1st Line Biologics vs csDMARDs in Adult Still's Disease

Jack Cush, MD

Apr 01, 2025 9:00 am

A German multicentre, retrospective study assessed the first-line efficacy of biologics and conventional synthetic DMARD therapy in patients with adult-onset Still's disease (AOSD) and found biologic agents were significantly better with sustained, event-free remissions and fewer complications.

Adults meeting Yamaguchi classification criteria for AOSD with an incident diagnosis or a flare without any maintenance treatment (including glucocorticoids) were enrolled, treated and assessed at at weeks 12 and 72. The primary endpoint was sustained, event-free remission; defined as C-reactive protein <10 mg/L and no arthritis, rash, or fever; without complications. Analysis was by propensity score weighted logistic regression, thereby balancing for the initial Pouchot score, ferritin concentration, and age and sex differences between groups.

Drug therapy included biologic DMARDS (anakinra, canakinumab, and tocilizumab) and csDMARDs (methotrexate or glucocorticoids).

A total of 228 patients were screened (2007-2022 and 142 patients were excluded. The analysis included 86 AOSD patients (58% female; 98% were White; mean age at inclusion was 39 years). Choice of therapy was at the discretion of the treating physician. Half (49%) received a first-line conventional synthetic DMARD and half (51%) received a first-line biological DMARD; 89% received IL-1 inhibitors (predominantly anakinra) and 11% were treated with tocilizumab.

Biological DMARD therapy had a greater likelihood of of sustained, event-free remission (OR 7.20, 95% CI 2·50–36·64; p=0·0007).

At week 72, the primary endpoint (rate of sustained, event-free remission was:

50% biological DMARD group
12% csDMARD group

Glucocorticoid-related complications tended to be more common with csDMARDs (hypertension, steroid skin disease) and there were three (7%) deaths in the csDMARD group (two from macrophage activation syndrome, one unknown) versus none in the biologi DMARD group.

These findings support the first-line use of IL-1 or IL-6 inhibitors in Still's disease (as recommended by the ACR and EULAR–PReS guidelines for treatment of Still's disease), leading to better outcomes and potentially a lower risk of MAS and other complications (often related to over-use of corticosteroids).