Comparing the effectiveness and drug persistence of methotrexate, cyclosporine, and acitretin for psoriasis.

BACKGROUND

Conventional systemic agents remain the cornerstone treatment for psoriasis because of their availability and cost-effectiveness. However, few studies have compared the effectiveness and drug persistence of these agents in Asian populations.

OBJECTIVES

To evaluate the effectiveness and drug persistence of methotrexate, cyclosporine, and acitretin, and to identify factors associated with these outcomes.

METHODS

We reviewed data from 338 psoriasis patients treated with methotrexate, cyclosporine, or acitretin.

RESULTS

Out of 473 treatment courses, 239 (50.5%) involved methotrexate, 123 (26%) involved acitretin, and 111 (23.5%) involved cyclosporine. After 1 year, the proportion of patients who achieved absolute Psoriasis Area and Severity Index (PASI) ≤ 2 was greater with methotrexate (30.6%) and cyclosporine (22.2%) than with acitretin (9.5%). For absolute PASI ≤ 4, methotrexate (57%) and cyclosporine (47.2%) showed greater effectiveness than did acitretin (34.9%), with a significant difference only between methotrexate and acitretin (P = .017). The effectiveness findings were consistent in both the 1- and 3-year analyses. Multivariate analysis revealed that a high baseline PASI score significantly reduced the effectiveness of both methotrexate and cyclosporine. For methotrexate, a high body mass index was also associated with reduced effectiveness, whereas for acitretin, scalp involvement and male sex were key factors. Methotrexate demonstrated the longest drug survival at 1 year. Higher ages at psoriasis onset and systemic treatment-naive status were correlated with longer drug survival. Conversely, a higher body mass index and psychiatric comorbidities were linked to shorter survival.

LIMITATIONS: Methotrexate is typically the first-line systemic therapy in Thailand, which may underestimate the true efficacy of cyclosporine and acitretin when used subsequently.

CONCLUSION

Methotrexate was more effective and persistent than were cyclosporine and acitretin in a real-world setting.