Comparing Systemic Immunomodulatory Treatments for Atopic Dermatitis

The relative efficacies of systemic treatments for atopic dermatitis (AD) were outlined in results from a systematic review and meta-analysis published in JAMA Dermatology. Of the many therapies examined, abrocitinib 200 mg daily and upadacitinib 30 mg daily emerged as more effective in reducing AD symptoms compared with other regimens.

Investigators searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Latin American and Caribbean Health Science Information database, Global Resource of EczemA Trials database, and trial registries from inception through June 15, 2021 for randomized clinical trials assessing systemic immunomodulatory treatments for AD. Eligible trials enrolled patients with moderate-to-severe AD and had treatment periods at least 8 weeks in length. Outcomes of interest were changes in investigator-reported clinical scores, including the Eczema Area and Severity Index (EASI). Safety events were also captured. Bayesian network meta-analyses were conducted for each efficacy outcome. Risk of bias and evidence quality were assessed for each study and used to determine the certainty of each estimate.

The analyses included data from 60 studies with a pooled cohort of 16,579 patients. During up to 16 weeks of treatment in adults, abrocitinib 200 mg daily (mean difference [MD], 2.2; 95% credible interval [CrI], 0.2-4.0) and upadacitinib 30 mg daily (MD, 2.7; 95% CrI, 0.6-4.7) were associated with greater reductions in EASI than dupilumab with on-label dosing (600 mg then 300 mg every 2 weeks). By contrast, abrocitinib 100 mg daily (MD, −2.1; 95% CrI, −4.1 to −0.3), baricitinib 4 mg daily (MD, −3.2; 95% CrI, −5.7 to −0.8), baricitinib 2 mg daily (MD, −5.2; 95% CrI, −7.5 to −2.9), and tralokinumab 600 mg then 300 mg every 2 weeks (MD, −3.5; 95%CrI, −5.8 to −1.3) had smaller reductions in EASI compared with dupilumab. No substantial differences in EASI reductions were observed between upadacitinib 16 mg daily and dupilumab. Certainty of evidence was high for each comparison. Efficacy results were similar when using other metrics of disease severity, including the Patient Oriented Eczema Measure, Dermatology Life Quality Index, and Peak Pruritus Numeric Rating Scales. All estimates were of high certainty.

Safety events were diverse. Abrocitinib 100 mg daily was associated with more serious adverse events than dupilumab (odds ratio [OR], 2.6; 95% CrI, 1.1-6.4), although the evidence for this association was of low quality. Due to data heterogeneity, the difference in withdrawal severity across therapies could not be estimated.

In this network meta-analysis of AD treatments, abrocitinib 200 mg and upadacitinib 30 mg were associated with slightly better index scores than dupilumab.

Study limitations include between-study differences in methodology and outcome measures. Further, data were sparse regarding drugs other than dupilumab, abrocitinib, baricitinib, tralokinumab, and upadacitinib.

“Our results may aid shared decision-making between clinicians and patients seeking to understand the relative merits of different treatment options for moderate-to-severe atopic dermatitis,” investigators wrote.

Disclosure: Several study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 

Reference

Drucker AM, Morra DE, Prieto-Merino D, et al. Systemic immunomodulatory treatments for atopic dermatitis: update of a living systematic review and network meta-analysis. JAMA Dermatol. Published online March 16, 2022. doi: 10.1001/jamadermatol.2022.0455