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Chao CH, Wu CY, Chou FL, Chen YJ. Methotrexate did not add skin cancer risk in patients with psoriasis receiving narrowband ultraviolet B phototherapy: a nationwide retrospective cohort study. Clin Exp Dermatol 2024; 49:459-465. [PMID: 38056487 DOI: 10.1093/ced/llad424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 11/21/2023] [Accepted: 11/26/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND In the era of biologic therapy, phototherapy and methotrexate (MTX) are still commonly used for treatment in patients with moderate-to-severe psoriasis. However, the skin cancer risk following a combination of MTX and narrowband ultraviolet B (NB-UVB) has rarely been explored. OBJECTIVES To investigate whether MTX plus NB-UVB increases skin cancer risk in patients with psoriasis. METHODS We conducted a retrospective cohort study of data in the Taiwan National Health Insurance Research Database from 1997 to 2013. Cumulative incidences and multivariate analysis were investigated using a competing risk regression model, comparing skin cancer risk between cohorts of people having combination therapy and those using NB-UVB alone, matched for relative confounders. We further conducted a sensitivity analysis for those receiving a higher MTX dose. Standardized incidence ratios (SIRs) were calculated for skin cancer risk. RESULTS We enrolled 3203 participants in each cohort. No significant differences in skin cancers were noted between the two cohorts for the cumulative incidences (log-rank test, P = 0.28) and for the hazard ratio (HRs) [adjusted HR 0.50, 95% confidence interval (CI) 0.15-1.63, P = 0.247] in the competing risk regression model. There were also no significant differences between those receiving higher-dose MTX and UVB alone in the cumulative incidences of skin cancers (P = 0.23) and the HR (adjusted HR = 0.29, 95% CI 0.04-2.21, P = 0.23) in the multivariate analysis. There was no significant difference in the SIR between the two cohorts compared with the general population. CONCLUSIONS In the Taiwanese population, MTX does not increase skin cancer risk in patients with moderate-to-severe psoriasis receiving NB-UVB.
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Affiliation(s)
| | - Chun-Ying Wu
- Division of Translational Research
- Institute of Biomedical Informatics and Research Center for Epidemic Prevention and
- Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Public Health, China Medical University, Taichung, Taiwan
- National Institute of Cancer Research and Institute of Population Health Science, National Health Research Institutes, Miaoli, Taiwan
| | - Fan-Ling Chou
- Department of Dermatology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Ju Chen
- Department of Dermatology, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, National Chung Hsing University, Taichung, Taiwan
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Sreya R, Nene S, Pathade V, Singh SB, Srivastava S. Emerging trends in combination strategies with phototherapy in advanced psoriasis management. Inflammopharmacology 2023:10.1007/s10787-023-01257-2. [PMID: 37326755 DOI: 10.1007/s10787-023-01257-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 05/21/2023] [Indexed: 06/17/2023]
Abstract
Psoriasis is a non-contagious, chronic, relapsing inflammatory skin disease with cutaneous manifestations such as red, raised scaly plaques. Current treatment approaches for psoriasis comprise topical therapy, systemic therapy, phototherapy, psoralen with UVA(PUVA) and biologics. Regardless of the progression in therapeutic approaches (novel therapies like biologics) in psoriasis, phototherapy is also an economical, compelling and safe treatment option that lacks the immunosuppressive properties as well as the toxicities of traditional modalities. It can be combined safely with other therapeutic options such as topical therapies and novel biologics and provide effective therapy. The aim of the current review is to analyze the literature on the safety as well as the efficacy of phototherapy with various treatment modalities in the management of psoriasis. This review summarizes randomized controlled clinical trials addressing combinations of phototherapy with other treatment modalities for the management of psoriasis. The findings of these clinical studies are elaborated.
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Affiliation(s)
- Ratnam Sreya
- Pharmaceutical Innovation and Translational Research Lab (PITRL), Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER), Balanagar, Hyderabad, Telangana, 500037, India
| | - Shweta Nene
- Pharmaceutical Innovation and Translational Research Lab (PITRL), Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER), Balanagar, Hyderabad, Telangana, 500037, India
| | - Vrushali Pathade
- Pharmaceutical Innovation and Translational Research Lab (PITRL), Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER), Balanagar, Hyderabad, Telangana, 500037, India
| | - Shashi Bala Singh
- Department of Biological Sciences, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, India
| | - Saurabh Srivastava
- Pharmaceutical Innovation and Translational Research Lab (PITRL), Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER), Balanagar, Hyderabad, Telangana, 500037, India.
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Li Y, Cao Z, Guo J, Li Q, Zhu W, Kuang Y, Chen X. Assessment of efficacy and safety of UV-based therapy for psoriasis: a network meta-analysis of randomized controlled trials. Ann Med 2022; 54:159-169. [PMID: 34989291 PMCID: PMC8741237 DOI: 10.1080/07853890.2021.2022187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Previous studies have proven that ultraviolet (UV)-based phototherapy, including UVB or psoralen UVA (PUVA), and their combination therapies, is effective for psoriasis treatment. OBJECTIVE To compare the clinical efficacy and adverse events (AEs) of different UV-based phototherapy in psoriasis. METHODS PubMed, Cochrane Library, Scopus and Embase were systematically searched. A random-effect model network meta-analysis with frequentist framework was performed, and results were reported as risk ratios (RRs) with 95% CI. The main variable for assessing effectiveness and safety are PASI 75 response and withdrawal due to AEs. Ranking effects were calculated by surface under the cumulative ranking analysis (SUCRA). RESULTS Thirty-two studies involving a total of 2120 psoriasis patients were included in this network meta-analysis. Overall, no significant difference was reported with respect to withdrawal due to AEs or incidence of erythema. The relatively safest strategy was combined adjuvant therapy with PUVA (cPUVA), especially PUVA combined with calcium/vitamin D derivatives (RR 0.98, 95% CI [0.30-3.17], SUCRA = 80.8%). Both cPUVA (RR 1.39, 95% CI [1.00- 1.94]) and combined adjuvant therapy with UVB (cUVB) (RR 1.27, 95% CI [1.03-1.57]) showed a superior effect than the monotherapy of UVA or UVB, respectively. PUVA combined with vitamin D and its derivatives (PAVD) ranked highest concerning clinical effect and safety (clusterank value = 7393.2). CONCLUSIONS The efficacy of all the combination therapy regimens was significantly superior to that of UV monotherapy, without significant differences in tolerability and safety. cUVB and cPUVA, and particularly the combination of UVA with calcium/vitamin D derivatives, was ranked as the overall safest and most effective phototherapy method.
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Affiliation(s)
- Yajia Li
- Department of Dermatology, Hunan Key Laboratory of Skin Cancer and Psoriasis; Hunan Engineering Research Center of Skin Health and Disease, Xiangya Hospital, Central South University, Changsha, China
| | - Ziqin Cao
- Department of Spine Surgery, the Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jia Guo
- Department of Dermatology, Hunan Key Laboratory of Skin Cancer and Psoriasis; Hunan Engineering Research Center of Skin Health and Disease, Xiangya Hospital, Central South University, Changsha, China
| | - Qiangxiang Li
- National Clinical Research Center for Geriatric Disorders of Xiangya hospital, Central South University (Sub-center of Ningxia), Yinchuan, Ningxia Hui Autonomous Region 750001, China.,Ningxia Geriatric Disease Clinical Research Center, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, Ningxia Hui Autonomous Region 750001, China.,Hunan People's Hospital, Geriatrics Institute of Hunan Province, Changsha, China, Changsha 410002, China
| | - Wu Zhu
- Department of Dermatology, Hunan Key Laboratory of Skin Cancer and Psoriasis; Hunan Engineering Research Center of Skin Health and Disease, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Yehong Kuang
- Department of Dermatology, Hunan Key Laboratory of Skin Cancer and Psoriasis; Hunan Engineering Research Center of Skin Health and Disease, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Xiang Chen
- Department of Dermatology, Hunan Key Laboratory of Skin Cancer and Psoriasis; Hunan Engineering Research Center of Skin Health and Disease, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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Sbidian E, Chaimani A, Garcia-Doval I, Doney L, Dressler C, Hua C, Hughes C, Naldi L, Afach S, Le Cleach L. Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis. Cochrane Database Syst Rev 2022; 5:CD011535. [PMID: 35603936 PMCID: PMC9125768 DOI: 10.1002/14651858.cd011535.pub5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Psoriasis is an immune-mediated disease with either skin or joints manifestations, or both, and it has a major impact on quality of life. Although there is currently no cure for psoriasis, various treatment strategies allow sustained control of disease signs and symptoms. The relative benefit of these treatments remains unclear due to the limited number of trials comparing them directly head-to-head, which is why we chose to conduct a network meta-analysis. OBJECTIVES To compare the efficacy and safety of non-biological systemic agents, small molecules, and biologics for people with moderate-to-severe psoriasis using a network meta-analysis, and to provide a ranking of these treatments according to their efficacy and safety. SEARCH METHODS For this update of the living systematic review, we updated our searches of the following databases monthly to October 2021: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase. SELECTION CRITERIA Randomised controlled trials (RCTs) of systemic treatments in adults over 18 years with moderate-to-severe plaque psoriasis, at any stage of treatment, compared to placebo or another active agent. The primary outcomes were: proportion of participants who achieved clear or almost clear skin, that is, at least Psoriasis Area and Severity Index (PASI) 90; proportion of participants with serious adverse events (SAEs) at induction phase (8 to 24 weeks after randomisation). DATA COLLECTION AND ANALYSIS We conducted duplicate study selection, data extraction, risk of bias assessment and analyses. We synthesised data using pairwise and network meta-analysis (NMA) to compare treatments and rank them according to effectiveness (PASI 90 score) and acceptability (inverse of SAEs). We assessed the certainty of NMA evidence for the two primary outcomes and all comparisons using CINeMA, as very low, low, moderate, or high. We contacted study authors when data were unclear or missing. We used the surface under the cumulative ranking curve (SUCRA) to infer treatment hierarchy, from 0% (worst for effectiveness or safety) to 100% (best for effectiveness or safety). MAIN RESULTS This update includes an additional 19 studies, taking the total number of included studies to 167, and randomised participants to 58,912, 67.2% men, mainly recruited from hospitals. Average age was 44.5 years, mean PASI score at baseline was 20.4 (range: 9.5 to 39). Most studies were placebo-controlled (57%). We assessed a total of 20 treatments. Most (140) trials were multicentric (two to 231 centres). One-third of the studies (57/167) had high risk of bias; 23 unclear risk, and most (87) low risk. Most studies (127/167) declared funding by a pharmaceutical company, and 24 studies did not report a funding source. Network meta-analysis at class level showed that all interventions (non-biological systemic agents, small molecules, and biological treatments) showed a higher proportion of patients reaching PASI 90 than placebo. Anti-IL17 treatment showed a higher proportion of patients reaching PASI 90 compared to all the interventions, except anti-IL23. Biologic treatments anti-IL17, anti-IL12/23, anti-IL23 and anti-TNF alpha showed a higher proportion of patients reaching PASI 90 than the non-biological systemic agents. For reaching PASI 90, the most effective drugs when compared to placebo were (SUCRA rank order, all high-certainty evidence): infliximab (risk ratio (RR) 50.19, 95% CI 20.92 to 120.45), bimekizumab (RR 30.27, 95% CI 25.45 to 36.01), ixekizumab (RR 30.19, 95% CI 25.38 to 35.93), risankizumab (RR 28.75, 95% CI 24.03 to 34.39). Clinical effectiveness of these drugs was similar when compared against each other. Bimekizumab, ixekizumab and risankizumab showed a higher proportion of patients reaching PASI 90 than other anti-IL17 drugs (secukinumab and brodalumab) and guselkumab. Infliximab, anti-IL17 drugs (bimekizumab, ixekizumab, secukinumab and brodalumab) and anti-IL23 drugs (risankizumab and guselkumab) except tildrakizumab showed a higher proportion of patients reaching PASI 90 than ustekinumab and three anti-TNF alpha agents (adalimumab, certolizumab and etanercept). Ustekinumab was superior to certolizumab; adalimumab and ustekinumab were superior to etanercept. No significant difference was shown between apremilast and two non-biological drugs: ciclosporin and methotrexate. We found no significant difference between any of the interventions and the placebo for the risk of SAEs. The risk of SAEs was significantly lower for participants on methotrexate compared with most of the interventions. Nevertheless, the SAE analyses were based on a very low number of events with low- to moderate-certainty for all the comparisons (except methotrexate versus placebo, which was high-certainty). The findings therefore have to be viewed with caution. For other efficacy outcomes (PASI 75 and Physician Global Assessment (PGA) 0/1), the results were similar to the results for PASI 90. Information on quality of life was often poorly reported and was absent for several of the interventions. AUTHORS' CONCLUSIONS Our review shows that, compared to placebo, the biologics infliximab, bimekizumab, ixekizumab, and risankizumab were the most effective treatments for achieving PASI 90 in people with moderate-to-severe psoriasis on the basis of high-certainty evidence. This NMA evidence is limited to induction therapy (outcomes measured from 8 to 24 weeks after randomisation), and is not sufficient for evaluating longer-term outcomes in this chronic disease. Moreover, we found low numbers of studies for some of the interventions, and the young age (mean 44.5 years) and high level of disease severity (PASI 20.4 at baseline) may not be typical of patients seen in daily clinical practice. We found no significant difference in the assessed interventions and placebo in terms of SAEs, and the safety evidence for most interventions was low to moderate quality. More randomised trials directly comparing active agents are needed, and these should include systematic subgroup analyses (sex, age, ethnicity, comorbidities, psoriatic arthritis). To provide long-term information on the safety of treatments included in this review, an evaluation of non-randomised studies and postmarketing reports from regulatory agencies is needed. Editorial note: This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Emilie Sbidian
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Clinical Investigation Centre, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Anna Chaimani
- Université de Paris, Centre of Research in Epidemiology and Statistics (CRESS), INSERM, F-75004, Paris, France
- Cochrane France, Paris, France
| | - Ignacio Garcia-Doval
- Department of Dermatology, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Liz Doney
- Cochrane Skin, Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Corinna Dressler
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Camille Hua
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Carolyn Hughes
- c/o Cochrane Skin Group, The University of Nottingham, Nottingham, UK
| | - Luigi Naldi
- Centro Studi GISED (Italian Group for Epidemiologic Research in Dermatology) - FROM (Research Foundation of Ospedale Maggiore Bergamo), Padiglione Mazzoleni - Presidio Ospedaliero Matteo Rota, Bergamo, Italy
| | - Sivem Afach
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Laurence Le Cleach
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
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Myers E, Kheradmand S, Miller R. An Update on Narrowband Ultraviolet B Therapy for the Treatment of Skin Diseases. Cureus 2021; 13:e19182. [PMID: 34873522 PMCID: PMC8634827 DOI: 10.7759/cureus.19182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2021] [Indexed: 12/25/2022] Open
Abstract
The objective of this review is to provide an update on narrowband ultraviolet B (NB-UVB) as a treatment for various skin conditions. NB-UVB works by suppressing the cutaneous cell-mediated immune response and has been shown to be an efficacious and clinically tolerable treatment for a range of inflammatory dermatoses. A literature search was conducted by advanced searches of PubMed for NB-UVB treatment of dermatologic skin diseases with a focus on reports from 2010 to 2021, including both office-based and home-based phototherapy (HBPT). Data were prioritized based on studies with a high level of evidence using the Oxford Evidence-Based Medicine guidance. We found that NB-UVB continues to serve as an effective form of therapy for several cutaneous conditions, including vitiligo, psoriasis, atopic dermatitis, mycosis fungoides, and other inflammatory dermatoses. The recent introduction of Janus kinase inhibitors in combination with NB-UVB suggests future promise in the treatment of vitiligo. Despite its rise in popularity, a decline was seen in office-based NB-UVB treatment during the coronavirus disease 2019 pandemic. Options are available to deliver NB-UVB at home with comparable efficacy to office-based treatments. In conclusion, for a select group of patients and conditions, NB-UVB continues to serve as an effective treatment modality with minimal side effects, with HBPT serving as an option to improve patient compliance.
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Affiliation(s)
- Elisha Myers
- Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Shiva Kheradmand
- Dermatology, Hospital Corporation of America/University of South Florida Morsani College of Medicine: Largo Medical Center, Largo, USA
| | - Richard Miller
- Dermatology, Hospital Corporation of America/University of South Florida Morsani College of Medicine: Largo Medical Center, Largo, USA
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Arora S, Das P, Arora G. Systematic Review and Recommendations to Combine Newer Therapies With Conventional Therapy in Psoriatic Disease. Front Med (Lausanne) 2021; 8:696597. [PMID: 34490293 PMCID: PMC8416676 DOI: 10.3389/fmed.2021.696597] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 07/28/2021] [Indexed: 01/16/2023] Open
Abstract
Background: Psoriasis continues to have unmet needs in its management despite introduction of newer molecules. Monotherapy with these newer agents may not achieve therapeutic goals in all cases, hence necessitating their combinations with other molecules. Improved understanding of newer as well as conventional treatment modalities and experiences in their combinations hence necessitates therapeutic guidelines for their use in psoriasis. Objective: To review the combinations of treatments reported in literature and recommendations for their use based on best current evidence in literature. Methods: A literature review of MEDLINE database for studies evaluating combinations of newer therapies with conventional therapies in psoriasis was done. Newer therapies were identified as biologic disease modifying anti rheumatic drugs and other molecules such as apremilast while conventional therapies included methotrexate, cyclosporine, or retinoids, phototherapy and others. The therapeutic guidelines are proposed with the aim to provide evidenced based approach to combine newer and conventional agents in day-to-day psoriasis management. Findings: Combination of acitretin and narrow band ultraviolet B (NB-UVB)/Psoralen with ultraviolet A (PUVA) achieves faster clearance and allows reduction of dose of the latter. A variable outcome is reported of methotrexate with TNF-α inhibitors vs. TNF-α inhibitors alone, although addition of methotrexate appears to reduce immunogenicity of TNF-α inhibitors thereby preventing formation of anti-drug antibodies especially in case of infliximab. While combination of acitretin and PUVA is beneficial, combining TNF-α inhibitors and phototherapy too produces better and faster results but long term risks of Non Melanoma Skin Cancers (NMSCs) may preclude their use together. Combination of cyclosporine and phototherapy is not recommended due to greater chances of NMSCs. Adding phototherapy to Fumaric Acid Esters (FAEs) improves efficacy. Apremilast can be safely combined with available biologic agents in patients with plaque psoriasis or psoriatic arthritis not responding adequately to biologics alone. Hydroxyurea and acitretin may be used together increasing their efficacy and reducing doses of both and hence their adverse effects. Conclusion: Selected clinical scenarios shall benefit from combinations therapies, improving efficacy of both conventional and newer agents and at the same time helping reduce toxicity of higher dosages when used individually.
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Affiliation(s)
- Sandeep Arora
- Department of Dermatology, Army College of Medical Sciences & Base Hospital Delhi Cantt, New Delhi, India
| | - Pankaj Das
- Department of Dermatology, Army College of Medical Sciences & Base Hospital Delhi Cantt, New Delhi, India
| | - Gulhima Arora
- Consultant Dermatologist, Mehektagul Dermaclinic, New Delhi, India
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Sbidian E, Chaimani A, Garcia-Doval I, Doney L, Dressler C, Hua C, Hughes C, Naldi L, Afach S, Le Cleach L. Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis. Cochrane Database Syst Rev 2021; 4:CD011535. [PMID: 33871055 PMCID: PMC8408312 DOI: 10.1002/14651858.cd011535.pub4] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Psoriasis is an immune-mediated disease for which some people have a genetic predisposition. The condition manifests in inflammatory effects on either the skin or joints, or both, and it has a major impact on quality of life. Although there is currently no cure for psoriasis, various treatment strategies allow sustained control of disease signs and symptoms. Several randomised controlled trials (RCTs) have compared the efficacy of the different systemic treatments in psoriasis against placebo. However, the relative benefit of these treatments remains unclear due to the limited number of trials comparing them directly head-to-head, which is why we chose to conduct a network meta-analysis. OBJECTIVES To compare the efficacy and safety of non-biological systemic agents, small molecules, and biologics for people with moderate-to-severe psoriasis using a network meta-analysis, and to provide a ranking of these treatments according to their efficacy and safety. SEARCH METHODS For this living systematic review we updated our searches of the following databases monthly to September 2020: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase. We searched two trials registers to the same date. We checked the reference lists of included studies and relevant systematic reviews for further references to eligible RCTs. SELECTION CRITERIA Randomised controlled trials (RCTs) of systemic treatments in adults (over 18 years of age) with moderate-to-severe plaque psoriasis or psoriatic arthritis whose skin had been clinically diagnosed with moderate-to-severe psoriasis, at any stage of treatment, in comparison to placebo or another active agent. The primary outcomes of this review were: the proportion of participants who achieved clear or almost clear skin, that is, at least Psoriasis Area and Severity Index (PASI) 90 at induction phase (from 8 to 24 weeks after the randomisation), and the proportion of participants with serious adverse events (SAEs) at induction phase. We did not evaluate differences in specific adverse events. DATA COLLECTION AND ANALYSIS Several groups of two review authors independently undertook study selection, data extraction, 'Risk of bias' assessment, and analyses. We synthesised the data using pair-wise and network meta-analysis (NMA) to compare the treatments of interest and rank them according to their effectiveness (as measured by the PASI 90 score) and acceptability (the inverse of serious adverse events). We assessed the certainty of the body of evidence from the NMA for the two primary outcomes and all comparisons, according to CINeMA, as either very low, low, moderate, or high. We contacted study authors when data were unclear or missing. We used the surface under the cumulative ranking curve (SUCRA) to infer on treatment hierarchy: 0% (treatment is the worst for effectiveness or safety) to 100% (treatment is the best for effectiveness or safety). MAIN RESULTS We included 158 studies (18 new studies for the update) in our review (57,831 randomised participants, 67.2% men, mainly recruited from hospitals). The overall average age was 45 years; the overall mean PASI score at baseline was 20 (range: 9.5 to 39). Most of these studies were placebo-controlled (58%), 30% were head-to-head studies, and 11% were multi-armed studies with both an active comparator and a placebo. We have assessed a total of 20 treatments. In all, 133 trials were multicentric (two to 231 centres). All but two of the outcomes included in this review were limited to the induction phase (assessment from 8 to 24 weeks after randomisation). We assessed many studies (53/158) as being at high risk of bias; 25 were at an unclear risk, and 80 at low risk. Most studies (123/158) declared funding by a pharmaceutical company, and 22 studies did not report their source of funding. Network meta-analysis at class level showed that all of the interventions (non-biological systemic agents, small molecules, and biological treatments) were significantly more effective than placebo in reaching PASI 90. At class level, in reaching PASI 90, the biologic treatments anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha were significantly more effective than the small molecules and the non-biological systemic agents. At drug level, infliximab, ixekizumab, secukinumab, brodalumab, risankizumab and guselkumab were significantly more effective in reaching PASI 90 than ustekinumab and three anti-TNF alpha agents: adalimumab, certolizumab, and etanercept. Ustekinumab and adalimumab were significantly more effective in reaching PASI 90 than etanercept; ustekinumab was more effective than certolizumab, and the clinical effectiveness of ustekinumab and adalimumab was similar. There was no significant difference between tofacitinib or apremilast and three non-biological drugs: fumaric acid esters (FAEs), ciclosporin and methotrexate. Network meta-analysis also showed that infliximab, ixekizumab, risankizumab, bimekizumab, secukinumab, guselkumab, and brodalumab outperformed other drugs when compared to placebo in reaching PASI 90. The clinical effectiveness of these drugs was similar, except for ixekizumab which had a better chance of reaching PASI 90 compared with secukinumab, guselkumab and brodalumab. The clinical effectiveness of these seven drugs was: infliximab (versus placebo): risk ratio (RR) 50.29, 95% confidence interval (CI) 20.96 to 120.67, SUCRA = 93.6; high-certainty evidence; ixekizumab (versus placebo): RR 32.48, 95% CI 27.13 to 38.87; SUCRA = 90.5; high-certainty evidence; risankizumab (versus placebo): RR 28.76, 95% CI 23.96 to 34.54; SUCRA = 84.6; high-certainty evidence; bimekizumab (versus placebo): RR 58.64, 95% CI 3.72 to 923.86; SUCRA = 81.4; high-certainty evidence; secukinumab (versus placebo): RR 25.79, 95% CI 21.61 to 30.78; SUCRA = 76.2; high-certainty evidence; guselkumab (versus placebo): RR 25.52, 95% CI 21.25 to 30.64; SUCRA = 75; high-certainty evidence; and brodalumab (versus placebo): RR 23.55, 95% CI 19.48 to 28.48; SUCRA = 68.4; moderate-certainty evidence. Conservative interpretation is warranted for the results for bimekizumab (as well as mirikizumab, tyrosine kinase 2 inhibitor, acitretin, ciclosporin, fumaric acid esters, and methotrexate), as these drugs, in the NMA, have been evaluated in few trials. We found no significant difference between any of the interventions and the placebo for the risk of SAEs. Nevertheless, the SAE analyses were based on a very low number of events with low to moderate certainty for all the comparisons. Thus, the results have to be viewed with caution and we cannot be sure of the ranking. For other efficacy outcomes (PASI 75 and Physician Global Assessment (PGA) 0/1) the results were similar to the results for PASI 90. Information on quality of life was often poorly reported and was absent for several of the interventions. AUTHORS' CONCLUSIONS Our review shows that compared to placebo, the biologics infliximab, ixekizumab, risankizumab, bimekizumab, secukinumab, guselkumab and brodalumab were the most effective treatments for achieving PASI 90 in people with moderate-to-severe psoriasis on the basis of moderate- to high-certainty evidence. This NMA evidence is limited to induction therapy (outcomes were measured from 8 to 24 weeks after randomisation) and is not sufficient for evaluation of longer-term outcomes in this chronic disease. Moreover, we found low numbers of studies for some of the interventions, and the young age (mean age of 45 years) and high level of disease severity (PASI 20 at baseline) may not be typical of patients seen in daily clinical practice. Another major concern is that short-term trials provide scanty and sometimes poorly-reported safety data and thus do not provide useful evidence to create a reliable risk profile of treatments. We found no significant difference in the assessed interventions and placebo in terms of SAEs, and the evidence for all the interventions was of low to moderate quality. In order to provide long-term information on the safety of the treatments included in this review, it will also be necessary to evaluate non-randomised studies and postmarketing reports released from regulatory agencies. In terms of future research, randomised trials directly comparing active agents are necessary once high-quality evidence of benefit against placebo is established, including head-to-head trials amongst and between non-biological systemic agents and small molecules, and between biological agents (anti-IL17 versus anti-IL23, anti-IL23 versus anti-IL12/23, anti-TNF alpha versus anti-IL12/23). Future trials should also undertake systematic subgroup analyses (e.g. assessing biological-naïve participants, baseline psoriasis severity, presence of psoriatic arthritis, etc.). Finally, outcome measure harmonisation is needed in psoriasis trials, and researchers should look at the medium- and long-term benefit and safety of the interventions and the comparative safety of different agents. Editorial note: This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Emilie Sbidian
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Clinical Investigation Centre, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Anna Chaimani
- Université de Paris, Centre of Research in Epidemiology and Statistics (CRESS), INSERM, F-75004, Paris, France
- Cochrane France, Paris, France
| | - Ignacio Garcia-Doval
- Department of Dermatology, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Liz Doney
- Centre of Evidence Based Dermatology, Cochrane Skin Group, The University of Nottingham, Nottingham, UK
| | - Corinna Dressler
- Division of Evidence Based Medicine, Department of Dermatology, Venerology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Camille Hua
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Carolyn Hughes
- c/o Cochrane Skin Group, The University of Nottingham, Nottingham, UK
| | - Luigi Naldi
- Centro Studi GISED (Italian Group for Epidemiologic Research in Dermatology) - FROM (Research Foundation of Ospedale Maggiore Bergamo), Padiglione Mazzoleni - Presidio Ospedaliero Matteo Rota, Bergamo, Italy
| | - Sivem Afach
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Laurence Le Cleach
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
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Vieyra-Garcia PA, Wolf P. A deep dive into UV-based phototherapy: Mechanisms of action and emerging molecular targets in inflammation and cancer. Pharmacol Ther 2020; 222:107784. [PMID: 33316286 DOI: 10.1016/j.pharmthera.2020.107784] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/25/2020] [Indexed: 02/07/2023]
Abstract
UV-based phototherapy (including psoralen plus UVA (PUVA), UVB and UVA1) has a long, successful history in the management of numerous cutaneous disorders. Photoresponsive diseases are etiologically diverse, but most involve disturbances in local (and occasionally systemic) inflammatory cells and/or abnormalities in keratinocytes that trigger inflammation. UV-based phototherapy works by regulating the inflammatory component and inducing apoptosis of pathogenic cells. This results in a fascinating and complex network of simultaneous events-immediate transcriptional changes in keratinocytes, immune cells, and pigment cells; the emergence of apoptotic bodies; and the trafficking of antigen-presenting cells in skin-that quickly transform the microenvironment of UV-exposed skin. Molecular elements in this system of UV recognition and response include chromophores, metabolic byproducts, innate immune receptors, neurotransmitters and mediators such as chemokines and cytokines, antimicrobial peptides, and platelet activating factor (PAF) and PAF-like molecules that simultaneously shape the immunomodulatory effects of UV and their interplay with the microbiota of the skin and beyond. Phototherapy's key effects-proapoptotic, immunomodulatory, antipruritic, antifibrotic, propigmentary, and pro-prebiotic-promote clinical improvement in various skin diseases such as psoriasis, atopic dermatitis (AD), graft-versus-host disease (GvHD), vitiligo, scleroderma, and cutaneous T-cell lymphoma (CTCL) as well as prevention of polymorphic light eruption (PLE). As understanding of phototherapy improves, new therapies (UV- and non-UV-based) are being developed that will modify regulatory T-cells (Treg), interact with (resident) memory T-cells and /or utilize agonists and antagonists as well as antibodies targeting soluble molecules such as cytokines and chemokines, transcription factors, and a variety of membrane-associated receptors.
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Affiliation(s)
- Pablo A Vieyra-Garcia
- Department of Dermatology, Medical University of Graz, Auenbruggerplatz 8, Graz A-8036, Austria.
| | - Peter Wolf
- Department of Dermatology, Medical University of Graz, Auenbruggerplatz 8, Graz A-8036, Austria.
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Ara S, Mowla MR, Alam M, Khan I. Efficacy of oral methotrexate (MTX) monotherapy vs oral MTX plus narrowband ultraviolet light B phototherapy in palmoplantar psoriasis. Dermatol Ther 2020; 33:e13486. [PMID: 32356586 DOI: 10.1111/dth.13486] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/20/2020] [Accepted: 04/25/2020] [Indexed: 12/13/2022]
Abstract
Palmoplantar psoriasis (PPP) is a chronic, inflammatory dermatosis of the palms and/or soles with significant morbidity. It is notoriously difficult to treat and unresponsive to traditional topical agents. We aim to compare the effect of oral methotrexate (MTX) monotherapy vs MTX plus narrowband ultraviolet light B (NB-UVB) in the treatment of recalcitrant PPP. This was a comparative clinical trial involving 90 patients of PPP. Eligible patients were randomly assigned to one of the two treatment groups. We aim patients in group A received 10 mg oral MTX weekly, and patients in group B received oral MTX 10 mg weekly and NB-UVB sessions twice weekly for 12 weeks. There was a statistically significant difference in reduction of modified PPP Area Severity Index (m-PPPASI) of patients in MTX plus NB-UVB at week 12. The mean m-PPPASI at week 12 was 3.66 ± 2.11 in MTX plus NB-UVB group and 6.51 ± 2.04 in MTX only group (P < .001). Marked improvement (m-PPPASI 75) was achieved in 20 (44.44%) patients in MTX plus NB-UVB group compared with 6 (13.3%) in MTX monotherapy group (P < .001). Combination of MTX and NB-UVB phototherapy helps to attain a better clinical response (reduction in m-PPPASI score) than MTX monotherapy in the treatment of recalcitrant PPP.
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Affiliation(s)
- Shamim Ara
- Department of Dermatology and Venereology, Chittagong International Medical College, Chittagong, Bangladesh
| | - Mohammad Rafiqul Mowla
- Department of Dermatology and Venereology, Chittagong Medical College, Chittagong, Bangladesh
| | - Mansurul Alam
- Department of Dermatology and Venereology, Cox's Bazar Medical College, Cox's Bazar, Bangladesh
| | - Ismail Khan
- Department of Pharmacology, Chittagong Medical University, Chittagong, Bangladesh
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Menter A, Gelfand JM, Connor C, Armstrong AW, Cordoro KM, Davis DMR, Elewski BE, Gordon KB, Gottlieb AB, Kaplan DH, Kavanaugh A, Kiselica M, Kivelevitch D, Korman NJ, Kroshinsky D, Lebwohl M, Leonardi CL, Lichten J, Lim HW, Mehta NN, Paller AS, Parra SL, Pathy AL, Prater EF, Rahimi RS, Rupani RN, Siegel M, Stoff B, Strober BE, Tapper EB, Wong EB, Wu JJ, Hariharan V, Elmets CA. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management of psoriasis with systemic nonbiologic therapies. J Am Acad Dermatol 2020; 82:1445-1486. [PMID: 32119894 DOI: 10.1016/j.jaad.2020.02.044] [Citation(s) in RCA: 157] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/10/2020] [Accepted: 02/14/2020] [Indexed: 02/08/2023]
Abstract
Psoriasis is a chronic inflammatory disease involving multiple organ systems and affecting approximately 2% of the world's population. In this guideline, we focus the discussion on systemic, nonbiologic medications for the treatment of this disease. We provide detailed discussion of efficacy and safety for the most commonly used medications, including methotrexate, cyclosporine, and acitretin, and provide recommendations to assist prescribers in initiating and managing patients on these treatments. Additionally, we discuss newer therapies, including tofacitinib and apremilast, and briefly touch on a number of other medications, including fumaric acid esters (used outside the United States) and therapies that are no longer widely used for the treatment of psoriasis (ie, hydroxyurea, leflunomide, mycophenolate mofetil, thioguanine, and tacrolimus).
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Affiliation(s)
| | - Joel M Gelfand
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | - Kelly M Cordoro
- Department of Dermatology, University of California, San Francisco School of Medicine, San Diego, California
| | | | | | | | - Alice B Gottlieb
- Department of Dermatology, Icahn School of Medicine at Mt. Sinai, New York, New York
| | | | | | - Matthew Kiselica
- Patient Advocate, National Psoriasis Foundation, Portland, Oregon
| | | | - Neil J Korman
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - Mark Lebwohl
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Jason Lichten
- Patient Advocate, National Psoriasis Foundation, Portland, Oregon
| | - Henry W Lim
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan
| | - Nehal N Mehta
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Amy S Paller
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Arun L Pathy
- Colorado Permanente Medical Group, Centennial, Colorado
| | | | | | - Reena N Rupani
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Bruce E Strober
- Central Connecticut Dermatology, Cromwell, Connecticut; Yale University, New Haven, Connecticut
| | - Elliot B Tapper
- Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Emily B Wong
- San Antonio Uniformed Services Health Education Consortium, Joint-Base San Antonio, Texas
| | - Jashin J Wu
- Dermatology Research and Education Foundation, Irvine, California
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11
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Krenitsky A, Ghamrawi RI, Feldman SR. Phototherapy: a Review and Update of Treatment Options in Dermatology. CURRENT DERMATOLOGY REPORTS 2020. [DOI: 10.1007/s13671-020-00290-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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12
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Sbidian E, Chaimani A, Afach S, Doney L, Dressler C, Hua C, Mazaud C, Phan C, Hughes C, Riddle D, Naldi L, Garcia-Doval I, Le Cleach L. Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis. Cochrane Database Syst Rev 2020; 1:CD011535. [PMID: 31917873 PMCID: PMC6956468 DOI: 10.1002/14651858.cd011535.pub3] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Psoriasis is an immune-mediated disease for which some people have a genetic predisposition. The condition manifests in inflammatory effects on either the skin or joints, or both, and it has a major impact on quality of life. Although there is currently no cure for psoriasis, various treatment strategies allow sustained control of disease signs and symptoms. Several randomised controlled trials (RCTs) have compared the efficacy of the different systemic treatments in psoriasis against placebo. However, the relative benefit of these treatments remains unclear due to the limited number of trials comparing them directly head-to-head, which is why we chose to conduct a network meta-analysis. This is the baseline update of a Cochrane Review first published in 2017, in preparation for this Cochrane Review becoming a living systematic review. OBJECTIVES To compare the efficacy and safety of conventional systemic agents, small molecules, and biologics for people with moderate-to-severe psoriasis, and to provide a ranking of these treatments according to their efficacy and safety. SEARCH METHODS We updated our research using the following databases to January 2019: the Cochrane Skin Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS and the conference proceedings of a number of dermatology meetings. We also searched five trials registers and the US Food and Drug Administration (FDA) and European Medicines Agency (EMA) reports (until June 2019). We checked the reference lists of included and excluded studies for further references to relevant RCTs. SELECTION CRITERIA Randomised controlled trials (RCTs) of systemic treatments in adults (over 18 years of age) with moderate-to-severe plaque psoriasis or psoriatic arthritis whose skin had been clinically diagnosed with moderate-to-severe psoriasis, at any stage of treatment, in comparison to placebo or another active agent. The primary outcomes of this review were: the proportion of participants who achieved clear or almost clear skin, that is, at least Psoriasis Area and Severity Index (PASI) 90 at induction phase (from 8 to 24 weeks after the randomisation), and the proportion of participants with serious adverse effects (SAEs) at induction phase. We did not evaluate differences in specific adverse effects. DATA COLLECTION AND ANALYSIS Several groups of two review authors independently undertook study selection, data extraction, 'Risk of bias' assessment, and analyses. We synthesised the data using pair-wise and network meta-analysis (NMA) to compare the treatments of interest and rank them according to their effectiveness (as measured by the PASI 90 score) and acceptability (the inverse of serious adverse effects). We assessed the certainty of the body of evidence from the NMA for the two primary outcomes, according to GRADE, as either very low, low, moderate, or high. We contacted study authors when data were unclear or missing. MAIN RESULTS We included 140 studies (31 new studies for the update) in our review (51,749 randomised participants, 68% men, mainly recruited from hospitals). The overall average age was 45 years; the overall mean PASI score at baseline was 20 (range: 9.5 to 39). Most of these studies were placebo-controlled (59%), 30% were head-to-head studies, and 11% were multi-armed studies with both an active comparator and a placebo. We have assessed a total of 19 treatments. In all, 117 trials were multicentric (two to 231 centres). All but two of the outcomes included in this review were limited to the induction phase (assessment from 8 to 24 weeks after randomisation). We assessed many studies (57/140) as being at high risk of bias; 42 were at an unclear risk, and 41 at low risk. Most studies (107/140) declared funding by a pharmaceutical company, and 22 studies did not report the source of funding. Network meta-analysis at class level showed that all of the interventions (conventional systemic agents, small molecules, and biological treatments) were significantly more effective than placebo in terms of reaching PASI 90. At class level, in terms of reaching PASI 90, the biologic treatments anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha were significantly more effective than the small molecules and the conventional systemic agents. At drug level, in terms of reaching PASI 90, infliximab, all of the anti-IL17 drugs (ixekizumab, secukinumab, bimekizumab and brodalumab) and the anti-IL23 drugs (risankizumab and guselkumab, but not tildrakizumab) were significantly more effective in reaching PASI 90 than ustekinumab and 3 anti-TNF alpha agents: adalimumab, certolizumab and etanercept. Adalimumab and ustekinumab were significantly more effective in reaching PASI 90 than certolizumab and etanercept. There was no significant difference between tofacitinib or apremilast and between two conventional drugs: ciclosporin and methotrexate. Network meta-analysis also showed that infliximab, ixekizumab, risankizumab, bimekizumab, guselkumab, secukinumab and brodalumab outperformed other drugs when compared to placebo in reaching PASI 90. The clinical effectiveness for these seven drugs was similar: infliximab (versus placebo): risk ratio (RR) 29.52, 95% confidence interval (CI) 19.94 to 43.70, Surface Under the Cumulative Ranking (SUCRA) = 88.5; moderate-certainty evidence; ixekizumab (versus placebo): RR 28.12, 95% CI 23.17 to 34.12, SUCRA = 88.3, moderate-certainty evidence; risankizumab (versus placebo): RR 27.67, 95% CI 22.86 to 33.49, SUCRA = 87.5, high-certainty evidence; bimekizumab (versus placebo): RR 58.64, 95% CI 3.72 to 923.86, SUCRA = 83.5, low-certainty evidence; guselkumab (versus placebo): RR 25.84, 95% CI 20.90 to 31.95; SUCRA = 81; moderate-certainty evidence; secukinumab (versus placebo): RR 23.97, 95% CI 20.03 to 28.70, SUCRA = 75.4; high-certainty evidence; and brodalumab (versus placebo): RR 21.96, 95% CI 18.17 to 26.53, SUCRA = 68.7; moderate-certainty evidence. Conservative interpretation is warranted for the results for bimekizumab (as well as tyrosine kinase 2 inhibitor, acitretin, ciclosporin, fumaric acid esters, and methotrexate), as these drugs, in the NMA, have been evaluated in few trials. We found no significant difference between any of the interventions and the placebo for the risk of SAEs. Nevertheless, the SAE analyses were based on a very low number of events with low to very low certainty for just under half of the treatment estimates in total, and moderate for the others. Thus, the results have to be viewed with caution and we cannot be sure of the ranking. For other efficacy outcomes (PASI 75 and Physician Global Assessment (PGA) 0/1) the results were very similar to the results for PASI 90. Information on quality of life was often poorly reported and was absent for several of the interventions. AUTHORS' CONCLUSIONS Our review shows that compared to placebo, the biologics infliximab, ixekizumab, risankizumab, bimekizumab, guselkumab, secukinumab and brodalumab were the best choices for achieving PASI 90 in people with moderate-to-severe psoriasis on the basis of moderate- to high-certainty evidence (low-certainty evidence for bimekizumab). This NMA evidence is limited to induction therapy (outcomes were measured from 8 to 24 weeks after randomisation) and is not sufficient for evaluation of longer-term outcomes in this chronic disease. Moreover, we found low numbers of studies for some of the interventions, and the young age (mean age of 45 years) and high level of disease severity (PASI 20 at baseline) may not be typical of patients seen in daily clinical practice. Another major concern is that short-term trials provide scanty and sometimes poorly-reported safety data and thus do not provide useful evidence to create a reliable risk profile of treatments. Indeed, we found no significant difference in the assessed interventions and placebo in terms of SAEs, but the evidence for all the interventions was of very low to moderate quality. In order to provide long-term information on the safety of the treatments included in this review, it will also be necessary to evaluate non-randomised studies and postmarketing reports released from regulatory agencies. In terms of future research, randomised trials comparing directly active agents are necessary once high-quality evidence of benefit against placebo is established, including head-to-head trials amongst and between conventional systemic and small molecules, and between biological agents (anti-IL17 versus anti-IL23, anti-IL23 versus anti-IL12/23, anti-TNF alpha versus anti-IL12/23). Future trials should also undertake systematic subgroup analyses (e.g. assessing biological-naïve participants, baseline psoriasis severity, presence of psoriatic arthritis, etc.). Finally, outcome measure harmonisation is needed in psoriasis trials, and researchers should look at the medium- and long-term benefit and safety of the interventions and the comparative safety of different agents. Editorial note: This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Emilie Sbidian
- Hôpital Henri Mondor, Department of Dermatology, 51 Avenue du Maréchal de Lattre de Tassigny, Créteil, France, 94000
- Hôpital Henri Mondor, Clinical Investigation Centre, Créteil, France, 94010
- Université Paris Est Créteil (UPEC), Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Créteil, France
| | - Anna Chaimani
- Université de Paris, Research Center in Epidemiology and Statistics Sorbonne Paris Cité (CRESS-UMR1153), Inserm, Inra, F-75004, Paris, France
- Cochrane France, Paris, France
| | - Sivem Afach
- Université Paris Est Créteil (UPEC), Epidemiology in dermatology and evaluation of therapeutics (EpiDermE) - EA 7379, Créteil, France
| | - Liz Doney
- Cochrane Skin Group, The University of Nottingham, Centre of Evidence Based Dermatology, A103, King's Meadow Campus, Lenton Lane, Nottingham, UK, NG7 2NR
| | - Corinna Dressler
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Division of Evidence Based Medicine, Department of Dermatology, Venerology and Allergology, Charitéplatz 1, Berlin, Germany, 10117
| | - Camille Hua
- Hôpital Henri Mondor, Department of Dermatology, 51 Avenue du Maréchal de Lattre de Tassigny, Créteil, France, 94000
| | - Canelle Mazaud
- Hôpital Henri Mondor, Department of Dermatology, 51 Avenue du Maréchal de Lattre de Tassigny, Créteil, France, 94000
| | - Céline Phan
- Centre Hospitalier Victor Dupouy, Department of Dermatology, Argenteuil, France
| | - Carolyn Hughes
- The University of Nottingham, c/o Cochrane Skin Group, A103, King's Meadow Campus, Lenton Lane, Nottingham, UK, NG7 2NR
| | - Dru Riddle
- Texas Christian University (TCU), School of Nurse Anesthesia, Fort Worth, Texas, USA
| | - Luigi Naldi
- Padiglione Mazzoleni - Presidio Ospedaliero Matteo Rota, Centro Studi GISED (Italian Group for Epidemiologic Research in Dermatology) - FROM (Research Foundation of Ospedale Maggiore Bergamo), Via Garibaldi 13/15, Bergamo, Italy, 24122
| | - Ignacio Garcia-Doval
- Complexo Hospitalario Universitario de Vigo, Department of Dermatology, Meixoeiro sn, Vigo, Spain, 36214
| | - Laurence Le Cleach
- Hôpital Henri Mondor, Department of Dermatology, 51 Avenue du Maréchal de Lattre de Tassigny, Créteil, France, 94000
- Université Paris Est Créteil (UPEC), Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Créteil, France
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Silpa-Archa N, Pattanaprichakul P, Charoenpipatsin N, Jansuwan N, Udompunthurak S, Chularojanamontri L, Wongpraparut C. The efficacy of UVA1 phototherapy in psoriasis: Clinical and histological aspects. PHOTODERMATOLOGY PHOTOIMMUNOLOGY & PHOTOMEDICINE 2019; 36:21-28. [PMID: 31309611 DOI: 10.1111/phpp.12498] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/12/2019] [Accepted: 07/01/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although ultraviolet A1 (UVA1) phototherapy is available for nearly 30 years, only few studies have been conducted for plaque-type psoriasis. OBJECTIVES To determine the efficacy and safety of UVA1 phototherapy in psoriasis by assessing the clinical and histological outcomes. METHODS This open study enrolled 15 patients with moderate to severe plaque-type psoriasis. All of the patients had skin type IV. A whole-body UVA1 device consisting of 24 lamps, was irradiated at a medium dose of 50 J/cm2 three-times weekly for 30 sessions. Topical and systemic psoriasis treatments were discontinued before and during treatment; patients could only use emollients and antihistamines until 1-month post-completion. Psoriasis Area and Severity Index (PASI) scores were determined at baseline; at sessions 10th, 20th and 30th; and 1 month after treatment. Four-millimetre punch biopsies were obtained from the same psoriasis lesion at baseline and session 30th. Changes in histopathological gradings and polymorphonuclear, lymphocyte and Langerhans cell numbers were monitored. RESULTS Twelve patients completed the study. The mean age was 41.3 years (range: 25-71). The median PASI scores at baseline, session 30th and 1-month post-treatment were 16 (8.2, 43.3), 11 (4.4, 43.3) and 9.2 (2.7, 36.4), respectively. Although the PASI scores had improved significantly by 1-month post-treatment (P = .006), the histological parameters demonstrated minimal changes. All patients tolerated the phototherapy well and the most common side effect was skin tanning. CONCLUSIONS While medium-dose UVA1 phototherapy demonstrated some efficacy in moderate to severe plaque-type psoriasis. However, it might not be an excellent choice.
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Affiliation(s)
- Narumol Silpa-Archa
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Penvadee Pattanaprichakul
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Norramon Charoenpipatsin
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Natchaya Jansuwan
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Suthipol Udompunthurak
- Division of Clinical Epidemiology, Office of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Leena Chularojanamontri
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chanisada Wongpraparut
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Elmets CA, Lim HW, Stoff B, Connor C, Cordoro KM, Lebwohl M, Armstrong AW, Davis DMR, Elewski BE, Gelfand JM, Gordon KB, Gottlieb AB, Kaplan DH, Kavanaugh A, Kiselica M, Kivelevitch D, Korman NJ, Kroshinsky D, Leonardi CL, Lichten J, Mehta NN, Paller AS, Parra SL, Pathy AL, Farley Prater EA, Rupani RN, Siegel M, Strober BE, Wong EB, Wu JJ, Hariharan V, Menter A. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis with phototherapy. J Am Acad Dermatol 2019; 81:775-804. [PMID: 31351884 DOI: 10.1016/j.jaad.2019.04.042] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 04/11/2019] [Indexed: 01/12/2023]
Abstract
Psoriasis is a chronic inflammatory disease involving multiple organ systems and affecting approximately 3.2% of the world's population. In this section of the guidelines of care for psoriasis, we will focus the discussion on ultraviolet (UV) light-based therapies, which include narrowband and broadband UVB, UVA in conjunction with photosensitizing agents, targeted UVB treatments such as with an excimer laser, and several other modalities and variations of these core phototherapies, including newer applications of pulsed dye lasers, intense pulse light, and light-emitting electrodes. We will provide an in-depth, evidence-based discussion of efficacy and safety for each treatment modality and provide recommendations and guidance for the use of these therapies alone or in conjunction with other topical and/or systemic psoriasis treatments.
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Affiliation(s)
| | - Henry W Lim
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan
| | | | | | - Kelly M Cordoro
- University of California, San Francisco School of Medicine, Department of Dermatology, San Francisco, California
| | - Mark Lebwohl
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | | | - Joel M Gelfand
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | - Alice B Gottlieb
- Department of Dermatology, Icahn School of Medicine at Mt. Sinai, New York, New York
| | | | | | | | | | - Neil J Korman
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | | | | | - Nehal N Mehta
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Amy S Paller
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Arun L Pathy
- Colorado Permanente Medical Group, Centennial, Colorado
| | | | - Reena N Rupani
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Bruce E Strober
- University of Connecticut, Farmington, Connecticut; Probidity Medical Research, Waterloo, Ontario, Canada
| | - Emily B Wong
- San Antonio Uniformed Services Health Education Consortium, Joint-Base San Antonio, San Antonio, Texas
| | - Jashin J Wu
- Dermatology Research and Education Foundation, Irvine, California
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15
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Arnone M, Takahashi MDF, Carvalho AVED, Bernardo WM, Bressan AL, Ramos AMC, Terena AC, Souza CDS, Nunes DH, Bortoletto MCDC, Oliveira MDFSPD, Neffá JM, Fieri LC, Azulay-Abulafia L, Felix PAO, Magalhaes RF, Romiti R, Jaime TJ. Diagnostic and therapeutic guidelines for plaque psoriasis - Brazilian Society of Dermatology. An Bras Dermatol 2019; 94:76-107. [PMID: 31166402 PMCID: PMC6544036 DOI: 10.1590/abd1806-4841.2019940211] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 01/28/2019] [Indexed: 02/07/2023] Open
Abstract
Psoriasis is a chronic inflammatory disease that affects 1.3% of the Brazilian
population. The most common clinical manifestations are erythematous, scaling
lesions that affect both genders and can occur on any anatomical site,
preferentially involving the knees, elbows, scalp and genitals. Besides the
impact on the quality of life, the systemic nature of the disease makes
psoriasis an independent risk factor for cardiovascular disease, especially in
young patients with severe disease. By an initiative of the Brazilian Society of
Dermatology, dermatologists with renowned clinical experience in the management
of psoriasis were invited to form a work group that, in a partnership with the
Brazilian Medical Association, dedicated themselves to create the Plaque
Psoriasis Diagnostic and Treatment Guidelines. The relevant issues for the
diagnosis (evaluation of severity and comorbidities) and treatment of plaque
psoriasis were defined. The issues generated a search strategy in the
Medline-PubMed database up to July 2018. Subsequently, the answers to the
questions of the recommendations were devised, and each reference selected
presented the respective level of recommendation and strength of scientific
evidence. The final recommendations for making up the final text were worded by
the coordinators.
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Affiliation(s)
- Marcelo Arnone
- Hospital das Clínicas, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | - Wanderley Marques Bernardo
- Center of Development of Medical Education, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Aline Lopes Bressan
- Service of Dermatology, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Andrea Machado Coelho Ramos
- Service of Dermatology, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | | | - Cacilda da Silva Souza
- Department of Internal Medicine, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Daniel Holthausen Nunes
- Service of Dermatology, Hospital Universitário, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | | | | | - Jane Marcy Neffá
- Department of Medicine, Dermatology Clinic, Universidade Federal Fluminense, Niterói, RJ, Brazil
| | | | - Luna Azulay-Abulafia
- Faculty of Medical Sciences, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Renata Ferreira Magalhaes
- Department of Internal Medicine, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Ricardo Romiti
- Hospital das Clínicas, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil
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16
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Serafino A, Nicotera G, Andreola F, Giovannini D, Zonfrillo M, Sferrazza G, Calcaterra A, De Angelis C, Camponeschi C, Pierimarchi P. Synergistic antiproliferative and differentiating effect of 2,4-monofurfurylidene-tetra-O-methylsorbitol and 4,6-dimethyl-2-(3,4,5-trimethoxyphenylamino)pyrimidine on primary and immortalized keratinocytes. Biomed Pharmacother 2018; 107:155-167. [PMID: 30086462 DOI: 10.1016/j.biopha.2018.07.174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 07/31/2018] [Accepted: 07/31/2018] [Indexed: 10/28/2022] Open
Abstract
Psoriasis is one of the most common chronic autoinflammatory skin disease, associated with hyperproliferation and abnormal differentiation of keratinocytes, inflammation, and angiogenesis. The available treatments for psoriasis are not curative and may have numerous side effects, and topical administration is preferred over systemic therapy due to the reduced systemic burden of the drug. Thus, novel and more efficacious formulations of anti-inflammatory and/or differentiating compounds for topical application could be very useful for the disease management and for improving the quality of life of the patients. Here we evaluated the potential as anti-psoriatic of an equimolar mixture of two compounds, 2,4-Monofurfurylidene-tetra-O-methylsorbitol (Compound A) and 4,6-dimethyl-2-(3,4,5-trimethoxyphenylamino)pyrimidine (Compound B), that, used individually, are known to possess immunomodulating properties (Compound A) and keratolitic and anti-inflammatory activity (Compound B). Human immortalized keratinocyte cell line (HaCaT cells) and primary human keratinocyte cells from adult donor (HEKa) were used as in vitro experimental models. We show that the mix A + B exhibits antiproliferative activity and induces terminal differentiation more efficiently than compounds A and B used individually. We confirm that the compound B is the active ingredient of the mixture and the mainly responsible for anti-psoriatic activity, but the mix A + B is more effective and possesses lower cytotoxicity than the compound B alone. This could be ascribable to the association with compound A, that is known to possess, in addition to the immunomodulating ability, antioxidant and antiradical action. Our results indicate that mix A + B could be a suitable candidate for a new cosmeceutical formulation for topical treatment of psoriasis.
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Affiliation(s)
- Annalucia Serafino
- Institute of Translational Pharmacology, National Research Council of Italy, Rome, Italy.
| | - Giuseppe Nicotera
- Institute of Translational Pharmacology, National Research Council of Italy, Rome, Italy
| | - Federica Andreola
- Institute of Translational Pharmacology, National Research Council of Italy, Rome, Italy
| | - Daniela Giovannini
- Institute of Translational Pharmacology, National Research Council of Italy, Rome, Italy
| | - Manuela Zonfrillo
- Institute of Translational Pharmacology, National Research Council of Italy, Rome, Italy
| | - Gianluca Sferrazza
- Institute of Translational Pharmacology, National Research Council of Italy, Rome, Italy
| | - Andrea Calcaterra
- University of Rome "La Sapienza", Department of Chemistry and Technology of Drugs, Rome, Italy
| | | | | | - Pasquale Pierimarchi
- Institute of Translational Pharmacology, National Research Council of Italy, Rome, Italy
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17
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Howell ST, Cardwell LA, Feldman SR. A Review and Update of Phototherapy Treatment Options for Psoriasis. CURRENT DERMATOLOGY REPORTS 2018. [DOI: 10.1007/s13671-018-0211-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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18
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Sbidian E, Chaimani A, Garcia‐Doval I, Do G, Hua C, Mazaud C, Droitcourt C, Hughes C, Ingram JR, Naldi L, Chosidow O, Le Cleach L. Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis. Cochrane Database Syst Rev 2017; 12:CD011535. [PMID: 29271481 PMCID: PMC6486272 DOI: 10.1002/14651858.cd011535.pub2] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Psoriasis is an immune-mediated disease for which some people have a genetic predisposition. The condition manifests in inflammatory effects on either the skin or joints, or both, and it has a major impact on quality of life. Although there is currently no cure for psoriasis, various treatment strategies allow sustained control of disease signs and symptoms. Several randomised controlled trials (RCTs) have compared the efficacy of the different systemic treatments in psoriasis against placebo. However, the relative benefit of these treatments remains unclear due to the limited number of trials comparing them directly head to head, which is why we chose to conduct a network meta-analysis. OBJECTIVES To compare the efficacy and safety of conventional systemic agents (acitretin, ciclosporin, fumaric acid esters, methotrexate), small molecules (apremilast, tofacitinib, ponesimod), anti-TNF alpha (etanercept, infliximab, adalimumab, certolizumab), anti-IL12/23 (ustekinumab), anti-IL17 (secukinumab, ixekizumab, brodalumab), anti-IL23 (guselkumab, tildrakizumab), and other biologics (alefacept, itolizumab) for patients with moderate to severe psoriasis and to provide a ranking of these treatments according to their efficacy and safety. SEARCH METHODS We searched the following databases to December 2016: the Cochrane Skin Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS. We also searched five trials registers and the U.S. Food and Drug Administration (FDA) and European Medicines Agency (EMA) reports. We checked the reference lists of included and excluded studies for further references to relevant RCTs. We searched the trial results databases of a number of pharmaceutical companies and handsearched the conference proceedings of a number of dermatology meetings. SELECTION CRITERIA Randomised controlled trials (RCTs) of systemic and biological treatments in adults (over 18 years of age) with moderate to severe plaque psoriasis or psoriatic arthritis whose skin had been clinically diagnosed with moderate to severe psoriasis, at any stage of treatment, in comparison to placebo or another active agent. DATA COLLECTION AND ANALYSIS Three groups of two review authors independently undertook study selection, data extraction, 'Risk of bias' assessment, and analyses. We synthesised the data using pair-wise and network meta-analysis (NMA) to compare the treatments of interest and rank them according to their effectiveness (as measured by the Psoriasis Area and Severity Index score (PASI) 90) and acceptability (the inverse of serious adverse effects). We assessed the certainty of the body of evidence from the NMA for the two primary outcomes, according to GRADE; we evaluated evidence as either very low, low, moderate, or high. We contacted study authors when data were unclear or missing. MAIN RESULTS We included 109 studies in our review (39,882 randomised participants, 68% men, all recruited from a hospital). The overall average age was 44 years; the overall mean PASI score at baseline was 20 (range: 9.5 to 39). Most of these studies were placebo controlled (67%), 23% were head-to-head studies, and 10% were multi-armed studies with both an active comparator and placebo. We have assessed all treatments listed in the objectives (19 in total). In all, 86 trials were multicentric trials (two to 231 centres). All of the trials included in this review were limited to the induction phase (assessment at less than 24 weeks after randomisation); in fact, all trials included in the network meta-analysis were measured between 12 and 16 weeks after randomisation. We assessed the majority of studies (48/109) as being at high risk of bias; 38 were assessed as at an unclear risk, and 23, low risk.Network meta-analysis at class level showed that all of the interventions (conventional systemic agents, small molecules, and biological treatments) were significantly more effective than placebo in terms of reaching PASI 90.In terms of reaching PASI 90, the biologic treatments anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha were significantly more effective than the small molecules and the conventional systemic agents. Small molecules were associated with a higher chance of reaching PASI 90 compared to conventional systemic agents.At drug level, in terms of reaching PASI 90, all of the anti-IL17 agents and guselkumab (an anti-IL23 drug) were significantly more effective than the anti-TNF alpha agents infliximab, adalimumab, and etanercept, but not certolizumab. Ustekinumab was superior to etanercept. No clear difference was shown between infliximab, adalimumab, and etanercept. Only one trial assessed the efficacy of infliximab in this network; thus, these results have to be interpreted with caution. Tofacitinib was significantly superior to methotrexate, and no clear difference was shown between any of the other small molecules versus conventional treatments.Network meta-analysis also showed that ixekizumab, secukinumab, brodalumab, guselkumab, certolizumab, and ustekinumab outperformed other drugs when compared to placebo in terms of reaching PASI 90: the most effective drug was ixekizumab (risk ratio (RR) 32.45, 95% confidence interval (CI) 23.61 to 44.60; Surface Under the Cumulative Ranking (SUCRA) = 94.3; high-certainty evidence), followed by secukinumab (RR 26.55, 95% CI 20.32 to 34.69; SUCRA = 86.5; high-certainty evidence), brodalumab (RR 25.45, 95% CI 18.74 to 34.57; SUCRA = 84.3; moderate-certainty evidence), guselkumab (RR 21.03, 95% CI 14.56 to 30.38; SUCRA = 77; moderate-certainty evidence), certolizumab (RR 24.58, 95% CI 3.46 to 174.73; SUCRA = 75.7; moderate-certainty evidence), and ustekinumab (RR 19.91, 95% CI 15.11 to 26.23; SUCRA = 72.6; high-certainty evidence).We found no significant difference between all of the interventions and the placebo regarding the risk of serious adverse effects (SAEs): the relative ranking strongly suggested that methotrexate was associated with the best safety profile regarding all of the SAEs (RR 0.23, 95% CI 0.05 to 0.99; SUCRA = 90.7; moderate-certainty evidence), followed by ciclosporin (RR 0.23, 95% CI 0.01 to 5.10; SUCRA = 78.2; very low-certainty evidence), certolizumab (RR 0.49, 95% CI 0.10 to 2.36; SUCRA = 70.9; moderate-certainty evidence), infliximab (RR 0.56, 95% CI 0.10 to 3.00; SUCRA = 64.4; very low-certainty evidence), alefacept (RR 0.72, 95% CI 0.34 to 1.55; SUCRA = 62.6; low-certainty evidence), and fumaric acid esters (RR 0.77, 95% CI 0.30 to 1.99; SUCRA = 57.7; very low-certainty evidence). Major adverse cardiac events, serious infections, or malignancies were reported in both the placebo and intervention groups. Nevertheless, the SAEs analyses were based on a very low number of events with low to very low certainty for just over half of the treatment estimates in total, moderate for the others. Thus, the results have to be considered with caution.Considering both efficacy (PASI 90 outcome) and acceptability (SAEs outcome), highly effective treatments also had more SAEs compared to the other treatments, and ustekinumab, infliximab, and certolizumab appeared to have the better trade-off between efficacy and acceptability.Regarding the other efficacy outcomes, PASI 75 and Physician Global Assessment (PGA) 0/1, the results were very similar to the results for PASI 90.Information on quality of life was often poorly reported and was absent for a third of the interventions. AUTHORS' CONCLUSIONS Our review shows that compared to placebo, the biologics ixekizumab, secukinumab, brodalumab, guselkumab, certolizumab, and ustekinumab are the best choices for achieving PASI 90 in people with moderate to severe psoriasis on the basis of moderate- to high-certainty evidence. At class level, the biologic treatments anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha were significantly more effective than the small molecules and the conventional systemic agents, too. This NMA evidence is limited to induction therapy (outcomes were measured between 12 to 16 weeks after randomisation) and is not sufficiently relevant for a chronic disease. Moreover, low numbers of studies were found for some of the interventions, and the young age (mean age of 44 years) and high level of disease severity (PASI 20 at baseline) may not be typical of patients seen in daily clinical practice.Another major concern is that short-term trials provide scanty and sometimes poorly reported safety data and thus do not provide useful evidence to create a reliable risk profile of treatments. Indeed, we found no significant difference in the assessed interventions and placebo in terms of SAEs. Methotrexate appeared to have the best safety profile, but as the evidence was of very low to moderate quality, we cannot be sure of the ranking. In order to provide long-term information on the safety of the treatments included in this review, it will be necessary to evaluate non-randomised studies and postmarketing reports released from regulatory agencies as well.In terms of future research, randomised trials comparing directly active agents are necessary once high-quality evidence of benefit against placebo is established, including head-to-head trials amongst and between conventional systemic and small molecules, and between biological agents (anti-IL17 versus anti-IL23, anti-IL23 versus anti-IL12/23, anti-TNF alpha versus anti-IL12/23). Future trials should also undertake systematic subgroup analyses (e.g. assessing biological-naïve patients, baseline psoriasis severity, presence of psoriatic arthritis, etc.). Finally, outcome measure harmonisation is needed in psoriasis trials, and researchers should look at the medium- and long-term benefit and safety of the interventions and the comparative safety of different agents.
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Affiliation(s)
| | | | - Ignacio Garcia‐Doval
- Complexo Hospitalario Universitario de VigoDepartment of DermatologyTorrecedeira 10, 2º AVigoSpain36202
| | - Giao Do
- Hôpital Henri MondorDepartment of Dermatology51 Avenue du Maréchal de Lattre de TassignyCréteilFrance94000
| | - Camille Hua
- Hôpital Henri MondorDepartment of Dermatology51 Avenue du Maréchal de Lattre de TassignyCréteilFrance94000
| | - Canelle Mazaud
- Hôpital Henri MondorDepartment of Dermatology51 Avenue du Maréchal de Lattre de TassignyCréteilFrance94000
| | - Catherine Droitcourt
- Université de Rennes 1Department of Dermatology2 rue Henri le GuillouxRennesFrance35000
| | - Carolyn Hughes
- The University of Nottinghamc/o Cochrane Skin GroupA103, King's Meadow CampusLenton LaneNottinghamUKNG7 2NR
| | - John R Ingram
- Cardiff UniversityDepartment of Dermatology & Wound Healing, Cardiff Institute of Infection & Immunity3rd Floor Glamorgan HouseHeath ParkCardiffUKCF14 4XN
| | - Luigi Naldi
- Padiglione Mazzoleni ‐ Presidio Ospedaliero Matteo RotaCentro Studi GISED (Italian Group for Epidemiologic Research in Dermatology) ‐ FROM (Research Foundation of Ospedale Maggiore Bergamo)Via Garibaldi 13/15BergamoItaly24122
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19
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Jacobi A, Rustenbach SJ, Augustin M. Comorbidity as a predictor for drug survival of biologic therapy in patients with psoriasis. Int J Dermatol 2015; 55:296-302. [DOI: 10.1111/ijd.12879] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 09/18/2014] [Accepted: 10/06/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Arnd Jacobi
- Institute for Health Services Research in Dermatology and Nursing (IVDP); University Medical Center Hamburg-Eppendorf; Hamburg Germany
- Department of Dermatology and Allergology; Philipps University Marburg; Marburg Germany
| | - Stephan J. Rustenbach
- Institute for Health Services Research in Dermatology and Nursing (IVDP); University Medical Center Hamburg-Eppendorf; Hamburg Germany
| | - Matthias Augustin
- Institute for Health Services Research in Dermatology and Nursing (IVDP); University Medical Center Hamburg-Eppendorf; Hamburg Germany
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20
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Can pretreatment serum calcium level predict the efficacy of methotrexate in the treatment of severe plaque psoriasis? J Am Acad Dermatol 2015; 73:991-7.e3. [PMID: 26416303 DOI: 10.1016/j.jaad.2015.08.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 08/10/2015] [Accepted: 08/15/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND The efficacy of methotrexate (MTX) varies in the treatment of psoriasis. OBJECTIVE We sought to identify an indicator from routine pretreatment tests to predict MTX efficacy in the treatment of psoriasis. METHODS In a retrospective analysis of 77 psoriatic patients, the correlation between MTX efficacy and pretreatment routine test results was analyzed with Spearman correlation. The potential risks were further evaluated with a linear regression model. Receiver operating characteristic analysis was performed to examine the effectiveness of serum total calcium (tCa) to predict the effect of MTX on psoriasis. The highest Youden index was used to determine the cutoff point, with which the positive and negative predictive values were calculated. Synergistic effects of MTX and calcium on keratinocyte growth and psoriasis-like mouse model were also investigated. RESULTS The pretreatment tCa level exhibited the closest association with MTX efficacy. The relative psoriasis improvement with tCa was 61.07% (95% confidence interval, 42.85-79.29; P < .001) and better improvements were observed in patients with higher tCa (r = 0.588; P < .002). MTX inhibited keratinocyte growth, which was enhanced synergistically by calcium. In a psoriasis-like mouse model, MTX strongly inhibited epidermis proliferation in the high-calcium group. LIMITATIONS One limitation of our study is the relatively small sample size. CONCLUSION Pretreatment tCa level has the highest correlation with MTX efficacy, which might be useful in predicting beneficial treatment results in psoriasis. Larger studies are required to confirm our findings.
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