Systemic psoriasis treatments

[Fred]

This is a meta-analysis of randomized controlled trials investigating the efficacy of systemic treatment approved for moderate-to-severe psoriasis. Including 48 randomised controlled trials totalling 16,696 patients using Remicade, Humira, Stelara, Enbrel, Methotrexate, Cyclosporine, and Fumaric acid.

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Background:
Dermatologists may choose from various conventional and biological systemic agents to treat patients with moderate-to-severe psoriasis.

Objectives:
To systematically analyse the efficacy and tolerability of approved treatments for moderate-to-severe psoriasis.

Methods:
Systematic review and meta-analysis of randomised controlled trials (RCTs) investigating the efficacy of systemic treatment approved for moderate-to-severe psoriasis. Efficacy was assessed as the proportion of participants with PASI-75 response at primary efficacy measurement (week 8 - 16). Safety was summarized as rates of adverse events and withdrawals. Direct and indirect comparative efficacy was assessed by random-effects meta-analysis of risk differences (RD).

Results:
48 eligible RCTs totalling 16,696 patients (11,178 randomised to biologics, 1,888 to conventional treatments) were identified. In placebo-controlled trials, infliximab was most efficacious (RD 76%; 95%CI 73-79%). Adalimumab (RD 61%; 95%CI 56-67%), ustekinumab 45mg (RD 63%; 95%CI 59-66%), and 90mg (RD 67%; 95%CI 60-74%) each had similar efficacy. These biologics are more effective than etanercept and all conventional treatments. Head-to-head trials indicate superiority of adalimumab and infliximab over methotrexate (MTX), superiority of ustekinumab over etanercept, non-significant superiority of cyclosporine vs MTX, and dose-dependent efficacy of etanercept and ustekinumab. Fumaric acid is similarly efficacious as MTX. Safety of treatments could not be pooled due to a lack of standardisation in reporting across trials.

Conclusions:
Qualitative and quantitative evidence is much stronger for biological interventions than for conventional treatments.

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