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Journal of the American Academy of Dermatology
Volume 71, n° 6
pages 1167-1175 (décembre 2014)
Doi : 10.1016/j.jaad.2014.08.003
accepted : 5 August 2014
Original Articles

Comparative effectiveness of less commonly used systemic monotherapies and common combination therapies for moderate to severe psoriasis in the clinical setting

Junko Takeshita, MD, PhD a, b, , Shuwei Wang, MD c, Daniel B. Shin, MS a, b, Kristina Callis Duffin, MD, MSCI d, Gerald G. Krueger, MD d, Robert E. Kalb, MD e, Jamie D. Weisman, MD f, Brian R. Sperber, MD, PhD g, Michael B. Stierstorfer, MD h, Bruce A. Brod, MD i, Stephen M. Schleicher, MD j, Andrew D. Robertson, PhD k, Kristin A. Linn, PhD b, Russell T. Shinohara, PhD b, Andrea B. Troxel, ScD b, Abby S. Van Voorhees, MD a, Joel M. Gelfand, MD, MSCE a, b
a Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 
b Department of Epidemiology and Biostatistics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 
c Thomas Jefferson University, Philadelphia, Pennsylvania 
d Department of Dermatology, University of Utah School of Medicine, Salt Lake City, Utah 
e Department of Dermatology, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York 
f Peachtree Dermatology Associates, Atlanta, Georgia 
g Colorado Springs Dermatology Clinic, Colorado Springs, Colorado 
h East Penn Dermatology, North Wales, Pennsylvania 
i Dermatology Associates of Lancaster, Lancaster, Pennsylvania 
j DermDox Centers for Dermatology, Hazleton, Pennsylvania 
k National Psoriasis Foundation, Portland, Oregon 

Reprint requests: Junko Takeshita, MD, PhD, Department of Dermatology, University of Pennsylvania, 1463 Penn Tower, One Convention Ave, Philadelphia, PA 19104.

The effectiveness of psoriasis therapies in real-world settings remains relatively unknown.


We sought to compare the effectiveness of less commonly used systemic therapies and commonly used combination therapies for psoriasis.


This was a multicenter cross-sectional study of 203 patients with plaque psoriasis receiving less common systemic monotherapy (acitretin, cyclosporine, or infliximab) or common combination therapies (adalimumab, etanercept, or infliximab and methotrexate) compared with 168 patients receiving methotrexate evaluated at 1 of 10 US outpatient dermatology sites participating in the Dermatology Clinical Effectiveness Research Network.


In adjusted analyses, patients on acitretin (relative response rate 2.01; 95% confidence interval [CI] 1.18-3.41), infliximab (relative response rate 1.93; 95% CI 1.26-2.98), adalimumab and methotrexate (relative response rate 3.04; 95% CI 2.12-4.36), etanercept and methotrexate (relative response rate 2.22; 95% CI 1.25-3.94), and infliximab and methotrexate (relative response rate 1.72; 95% CI 1.10-2.70) were more likely to have clear or almost clear skin compared with patients on methotrexate. There were no differences among treatments when response rate was defined by health-related quality of life.


Single time point assessment may result in overestimation of effectiveness.


The efficacy of therapies in clinical trials may overestimate their effectiveness as used in clinical practice. Although physician-reported relative response rates were different among therapies, absolute differences were small and did not correspond to differences in patient-reported outcomes.

The full text of this article is available in PDF format.

Key words : biologics, combination therapy, comparative effectiveness, Dermatology Life Quality Index, Physician Global Assessment, psoriasis, quality of life, systemic treatments

Abbreviations used : BSA, DLQI, FDA, IQR, PASI, PGA, RCT

 Supported by grant RC1-AR058204 and K24-AR064310 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (Dr Gelfand), National Psoriasis Foundation Fellowship Award (Dr Takeshita), Dermatology Foundation Career Development Award (Dr Takeshita), and Training Grant T32-AR007465 (Mr Shin and Dr Wang) from the National Institutes of Health. The sponsors had no role in the design and conduct of the study; in the collection, management, analysis, and interpretation of the data; in the preparation, review, or approval of the manuscript; or in the decision to submit the manuscript for publication.
 Disclosure: Dr Callis Duffin was an investigator, consultant, and/or speaker for AbbVie, Amgen Inc, ApoPharma, Bristol-Myers Squibb, Celgene, Eli Lilly, Genzyme, Incyte, Janssen, NovoNordisk, Pfizer Inc, and Wyeth, receiving honoraria and/or salary; served on the advisory board of Amgen Inc; and received residency/fellowship program funding from AbbVie and Amgen Inc. Dr Gelfand served as a consultant for AbbVie, Amgen Inc, Celgene Corp, Eli Lilly, Janssen, Merck, Novartis Corp, and Pfizer Inc, receiving honoraria; had grants or has pending grants from AbbVie, Amgen Inc, Eli Lilly, Genentech Inc, Novartis Corp, and Pfizer Inc; and received payment for continuing medical education work related to psoriasis. Dr Kalb served as a consultant for AbbVie, Amgen Inc, Janssen, LEO Pharma Inc, and Stiefel Laboratories Inc, receiving honoraria; served as an investigator for AbbVie, Amgen Inc, Astellas Pharma Inc, and Janssen, receiving honoraria; and served as a speaker for AbbVie, Amgen Inc, Galderma Laboratories LP, Janssen, and Stiefel Laboratories Inc. Dr Krueger served as a consultant for AbbVie, Amgen Inc, and Janssen; had grants or has pending grants from AbbVie and Amgen Inc; and received payment for lectures and travel-related expenses from AbbVie, Amgen Inc, and Janssen. Dr Robertson is employed by the National Psoriasis Foundation, which receives unrestricted financial support from companies that make products used to treat psoriasis and psoriatic arthritis, including AbbVie, Amgen Inc, Eli Lilly, Galderma Laboratories LP, Janssen, LEO Pharma Inc, Pfizer Inc, and Stiefel Laboratories Inc. Dr Schleicher has served as an investigator for Eli Lilly and Merck, receiving honoraria and/or salary; and received payment for lectures from Janssen and Aqua Pharmaceuticals. Dr Sperber is the medical director of Stephens and Associates, served as a consultant for Amgen Inc, and had grants or has pending grants from AbbVie and Janssen. Dr Van Voorhees served on advisory boards for AbbVie, Amgen Inc, Celgene, Janssen, LEO Pharma Inc Novartis Corp, Pfizer Inc, and Warner Chilcott; served as an investigator for AbbVie and Amgen Inc, receiving grants; served as a consultant for Amgen Inc; and receives other income from Merck. Dr Weisman had grants or has pending grants from AbbVie, Braintree Laboratories Inc, Celgene Corp, Cipher Pharmaceuticals Inc, and LEO Pharma Inc; and received payments for lectures from AbbVie and Amgen Inc. Drs Takeshita, Wang, Stierstorfer, Brod, Linn, Shinohara, and Troxel, and Mr Shin have no conflicts of interest to declare.

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