PMR: Spare The Steroids Please Save

Steroids remain both the cornerstone and the Achilles' heel of PMR management. We have aspirations of briskly tapering our patients once they have had their honeymoon phase with prednisone. But when Ms. Jones calls you with a reported second PMR symptom relapse at a 6 milligram daily dose of prednisone ten months into her diagnosis then the creeping in of therapeutic inertia becomes real. 

The advent of IL-6 inhibitor use in PMR has emerged as a tool to spare our patients from the dangers of long-term steroid exposure which includes both approved agent sarilumab (Kevzara) and  off-label use of tocilizumab. But have these therapies changed real‑world outcomes?

Abstract #0185 presented at #ACR26 evaluated a PMR cohort derived from claims data to shed some light on the questions of real world steroid sparing capabilities of available IL-6i agents. The authors also sought out to determine how these agents impact key steroid-associated adverse events including infections, osteoporosis and diabetes over a 2 year period. 

Among 1,088 IL‑6Ri users (442 sarilumab, 646 tocilizumab), 431 were matched 1:1 to glucocorticoid‑monotherapy patients. In year 1, IL‑6Ri patients had fewer median steroid days (146 vs 230) and a lower cumulative prednisone dose (906 vs 1,761 mg). In year 2 (357 vs 379 still observed), the gap widened in relative terms: 6 vs 66 days and 105 vs 360 mg. Crude rates of infection, fracture, osteoporosis, and new or worsened diabetes were similar or numerically higher with IL‑6Ri in year 1, then lower in year 2. Serious infections and all infections were significantly reduced in year 2. 

As a matched claims analysis, these results are hypothesis‑generating, and residual confounding can't be excluded.

With these data in mind, we need to think more seriously about what long-term steroid exposure means for our patients. Although IL-6i drugs don’t provide us and our patients with the rapid satisfaction that steroids have to offer, the potential fruits of steroid-sparing therapy may take time to bear. IL‑6i treatment should be considered at first PMR relapse or when steroid dependence remains.