Biologics vs MTX for paediatric psoriasis

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Severity and drug survival are improved more by biologics than methotrexate

Biologic drugs help reduce psoriasis severity and improve drug survival rates more than methotrexate, according to a study of more than 200 paediatric patients.

The real-world study of patients at 20 European and North American paediatric psoriasis centres found that biologics led to lower Psoriasis Area and Severity Index (PASI) and Physician Global Assessment (PGA) scores after six months of treatment – although methotrexate helped too.

The chronic inflammatory skin disorder affects more than 1% of children globally, but there has been little research into the real-world effectiveness of these drugs.

“Although most children affected by psoriasis have mild psoriasis that is responsive to topical therapy, approximately 20% of children have moderate to severe disease that may require phototherapy or systemic therapy,” lead author Dr Inge Bronckers, of the department of dermatology at Radboud University in the Netherlands, and colleagues, wrote in JAMA Dermatology.

“Despite the common use of methotrexate and tumour necrosis factor–targeting biologics in children, to our knowledge, only methotrexate and adalimumab have been compared head-to-head and prospectively,” Dr Bronckers wrote.

This makes it challenging for clinicians to choose the best treatment for their patients.

To address this, the team analysed the medical records of 234 paediatric individuals with moderate-to-severe psoriasis who received at least three months of either methotrexate or a biologic before their 18th birthday. Patients were included if they took the medication either alone or sequentially, but not if they were taking it at the same time.

The team compared each participants’ PASI and PGA scores from the beginning of the treatment and again after six months. Treatment success was defined as a PGA score of 0 or 1, representing clear or almost clear skin, or at least a 75% improvement in PASI score.

About 70% of the patients exclusively received methotrexate, and 20% received biologics. One in 10 received both sequentially, with all-bar-one receiving methotrexate first.

Etanercept was the most frequently prescribed biologic (73%), followed by adalimumab (20%).

At six months, 40% of the patients on methotrexate had a 75% reduction in PASI scores, compared with 71% of those taking biologics. Similarly, only 36% of patients receiving methotrexate had achieved a PGA score of 0 or 1, compared with 49% of those on biologics – although this did not reach statistical significance.

While the current restrictions did not allow doctors to proceed directly to biologics, there was increasing data to suggest that in the future – when the drugs were more freely available – they would be used more as a first-line treatment in these patients, Associate Professor Paul Bird, at the University of NSW, told Rheumatology Republic.

Improved symptom severity and drug survival weren’t the only appeal of biologics either, he said.

“Not only does the skin clear, but the person’s fatigue improves, their overall wellbeing improves and their nails improve,” said Professor Bird. ”And there are a lot less nuisance side-effects.”

However, biologics are also more expensive than methotrexate, despite needing less laboratory monitoring.

“Methotrexate still has an important position in the treatment of paediatric psoriasis,” Dr Bronckers concluded.

The study was supported by a grant from the International Psoriasis Council, and Professor Bird has undertaken consulting and been on advisory boards for Pfizer, Abbvie, Jannsen, Novartis and UCB.

JAMA Dermatology 2020, 5 February

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