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The doses of targeted immune modulator in the three arms were: 50 mg etanercept twice weekly, ustekinumab 45 mg at week 0 and week 4, or ustekinumab 90 mg at week 0 and week 4. The trial lasted 12 weeks and patients and study personnel administering the drugs were not blinded to treatment allocation. All other study personnel including assessors and data managers were blinded to treatment allocation. The results of this one trial indicated that ustekinumab is superior to etanercept for treating plaque psoriasis. Significantly more patients in both ustekinumab groups achieved the primary outcome of a Psoriasis Area and Severity Index 75 response compared with etanercept (etanercept 50 mg, 56. Similarly, statistically significantly more patients in both ustekinumab groups demonstrated cleared or minimal disease with the Physician’s Global Assessment (etanercept 50 mg, 49%; ustekinumab 45 mg, 65. Detailed assessment: Indirect evidence on the comparative effectiveness We did not find any indirect evidence on the comparative effectiveness of the targeted immune modulators for plaque psoriasis. Detailed assessment: Evidence on the general efficacy Because of the small number of head-to-head trials, we reviewed placebo-controlled trials. We summarized evidence on the general efficacy of targeted immune modulators in the treatment of plaque psoriasis; however, this did not provide evidence on the comparative efficacy and tolerability of targeted immune modulators. Adalimumab 236,237 235,238,239 Two good and three fair studies provided evidence on the general efficacy of adalimumab for the treatment of moderate to severe plaque psoriasis in adult patients. All five trials had a primary endpoint of PASI 75 or hfPGA between week 12 and 16 and included one arm where patients received an initial dose of 80 mg adalimumab subcutaneously followed by 40 mg adalimumab every other week. Furthermore, one trial included methotrexate as a comparison 236 arm and one trial also included a dose of adalimumab that is higher than the approved dose for 235 plaque psoriasis (80 mg initial dose followed by 40 mg weekly). One trial looked specifically 239 at patients with psoriasis of the hands and/or feet. All results consistently demonstrated that adalimumab is more efficacious than placebo for Psoriasis Area and Severity Index, Physician Global Assessment, Dermatology Life Quality Index and health-related quality of life outcomes. Between 53% and 81% of patients in the adalimumab every other week arms achieved a Psoriasis Area and Severity Index 75 response compared with 4% to 19% of placebo-treated patients.

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