However, it has been reported that in patients with severe clinical conditions (e.g., severe psoriasis and active PsA) and with a higher risk of cardiovascular diseases (e.g., obesity, hypertension, diabetes or dyslipidemia), bDMARDs, particularly TNF-alpha inhibitors, may be prescribed at an earlier stage, as these drugs may reduce the inflammatory burden and should be particularly preferred to cyclosporine (which may worsen hypertension, dyslipidemia, diabetes or renal disease) or acitretin (which can induce or worsen dyslipidemia) in patients at cardiovascular risk [34]. This evidence concerns the gene TNF and obesity due to melanocortin 4 receptor deficiency.