Panelists at ACR Convergence 2023 Debate the Merits of IL-6 Inhibitors vs. Glucocorticoids for the Initial Treatment of GCA & PMR
SAN DIEGO—At a scientific session of ACR Convergence on Monday, Nov. 13, two panelists discussed treatment approaches for giant cell arteritis (GCA) and polymyalgia rheumatica (PMR), debating the use of anti-IL-6 therapies at disease onset.
PMR and GCA are closely linked, overlapping syndromes occurring almost exclusively in people aged 50 or older. Both are highly responsive to glucocorticoids, which have been the treatment approach for many years.
Robert Spiera, MD, a rheumatologist and director of the Scleroderma, Vasculitis and Myositis Center at the Hospital for Special Surgery, New York City, pointed out that research in the past decade has convincingly demonstrated the effectiveness of anti-interleukin (IL) 6 therapies for both conditions via well-designed clinical trials. He also underscored that the rheumatology community agrees on the major need for glucocorticoid-sparing therapies in both disorders to reduce side effects and toxicities.
“What remains unclear, however, is whether anti-IL-6 therapies should be first-line in all patients and whether they should be first-line in specific populations,” Dr. Spiera said.
Differences in current treatment guidelines reflect this current equipoise in understanding. Whereas the recent ACR guideline conditionally recommends using oral glucocorticoids with the IL-6 inhibitor tocilizumab over oral glucocorticoids alone in newly diagnosed patients with GCA, EULAR guidelines recommend tocilizumab only for a subset of patients (e.g., those with refractory disease or those at high risk of complications from glucocorticoids). Note: The current ACR guideline on PMR was completed before the most recent clinical trials of these agents.1,2
Dr. Spiera debated whether anti-IL-6 treatments should be initiated at disease outset, coming down against the premise.
Philip Seo, MD, MHS, an associate professor in the Division of Rheumatology at Johns Hopkins University, Baltimore, and former physician editor of The Rheumatologist, presented arguments in favor of initiating treatment at disease outset.
Although, Dr. Spiera noted that each panelist could have argued for the other position.
Using IL-6 Inhibitors at Disease Onset: Con
Dr. Spiera explained that, unlike the biologics used in conditions like rheumatoid arthritis, evidence has not convincingly demonstrated that anti-IL-6 therapies are truly disease modifying in GCA. For example, scientists haven’t shown that anti-IL-6 therapies help prevent aneurysms or cranial ischemic complications.