There are numerous systemic medications in use for psoriasis, with additional investigational agents being studied. However, head-to-head, randomized clinical trials are rare and cannot feasibly compare all treatments. A network meta-analysis (NMA) synthesizes the available evidence to provide estimates for all pairwise comparisons. Here, we summarize and appraise two recent NMAs that assessed systemic therapies for moderate-to-severe psoriasis.
Two systematic reviews searched databases and the grey literature to identify relevant randomized clinical trials.
The reviews mostly included trials that involved adults with moderate-to-severe psoriasis. One of the reviews also included two trials involving children.
Interventions common to both reviews include adalimumab, etanercept, infliximab, ustekinumab, ixekizumab, secukinumab and methotrexate. One of the reviews included additional interventions, primarily other biological agents along with new small-molecule treatments and systemic conventional treatments.
One review focused on 'clear/nearly clear' and withdrawals from adverse events as study outcomes, while the second review focused on improvement of ≥ 90% measured on the Psoriasis Area and Severity Index (PASI 90) and serious adverse events.
Additional outcomes included quality of life, PASI 75, Physician's Global Assessment of 0/1 and any adverse event.
Overall, both NMAs are of high quality and provide a comprehensive summary of the evidence base and treatment effects. Results, in terms of both estimates and rankings, suggest that newer biologics targeting the interleukin (IL)-12/23 and IL-17 axes appear to be more effective than older biologics and oral agents.
Patients, clinicians and policy makers can use the relative efficacy assessments of NMAs to inform decision making regarding the clearance of psoriasis skin lesions at relevant time points and improvement in quality of life.