QD93 - Which IL - 1 Inhibitor Save
QD Clinic - Lessons from the clinic
Considerations for which IL-1 inhibitor to use with RA, Stills or autoinflammatory disease
Features Dr. Jack Cush
Transcription
This is QD clinic. Hi. I'm doctor Jack Cush with RheumNow. Today's QD clinic is brought to you by RheumNow's virtual ACR twenty twenty coverage. You give us two hours, we'll give you the ACR.
Today's case is a discussion of which IL one inhibitor should I use. I treat a lot of patients with auto inflammatory disease. I'm a self declared king expert of Still's disease. That's because no one will fight me for the title. And, and I use a lot of IL-one inhibitors.
You know, there's three on the market. There's rilanacept, which is given every eight weeks. There's canakinumab, which is given generally every four weeks. And then there's anakinra, which is given, every day. So when I'm treating someone either with Still's disease or FMF or Schnitzler syndrome or, you know, hyper IgD syndrome that you know, these are all IL-one responsive disorders.
The question is, which one do I use? Heretofore, I almost always use Anakinra first. One, because it's cheaper than the other ones. They're all really expensive these days because these drugs are indicated for very rare disorder, so that jacks up the price quite a bit. But I tend to use anakinra because it's very short acting and has a half life of six hours.
Works pretty quick, and it also is dissolved pretty quick, meaning when you stop it, its effect goes away and people will flare within one to three days on anakinra. The other ones are antibodies, monoclonal antibodies, which have a much longer half life. So, again, previously, I would use anakinra as my starting drug. And once the patient had gotten used to daily injections of anakinra and had done well, then I would switch them over to canakinumab, usually either when they complained of daily injections or, I was concerned about compliance or the insurance companies were giving me a hard time. The equation changes more recently with the FDA approval of canakinumab for, adult Still's disease.
It's actually the only drug that's approved for adult Still's disease. Now, there are, again, the other, IL-one inhibitors. Anakinra is approved, as you know, in, for use in RA and also for CAPS, the cryopyrin associated periodic syndromes. And then, canakinumab is also approved for systemic JIA. The CAPS, FMF, hyper IgD syndrome, and TRAPS.
And rilanosept is only approved for just CAP disorders. So when treating RA, you have an FDA approval for anakinra. When treating Still's disease in the kids, you really or adults, you really only have an FDA approval for, canakinumab or Ilaris. Again, the differences here are, the the half life. Six hours for anakinra, twenty six days for anakinra.
And so the dosing regimens are either daily for anakinra or every four weeks for anakinra. The doses are a hundred or two hundred milligrams given daily at night with anakinra. I use it at night because most of the fever occurs at night, and it's a very short half life drug. Some people will require two hundred, and that's higher than the prescribed dose. But when you're treating hot, red, inflammatory, systemic, autoinflammatory disease, you might need higher than normal doses that you would use in RA or other disorders.
When you're using canakinumab, the dose is either a hundred and fifty or three hundred milligrams given every four weeks. Now these are sub q administered drugs. The, you know, the they do have the problem of, of, ISRs, injection site reactions that usually go away after a month or so, and they're never serious adverse events where or hospitalizable, or the lesions are usually just red, elevated urticarial, but not itchy lesions and not mild discomfort that, again, will go away with repeated injections. So, which one do I use now? That's really the big question.
I think it depends on what the need for rapid control or chronic control is. I think the onset of anakinra is an advantage, but its disadvantages is a daily injection. And you have to rotate sites, and patients don't usually like to inject their abdomen that much, and they run out of sites on their legs, and God forbid, they're using their upper arms or buttocks. But if I'm looking for chronic control, maybe I can acutely control the condition with steroids. Often, if I'm using an IL one inhibitor, I'm usually using a background of methotrexate or another DMart.
And then you could use canakinumab as your first drug as well. If you're fighting the fight with insurance for FDA, you know, that this is not an approved drug, well, then your only option for Still's disease is going to be, canakinumab because it's not approved for, Still's in kids or in adults with anakinra. So that's my 2ยข on, IL-one inhibitors. Again, tune into RheumNow for expanded coverage of the ACR twenty twenty meeting. If you only had two hours or four hours to cut to review the ACR, and you can do it asynchronously, you can do it at night or during the meeting or in the morning before the meeting, It's all gonna be online.
How would you do this? I mean, you can go to the ACR website. It's gonna be good. Or you can go to our website, rheumnow.com, and see perspectives by key opinion leaders, see a lot of videos, a number of podcasts, panel discussions, takeaway message messages, all on video or audio, and then there's gonna be written content by our faculty of over 24 people covering the meeting. So tune in the room now starting November 1 all the way through the thirteenth.
We'll talk to you tomorrow on QD clinic.
Today's case is a discussion of which IL one inhibitor should I use. I treat a lot of patients with auto inflammatory disease. I'm a self declared king expert of Still's disease. That's because no one will fight me for the title. And, and I use a lot of IL-one inhibitors.
You know, there's three on the market. There's rilanacept, which is given every eight weeks. There's canakinumab, which is given generally every four weeks. And then there's anakinra, which is given, every day. So when I'm treating someone either with Still's disease or FMF or Schnitzler syndrome or, you know, hyper IgD syndrome that you know, these are all IL-one responsive disorders.
The question is, which one do I use? Heretofore, I almost always use Anakinra first. One, because it's cheaper than the other ones. They're all really expensive these days because these drugs are indicated for very rare disorder, so that jacks up the price quite a bit. But I tend to use anakinra because it's very short acting and has a half life of six hours.
Works pretty quick, and it also is dissolved pretty quick, meaning when you stop it, its effect goes away and people will flare within one to three days on anakinra. The other ones are antibodies, monoclonal antibodies, which have a much longer half life. So, again, previously, I would use anakinra as my starting drug. And once the patient had gotten used to daily injections of anakinra and had done well, then I would switch them over to canakinumab, usually either when they complained of daily injections or, I was concerned about compliance or the insurance companies were giving me a hard time. The equation changes more recently with the FDA approval of canakinumab for, adult Still's disease.
It's actually the only drug that's approved for adult Still's disease. Now, there are, again, the other, IL-one inhibitors. Anakinra is approved, as you know, in, for use in RA and also for CAPS, the cryopyrin associated periodic syndromes. And then, canakinumab is also approved for systemic JIA. The CAPS, FMF, hyper IgD syndrome, and TRAPS.
And rilanosept is only approved for just CAP disorders. So when treating RA, you have an FDA approval for anakinra. When treating Still's disease in the kids, you really or adults, you really only have an FDA approval for, canakinumab or Ilaris. Again, the differences here are, the the half life. Six hours for anakinra, twenty six days for anakinra.
And so the dosing regimens are either daily for anakinra or every four weeks for anakinra. The doses are a hundred or two hundred milligrams given daily at night with anakinra. I use it at night because most of the fever occurs at night, and it's a very short half life drug. Some people will require two hundred, and that's higher than the prescribed dose. But when you're treating hot, red, inflammatory, systemic, autoinflammatory disease, you might need higher than normal doses that you would use in RA or other disorders.
When you're using canakinumab, the dose is either a hundred and fifty or three hundred milligrams given every four weeks. Now these are sub q administered drugs. The, you know, the they do have the problem of, of, ISRs, injection site reactions that usually go away after a month or so, and they're never serious adverse events where or hospitalizable, or the lesions are usually just red, elevated urticarial, but not itchy lesions and not mild discomfort that, again, will go away with repeated injections. So, which one do I use now? That's really the big question.
I think it depends on what the need for rapid control or chronic control is. I think the onset of anakinra is an advantage, but its disadvantages is a daily injection. And you have to rotate sites, and patients don't usually like to inject their abdomen that much, and they run out of sites on their legs, and God forbid, they're using their upper arms or buttocks. But if I'm looking for chronic control, maybe I can acutely control the condition with steroids. Often, if I'm using an IL one inhibitor, I'm usually using a background of methotrexate or another DMart.
And then you could use canakinumab as your first drug as well. If you're fighting the fight with insurance for FDA, you know, that this is not an approved drug, well, then your only option for Still's disease is going to be, canakinumab because it's not approved for, Still's in kids or in adults with anakinra. So that's my 2ยข on, IL-one inhibitors. Again, tune into RheumNow for expanded coverage of the ACR twenty twenty meeting. If you only had two hours or four hours to cut to review the ACR, and you can do it asynchronously, you can do it at night or during the meeting or in the morning before the meeting, It's all gonna be online.
How would you do this? I mean, you can go to the ACR website. It's gonna be good. Or you can go to our website, rheumnow.com, and see perspectives by key opinion leaders, see a lot of videos, a number of podcasts, panel discussions, takeaway message messages, all on video or audio, and then there's gonna be written content by our faculty of over 24 people covering the meeting. So tune in the room now starting November 1 all the way through the thirteenth.
We'll talk to you tomorrow on QD clinic.
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