Biologics may be superior to methotrexate in pediatric psoriasis
Biologics were more likely to improve psoriasis than methotrexate in pediatric patients, as assessed by both the Psoriasis Area and Severity Index and Physician Global Assessment, according to a study.
A retrospective medical records review of pediatric patients treated for moderate to severe psoriasis at 20 European and North American centers compared PASI and/or PGA scores at baseline and after 6 months of treatment.
Of 234 patients who were treated with biologics or methotrexate, 163 received only methotrexate, while 47 received only biologics and 24 received the treatments sequentially. Biologics prescribed were etanercept (73.2%), adalimumab (19.7%), ustekinumab (5.6%) and infliximab (1.4%).
“Our international, retrospective cohort study appears to support a greater reduction in psoriasis severity from use of biologics compared with methotrexate in a real-world practice setting and showed a longer overall drug survival,” the study authors wrote. “To our knowledge, this is the first study to compare drug survival rates and the real-world utility profiles of methotrexate and biologics in pediatric psoriasis.”
Defined as the time patients received a specific drug, drug survival was delineated by three events: discontinuation in general, discontinuation due to ineffectiveness and discontinuation due to adverse events.
The overall drug survival for methotrexate was 77.5% after 1 year, 50.3% after 3 years and 35.9% after 5 years, while in the biologics group, the overall drug survival was 83.4% after 1 year, 64.3% after 3 years and 57.1% after 5 years.
In terms of psoriasis severity, PASI 75 was achieved in 40% of methotrexate-treated patients after 6 months compared with 71.4% of biologics-treated patients (P = .02). PGA 0/1 was higher in the biologics group (48.6%) compared with the methotrexate group (35.6%), but the difference was not statistically significant.
“In addition to their documented efficacy, biologics are convenient to use, require less monitoring and are associated with fewer treatment-related toxic effects than conventional agents in children, making them an attractive treatment option,” the authors wrote.
However, methotrexate is still a viable option due to its cost-effectiveness compared with biologics.- by Rebecca L. Forand
Disclosures: Bronkers reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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There are many targeted therapies for psoriasis, and while biologic agents have been approved for more than 15 years for adults, utilization has been limited in pediatrics, partially due to having limited studies and only a few agents specifically approved for teens and younger children. This study is an intriguing one, as it examines comparative outcomes in patients treated with biologic agents as compared with methotrexate. The study showed greater reduction of psoriasis severity with biologics, as well as longer continued utilization of the medications (known as “drug survival”).
In some cases, pediatric patients may have to fail treatment with oral methotrexate before a biologic can be initiated and approved by insurance. This may lead to delays in effective treatment with a negative impact in quality of life and less improvement in psoriasis severity. The data showed that 75% improvement from baseline (PASI 75) was seen in 40% of methotrexate-treated patients vs. 71.4% treated with biologics. That is quite a difference, with more than 30% more individuals getting to a big milestone in improvement with biologic agents. The study also showed that getting to “clear/almost clear” was more likely with biologic agents.
The data provided by this article can be considered as a push toward making biologics first-line treatment for pediatric psoriasis, while it does not belittle methotrexate as a therapy. Certainly, having an expanded set of indications at different ages can help us shift to the biologic age in pediatrics. Recently, ixekizumab was approved for psoriasis in children 6 years of age and older, joining etanercept, approved down to 4 years of age, and ustekinumab, approved for 12 years and older. Other studies of biologics and oral agents are in the works or recently completed and may help to expand approvals for children and teenagers in the next few years.
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