Original article
The role of adjuvant therapy in pemphigus: A systematic review and meta-analysis

https://doi.org/10.1016/j.jaad.2015.04.038Get rights and content

Background

The assumption that adjuvant modalities have added value to oral glucocorticoids in the treatment of pemphigus is intuitively sound but has not been conclusively proven.

Objective

We sought to compare the efficacy and safety of oral glucocorticoid treatment with or without adjuvants for pemphigus vulgaris and pemphigus foliaceus.

Methods

We performed a systematic review and meta-analysis of randomized controlled trials. The primary outcome was remission. Secondary outcomes were disease control, time to disease control, relapse, time to relapse, cumulative glucocorticoid dose, withdrawal because of adverse events, and all-cause death. Trials were pooled irrespective of adjuvant type evaluated.

Results

Ten trials (559 participants) were included. Adjuvants evaluated were azathioprine, mycophenolate mofetil, cyclophosphamide, cyclosporine, intravenous immunoglobulin, plasma exchange, and infliximab; not all were included in every analysis. Although adjuvants were not beneficial for achieving remission, they were found to collectively decrease the risk of relapse by 29% (relative risk 0.71, 95% confidence interval 0.53-0.95).

Limitations

Different adjuvants were pooled together.

Conclusion

Adjuvants have a role in pemphigus treatment, at least in reducing the risk of relapse. Further randomized controlled trials of other promising modalities are warranted.

Section snippets

Methods

The systematic review and meta-analysis were conducted and reported in accordance with the PRISMA statement.8 The review protocol was registered on PROSPERO and can be accessed at: www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014014160.

Only studies that met the following criteria were included in the analysis:

  • RCTs of combined GC plus adjuvant treatment for PV, PF, or both compared with oral GCs alone or with a placebo.

  • Inclusion of patients of any age with PV or PF diagnosed according

Results

The literature search yielded 261 titles and abstracts (Fig 1). Eleven trials fulfilled the eligibility criteria, including 10 original publications11, 12, 13, 14, 15, 16, 17, 18, 19, 20 and 1 follow-up report of an already included trial combined with the initial trial data.11, 21 Characteristics of included trials are detailed in Table I. They included a total of 559 patients, 516 with PV and 43 with PF. All study patients were adults; 54% to 72% were female. Six trials included patients with

Discussion

The aim of this review was to determine whether the common practice of adding adjuvant therapy to oral GCs is justified. Our results showed that adjuvant therapy did not increase the number of patients who achieved remission. However, it had significant added value for other important outcomes. The addition of adjuvant therapy was associated with a decrease in relapses, such that 12 patients needed to be treated with adjuvant therapy to prevent 1 relapse with oral GCs alone. Specifically MMF,

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  • Cited by (0)

    Funding sources: None.

    Conflicts of interest: None declared.

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