Rapid Action or Sustained Effect? Methotrexate vs Ciclosporin for Pediatric AD

MONTREAL — Children and young people with severe atopic dermatitis had a more rapid treatment response with ciclosporin, but more sustained disease control with methotrexate in the TREAT study, investigators reported at the annual meeting of the International Society of Atopic Dermatitis (ISAD).

The findings are important, since many regulatory bodies require patients to have tried such first-line conventional systemic therapies before moving on to novel therapeutics, explained lead investigator Carsten Flohr, MD, PhD, research and development lead at St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust London, United Kingdom.

"We don't really have much pediatric trial data; very often the pediatric data that we have is buried in adult trials and when it comes to an adequately powered randomized controlled trial with conventional systemic medication in pediatric patients, we don't have one — so we're lacking that gold standard," said Flohr, who is also chair in dermatology and population health sciences at King's College London.

In the TREAT trial, 103 patients with AD (mean age, 10 years) who had not responded to topical treatment, were randomly assigned to either oral ciclosporin (4 mg/kg daily) or methotrexate (0.4 mg/kg weekly) for 36 weeks and then followed for another 24 weeks off therapy for the co-primary outcomes of change in objective Scoring Atopic Dermatitis (o-SCORAD) at 12 weeks, as well as time to first significant flare after treatment cessation, defined as returning to baseline o-SCORAD, or restarting a systemic treatment.

Secondary outcomes included disease severity and quality of life (QOL) measures, as well as safety. At baseline, the mean o-SCORAD was 46.81, with mean Eczema Area and Severity Index (EASI) and Patient Oriented Eczema Measure (POEM) scores of 28.05 and 20.62 respectively. The mean Children's Dermatology Life Quality Index (CDLQI) score was 14.96.

Looking at change in eczema severity measured by o-SCORAD at 12 weeks, ciclosporin was superior to methotrexate, with a mean difference in o-SCORAD change of -5.69 (P =.01). For the co-primary endpoint of time to first significant flare during the 24 weeks after treatment cessation, "there was a trend toward more flare activity in the ciclosporin group, although with a hazard ratio of 1.55, this was statistically not significant," Flohr said.

On a graph showing mean EASI scores from baseline through the 60-week study period, Flohr explained how the score first dropped more precipitously in patients treated with ciclosporin compared with those treated with methotrexate, reaching a statistically significant difference between the groups by 12 weeks (-3.13, P = .0145).

However, after that time, while the EASI score among those on methotrexate continued to drop, the ciclosporin score evened out, so that by 20 weeks, methotrexate EASI scores were better, and remained so until the end of treatment and further, out to 60 weeks (mean difference -6.36, P < .001). "The most interesting bit of this graph is [that] the curve is pointing downwards for methotrexate up to the 9-month point, suggesting these people had not reached their full therapeutic potential yet, whereas if you're on ciclosporin you plateau and there's not much additional improvement, if at all, and then people [on ciclosporin] start going up in their disease activity off therapy," he said.

The same pattern was seen with all the other outcome measures, including o-SCORAD and POEM.

Quality of life significantly improved by about 8 points in both treatment groups, with no significant differences between groups, and this improvement was sustained through the 24 weeks following cessation of therapy. However, during this treatment-free phase, patients on methotrexate had fewer parent-reported flares compared with those on ciclosporin (mean 6.19 vs 5.40 flares, P =.0251), although there was no difference between groups in time to first flare.

Describing the treatment safety as "overall reassuring," Flohr said there were slightly more nonserious adverse events in the methotrexate arm (407 vs 369), with nausea occurring more often in this group (43.1% vs 17.6%).

"I think we were seeing this clinically, but to see it in a clinical trial gives us more confidence in discussing with parents," said session moderator Melinda Gooderham, MD, assistant professor at Queens University, Kingston, Canada, and medical director at the SKiN Centre for Dermatology in Peterborough.

What she also took away from the study was safety of these treatments. "The discontinuation rate was not different with either drug, so it's not like ciclosporin works fast but all these people have problems and discontinue," Gooderham told Medscape "That's also reassuring."

Asked which treatment she prefers, Gooderham, who is also a consultant physician at Peterborough Regional Health Centre, picked methotrexate "because of the lasting effect. But there are times when you may need more rapid control…where I might choose ciclosporin first, but for me it's maybe 90% methotrexate first, 10% ciclosporin."

Flohr and Gooderham report no relevant financial relationships. The study was funded by the National Institute for Health and Care Research.

International Society of Atopic Dermatitis (ISAD) 2022: Abstract OL.27. Presented October 19, 2022.

Kate Johnson is a Montreal-based freelance medical journalist who has been writing for more than 30 years about all areas of medicine.

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