Comparison of 11 Biologic Agents for Psoriasis

Vials of biologics therapy
Vials of biologics therapy
A valuable comparison of 11 biologic agents used to treat psoriasis and the commonly prescribed conventional systemic agent methotrexate is provided.

The efficacy and safety data of 11 biologic agents for psoriasis treatment were outlined in a meta-analysis published in the British Journal of Dermatology.  

This study was conducted to update a 2017 meta-analysis on the comparative efficacy and tolerability of all biologic agent treatment options for psoriasis. Investigators conducted a systematic search of the MEDLINE, PubMed, Embase and Cochrane databases from inception through September 7, 2018 for randomized controlled trials describing the efficacy and tolerability of 11 licensed biologic agents. Therapies of interest included tumor necrosis factor inhibitors (adalimumab, etanercept, infliximab, certolizumab pegol), interleukin (IL)-12/IL-23p40 inhibitors (ustekinumab), IL-17A inhibitors (secukinumab, ixekizumab), IL-17RA inhibitors (brodalumab), and IL-23p19 inhibitors (guselkumab, tildrakizumab, risankizumab). The primary efficacy outcome was clear or near-clear skin after 10 to 16 weeks of treatment. The primary tolerability outcome was treatment withdrawal due to adverse events. Network meta-analysis was used to compare biologic agents with one another and with methotrexate or placebo. Hierarchical cluster analyses were used to compare efficacy and tolerability of drugs.

Data from 62 randomized controlled trials were included. The pooled cohort comprised 31,899 patients. Patient characteristics were generally similar across studies. The majority of all patients (68.7%) were men, and mean age was 44.7 years. All studies included patients with moderate to severe psoriasis. The risk for bias for most studies was low. Relative to placebo and methotrexate, all biologic agents had increased odds of efficacy at 10 to 16 weeks. Specifically, biologic agents were associated with increased likelihood of achieving ≥90% improvement on Psoriasis Area and Severity Index or Physician’s Global Assessment score of 0 or 1. Compared with placebo, the highest odds of withdrawal were observed with infliximab and ixekizumab. However, drug withdrawal rates were low across all trials.

Hierarchical cluster analyses revealed 3 clusters of treatment when considering efficacy and tolerability. Adalimumab, certolizumab pegol, ustekinumab, secukinumab, brodalumab, guselkumab, risankizumab, and tildrakizumab had high efficacy and tolerability. The second cluster—infliximab and ixekizumab—was defined by high efficacy but lower tolerability than other biologic agents. Methotrexate, placebo, and etanercept comprised the third cluster: agents with moderate tolerability and poor efficacy.

In this network meta-analysis, biologic agents tended to cluster together with respect to efficacy and tolerability, suggesting comparable utility as psoriasis treatment. However, results should be extrapolated with care, the study authors wrote; the low rate of drug withdrawals across the meta-analysis network prevented in-depth review of tolerability. “Drug-specific factors should be considered to achieve the optimal treatment choice for each individual” patient, investigators wrote.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry.

Please see the original reference for a full list of authors’ disclosures.


Mahil SK, Ezejimofor MC, Exton LS, et al. Comparing the efficacy and tolerability of biologic therapies in psoriasis: an updated network meta-analysis [published online June 20, 2020]. Br J Dermatol. doi: 10.1111/bjd.19325