Combination psoriasis treatments lack efficacy, safety information

the Clinical Advisor take:

Few trials evaluated the efficacy and safety of combination therapy in moderate-to-severe psoriasis, a review published in JAMA Dermatology suggest.

“While monotherapy with biologic agents is effective for many patients with psoriasis, some patients require combination therapy,” wrote April W. Armstrong, MD, MPH, of the University of Colorado in Denver, and colleagues.

“Evidence-based recommendations on combination therapy provide guidance for treating appropriately selected patients with psoriasis.”

To make evidence-based, best practice recommendations regarding combining biologics with other systemic treatments, including phototherapy, oral medications, or other biologics, for psoriasis treatment, the investigators reviewed evidence from MEDLINE database studies from January 1, 1946 to June 18, 2013.

Combining biologics, such as etanercept or adalimumab, with phototherapy likely results in greater reduction in disease severity than either alone, reported the scientists. Etanercept and methotrexate combination is more effective than monotherapy with either medication. A combination of infliximab with methotrexate results in greater efficacy than infliximab alone.

With concomitant use of acitretin, the dosing of etanercept can be reduced to maintain similar levels of efficacy. Short-term cyclosporine use has been combined with etanercept or adalimumab to control psoriasis flares.

Based on the expert opinion of the Medical Board of the National Psoriasis Foundation, the preferred order for combining a second modality with biologics is biologic and methotrexate combination, biologic and acitretin combination, and then biologic and phototherapy combination.

“In the psoriasis literature, there are overall insufficient data on combining biologics with acitretin, cyclosporine, or a second biologic,” noted the investigators.

“Among appropriately selected patients with psoriasis, carefully chosen combinations may result in greater efficacy, while minimizing toxicity.