Efficacy and safety of systemic treatments for moderate-to-severe atopic dermatitis: A聽systematic review

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• 作者：Evelien Roekevisch ; Phyllis Ira Spuls ; Denise Kuester ; Jacqueline Limpens ; Jochen Schmitt
• 关键词：Atopic dermatitis ; evidence-based medicine/systematic review ; immunosuppressive therapy ; immunomodulator ; systemic treatment ; recommendations ; GRADE
• 刊名：Journal of Allergy and Clinical Immunology
• 出版年：February, 2014
• 年：2014
• 卷：133
• 期：2
• 页码：429-438
• 全文大小：250 K

文摘

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Background

Many patients with moderate-to-severe atopic dermatitis (AD) require systemic immunomodulating treatment to achieve adequate disease control.

Objective

We sought to systematically evaluate the efficacy and safety of systemic treatments for moderate-to-severe AD.

Methods

A systematic literature search was performed in MEDLINE, EMBASE, and CENTRAL (until June 2012). Randomized controlled trials (RCTs) evaluating systemic immunomodulating treatments for moderate-to-severe AD were included. Selection, data extraction, quality assessment, and generation of treatment recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach were performed independently by 2 reviewers. Efficacy outcomes were clinical signs, symptoms, quality of life, and the course of AD. Safety data were compared by calculating the weekly incidence rates (as percentages) for adverse events.

Results

Thirty-four RCTs with 12 different systemic treatments and totaling 1653 patients were included. Fourteen trials consistently indicate that cyclosporin A聽efficaciously improves clinical signs of AD. Cyclosporin A聽is recommended as first-line treatment for short-term use. A聽second-line treatment option is azathioprine, but efficacy is lower, and evidence is weaker. Methotrexate can be considered a third-line treatment option. Recommendations are impossible for mycophenolate, montelukast, intravenous immunoglobulins, and systemic glucocorticosteroids because of limited evidence. A聽meta-analysis was not performed because of a lack of standardization in outcome measures.

Conclusion

Although 12 different interventions for moderate-to-severe AD have been studied in 34 RCTs, strong recommendations are only possible for the short-term use of cyclosporin A. Methodological limitations in the majority of trials prevent evidence-based conclusions. Large head-to-head trials evaluating long-term treatments are required.