Age alone should not be a limiting factor in psoriasis management, according to the findings of a new study.
The findings emphasized the need to have more studies on the effectiveness and safety of systemic therapies in older adults to optimize personalized, effective, and safe management of psoriasis.
Marieke E. C. van Winden, MD, MSc, and colleagues evaluated the effectiveness and safety of systemic antipsoriatic therapies in patients at least 65 years old. They conducted a systematic review using Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials. The team searched for all synonyms of psoriasis and older adults.
The investigators included randomized clinical trials, cohort studies, large case series, and meta-analyses that assessed the efficacy, effectiveness, and/or safety in patients at least 65 years old with psoriasis.
The primary study outcome was efficacy or effectiveness. To measure this, the team evaluated the percentage of older adults who achieved a reduction of 75% in the Psoriasis Area and Severity Index (PASI75) at weeks 12-16. Additional outcomes included PASI50, PASI90, and PASI100 at weeks 12-16 and long-term effectiveness and treatment-related safety and tolerability.
The team evaluated 31 studies with a total of 39,561 patients. Of the studies analyzed, 17 reported on effectiveness and safety of systemic antipsoriatic therapies, and 14 were considered relevant by reviewers despite not describing patients at least 65 years old.
There were 3 articles that assessed the effectiveness of methotrexate and 4 studies assessed the safety and tolerability of the therapy in patients at least 65 years old. Nearly half of the patients achieved PASI75 at week 12. In 2 studies, investigators concluded the mean effective dose of methotrexate was significantly lower for patients older than 70 years old compared to younger patients.
For studies assessing cyclosporine, it was found that at week 12, 46-52.6% of the included patients reached PASI75. There was no data on the long-term effectiveness of the therapy. Use of cyclosporine in patients at least 65 years old was associated with a significantly higher overall rate of adverse events (1.4 per patient-year) compared with methotrexate (.12 per patient-year; P <.001).
Among studies evaluating acitretin, 27-47.8% of patients included achieved PASI75. There was no significant association between age and treatment failure or response rate. Effectiveness was significantly lower compared with methotrexate (49%; P=.01), etanercept (65%; P <.001), adalimumab (65%; P <.01), and infliximab (93%; P <.05). Investigators reported no correlation between the incidence of adverse effects and age (P=.62).
Overall, among the systemic therapies evaluated, a reduction of 75% in PASI was achieved in 49-74% methotrexate sodium users at least 65 years old, 46-52.6% of 178 older cyclosporin users, 27-47.8% of 108 older acitretin users, 15.6-64% of 256 etanercept users at least 65 years old, 66.7-93% of 43 infliximab older users, 60.7-65% of 100 adalimumab users at least 65 years old, 56.5% of 46 older ustekinumab users, and 86.4% of 67 secukinumab users at least 65 years.
For acitretin, etanercept, adalimumab, and secukinumab, the effectiveness was not associated with age, while studies of other systemic antipsoriatic therapies did not have age group comparisons.
The investigators found older age was significantly associated with renal function deterioration in those who used cyclosporin and with lymphopenia in those who used fumaric acid esters (HR, 2.42; 95% CI, 1.65-3.55; P <.001). Among those using biologics, infections were the most frequently reported adverse events in patients at least 65 years old, but there was no significant association with age.
“The results of this systematic review on psoriasis management in older adults indicate that age should not be a limiting factor in its own right,” study authors wrote.
More data are needed on the efficacy, effectiveness, and safety of systemic therapies in those at least 65 years old.
The study, “Effectiveness and Safety of Systemic Therapy for Psoriasis in Older Adults,” was published online in JAMA Dermatology.