But for both conditions, he added, “You should also be attentive to risks of glucocorticoid complications and have a low threshold to introduce IL-6 inhibitors for a flare or for glucocorticoid intolerance.”
Using IL-6 Inhibitors at Disease Onset: Pro
Dr. Seo responded from the other perspective. “Simply put, this is the structure of my argument,” he said. “Biologics work, and glucocorticoids are bad.”
Dr. Seo discussed some data which followed up on GIACTA trial participants after initial study completion. The results demonstrated that patients who were originally randomized to receive treatment with tocilizumab had a longer time to first relapse and had higher rates of treatment-free remission, indicating a potential prolonged benefit to tocilizumab treatment in GCA.5
Dr. Seo also acknowledged that many rheumatologists might be more skeptical about IL-6 inhibition as initial treatment in patients with PMR compared to GCA. He drew attention to the trial of the IL-6 inhibitor sarilumab in PMR, led by Dr. Spiera. He noted that in addition to demonstrating efficacy of the drug, it also demonstrated how frequently glucocorticoids fail at keeping patients in sustained remission.6 “Every time a patient flares, they go back on higher doses of glucocorticoids for a prolonged period, leading to other glucocorticoid side effects,” Dr. Seo said.
Citing some additional studies, Dr. Seo argued that the current data indicate that IL-6 inhibition is an overall effective approach for PMR, with an increase in glucocorticoid-free remission periods in patients treated with IL-6 at disease onset.7,8
Dr. Seo acknowledged that clinicians may be reluctant to initially employ IL-6 inhibitors in older patients due to concerns about infection or the very rare but potentially devastating possibility of colonic perforation. Dr. Seo shared that the rate of serious infections with IL-6 blockade is between four to six per 100 patient-years.9 But he noted that that rate is similar to that of adalimumab, which clinicians are usually comfortable prescribing in rheumatoid arthritis.
Clinicians may also be hesitant about starting with IL-6 inhibition because they don’t think of PMR as requiring high prednisone doses. However, Dr. Seo shared data indicating that patients are often treated with at least 15 milligrams of prednisone daily, with many patients treated at 25 mg or higher.10 And he noted that even though PMR patients should ideally be tapered off steroids within a year, a meta-analysis found that about half of patients remain on at least some glucocorticoids two years after initiating therapy.11
