Review ranks the 4 most effective biologic therapies for psoriasis

By Michael Woodhead

6 Feb 2020

An ‘elite’ group of  four biologic therapies has been identified as having the best short and long-term efficacy in moderate to severe psoriasis in a network meta-analysis.

Risankizumab-rzaa, guselkumab, ixekizumab, and brodalumab were associated with the highest estimated PASI (Psoriasis Area  and Severity Index) 90% response rates in an analysis that combined data from 60 phase 2, 3 and 4 randomised clinical trials.

The comparison was undertaken to overcome the lack of head-to-head trials of novel treatments for plaque psoriasis, according to the US authors of the review published in JAMA Dermatology.

While acknowledging the drawbacks of using meta-analyses for data from different drug trials, the study authors said they believed the findings provided a comprehensive assessment of the comparative short-term and long-term efficacy among the many novel treatments for psoriasis.

An initial network meta-analysis found that the four therapies had the highest estimated PASI 75, 90 and 100 response rates in the short term (10-16 weeks), and were significantly higher than those for comparators such as adalimumab, apremilast, certolizumab pegol, dimethyl fumarate, etanercept, tildrakizumab-asmn, and ustekinumab.

The estimated PASI 90 response rates at 10-16 weeks were 71.6% for risankizumab-rzaa; 70.8% for brodalumab; 70.6% for ixekizumab and 67.3% for guselkumab.

A further meta-analysis of 22 trials of longer term efficacy found that the same four drugs also had the highest response rates in psoriasis at 44-60 weeks.

The estimated PASI 90 response rates at 44 to 60 weeks from baseline were 79.4% for risankizumab-rzaa, 76.5% for guselkumab, 74.0% for brodalumab and 73.9% for ixekizumab.

There were no statistically significant differences in short-term efficacy between the four top therapies. Over the long term, brodalumab, guselkumab, ixekizumab, risankizumab-rzaa, and secukinumab had significantly higher PASI response rates than those corresponding to adalimumab, apremilast, infliximab, etanercept, and ustekinumab.

The study investigators said the increasing number therapeutic options for psoriasis, and the lack of head-to-head trials meant “it has become increasingly challenging for clinicians to compare across the available treatments for clinical decision making.”

“This study provides an assessment of both short-term and long-term comparative efficacy among treatments for moderate to severe plaque psoriasis which can help healthcare stakeholders optimise treatment regimens,” they concluded.

An accompanying commentary article said the network meta-analysis approach had many flaws and the  best long-term comparative efficacy estimates would come from real-world, disease-based registries that follow up thousands of patients on multiple drugs over many years.

Nevertheless the raw rankings of efficacy “offer a valuable starting point from which to initiate discussions with patients and improve shared decision making related to choosing the most appropriate psoriasis treatment,” it concluded.

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