weeks (Q4W/Q8W) demonstrated a favorable and consistent safety profile for up to 2 years in both tumor necrosis factor-α inhibitor (TNFi)-naive and TNFi-experienced patients with active psoriatic arthritis (PsA).

Major finding: In TNFi-naive vs TNFi-experienced patients receiving guselkumab, adverse events rates were consistent through 24 weeks (220.8/100 person-years [PY] vs 251.6/100 PY) and remained low through 2 years (139.69/100 PY vs 174.0/100 PY).

Study details: This pooled safety analysis of four phase 2/3 trials included 1554 TNFi-naive and TNFi-experienced patients with active PsA who were randomly assigned to receive 100 mg guselkumab Q4W or Q8W for ≤2 years or placebo with a crossover at week 24 to guselkumab Q4W or Q8W.

Disclosures: The four trials were funded by Janssen Research & Development, LLC. Seven authors declared being current or former employees of Janssen or owning stock or stock options in Johnson & Johnson. Several authors reported ties with Janssen and other sources.

Source: Rahman P et al. Safety of guselkumab with and without prior TNF-α inhibitor treatment: Pooled results across four studies in patients with psoriatic arthritis. J Rheumatol. 2023 (Jan 15). Doi: 10.3899/jrheum.220928

Key clinical point: A dose of 100 mg guselkumab every 4 or 8 weeks (Q4W/Q8W) demonstrated a favorable and consistent safety profile for up to 2 years in both tumor necrosis factor-α inhibitor (TNFi)-naive and TNFi-experienced patients with active psoriatic arthritis (PsA).

Major finding: In TNFi-naive vs TNFi-experienced patients receiving guselkumab, adverse events rates were consistent through 24 weeks (220.8/100 person-years [PY] vs 251.6/100 PY) and remained low through 2 years (139.69/100 PY vs 174.0/100 PY).

Study details: This pooled safety analysis of four phase 2/3 trials included 1554 TNFi-naive and TNFi-experienced patients with active PsA who were randomly assigned to receive 100 mg guselkumab Q4W or Q8W for ≤2 years or placebo with a crossover at week 24 to guselkumab Q4W or Q8W.

Disclosures: The four trials were funded by Janssen Research & Development, LLC. Seven authors declared being current or former employees of Janssen or owning stock or stock options in Johnson & Johnson. Several authors reported ties with Janssen and other sources.

Source: Rahman P et al. Safety of guselkumab with and without prior TNF-α inhibitor treatment: Pooled results across four studies in patients with psoriatic arthritis. J Rheumatol. 2023 (Jan 15). Doi: 10.3899/jrheum.220928

Key clinical point: A dose of 100 mg guselkumab every 4 or 8 weeks (Q4W/Q8W) demonstrated a favorable and consistent safety profile for up to 2 years in both tumor necrosis factor-α inhibitor (TNFi)-naive and TNFi-experienced patients with active psoriatic arthritis (PsA).

Major finding: In TNFi-naive vs TNFi-experienced patients receiving guselkumab, adverse events rates were consistent through 24 weeks (220.8/100 person-years [PY] vs 251.6/100 PY) and remained low through 2 years (139.69/100 PY vs 174.0/100 PY).

Study details: This pooled safety analysis of four phase 2/3 trials included 1554 TNFi-naive and TNFi-experienced patients with active PsA who were randomly assigned to receive 100 mg guselkumab Q4W or Q8W for ≤2 years or placebo with a crossover at week 24 to guselkumab Q4W or Q8W.

Disclosures: The four trials were funded by Janssen Research & Development, LLC. Seven authors declared being current or former employees of Janssen or owning stock or stock options in Johnson & Johnson. Several authors reported ties with Janssen and other sources.

Source: Rahman P et al. Safety of guselkumab with and without prior TNF-α inhibitor treatment: Pooled results across four studies in patients with psoriatic arthritis. J Rheumatol. 2023 (Jan 15). Doi: 10.3899/jrheum.220928

Childhood obesity is a risk factor for four of the five subtypes of adult-onset diabetes, emphasizing the importance of childhood weight control, according to a collaborative study from the Karolinska Institutet in Stockholm, the University of Bristol (England), and Sun Yat-Sen University in China.

“Our finding is that children who have a bigger body size than the average have increased risks of developing almost all subtypes of adult-onset diabetes, except for the mild age-related subtype,” lead author Yuxia Wei, a PhD student from the Karolinska Institutet, said in an interview. “This tells us that it is important to prevent overweight/obesity in children and important for pediatric patients to lose weight if they have already been overweight/obese,” she added, while acknowledging that the study did not examine whether childhood weight loss would prevent adult-onset diabetes.

The study, published online in Diabetologia, used Mendelian randomization (MR), with data from genome-wide association studies (GWAS) of childhood obesity and the five subtypes of adult-onset diabetes: latent autoimmune diabetes in adults (LADA, proxy for severe autoimmune diabetes), severe insulin-deficient diabetes (SIDD), severe insulin-resistant diabetes (SIRD), mild obesity-related diabetes (MOD), and mild age-related diabetes (MARD). MR is “a rather new but commonly used and established technique that uses genetic information to study the causal link between an environmental risk factor and a disease, while accounting for the influence of other risk factors,” Ms. Wei explained.

To identify genetic variations associated with obesity, the study used statistics from a GWAS of 453,169 Europeans who self-reported body size at age 10 years in the UK Biobank study. After adjustment for sex, age at baseline, type of genotyping array, and month of birth, they identified 295 independent single nucleotide polymorphisms (SNPs) for childhood body size.

The researchers also used data from two GWAS of European adults with newly diagnosed diabetes, or without diabetes, to identify SNPs in 8,581 individuals with LADA, 3,937 with SIDD, 3,874 with SIRD, 4,118 with MOD, and 5,605 with MARD.

They then used MR to assess the association of genetically predicted childhood body size with the different diabetes subtypes.

The analysis showed that, with the exception of MARD, all other adult-onset diabetes subtypes were causally associated with childhood obesity, with odds ratio of 1.62 for LADA, 2.11 for SIDD, 2.76 for SIRD, and 7.30 for MOD. However, a genetic correlation between childhood obesity and adult-onset diabetes was found only for MOD, and no other subtypes. “The weak genetic correlation between childhood obesity and adult diabetes indicates that the genes promoting childhood adiposity are largely distinct from those promoting diabetes during adulthood,” noted the authors.

The findings indicate that “childhood body size and MOD may share some genetic mutations,” added Ms. Wei. “That is to say, some genes may affect childhood body size and MOD simultaneously.” But the shared genes do demonstrate the causal effect of childhood obesity on MOD, she explained. The causal effect is demonstrated through the MR analysis.

Additionally, they noted that while “the link between childhood body size and SIRD is expected, given the adverse effects of adiposity on insulin sensitivity ... the smaller OR for SIRD than for MOD suggests that non–obesity-related and/or nongenetic effects may be the main factors underlying the development of SIRD.” Asked for her theory on how childhood body size could affect diabetes subtypes characterized by autoimmunity (LADA) or impaired insulin secretion (SIDD), Ms. Wei speculated that “excess fat around the pancreas can affect insulin secretion and that impaired insulin secretion is also an important problem for LADA.”

Another theory is that it might be “metabolic memory,” suggested Jordi Merino, PhD, of the University of Copenhagen and Harvard University, Boston, who was not involved in the research. “Being exposed to obesity during childhood will tell the body to produce more insulin/aberrant immunity responses later in life.”

Dr. Merino said that, overall, the study’s findings “highlight the long and lasting effect of early-life adiposity and metabolic alterations on different forms of adult-onset diabetes,” adding that this is the first evidence “that childhood adiposity is not only linked to the more traditional diabetes subtype consequence of increased insulin resistance but also subtypes driven by autoimmunity or impaired insulin secretion.” He explained that genetics is “only part of the story” driving increased diabetes risk and “we do not know much about other factors interacting with genetics, but the results from this Mendelian randomization analysis suggest that childhood obesity is a causal factor for all adult-onset diabetes subtypes. Identifying causal factors instead of associative factors is critical to implement more targeted preventive and therapeutic strategies.”

He acknowledged, “There is a long path for these results to be eventually implemented in clinical practice, but they can support early weight control strategies for preventing different diabetes subtypes.”

The study was supported by the Swedish Research Council, Research Council for Health, Working Life and Welfare, and Novo Nordisk Foundation. Ms. Wei received a scholarship from the China Scholarship Council. One coauthor is an employee of GlaxoSmithKline. Dr. Merino reported no conflicts of interest.

Childhood obesity is a risk factor for four of the five subtypes of adult-onset diabetes, emphasizing the importance of childhood weight control, according to a collaborative study from the Karolinska Institutet in Stockholm, the University of Bristol (England), and Sun Yat-Sen University in China.

“Our finding is that children who have a bigger body size than the average have increased risks of developing almost all subtypes of adult-onset diabetes, except for the mild age-related subtype,” lead author Yuxia Wei, a PhD student from the Karolinska Institutet, said in an interview. “This tells us that it is important to prevent overweight/obesity in children and important for pediatric patients to lose weight if they have already been overweight/obese,” she added, while acknowledging that the study did not examine whether childhood weight loss would prevent adult-onset diabetes.

The study, published online in Diabetologia, used Mendelian randomization (MR), with data from genome-wide association studies (GWAS) of childhood obesity and the five subtypes of adult-onset diabetes: latent autoimmune diabetes in adults (LADA, proxy for severe autoimmune diabetes), severe insulin-deficient diabetes (SIDD), severe insulin-resistant diabetes (SIRD), mild obesity-related diabetes (MOD), and mild age-related diabetes (MARD). MR is “a rather new but commonly used and established technique that uses genetic information to study the causal link between an environmental risk factor and a disease, while accounting for the influence of other risk factors,” Ms. Wei explained.

To identify genetic variations associated with obesity, the study used statistics from a GWAS of 453,169 Europeans who self-reported body size at age 10 years in the UK Biobank study. After adjustment for sex, age at baseline, type of genotyping array, and month of birth, they identified 295 independent single nucleotide polymorphisms (SNPs) for childhood body size.

The researchers also used data from two GWAS of European adults with newly diagnosed diabetes, or without diabetes, to identify SNPs in 8,581 individuals with LADA, 3,937 with SIDD, 3,874 with SIRD, 4,118 with MOD, and 5,605 with MARD.

They then used MR to assess the association of genetically predicted childhood body size with the different diabetes subtypes.

The analysis showed that, with the exception of MARD, all other adult-onset diabetes subtypes were causally associated with childhood obesity, with odds ratio of 1.62 for LADA, 2.11 for SIDD, 2.76 for SIRD, and 7.30 for MOD. However, a genetic correlation between childhood obesity and adult-onset diabetes was found only for MOD, and no other subtypes. “The weak genetic correlation between childhood obesity and adult diabetes indicates that the genes promoting childhood adiposity are largely distinct from those promoting diabetes during adulthood,” noted the authors.

The findings indicate that “childhood body size and MOD may share some genetic mutations,” added Ms. Wei. “That is to say, some genes may affect childhood body size and MOD simultaneously.” But the shared genes do demonstrate the causal effect of childhood obesity on MOD, she explained. The causal effect is demonstrated through the MR analysis.

Additionally, they noted that while “the link between childhood body size and SIRD is expected, given the adverse effects of adiposity on insulin sensitivity ... the smaller OR for SIRD than for MOD suggests that non–obesity-related and/or nongenetic effects may be the main factors underlying the development of SIRD.” Asked for her theory on how childhood body size could affect diabetes subtypes characterized by autoimmunity (LADA) or impaired insulin secretion (SIDD), Ms. Wei speculated that “excess fat around the pancreas can affect insulin secretion and that impaired insulin secretion is also an important problem for LADA.”

Another theory is that it might be “metabolic memory,” suggested Jordi Merino, PhD, of the University of Copenhagen and Harvard University, Boston, who was not involved in the research. “Being exposed to obesity during childhood will tell the body to produce more insulin/aberrant immunity responses later in life.”

Dr. Merino said that, overall, the study’s findings “highlight the long and lasting effect of early-life adiposity and metabolic alterations on different forms of adult-onset diabetes,” adding that this is the first evidence “that childhood adiposity is not only linked to the more traditional diabetes subtype consequence of increased insulin resistance but also subtypes driven by autoimmunity or impaired insulin secretion.” He explained that genetics is “only part of the story” driving increased diabetes risk and “we do not know much about other factors interacting with genetics, but the results from this Mendelian randomization analysis suggest that childhood obesity is a causal factor for all adult-onset diabetes subtypes. Identifying causal factors instead of associative factors is critical to implement more targeted preventive and therapeutic strategies.”

He acknowledged, “There is a long path for these results to be eventually implemented in clinical practice, but they can support early weight control strategies for preventing different diabetes subtypes.”

The study was supported by the Swedish Research Council, Research Council for Health, Working Life and Welfare, and Novo Nordisk Foundation. Ms. Wei received a scholarship from the China Scholarship Council. One coauthor is an employee of GlaxoSmithKline. Dr. Merino reported no conflicts of interest.

Childhood obesity is a risk factor for four of the five subtypes of adult-onset diabetes, emphasizing the importance of childhood weight control, according to a collaborative study from the Karolinska Institutet in Stockholm, the University of Bristol (England), and Sun Yat-Sen University in China.

“Our finding is that children who have a bigger body size than the average have increased risks of developing almost all subtypes of adult-onset diabetes, except for the mild age-related subtype,” lead author Yuxia Wei, a PhD student from the Karolinska Institutet, said in an interview. “This tells us that it is important to prevent overweight/obesity in children and important for pediatric patients to lose weight if they have already been overweight/obese,” she added, while acknowledging that the study did not examine whether childhood weight loss would prevent adult-onset diabetes.

The study, published online in Diabetologia, used Mendelian randomization (MR), with data from genome-wide association studies (GWAS) of childhood obesity and the five subtypes of adult-onset diabetes: latent autoimmune diabetes in adults (LADA, proxy for severe autoimmune diabetes), severe insulin-deficient diabetes (SIDD), severe insulin-resistant diabetes (SIRD), mild obesity-related diabetes (MOD), and mild age-related diabetes (MARD). MR is “a rather new but commonly used and established technique that uses genetic information to study the causal link between an environmental risk factor and a disease, while accounting for the influence of other risk factors,” Ms. Wei explained.

To identify genetic variations associated with obesity, the study used statistics from a GWAS of 453,169 Europeans who self-reported body size at age 10 years in the UK Biobank study. After adjustment for sex, age at baseline, type of genotyping array, and month of birth, they identified 295 independent single nucleotide polymorphisms (SNPs) for childhood body size.

The researchers also used data from two GWAS of European adults with newly diagnosed diabetes, or without diabetes, to identify SNPs in 8,581 individuals with LADA, 3,937 with SIDD, 3,874 with SIRD, 4,118 with MOD, and 5,605 with MARD.

They then used MR to assess the association of genetically predicted childhood body size with the different diabetes subtypes.

The analysis showed that, with the exception of MARD, all other adult-onset diabetes subtypes were causally associated with childhood obesity, with odds ratio of 1.62 for LADA, 2.11 for SIDD, 2.76 for SIRD, and 7.30 for MOD. However, a genetic correlation between childhood obesity and adult-onset diabetes was found only for MOD, and no other subtypes. “The weak genetic correlation between childhood obesity and adult diabetes indicates that the genes promoting childhood adiposity are largely distinct from those promoting diabetes during adulthood,” noted the authors.

The findings indicate that “childhood body size and MOD may share some genetic mutations,” added Ms. Wei. “That is to say, some genes may affect childhood body size and MOD simultaneously.” But the shared genes do demonstrate the causal effect of childhood obesity on MOD, she explained. The causal effect is demonstrated through the MR analysis.

Additionally, they noted that while “the link between childhood body size and SIRD is expected, given the adverse effects of adiposity on insulin sensitivity ... the smaller OR for SIRD than for MOD suggests that non–obesity-related and/or nongenetic effects may be the main factors underlying the development of SIRD.” Asked for her theory on how childhood body size could affect diabetes subtypes characterized by autoimmunity (LADA) or impaired insulin secretion (SIDD), Ms. Wei speculated that “excess fat around the pancreas can affect insulin secretion and that impaired insulin secretion is also an important problem for LADA.”

Another theory is that it might be “metabolic memory,” suggested Jordi Merino, PhD, of the University of Copenhagen and Harvard University, Boston, who was not involved in the research. “Being exposed to obesity during childhood will tell the body to produce more insulin/aberrant immunity responses later in life.”

Dr. Merino said that, overall, the study’s findings “highlight the long and lasting effect of early-life adiposity and metabolic alterations on different forms of adult-onset diabetes,” adding that this is the first evidence “that childhood adiposity is not only linked to the more traditional diabetes subtype consequence of increased insulin resistance but also subtypes driven by autoimmunity or impaired insulin secretion.” He explained that genetics is “only part of the story” driving increased diabetes risk and “we do not know much about other factors interacting with genetics, but the results from this Mendelian randomization analysis suggest that childhood obesity is a causal factor for all adult-onset diabetes subtypes. Identifying causal factors instead of associative factors is critical to implement more targeted preventive and therapeutic strategies.”

He acknowledged, “There is a long path for these results to be eventually implemented in clinical practice, but they can support early weight control strategies for preventing different diabetes subtypes.”

The study was supported by the Swedish Research Council, Research Council for Health, Working Life and Welfare, and Novo Nordisk Foundation. Ms. Wei received a scholarship from the China Scholarship Council. One coauthor is an employee of GlaxoSmithKline. Dr. Merino reported no conflicts of interest.

Midwives provide safe primary care for pregnant women who are at various levels of medical risk in British Columbia, Canada, new data suggest.

In most cases, for midwifery clients, birth outcomes were similar to or were better than birth outcomes of patients who had physician-led or obstetrician-led care.

In addition, midwifery clients were less likely to experience preterm births or have low-birth-weight babies and to experience cesarean deliveries or births involving instruments.

“Based on previous research, we know that midwives provide safe care for healthy childbearing people or those with no or few risk factors that might complicate the pregnancy or birth,” lead author Kathrin Stoll, PhD, a research associate in the University of British Columbia’s department of family practice, told this news organization.

“What we didn’t know until now is whether midwives provide safe care to people with moderate and high medical risks and what proportion of B.C. [British Columbia] midwifery clients are low, moderate, and high risk,” she said. “This is important to know because of the misperception that midwives only look after low-risk people. This misperception is sometimes used against midwives to justify giving them fewer resources and supports.”

The study was published  in the Canadian Medical Association Journal.
 

Increasing demand

Registered midwives have been part of the health care system in British Columbia since 1998, according to the study authors. The number of pregnant people who are attended by midwives during birth has steadily increased from 4.8% in 2004-2005 to 15.6% in 2019-2020.

The investigators analyzed 2008-2018 data from the British Columbia Perinatal Data Registry, which contains data for 99% of births, including home births. Their analysis included 425,056 births for which a family physician, an obstetrician, or a midwife was listed as the most responsible provider (MRP). The investigators assessed pregnancy risk status (low, moderate, or high), which was determined on the basis of an adapted perinatal risk scoring system used by the Alberta Perinatal Health Program. They estimated the differences in neonatal and maternal outcomes between MRP groups by calculating adjusted absolute and relative risks.

Among the 425,056 births, 63,151 (14.9%) had a midwife as the MRP, 189,679 (44.6%) had a family physician, and 172,226 (40.5%) had an obstetrician. The antenatal risk score ranged from 0 to 23 (median score, 2).

The proportion of births with midwife-led care increased from 9.2% to 19.8% from 2008-2018. In 2018, midwives were listed as the MRP for 24.3% of low-risk, 14.3% of moderate-risk, and 7.9% of high-risk births in the province. This represented an absolute increase of 9.1% for low-risk, 7.7% for moderate-risk, and 5.7% for high-risk births during the study period.

Among the 12,169 at-home births that took place during the study period, 9,776 (80.3%) were low-risk, 2,329 (19.1%) were moderate-risk, and 64 (0.5%) were high-risk births. As the risk score increased, so did the proportion of midwifery and family physician clients who were delivered by obstetricians. Across all risk strata, more family physician clients than midwifery clients underwent deliveries by obstetricians.

Overall, the risk of perinatal death for midwifery clients was similar to the risk for those under the care of family physicians across all risk levels. Low- and moderate-risk clients with midwife-led care were significantly less likely to experience a perinatal death, compared with those with obstetrician-led care, although the adjusted absolute risk differences were small. In the high-risk group, there was no significant difference in the rate of perinatal deaths between midwife-led and physician-led care.

In addition, clients with midwife-led care were significantly less likely to experience preterm birth and have a low-birth-weight baby regardless of medical risk level. The adjusted relative risk of an Apgar score of less than 7 at 5 minutes was significantly lower for midwife-led care than for physician-led care for nearly all comparisons.

The cesarean delivery rate among midwifery clients in the low-risk group was 7.2%, compared with 12.2% for family physicians and 42.3% for obstetrician clients. Cesarean delivery rates increased for midwifery clients as medical risk increased but were significantly lower than the physician rates across all medical risk levels.

Among low-risk clients, the absolute risk reduction for cesarean delivery was 34.4% with midwife-led care, compared with obstetrician-led care. The absolute risk difference increased to 55.3% for moderate-risk clients and to 42.2% for high-risk clients.
 

Labor induction varied

Although low-risk midwifery clients were significantly less likely to experience labor induction with oxytocin, high-risk midwifery clients were more than twice as likely to undergo induction with oxytocin than obstetrician clients (adjusted absolute difference, 11.3%).

For most risk levels, midwifery clients were less likely to have an assisted vaginal birth than physician clients, and they were significantly more likely to have a spontaneous vaginal birth. Low-risk clients who had a midwife as the MRP were nearly twice as likely to have a spontaneous vaginal birth than obstetricians’ clients, and moderate-risk clients were nearly four times as likely to have a spontaneous vaginal birth.

The rates of vaginal birth after cesarean delivery (VBAC) were significantly higher when a midwife was the MRP. In comparing midwifery clients with family physician clients, the relative and absolute differences were small, but they were larger when comparing midwifery clients with obstetrician clients. Among low-risk clients, the VBAC rate was 85.3% among midwifery clients, compared with 78.6% among family physician clients and 51.5% among obstetrician clients.

In general, the prevalence rates of adverse maternal outcomes (including blood transfusion, intensive care admissions, uterine rupture, and postpartum wound infection) were low for midwifery clients across all risk levels.

Breast- or chest-feeding at birth was significantly more common among midwifery clients across all risk levels as well.

Today, nearly 1 in 4 childbearing people in British Columbia receive care from a midwife at some point during pregnancy, birth, or the postpartum period, the study authors write. During the past 20 years, the profile of clients has evolved to include more moderate- and high-risk patients.

“Clients with more complex medical needs take more time and need more support,” said Dr. Stoll. “This means that midwives continue to stay on call, responding to pages and urgent medical concerns for their clients with no pay for being on call, no days off even for sick days, and unsafe working hours, often working more than 24 hours at a time. If we want to expand midwifery to communities where they are needed most, we need to provide an enabling environment.”

Additional studies are needed as to how different practice and remuneration models affect clinical outcomes, health care costs, and client and provider experiences, the study authors write. At the same time, there are several barriers to obtaining funding, conducting studies, and publishing research by and about midwives in Canada, Dr. Stoll said – barriers that she and her co-authors faced.
 

Seeking broader access

Alixandra Bacon, a registered midwife and president of the Canadian Association of Midwives, said, “These findings demonstrate that pregnant people at any level of medical risk can benefit from midwifery care. This is a testament both to the benefits of the Canadian midwifery model of care and to the seamless integration of midwifery into collaborative teams and the health system.” Ms. Bacon wasn’t involved with this study.

“If we can realize our goal of equitable access to midwifery care for all families in Canada, we can help to decrease rates of unnecessary medical intervention, preterm labor, and stillbirth,” she added.

“Midwifery is well established across most of Canada. This is yet one more piece of evidence that shows the clinical benefits of midwifery care,” Jasmin Tecson, a registered midwife and president of the Association of Ontario Midwives, said in an interview.

Ms. Tecson, who wasn’t involved with this study, noted the increasing number of clients with more complex health and social needs in Ontario. “It is time to think about how the skills and knowledge of midwives can be used with clients of different risk profiles and how the current scope of practice of midwives can be optimized and expanded,” she said. “For example, Ontario midwives are still required to prescribe medications from a limited list, despite the potential additional clinical risks and health system costs that this creates.”

The study received financial support from the University of British Columbia Stollery Fund and the University of British Columbia Work Learn Program. Dr. Stoll has an unpaid role with the Midwives Association Contract Negotiation Advisory Council. Ms. Bacon and Ms. Tecson disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Midwives provide safe primary care for pregnant women who are at various levels of medical risk in British Columbia, Canada, new data suggest.

In most cases, for midwifery clients, birth outcomes were similar to or were better than birth outcomes of patients who had physician-led or obstetrician-led care.

In addition, midwifery clients were less likely to experience preterm births or have low-birth-weight babies and to experience cesarean deliveries or births involving instruments.

“Based on previous research, we know that midwives provide safe care for healthy childbearing people or those with no or few risk factors that might complicate the pregnancy or birth,” lead author Kathrin Stoll, PhD, a research associate in the University of British Columbia’s department of family practice, told this news organization.

“What we didn’t know until now is whether midwives provide safe care to people with moderate and high medical risks and what proportion of B.C. [British Columbia] midwifery clients are low, moderate, and high risk,” she said. “This is important to know because of the misperception that midwives only look after low-risk people. This misperception is sometimes used against midwives to justify giving them fewer resources and supports.”

The study was published  in the Canadian Medical Association Journal.
 

Increasing demand

Registered midwives have been part of the health care system in British Columbia since 1998, according to the study authors. The number of pregnant people who are attended by midwives during birth has steadily increased from 4.8% in 2004-2005 to 15.6% in 2019-2020.

The investigators analyzed 2008-2018 data from the British Columbia Perinatal Data Registry, which contains data for 99% of births, including home births. Their analysis included 425,056 births for which a family physician, an obstetrician, or a midwife was listed as the most responsible provider (MRP). The investigators assessed pregnancy risk status (low, moderate, or high), which was determined on the basis of an adapted perinatal risk scoring system used by the Alberta Perinatal Health Program. They estimated the differences in neonatal and maternal outcomes between MRP groups by calculating adjusted absolute and relative risks.

Among the 425,056 births, 63,151 (14.9%) had a midwife as the MRP, 189,679 (44.6%) had a family physician, and 172,226 (40.5%) had an obstetrician. The antenatal risk score ranged from 0 to 23 (median score, 2).

The proportion of births with midwife-led care increased from 9.2% to 19.8% from 2008-2018. In 2018, midwives were listed as the MRP for 24.3% of low-risk, 14.3% of moderate-risk, and 7.9% of high-risk births in the province. This represented an absolute increase of 9.1% for low-risk, 7.7% for moderate-risk, and 5.7% for high-risk births during the study period.

Among the 12,169 at-home births that took place during the study period, 9,776 (80.3%) were low-risk, 2,329 (19.1%) were moderate-risk, and 64 (0.5%) were high-risk births. As the risk score increased, so did the proportion of midwifery and family physician clients who were delivered by obstetricians. Across all risk strata, more family physician clients than midwifery clients underwent deliveries by obstetricians.

Overall, the risk of perinatal death for midwifery clients was similar to the risk for those under the care of family physicians across all risk levels. Low- and moderate-risk clients with midwife-led care were significantly less likely to experience a perinatal death, compared with those with obstetrician-led care, although the adjusted absolute risk differences were small. In the high-risk group, there was no significant difference in the rate of perinatal deaths between midwife-led and physician-led care.

In addition, clients with midwife-led care were significantly less likely to experience preterm birth and have a low-birth-weight baby regardless of medical risk level. The adjusted relative risk of an Apgar score of less than 7 at 5 minutes was significantly lower for midwife-led care than for physician-led care for nearly all comparisons.

The cesarean delivery rate among midwifery clients in the low-risk group was 7.2%, compared with 12.2% for family physicians and 42.3% for obstetrician clients. Cesarean delivery rates increased for midwifery clients as medical risk increased but were significantly lower than the physician rates across all medical risk levels.

Among low-risk clients, the absolute risk reduction for cesarean delivery was 34.4% with midwife-led care, compared with obstetrician-led care. The absolute risk difference increased to 55.3% for moderate-risk clients and to 42.2% for high-risk clients.
 

Labor induction varied

Although low-risk midwifery clients were significantly less likely to experience labor induction with oxytocin, high-risk midwifery clients were more than twice as likely to undergo induction with oxytocin than obstetrician clients (adjusted absolute difference, 11.3%).

For most risk levels, midwifery clients were less likely to have an assisted vaginal birth than physician clients, and they were significantly more likely to have a spontaneous vaginal birth. Low-risk clients who had a midwife as the MRP were nearly twice as likely to have a spontaneous vaginal birth than obstetricians’ clients, and moderate-risk clients were nearly four times as likely to have a spontaneous vaginal birth.

The rates of vaginal birth after cesarean delivery (VBAC) were significantly higher when a midwife was the MRP. In comparing midwifery clients with family physician clients, the relative and absolute differences were small, but they were larger when comparing midwifery clients with obstetrician clients. Among low-risk clients, the VBAC rate was 85.3% among midwifery clients, compared with 78.6% among family physician clients and 51.5% among obstetrician clients.

In general, the prevalence rates of adverse maternal outcomes (including blood transfusion, intensive care admissions, uterine rupture, and postpartum wound infection) were low for midwifery clients across all risk levels.

Breast- or chest-feeding at birth was significantly more common among midwifery clients across all risk levels as well.

Today, nearly 1 in 4 childbearing people in British Columbia receive care from a midwife at some point during pregnancy, birth, or the postpartum period, the study authors write. During the past 20 years, the profile of clients has evolved to include more moderate- and high-risk patients.

“Clients with more complex medical needs take more time and need more support,” said Dr. Stoll. “This means that midwives continue to stay on call, responding to pages and urgent medical concerns for their clients with no pay for being on call, no days off even for sick days, and unsafe working hours, often working more than 24 hours at a time. If we want to expand midwifery to communities where they are needed most, we need to provide an enabling environment.”

Additional studies are needed as to how different practice and remuneration models affect clinical outcomes, health care costs, and client and provider experiences, the study authors write. At the same time, there are several barriers to obtaining funding, conducting studies, and publishing research by and about midwives in Canada, Dr. Stoll said – barriers that she and her co-authors faced.
 

Seeking broader access

Alixandra Bacon, a registered midwife and president of the Canadian Association of Midwives, said, “These findings demonstrate that pregnant people at any level of medical risk can benefit from midwifery care. This is a testament both to the benefits of the Canadian midwifery model of care and to the seamless integration of midwifery into collaborative teams and the health system.” Ms. Bacon wasn’t involved with this study.

“If we can realize our goal of equitable access to midwifery care for all families in Canada, we can help to decrease rates of unnecessary medical intervention, preterm labor, and stillbirth,” she added.

“Midwifery is well established across most of Canada. This is yet one more piece of evidence that shows the clinical benefits of midwifery care,” Jasmin Tecson, a registered midwife and president of the Association of Ontario Midwives, said in an interview.

Ms. Tecson, who wasn’t involved with this study, noted the increasing number of clients with more complex health and social needs in Ontario. “It is time to think about how the skills and knowledge of midwives can be used with clients of different risk profiles and how the current scope of practice of midwives can be optimized and expanded,” she said. “For example, Ontario midwives are still required to prescribe medications from a limited list, despite the potential additional clinical risks and health system costs that this creates.”

The study received financial support from the University of British Columbia Stollery Fund and the University of British Columbia Work Learn Program. Dr. Stoll has an unpaid role with the Midwives Association Contract Negotiation Advisory Council. Ms. Bacon and Ms. Tecson disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Midwives provide safe primary care for pregnant women who are at various levels of medical risk in British Columbia, Canada, new data suggest.

In most cases, for midwifery clients, birth outcomes were similar to or were better than birth outcomes of patients who had physician-led or obstetrician-led care.

In addition, midwifery clients were less likely to experience preterm births or have low-birth-weight babies and to experience cesarean deliveries or births involving instruments.

“Based on previous research, we know that midwives provide safe care for healthy childbearing people or those with no or few risk factors that might complicate the pregnancy or birth,” lead author Kathrin Stoll, PhD, a research associate in the University of British Columbia’s department of family practice, told this news organization.

“What we didn’t know until now is whether midwives provide safe care to people with moderate and high medical risks and what proportion of B.C. [British Columbia] midwifery clients are low, moderate, and high risk,” she said. “This is important to know because of the misperception that midwives only look after low-risk people. This misperception is sometimes used against midwives to justify giving them fewer resources and supports.”

The study was published  in the Canadian Medical Association Journal.
 

Increasing demand

Registered midwives have been part of the health care system in British Columbia since 1998, according to the study authors. The number of pregnant people who are attended by midwives during birth has steadily increased from 4.8% in 2004-2005 to 15.6% in 2019-2020.

The investigators analyzed 2008-2018 data from the British Columbia Perinatal Data Registry, which contains data for 99% of births, including home births. Their analysis included 425,056 births for which a family physician, an obstetrician, or a midwife was listed as the most responsible provider (MRP). The investigators assessed pregnancy risk status (low, moderate, or high), which was determined on the basis of an adapted perinatal risk scoring system used by the Alberta Perinatal Health Program. They estimated the differences in neonatal and maternal outcomes between MRP groups by calculating adjusted absolute and relative risks.

Among the 425,056 births, 63,151 (14.9%) had a midwife as the MRP, 189,679 (44.6%) had a family physician, and 172,226 (40.5%) had an obstetrician. The antenatal risk score ranged from 0 to 23 (median score, 2).

The proportion of births with midwife-led care increased from 9.2% to 19.8% from 2008-2018. In 2018, midwives were listed as the MRP for 24.3% of low-risk, 14.3% of moderate-risk, and 7.9% of high-risk births in the province. This represented an absolute increase of 9.1% for low-risk, 7.7% for moderate-risk, and 5.7% for high-risk births during the study period.

Among the 12,169 at-home births that took place during the study period, 9,776 (80.3%) were low-risk, 2,329 (19.1%) were moderate-risk, and 64 (0.5%) were high-risk births. As the risk score increased, so did the proportion of midwifery and family physician clients who were delivered by obstetricians. Across all risk strata, more family physician clients than midwifery clients underwent deliveries by obstetricians.

Overall, the risk of perinatal death for midwifery clients was similar to the risk for those under the care of family physicians across all risk levels. Low- and moderate-risk clients with midwife-led care were significantly less likely to experience a perinatal death, compared with those with obstetrician-led care, although the adjusted absolute risk differences were small. In the high-risk group, there was no significant difference in the rate of perinatal deaths between midwife-led and physician-led care.

In addition, clients with midwife-led care were significantly less likely to experience preterm birth and have a low-birth-weight baby regardless of medical risk level. The adjusted relative risk of an Apgar score of less than 7 at 5 minutes was significantly lower for midwife-led care than for physician-led care for nearly all comparisons.

The cesarean delivery rate among midwifery clients in the low-risk group was 7.2%, compared with 12.2% for family physicians and 42.3% for obstetrician clients. Cesarean delivery rates increased for midwifery clients as medical risk increased but were significantly lower than the physician rates across all medical risk levels.

Among low-risk clients, the absolute risk reduction for cesarean delivery was 34.4% with midwife-led care, compared with obstetrician-led care. The absolute risk difference increased to 55.3% for moderate-risk clients and to 42.2% for high-risk clients.
 

Labor induction varied

Although low-risk midwifery clients were significantly less likely to experience labor induction with oxytocin, high-risk midwifery clients were more than twice as likely to undergo induction with oxytocin than obstetrician clients (adjusted absolute difference, 11.3%).

For most risk levels, midwifery clients were less likely to have an assisted vaginal birth than physician clients, and they were significantly more likely to have a spontaneous vaginal birth. Low-risk clients who had a midwife as the MRP were nearly twice as likely to have a spontaneous vaginal birth than obstetricians’ clients, and moderate-risk clients were nearly four times as likely to have a spontaneous vaginal birth.

The rates of vaginal birth after cesarean delivery (VBAC) were significantly higher when a midwife was the MRP. In comparing midwifery clients with family physician clients, the relative and absolute differences were small, but they were larger when comparing midwifery clients with obstetrician clients. Among low-risk clients, the VBAC rate was 85.3% among midwifery clients, compared with 78.6% among family physician clients and 51.5% among obstetrician clients.

In general, the prevalence rates of adverse maternal outcomes (including blood transfusion, intensive care admissions, uterine rupture, and postpartum wound infection) were low for midwifery clients across all risk levels.

Breast- or chest-feeding at birth was significantly more common among midwifery clients across all risk levels as well.

Today, nearly 1 in 4 childbearing people in British Columbia receive care from a midwife at some point during pregnancy, birth, or the postpartum period, the study authors write. During the past 20 years, the profile of clients has evolved to include more moderate- and high-risk patients.

“Clients with more complex medical needs take more time and need more support,” said Dr. Stoll. “This means that midwives continue to stay on call, responding to pages and urgent medical concerns for their clients with no pay for being on call, no days off even for sick days, and unsafe working hours, often working more than 24 hours at a time. If we want to expand midwifery to communities where they are needed most, we need to provide an enabling environment.”

Additional studies are needed as to how different practice and remuneration models affect clinical outcomes, health care costs, and client and provider experiences, the study authors write. At the same time, there are several barriers to obtaining funding, conducting studies, and publishing research by and about midwives in Canada, Dr. Stoll said – barriers that she and her co-authors faced.
 

Seeking broader access

Alixandra Bacon, a registered midwife and president of the Canadian Association of Midwives, said, “These findings demonstrate that pregnant people at any level of medical risk can benefit from midwifery care. This is a testament both to the benefits of the Canadian midwifery model of care and to the seamless integration of midwifery into collaborative teams and the health system.” Ms. Bacon wasn’t involved with this study.

“If we can realize our goal of equitable access to midwifery care for all families in Canada, we can help to decrease rates of unnecessary medical intervention, preterm labor, and stillbirth,” she added.

“Midwifery is well established across most of Canada. This is yet one more piece of evidence that shows the clinical benefits of midwifery care,” Jasmin Tecson, a registered midwife and president of the Association of Ontario Midwives, said in an interview.

Ms. Tecson, who wasn’t involved with this study, noted the increasing number of clients with more complex health and social needs in Ontario. “It is time to think about how the skills and knowledge of midwives can be used with clients of different risk profiles and how the current scope of practice of midwives can be optimized and expanded,” she said. “For example, Ontario midwives are still required to prescribe medications from a limited list, despite the potential additional clinical risks and health system costs that this creates.”

The study received financial support from the University of British Columbia Stollery Fund and the University of British Columbia Work Learn Program. Dr. Stoll has an unpaid role with the Midwives Association Contract Negotiation Advisory Council. Ms. Bacon and Ms. Tecson disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.