title: Efficacy and safety of systemic treatments for moderate-to-severe psoriasis: meta-analysis of randomized controlled trials.
abstract: Dermatologists may choose from various conventional and biological systemic agents to treat patients with moderate-to-severe psoriasis. We set out to analyse systematically the efficacy and tolerability of approved treatments for moderate-to-severe psoriasis. We undertook a systematic review and meta-analysis of randomized controlled trials (RCTs) investigating the efficacy of systemic treatment approved for moderate-to-severe psoriasis. Efficacy was assessed as the proportion of participants with 75% improvement in Psoriasis Area and Severity Index 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 (RDs). In total, 48 eligible RCTs totalling 16 696 patients (11 178 randomized to biologics, 1888 to conventional treatments) were identified. In placebo-controlled trials, infliximab was the most efficacious [RD 76%, 95% confidence interval (CI) 73-79%]. Adalimumab (RD 61%, 95% CI 56-67%), and ustekinumab 45 mg (RD 63%, 95% CI 59-66%) and 90 mg (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 the superiority of adalimumab and infliximab over methotrexate (MTX), the superiority of ustekinumab over etanercept, the nonsignificant superiority of ciclosporin over MTX, and the dose-dependent efficacy of etanercept and ustekinumab. Fumaric acid is as efficacious as MTX. Safety of treatments could not be pooled due to a lack of standardization in reporting across trials. In conclusion, the qualitative and quantitative evidence is much stronger for biological interventions than for conventional treatments.
authors.affiliation: Centre for Evidence-Based Healthcare, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, D-01307, Dresden, Germany; Department of Occupational and Social Medicine, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, D-01307, Dresden, Germany.
authors.forename: J
authors.initials: J
authors.lastname: Schmitt
authors.forename: S
authors.initials: S
authors.lastname: Rosumeck
authors.forename: G
authors.initials: G
authors.lastname: Thomaschewski
authors.forename: B
authors.initials: B
authors.lastname: Sporbeck
authors.forename: E
authors.initials: E
authors.lastname: Haufe
authors.forename: A
authors.initials: A
authors.lastname: Nast
mesh_terms: D001685:Biological Factors / Q000627:therapeutic use*; D016572:Cyclosporine / Q000627:therapeutic use; D003879:Dermatologic Agents / Q000627:therapeutic use*; D005650:Fumarates / Q000627:therapeutic use; D006801:Humans; D008727:Methotrexate / Q000627:therapeutic use; D011565:Psoriasis / Q000188:drug therapy*; D016032:Randomized Controlled Trials as Topic; D012176:Retinoids / Q000627:therapeutic use; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D001685:Biological Factors; D003879:Dermatologic Agents; D005650:Fumarates; D012176:Retinoids; D016572:Cyclosporine; D008727:Methotrexate