Sarilumab for Relapse of Polymyalgia Rheumatica during Glucocorticoid Taper
In RCT (n=118), sarilumab, a monoclonal antibody that blocks interleukin-6 pathway, led to sustained remission at week 52 (17 of 60 [28%] vs 6 of 58 [10%]; p=0.02) and reduction in cumulative glucocorticoid dose (777 mg vs. 2044 mg; p<0.001) compared to placebo.
Source:
New England Journal of Medicine
SPS commentary:
According to an editorial, in addition to the results of previous trials both in similar and different populations, these findings represent a broadening of the strategic approach toward the management of polymyalgia rheumatica based on the treat-to-target principle, even beyond the definition of remission. It suggests that as evidence of the efficacy of interleukin-6 receptor blockade accumulates, it can be concluded that this approach is effective as second-line therapy after glucocorticoid failure, as well as first-line therapy in new-onset disease. It adds that a shortened period of glucocorticoid tapering is possible and interleukin-6 receptor blockade is beneficial in combination with a short-term glucocorticoid taper as compared with a full 52-week taper. However, it remains unclear which strategy is better: a step-down approach (i.e. initiation of sarilumab or tocilizumab with a rapid glucocorticoid taper and a subsequent additional taper of interleukin-6 receptor blocker) or a step-up approach (i.e. addition of interleukin-6 receptor blocker only after glucocorticoid therapy has been found to be insufficient).