Sixteen RCTs (n=7,931, range 33 to 835) were included in the review: three trials of alefacept (n=1,289); five of efalizumab (n=3,130); four of etanercept (n=2,017); and four of infliximab (n=1,495). The included studies were considered to be of high quality.
For PASI 75, all four interventions yielded significant differences over 10 to 14 weeks of treatment compared with placebo: infliximab (RR 17.40, 95% CI 6.41 to 47.19; NNT=2); etanercept (RR 11.73, 95% CI 8.04 to 17.11; NNT=3); efalizumab (RR 7.33, 95% CI 5.28 to 10.17; NNT=4); and alefacept (RR 3.70, 95% CI 2.38 to 5.75; NNT=8).
The risk of one or more adverse events for each intervention compared with placebo was significantly increased for: alefacept (RR 1.09, 95% CI: 1.01, 1.18; NNH=15); efalizumab (RR 1.15, 95% CI 1.09 to 1.20; NNH=9); and infliximab (RR 1.18, 95% CI 1.07 to 1.29; NNH=9). Serious adverse events were significantly increased for efalizumab (RR 1.92, 95% CI 1.05 to 3.51; NNH=60) compared with placebo.
Using PASI 90, significant differences compared to placebo were achieved for both etanercept (RR 21.44, 95% CI 9.52 to 48.26; NNT=5) and infliximab (RR 49.42, 95% CI 16.01 to 152.54; NNT=2).
Non-significant differences for alefacept and efalizumab were achieved using PASI 50.