Efficacy and safety of ciclosporin versus methotrexate in the treatment of severe atopic dermatitis in children and young people (TREAT): a multicentre parallel group assessor-blinded clinical trial
Carsten Flohr, Anna Rosala‐Hallas, Ashley P Jones, Paula Beattie, Susannah Baron, Fiona Browne, Sara Brown, J. E. Gach, Danielle Greenblatt, Ross Hearn, Eva Hilger, Ben Esdaile, Michael J. Cork, Emma Howard, Marie‐Louise Lovgren, Suzannah August, Farhiya Ashoor, Paula Williamson, Tess McPherson, Donal O’Kane, Jane Ravenscroft, Lindsay Shaw, Manish D. Sinha, Catherine Spowart, Leonie S. Taams, Bjorn Thomas, Mandy Wan, Tracey Sach, Alan D. Irvine, the TREAT Trial Investigators, Alison Layton, Tim Burton, Michael Grainge, Michael J. Arden-Jones, Saskia King, Michael R. Perkin, Alain Taı̈eb, Anthony D. Ormerod, R.J.G. Chalmers, Xinxue Liu, Amina Ahmed, Farhiya Ashoor, Carsten Flohr, Anna Rosala-Hallas, Amy Holton, Hannah D. Mason, Alan D. Irvine, Ashley P Jones, Tracey Sach, Catherine Spowart, Mandy Wan, Charlotte Walker, Suzannah August, Paula Beattie, Sara Brown, Mike Cork, Ben Esdaile, Carsten Flohr, J. E. Gach, Emma Howard, Alan D. Irvine, Tess McPherson, Donal O’Kane, Jane Ravenscroft, Lindsay Shaw, Caroline Allen, Susannah Baron, Danielle Greenblatt, Robert Hearn, Susannah Hoey, Rachael Jarret, Catherine Jury, Charlie Mitchell, Ruth Murphy, Graham S. Ogg, Alice Plant, Louise Newell, Jothsana Srinivasan, Emma Wedgeworth, Fiona Browne
Abstract
BACKGROUND: Conventional systemic drugs are used to treat children and young people (CYP) with severe atopic dermatitis (AD) worldwide, but no robust randomized controlled trial (RCT) evidence exists regarding their efficacy and safety in this population. While novel therapies have expanded therapeutic options, their high cost means traditional agents remain important, especially in lower-resource settings. OBJECTIVES: To compare the safety and efficacy of ciclosporin (CyA) with methotrexate (MTX) in CYP with severe AD in the TREatment of severe Atopic Eczema Trial (TREAT) trial. METHODS: We conducted a parallel group assessor-blinded RCT in 13 UK and Irish centres. Eligible participants aged 2-16 years and unresponsive to potent topical treatment were randomized to either oral CyA (4 mg kg-1 daily) or MTX (0.4 mg kg-1 weekly) for 36 weeks and followed-up for 24 weeks. Co-primary outcomes were change from baseline to 12 weeks in Objective Severity Scoring of Atopic Dermatitis (o-SCORAD) and time to first significant flare (relapse) after treatment cessation. Secondary outcomes included change in quality of life (QoL) from baseline to 60 weeks; number of participant-reported flares following treatment cessation; proportion of participants achieving ≥ 50% improvement in Eczema Area and Severity Index (EASI 50) and ≥ 75% improvement in EASI (EASI 75); and stratification of outcomes by filaggrin status. RESULTS: In total, 103 participants were randomized (May 2016-February 2019): 52 to CyA and 51 to MTX. CyA showed greater improvement in disease severity by 12 weeks [mean difference in o-SCORAD -5.69, 97.5% confidence interval (CI) -10.81 to -0.57 (P = 0.01)]. More participants achieved ≥ 50% improvement in o-SCORAD (o-SCORAD 50) at 12 weeks in the CyA arm vs. the MTX arm [odds ratio (OR) 2.60, 95% CI 1.23-5.49; P = 0.01]. By 60 weeks MTX was superior (OR 0.33, 95% CI 0.13-0.85; P = 0.02), a trend also seen for ≥ 75% improvement in o-SCORAD (o-SCORAD 75), EASI 50 and EASI 75. Participant-reported flares post-treatment were higher in the CyA arm (OR 3.22, 95% CI 0.42-6.01; P = 0.02). QoL improved with both treatments and was sustained after treatment cessation. Filaggrin status did not affect outcomes. The frequency of adverse events (AEs) was comparable between both treatments. Five (10%) participants on CyA and seven (14%) on MTX experienced a serious AE. CONCLUSIONS: Both CyA and MTX proved effective in CYP with severe AD over 36 weeks. Participants who received CyA showed a more rapid response to treatment, while MTX induced more sustained disease control after discontinuation.