Biologics Prove Best for Psoriasis Patients

Although all major treatment classes reviewed in a Cochrane meta-analysis were more effective than placebo for moderate to severe psoriasis, biologic agents appeared to be the most efficacious.

With data from 109 studies, anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha drugs were superior for achieving PASI 90 status (that is, 90% reduction in Psoriasis Area and Severity Index score), reported Emilie Sbidian, of Hôpital Henri Mondor, Department of Dermatology, Créteil, France, and colleagues.

 “A selection of treatments from the class of biological medicines appear to be the most effective systemic medicines for achieving a chronic plaque psoriasis score of PASI 90,” stated the authors online in Cochrane Library. “We found no significant difference in serious adverse effects when comparing any of the assessed treatments with placebo. However, as the evidence was of very low to moderate quality, we cannot be sure of these results,” they continued.

Two-thirds of the included studies were placebo controlled; 23% were head-to-head studies, and 10% were multi-armed studies with both an active comparator and placebo. All of the trials evaluated outcomes at 12-16 weeks after randomization.

Among the 39,882 total patients, average age was 44 years, mean PASI score at the start of the study was 20 (range 9.5-39), and two-thirds were men.

The researchers found that all of the anti-IL17 drugs and guselkumab (Tremfya) were more effective than the anti-TNF alpha drugs infliximab (Remicade), adalimumab (Humira), and etanercept (Enbrel) for reaching PASI 90 status.

Ustekinumab (Stelara, an IL-12/23 inhibitor) was better than etanercept but there was no clear difference between infliximab, adalimumab, and etanercept. Tofacitinib (Xeljanz, a small molecule) was superior to methotrexate (a conventional systemic agent), but there was no difference between the other small molecules and conventional drugs.

 Sbidian and colleagues also reported that compared with placebo treatment, risk of serious side effects and major adverse cardiac events were similar among all of the systemic medicines. Methotrexate had the best safety profile (based on moderate-certainty evidence), followed by ciclosporin (very low-certainty evidence), certolizumab (Cimzia; moderate-certainty evidence), infliximab (very low-certainty evidence), alefacept (Amevive; low-certainty evidence), and fumaric acid esters (very low-certainty evidence).

Looking at both efficacy and acceptability, the researchers noted that most effective treatments had more serious adverse events compared with the other treatments. Additionally, ustekinumab, infliximab, and certolizumab appeared to have the better trade-off between efficacy and acceptability, they added.

Sbidian and colleagues noted that some of the interventions had low numbers of studies, suggesting that more research needs to be conducted to directly compare the systemic medicines with each other, rather than with placebo. They also called for longer-term studies to provide more evidence about the benefit and safety of systemic medicines and to compare safety profiles.