Hydroxyurea: A New Treatment for Psoriasis
TL;DR: Hydroxyurea may be less toxic than methotrexate and is efficacious in the management of psoriasis and is indicated to determine relative efficacy and toxicity.
Abstract: In a double-blind study, nine of ten cases of severe psoriasis demonstrated clinical and histopathologic response to hydroxyurea. No toxic reactions were noted. The drug may be less toxic than methotrexate and is efficacious in the management of psoriasis. A double-blind comparison of hydroxyurea and methotrexate is indicated to determine relative efficacy and toxicity.
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TL;DR: Hydroxyurea increases the level of fetal hemoglobin, leading to a reduction in the incidence of vasoocclusive crises in sickle cell anemia, and hydroxyurea selectively reduces thelevel of episomal DNA and thus potentially may reduce drug resistance associated with duplicated genes retained as episomes.
420Â citations
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TL;DR: Management of psoriasis begins with identification of the extent of cutaneous disease, and a holistic, contractual approach to treatment is encouraged, with particular reference to psychosocial disability and quality-of-life issues.
302Â citations
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TL;DR: A network meta-analysis of randomised controlled trials of systemic and biological treatments in adults with moderate to severe plaque psoriasis or psoriatic arthritis and a ranking of these treatments according to their efficacy and safety is conducted.
Abstract: Background
Psoriasis is an immune-mediated disease for which some people have a genetic predisposition. The condition manifests in inflammatory effects on either the skin or joints, or both, and it has a major impact on quality of life. Although there is currently no cure for psoriasis, various treatment strategies allow sustained control of disease signs and symptoms. Several randomised controlled trials (RCTs) have compared the efficacy of the different systemic treatments in psoriasis against placebo. However, the relative benefit of these treatments remains unclear due to the limited number of trials comparing them directly head to head, which is why we chose to conduct a network meta-analysis.
Objectives
To compare the efficacy and safety of conventional systemic agents (acitretin, ciclosporin, fumaric acid esters, methotrexate), small molecules (apremilast, tofacitinib, ponesimod), anti-TNF alpha (etanercept, infliximab, adalimumab, certolizumab), anti-IL12/23 (ustekinumab), anti-IL17 (secukinumab, ixekizumab, brodalumab), anti-IL23 (guselkumab, tildrakizumab), and other biologics (alefacept, itolizumab) for patients with moderate to severe psoriasis and to provide a ranking of these treatments according to their efficacy and safety.
Search methods
We searched the following databases to December 2016: the Cochrane Skin Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS. We also searched five trials registers and the U.S. Food and Drug Administration (FDA) and European Medicines Agency (EMA) reports. We checked the reference lists of included and excluded studies for further references to relevant RCTs. We searched the trial results databases of a number of pharmaceutical companies and handsearched the conference proceedings of a number of dermatology meetings.
Selection criteria
Randomised controlled trials (RCTs) of systemic and biological treatments in adults (over 18 years of age) with moderate to severe plaque psoriasis or psoriatic arthritis whose skin had been clinically diagnosed with moderate to severe psoriasis, at any stage of treatment, in comparison to placebo or another active agent.
Data collection and analysis
Three groups of two review authors independently undertook study selection, data extraction, 'Risk of bias' assessment, and analyses. We synthesised the data using pair-wise and network meta-analysis (NMA) to compare the treatments of interest and rank them according to their effectiveness (as measured by the Psoriasis Area and Severity Index score (PASI) 90) and acceptability (the inverse of serious adverse effects). We assessed the certainty of the body of evidence from the NMA for the two primary outcomes, according to GRADE; we evaluated evidence as either very low, low, moderate, or high. We contacted study authors when data were unclear or missing.
Main results
We included 109 studies in our review (39,882 randomised participants, 68% men, all recruited from a hospital). The overall average age was 44 years; the overall mean PASI score at baseline was 20 (range: 9.5 to 39). Most of these studies were placebo controlled (67%), 23% were head-to-head studies, and 10% were multi-armed studies with both an active comparator and placebo. We have assessed all treatments listed in the objectives (19 in total). In all, 86 trials were multicentric trials (two to 231 centres). All of the trials included in this review were limited to the induction phase (assessment at less than 24 weeks after randomisation); in fact, all trials included in the network meta-analysis were measured between 12 and 16 weeks after randomisation. We assessed the majority of studies (48/109) as being at high risk of bias; 38 were assessed as at an unclear risk, and 23, low risk.
Network meta-analysis at class level showed that all of the interventions (conventional systemic agents, small molecules, and biological treatments) were significantly more effective than placebo in terms of reaching PASI 90.
In terms of reaching PASI 90, the biologic treatments anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha were significantly more effective than the small molecules and the conventional systemic agents. Small molecules were associated with a higher chance of reaching PASI 90 compared to conventional systemic agents.
At drug level, in terms of reaching PASI 90, all of the anti-IL17 agents and guselkumab (an anti-IL23 drug) were significantly more effective than the anti-TNF alpha agents infliximab, adalimumab, and etanercept, but not certolizumab. Ustekinumab was superior to etanercept. No clear difference was shown between infliximab, adalimumab, and etanercept. Only one trial assessed the efficacy of infliximab in this network; thus, these results have to be interpreted with caution. Tofacitinib was significantly superior to methotrexate, and no clear difference was shown between any of the other small molecules versus conventional treatments.
Network meta-analysis also showed that ixekizumab, secukinumab, brodalumab, guselkumab, certolizumab, and ustekinumab outperformed other drugs when compared to placebo in terms of reaching PASI 90: the most effective drug was ixekizumab (risk ratio (RR) 32.45, 95% confidence interval (CI) 23.61 to 44.60; Surface Under the Cumulative Ranking (SUCRA) = 94.3; high-certainty evidence), followed by secukinumab (RR 26.55, 95% CI 20.32 to 34.69; SUCRA = 86.5; high-certainty evidence), brodalumab (RR 25.45, 95% CI 18.74 to 34.57; SUCRA = 84.3; moderate-certainty evidence), guselkumab (RR 21.03, 95% CI 14.56 to 30.38; SUCRA = 77; moderate-certainty evidence), certolizumab (RR 24.58, 95% CI 3.46 to 174.73; SUCRA = 75.7; moderate-certainty evidence), and ustekinumab (RR 19.91, 95% CI 15.11 to 26.23; SUCRA = 72.6; high-certainty evidence).
We found no significant difference between all of the interventions and the placebo regarding the risk of serious adverse effects (SAEs): the relative ranking strongly suggested that methotrexate was associated with the best safety profile regarding all of the SAEs (RR 0.23, 95% CI 0.05 to 0.99; SUCRA = 90.7; moderate-certainty evidence), followed by ciclosporin (RR 0.23, 95% CI 0.01 to 5.10; SUCRA = 78.2; very low-certainty evidence), certolizumab (RR 0.49, 95% CI 0.10 to 2.36; SUCRA = 70.9; moderate-certainty evidence), infliximab (RR 0.56, 95% CI 0.10 to 3.00; SUCRA = 64.4; very low-certainty evidence), alefacept (RR 0.72, 95% CI 0.34 to 1.55; SUCRA = 62.6; low-certainty evidence), and fumaric acid esters (RR 0.77, 95% CI 0.30 to 1.99; SUCRA = 57.7; very low-certainty evidence). Major adverse cardiac events, serious infections, or malignancies were reported in both the placebo and intervention groups. Nevertheless, the SAEs analyses were based on a very low number of events with low to very low certainty for just over half of the treatment estimates in total, moderate for the others. Thus, the results have to be considered with caution.
Considering both efficacy (PASI 90 outcome) and acceptability (SAEs outcome), highly effective treatments also had more SAEs compared to the other treatments, and ustekinumab, infliximab, and certolizumab appeared to have the better trade-off between efficacy and acceptability.
Regarding the other efficacy outcomes, PASI 75 and Physician Global Assessment (PGA) 0/1, the results were very similar to the results for PASI 90.
Information on quality of life was often poorly reported and was absent for a third of the interventions.
Authors' conclusions
Our review shows that compared to placebo, the biologics ixekizumab, secukinumab, brodalumab, guselkumab, certolizumab, and ustekinumab are the best choices for achieving PASI 90 in people with moderate to severe psoriasis on the basis of moderate- to high-certainty evidence. At class level, the biologic treatments anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha were significantly more effective than the small molecules and the conventional systemic agents, too. This NMA evidence is limited to induction therapy (outcomes were measured between 12 to 16 weeks after randomisation) and is not sufficiently relevant for a chronic disease. Moreover, low numbers of studies were found for some of the interventions, and the young age (mean age of 44 years) and high level of disease severity (PASI 20 at baseline) may not be typical of patients seen in daily clinical practice.
Another major concern is that short-term trials provide scanty and sometimes poorly reported safety data and thus do not provide useful evidence to create a reliable risk profile of treatments. Indeed, we found no significant difference in the assessed interventions and placebo in terms of SAEs. Methotrexate appeared to have the best safety profile, but as the evidence was of very low to moderate quality, we cannot be sure of the ranking. In order to provide long-term information on the safety of the treatments included in this review, it will be necessary to evaluate non-randomised studies and postmarketing reports released from regulatory agencies as well.
In terms of future research, randomised trials comparing directly active agents are necessary once high-quality evidence of benefit against placebo is established, including head-to-head trials amongst and between conventional systemic and small molecules, and between biological agents (anti-IL17 versus anti-IL23, anti-IL23 versus anti-IL12/23, anti-TNF alpha versus anti-IL12/23). Future trials should also undertake systematic subgroup analyses (e.g. assessing biological-naive patients, baseline psoriasis severity, presence of psoriatic arthritis, etc.). Finally, outcome measure harmonisation is needed in psoriasis trials, and researchers should look at the medium- and long-term benefit and safety of the interventions and the comparative safety of different agents.
258Â citations
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TL;DR: Evaluating the clinical effectiveness, safety, tolerability and cost-effectiveness of etanercept and efalizumab for the treatment of moderate to severe chronic plaque psoriasis found that the response to etanorcept is maintained post-treatment, at least in the medium term, and data from uncontrolled follow-up phases reflect and extend these findings.
Abstract: OBJECTIVES: To evaluate the clinical effectiveness, safety, tolerability and cost-effectiveness of etanercept and efalizumab for the treatment of moderate to severe chronic plaque psoriasis. DATA SOURCES: Major electronic databases and several Internet resources were searched up to April 2004. REVIEW METHODS: Systematic reviews were undertaken of the efficacy, safety and economic reviews of etanercept and efalizumab. An existing systematic review of the efficacy and safety of other treatments was also updated. Economic models supplied by the manufacturers of etanercept and efalizumab were critiqued. An economic model was then developed of etanercept and efalizumab in the treatment of moderate to severe chronic plaque psoriasis. RESULTS: The review of the clinical evidence identified a total of 39 published and three unpublished studies: eight randomised controlled trials (RCTs) of the efficacy of etanercept (three trials) and efalizumab (five); 10 studies of the adverse effects of the interventions; and 24 RCTs of the efficacy of the other treatments for moderate to severe psoriasis. The trials of the efficacy of the interventions were all double-blind and placebo-controlled trials and generally of good quality, but three of the five efalizumab trials were poorly reported. A total of 1347 patients were included in the etanercept trials and 2963 in the efalizumab trials. Data on the efficacy of etanercept 25 mg twice a week for 12 weeks were available from three RCTs. On average, active treatment resulted in 62% of patients achieving a Psoriasis Area and Severity Index (PASI) 50, 33% achieving a PASI 75, 11% achieving a PASI 90 and 40% were assessed as clear or almost clear. These figures are not adjusted for changes relative to placebo. Improvement in quality of life as assessed by mean percentage change in Dermatology Life Quality Index (DLQI) was around 59% with etanercept 25 mg twice a week compared with 9% with placebo, and all mean differences that could be calculated were statistically significantly in favour of etanercept. Data on the efficacy of etanercept 50 mg twice a week for 12 weeks were available from two RCTs. Across the two trials, the proportion of patients achieving PASI 50, 75 and 90 was 76, 49 and 21%, respectively; the pooled relative risks were all statistically significantly in favour of etanercept. The findings for mean PASI after treatment, mean percentage change in PASI from baseline and mean percentage change in DLQI also demonstrated the efficacy of etanercept treatment. Evidence from one RCT indicates that the response to etanercept is maintained post-treatment, at least in the medium term, and data from uncontrolled follow-up phases reflect and extend these findings. Efalizumab at a dose of 1 mg/kg once a week subcutaneously was studied in five RCTs. Across these trials, 12 weeks of active treatment resulted in an average of 55% of patients achieving PASI 50, 27% PASI 75, 4.3% PASI 90 and 27% clear or minimal psoriasis status. These figures are not adjusted for changes relative to placebo. There is no evidence from RCTs that the response to efalizumab 1 mg/kg once a week is maintained when treatment continues beyond 12 weeks, and long-term follow-up data relate to a range of doses and are poorly reported and so cannot be used to draw even tentative conclusions regarding the long-term efficacy of efalizumab. Uncontrolled data from trial follow-up suggest that time to relapse may be around 60 days. No data indicating the existence or absence of any rebound in psoriasis after discontinuation of efalizumab were identified. There is no evidence relating to the efficacy of efalizumab upon retreatment. A mixed treatment comparison analysis found a higher response rate in terms of PASI 50, 75 and 90 with etanercept than with efalizumab. Injection site reactions appear to be the most common adverse effects of etanercept. Overall, etanercept appears to be well tolerated in short- and long-term use, although many of the long-term data are not from patients with psoriasis. Headache, chills and, to a lesser extent, nausea, myalgia, pain and fever are the common adverse events associated with efalizumab. Overall, withdrawal rates due to adverse events are low. Longer term data for efalizumab are not readily available for evaluation, but the adverse events data up to 3 years appear to reflect those over 12 weeks and to remain stable. Unfortunately, few data for serious infections and serious adverse events with efalizumab are available. For the primary analysis comparing etanercept, efalizumab and supportive care, the results of the York Model suggest that the biological therapies would only be cost-effective for all patients with moderate to severe psoriasis if the NHS were willing to pay over pound 60,000 per QALY gained. In patients with poor baseline quality of life (fourth quartile DLQI), efalizumab, etanercept 25 mg (intermittent), etanercept 25 mg (continuous) and etanercept 50 mg (intermittent) would be cost-effective as part of a treatment sequence if the NHS were willing to pay pound 45,000, pound 35,000, pound 45,000 and pound 65,000 per QALY gained, respectively. In patients who are also at high risk of inpatient hospitalisation (21 days per annum), these therapies would be cost-effective as part of a sequence as long as the NHS were willingness to pay pound 25,000, pound 20,000, pound 25,000 and pound 45,000 per QALY gained, respectively. As part of a secondary analysis including a wider range of systemic therapies as comparators, the York Model found that it would only be cost-effective to use etanercept and efalizumab in a sequence after methotrexate, ciclosporin and Fumaderm. CONCLUSIONS: Clinical trial data indicate that both etanercept and efalizumab are efficacious in patients who are eligible for systemic therapy, but the economic evaluation demonstrates that these biological therapies are likely to be cost-effective only in patients with poor baseline QoL and who are at risk of hospitalisation. Efficacy trials conducted in the specific population for which etanercept and efalizumab are licensed are required, as are long-term comparisons of etanercept and efalizumab with other treatments for moderate to severe psoriasis. Long-term efficacy trials and safety/tolerability data for patients treated with etanercept or efalizumab are required, as are trials on the response of specific subtypes of psoriasis to different drugs. Research on the rate of inpatient hospitalisation in patients with moderate to severe psoriasis is warranted, and the effect of treatment on this rate.
237Â citations
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TL;DR: A prior review of trials of methotrexate was used to find studies conducted before 1966 and the results of the search were crosschecked against the Cochrane Controlled Trials Register.
Abstract: Searching MEDLINE (from 1996 to June 1999) and EMBASE (from 1980 to June 1999) were searched. The search strategy used subject headings such as 'psoriasis', 'treatment', 'psoriasis-drug-therapy' and 'clinical trial', textwords including 'study', 'trial*' and 'random*', and the title words ' clinical-trial' or 'compar*'. The results of the search were crosschecked against the Cochrane Controlled Trials Register. In addition, the Science Citation Index and the European Dermato-Epidemiology Network trials register were searched. Further studies were identified by examining conference proceedings (e.g. Psoriasis From Gene to Clinic, and the International Psoriasis Symposium), by contacting the manufacturers of relevant drugs, and by handsearching relevant journals. A prior review of trials of methotrexate was used to find studies conducted before 1966.
219Â citations
References
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TL;DR: Hydxyurea, hydroxyurethane, and dihydroxyurea inhibit incorporation of thymidine into the DNA of monolayers of HeLa cells, but hydroxylamine inhibits cellular incorporation of all three precursors:Thymidine, uridine, and leucine.
Abstract: Hydroxyurea, hydroxyurethane, and dihydroxyurea inhibit incorporation of thymidine into the DNA of monolayers of HeLa cells. They do not affect incorporation of uridine into RNA or of leucine into protein. In contrast, hydroxylamine inhibits cellular incorporation of all three precursors: thymidine, uridine, and leucine. Hydroxyurea does not affect thymidine kinase, thymidylate kinase, or DNA polymerase reactions, but it does inhibit incorporation of cytidylic and guanylic acids into DNA in cell-free supernatants.
420Â citations
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TL;DR: This study attempts to characterize the hyperplasia of the epidermis in psoriasis, and to outline the kinetics of some of the changes in the tissues and cell populations involved.
Abstract: Adequate biologic definition of certain disease processes and the morphogenesis of lesions would seem to hold the advantage of giving a kind of understanding on which to base further explorations into the disease under concern. To date there seems to be general agreement that the epidermal lesion of psoriasis can be categorized by hyperplasia and increased mitotic activity of the epidermis. This limited definition does not specifically identify psoriasis, for it is also applicable to a number of unrelated epidermal lesions on which there is also but casual information. This study attempts to characterize the hyperplasia of the epidermis in psoriasis, and to outline the kinetics of some of the changes in the tissues and cell populations involved. Materials and Methods For the analyses described below, biopsy specimens of psoriasis lesions were obtained from the upper back of six patients (four men, two women) with psoriasis vulgaris; from four of
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TL;DR: Clinical experience and results in the treatment of psoriasis with parenteral methotrexate with weekly to biweekly injections of the drug were found to maintain improvement of the disease.
Abstract: This report discusses the biochemical, biological, and pharmacological actions of folic acid antagonists on the lesion of psoriasis and other tissues of the body. Clinical experience and results in the treatment of psoriasis with parenteral methotrexate are reviewed. Weekly to biweekly injections of the drug were found to maintain improvement of the disease.
143Â citations
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TL;DR: It has been shown that histologic response to aminopterin therapy of psoriatic lesions consists of reduced hyperkeratosis, paraker atosis, and acanthosis which parallel the observed clinical improvement in the psoriasis lesions.
Abstract: Since the reporting of clinical improvement observed in the treatment of psoriasis with aminopterin, 1 our interest has been aroused to reevaluate the results obtained with this drug as well as with its close relative amethopterin. These drugs were used in our private practice in relatively low but therapeutic dosage. These folic acid antagonists are known 2 to inhibit proliferation of connective tissue, anomalous and undifferentiated cells, and epithelial cells. By successfully competing with their analogue, folic acid, they interfere with the conversion of folic acid to the citrovorum factor which is important in the biosynthesis of nucleic acid components necessary in the development of epithelial cells. It has been shown that histologic response 2 to aminopterin therapy of psoriatic lesions consists of reduced hyperkeratosis, parakeratosis, and acanthosis which parallel the observed clinical improvement in the psoriatic lesions. The very nature of the action of amin
132Â citations
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TL;DR: Postnecrotic cirrhosis of the liver developed in three nonalcoholic patients with psoriasis who were maintained on a long-term regimen of orally administered folic acid antagonists, suggesting a need for caution in the use of methotrexate in benign disease.
Abstract: Postnecrotic cirrhosis of the liver developed in three nonalcoholic patients with psoriasis who were maintained on a long-term (11 to 40 months) regimen of orally administered folic acid antagonists. Portal hypertension with esophageal varices developed in two. The signs of cirrhosis developed insidiously and were not accompanied by signs of acute gastrointestinal or hematologic toxic conditions. There is a need for caution in the use of methotrexate in benign disease. A prospective study should be carried out to determine the best method of monitoring the hepatotoxicity of this drug during long-term administration.
113Â citations