Meta-analysis: which immunomodulator is most effective for psoriasis?

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Takeaway

  • A systematic review and meta-analysis compares available targeted immunomodulators for treatment of patients with moderate to severe plaque psoriasis.

Why this matters

  • Many patients do not receive adequate benefit from older therapies.

Study design

  • 34 randomized controlled trials (26 placebo-controlled and 8 direct comparisons) identified by systematic review were subjected to meta-analysis to determine the relative efficacy of targeted immunomodulators.
  • Included immunomodulators (trade name, method of action): adalimumab (Humira; anti-TNF-α), etanercept (Enbrel, anti-TNF-α), infliximab (Remicade, anti-TNF-α), ustekinumab (Stelara; IL 12/23), secukinumab (Cosentyx, IL 17-A), ixekizumab (Taltz, IL 17-A), brodalumab (Siliq, IL 17-A), and apremilast (Otezla, PDE-4).
  • Funding: Institute for Clinical and Economic Review.

Key results

  • All targeted immunomodulators had a higher rate of achieving ≥75% improvement in Psoriasis Area and Severity Index (PASI 75) compared with placebo.
  • Relative risk for PASI 75: 17.9 for ixekizumab, 17.3 for brodalumab, 16.2 for infliximab, 15.4 for secukinumab, 14.0 for ustekinumab,13.0 for adalimumab, 9.6 for etanercept, and 6.2 for apremilast.
  • Ixekizumab, brodalumab, and infliximab were statistically better than ustekinumab, adalimumab, etanercept, and apremilast; ixekizumab was also statistically superior to secukinumab.
  • Infliximab and ustekinumab were associated with the highest infection rates (36% for both).

    Limitations

    • Much of the evidence was short-term (10-16 weeks).