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Iorio L, Padoan R, Bond M, Dejaco C. Investigational agents for polymyalgia rheumatica treatment: assessing the critical needs for future development. Expert Opin Investig Drugs 2024; 33:671-676. [PMID: 38879822 DOI: 10.1080/13543784.2024.2366847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/07/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION Polymyalgia rheumatica (PMR) is an inflammatory rheumatic disorder characterized by pain and stiffness in the shoulder and pelvic girdles, constitutional symptoms, and elevated acute-phase reactants. Glucocorticoids (GCs) remain the first-choice treatment for PMR, but relapses are common. Identification of steroid-sparing agents is therefore of utmost importance. AREAS COVERED The efficacy of conventional immunosuppressive drugs is controversial. The use of interleukin (IL)-6 receptor inhibitors proved to be effective and safe in treating PMR patients. Currently, there are 12 ongoing clinical trials exploring potential treatments such as leflunomide, low-dose IL-2, rituximab, abatacept, secukinumab, Janus kinase inhibitors, and selective inhibitors like SPI-62 and ABBV 154. EXPERT OPINION The high efficacy of IL-6 R receptor inhibitors as well as the numerous drug trials currently recruiting suggest that several therapeutic options will be available in the near future. Accurate diagnosis and early stratification of PMR patients according to the giant cell arteritis-PMR Spectrum Disease 'GPSD' and potential risk factors for relapsing disease or GC-related adverse events are crucial to identify patients who would benefit most from GC-sparing agents. The development of internationally accepted definitions for remission and relapse is urgently needed. Early referral strategies to specialist settings would improve disease stratification and personalized treatment.
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Affiliation(s)
- Luca Iorio
- Rheumatology Unit, Department of Medicine DIMED, University of Padua, Padua, Italy
| | - Roberto Padoan
- Rheumatology Unit, Department of Medicine DIMED, University of Padua, Padua, Italy
| | - Milena Bond
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsus Medical University, Brunico, Italy
| | - Christian Dejaco
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsus Medical University, Brunico, Italy
- Department of Rheumatology and Immunology, Medical University of Graz, Graz, Austria
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Kawka L, Chevet B, Arnaud L, Becker G, Carvajal Alegria G, Felten R. The pipeline of immunomodulatory therapies in polymyalgia rheumatica and giant cell arteritis: A systematic review of clinical trials. Autoimmun Rev 2024; 23:103590. [PMID: 39122202 DOI: 10.1016/j.autrev.2024.103590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 08/01/2024] [Accepted: 08/04/2024] [Indexed: 08/12/2024]
Abstract
INTRODUCTION The objective of this systematic review was to provide an overview of current developments and potentially available therapeutic options for polymyalgia rheumatic (PMR) and giant cell arteritis (GCA), in the coming years. METHODS We conducted a systematic review of 17 national and international clinical trial databases for all disease-modifying anti-rheumatic drugs (DMARDs) for PMR and GCA that are already marketed, in clinical development or withdrawn. The search was performed on January 2024, with the keywords "polymyalgia rheumatica" and "giant cell arteritis". For each molecule, we only considered the study at the most advanced stage of clinical development. RESULTS For PMR, a total of 15 DMARDs were identified: 2 conventional synthetic DMARDs (csDMARDs), 11 biologic DMARDs (bDMARDs) and 2 targeted synthetic DMARDs (tsDMARDs). For GCA, 18 DMARDs were identified: 2 csDMARDs, 14 bDMARDs and 2 tsDMARDs. Currently, there are only 2 approved corticosteroid-sparing therapies in these diseases, which both target the IL-6 signaling pathway, namely tocilizumab in GCA and sarilumab in PMR. Most of the molecules in current development are repurposed from from other conditions and clinical research in PMR/GCA seems to be mostly driven by the potential to repurpose existing treatments rather than by translational research. CONCLUSION This systematic review identified 23 DMARDs evaluated for PMR and GCA: 3 csDMARDs, 17 bDMARDs and 3 tsDMARDs. Several promising treatments are likely to be marketed in the coming years.
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Affiliation(s)
- Lou Kawka
- Service de Rhumatologie, Centre National de Référence des Maladies Auto-immunes et Systémiques Rares (RESO), Hôpitaux Universitaires de Strasbourg, F-67000 Strasbourg, France
| | - Baptiste Chevet
- UMR 1227 Lymphocytes B et auto-immunité, université de Brest, Inserm, CHU de Brest, Brest, France; Service de Rhumatologie, Hôpital de la Cavale Blanche, CHU de Brest, Bd Tanguy-Prigent, 29200 Brest, France
| | - Laurent Arnaud
- Service de Rhumatologie, Centre National de Référence des Maladies Auto-immunes et Systémiques Rares (RESO), Hôpitaux Universitaires de Strasbourg, F-67000 Strasbourg, France
| | - Guillaume Becker
- Pôle Pharmacie-Pharmacologie, Hôpitaux Universitaires de Strasbourg, F-67000 Strasbourg, France; Département Universitaire de Pharmacologie, Addictologie, Toxicologie et Thérapeutique (DUPATT), Université de Strasbourg, Strasbourg, France
| | | | - Renaud Felten
- Service de Rhumatologie, Centre National de Référence des Maladies Auto-immunes et Systémiques Rares (RESO), Hôpitaux Universitaires de Strasbourg, F-67000 Strasbourg, France; Département Universitaire de Pharmacologie, Addictologie, Toxicologie et Thérapeutique (DUPATT), Université de Strasbourg, Strasbourg, France; Center for Clinical Investigation, INSERM U1434, Strasbourg, France.
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Wendling D, Al Tabaa O, Chevet B, Fakih O, Ghossan R, Hecquet S, Dernis E, Maheu E, Saraux A, Besson FL, Alegria GC, Cortet B, Fautrel B, Felten R, Morel J, Ottaviani S, Querellou-Lefranc S, Ramon A, Ruyssen-Witrand A, Seror R, Tournadre A, Foulquier N, Verlhac B, Verhoeven F, Devauchelle-Pensec V. Recommendations of the French Society of Rheumatology for the management in current practice of patients with polymyalgia rheumatica. Joint Bone Spine 2024; 91:105730. [PMID: 38583691 DOI: 10.1016/j.jbspin.2024.105730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVE To develop recommendations for the routine management of patients with polymyalgia rheumatica (PMR). METHODS Following standard procedures, a systematic review of the literature by five supervised junior rheumatologists, based on the questions selected by the steering committee (5 senior rheumatologists), was used as the basis for working meetings, followed by a one-day plenary meeting with the working group (15 members), leading to the development of the wording and determination of the strength of the recommendations and the level of agreement of the experts. RESULTS Five general principles and 19 recommendations were drawn up. Three recommendations relate to diagnosis and the use of imaging, and five to the assessment of the disease, its activity and comorbidities. Non-pharmacological therapies are the subject of one recommendation. Three recommendations concern initial treatment based on general corticosteroid therapy, five concern the reduction of corticosteroid therapy and follow-up, and two concern corticosteroid dependence and steroid-sparing treatments (anti-IL-6). CONCLUSION These recommendations take account of current data on PMR, with the aim of reducing exposure to corticosteroid therapy and its side effects in a fragile population. They are intended to be practical, to help practitioners in the day-to-day management of patients with PMR.
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Affiliation(s)
- Daniel Wendling
- Rhumatologie, CHU de Besançon et Université de Franche-Comté, boulevard Fleming, 25030 Besançon, France.
| | - Omar Al Tabaa
- Rhumatologie, Hôpital Cochin, AP-HP, Paris, France; Rhumatologie, Hôpital NOVO, Pontoise, France
| | - Baptiste Chevet
- Department of Rheumatology, CHU Brest, Université de Bretagne Occidentale (University Brest), INSERM (U1227), LabEx IGO, 29200 Brest, France
| | - Olivier Fakih
- Rhumatologie, CHU de Besançon et Université de Franche-Comté, boulevard Fleming, 25030 Besançon, France
| | - Roba Ghossan
- Rhumatologie, Hôpital Cochin, AP-HP, Paris, France
| | | | | | - Emmanuel Maheu
- Service de rhumatologie, Hôpital St Antoine, AP-HP, et cabinet médical, Paris, France
| | - Alain Saraux
- Department of Rheumatology, CHU Brest, Université de Bretagne Occidentale (University Brest), INSERM (U1227), LabEx IGO, 29200 Brest, France
| | - Florent L Besson
- Service de médecine nucléaire-imagerie moléculaire, Hôpitaux universitaires Paris-Saclay AP-HP, CHU Bicêtre, DMU SMART IMAGING, Le Kremlin-Bicêtre, France
| | | | - Bernard Cortet
- Service de rhumatologie, CHU de Lille, 59037 Lille, France
| | - Bruno Fautrel
- Service de rhumatologie, GH Pitié Salpêtrière, AP-HP.Sorbonne Université, INSERM UMRS 1136-5, Réseau de recherche clinique CRI-IMIDIATE, 75013 Paris, France
| | - Renaud Felten
- Service de rhumatologie et centre d'investigation clinique 1434, Hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Jacques Morel
- Service de rhumatologie. CHU et Université de Montpellier, Montpellier, France
| | | | - Solène Querellou-Lefranc
- Nuclear Medicine department, University Hospital, Brest, France, University of Western Brittany (UBO), Brest, France, Inserm, University of Brest, CHRU Brest, UMR 1304, GETBO, Brest cedex, France
| | - André Ramon
- Service de rhumatologie, CHU Dijon Bourgogne, Dijon, France
| | - Adeline Ruyssen-Witrand
- Centre de rhumatologie, CHU de Toulouse, Centre d'Investigation Clinique de Toulouse CIC1436, Inserm, Team PEPSS « Pharmacologie En Population cohorteS et biobanqueS », Université Paul Sabatier Toulouse 3, Toulouse, France
| | - Raphaèle Seror
- Service de rhumatologie, CHU Kremlin-Bicetre, AP-HP, Paris, France
| | - Anne Tournadre
- Rhumatologie CHU Clermont-Ferrand, Université Clermont Auvergne INRAe, Clermont-Ferrand, France
| | - Nathan Foulquier
- LBAI, UMR1227, University of Brest, Inserm, CHU de Brest, Brest, France
| | | | - Frank Verhoeven
- Rhumatologie, CHU de Besançon et Université de Franche-Comté, boulevard Fleming, 25030 Besançon, France
| | - Valérie Devauchelle-Pensec
- Department of Rheumatology, CHU Brest, Université de Bretagne Occidentale (University Brest), INSERM (U1227), LabEx IGO, 29200 Brest, France.
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Liew DF, Owen CE. Designing studies in newly diagnosed versus established polymyalgia rheumatica. THE LANCET. RHEUMATOLOGY 2023; 5:e701-e703. [PMID: 38251558 DOI: 10.1016/s2665-9913(23)00294-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 10/18/2023] [Indexed: 01/23/2024]
Affiliation(s)
- David Fl Liew
- Department of Rheumatology, Austin Health, Melbourne, VIC 3081, Australia; Department of Clinical Pharmacology and Therapeutics, Austin Health, Melbourne, VIC 3081, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia.
| | - Claire E Owen
- Department of Rheumatology, Austin Health, Melbourne, VIC 3081, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
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Saraux A, Le Henaff C, Dernis E, Carvajal-Alegria G, Tison A, Quere B, Petit H, Felten R, Jousse-Joulin S, Guellec D, Marhadour T, Kervarrec P, Cornec D, Querellou S, Nowak E, Souki A, Devauchelle-Pensec V. Abatacept in early polymyalgia rheumatica (ALORS): a proof-of-concept, randomised, placebo-controlled, parallel-group trial. THE LANCET. RHEUMATOLOGY 2023; 5:e728-e735. [PMID: 38251563 DOI: 10.1016/s2665-9913(23)00246-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/15/2023] [Accepted: 09/18/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Medium-dose glucocorticoids can improve symptoms in nearly all patients with polymyalgia rheumatica. According to its good safety profile, abatacept could be used instead of glucocorticoids in early polymyalgia rheumatica. We aimed to determine whether the efficacy of abatacept is sufficient to justify larger studies in early polymyalgia rheumatica. METHODS To evaluate whether abatacept allows low disease activity without glucocorticoids in early polymyalgia rheumatica, we conducted a proof-of-concept, randomised, double-blind, placebo-controlled, parallel-group trial. Participants were recruited from five centres in France (in Brest, Le Mans, Morlaix, Dinan and Saint Malo, and Strasbourg) and were included if they had recent-onset (<6 months) polymyalgia rheumatica with a C-reactive protein (CRP) polymyalgia rheumatica activity score (PMR-AS) of more than 17 without any signs or symptoms of giant cell arteritis (clinical and [18F]fluorodeoxyglucose PET-CT evaluation). Participants were randomly assigned (1:1) to receive weekly subcutaneous abatacept (125 mg) or matching placebo, with glucocorticoid rescue therapy allowed in cases of high disease activity, for 12 weeks, and then glucocorticoid treatment based on disease activity, until week 36. Investigators, patients, outcome assessors, and sponsor personnel were masked to group assignments. The primary endpoint was low disease activity (CRP PMR-AS ≤10) at week 12 without glucocorticoids and without rescue treatment. The study was powered to demonstrate a 60% difference in response rates between groups. Open-ended adverse events were collected at each visit by clinicians and were categorised following system organ class classification after study completion. The ALORS trial is registered with ClinicalTrials.gov, NCT03632187. FINDINGS 34 patients (22 women and 12 men) were randomly assigned between Dec 13, 2018, and Oct 21, 2021. All patients who had been randomly assigned were included in the analysis. The primary endpoint was reached by eight (50%) of 16 patients in the abatacept group and four (22%) of 18 patients in the placebo group (relative risk 2·2 [0·9-5·5]); crude p=0·15; adjusted p=0·070). Eight (50%) patients in the abatacept and 15 (83%) in the placebo group had adverse events. Four patients (one [6%] in the abatacept group and three [17%] in the placebo group) had serious adverse events. There were no deaths or new safety concerns. INTERPRETATION This study suggests that the effect of abatacept alone is not strong enough to justify larger studies in early polymyalgia rheumatica. This is only a first step in deciding whether a larger study should be conducted in early polymyalgia rheumatica and does not exclude a potential effect of abatacept in glucocorticoid-dependent polymyalgia rheumatica. FUNDING BMS Pharma France.
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Affiliation(s)
- Alain Saraux
- Rheumatology Unit, Hôpital de la Cavale Blanche, Brest, France; Université de Bretagne Occidentale (Univ Brest), CHU Brest, INSERM (U1227), Brest, France.
| | | | | | | | - Alice Tison
- Université de Bretagne Occidentale (Univ Brest), CHU Brest, INSERM (U1227), Brest, France
| | - Baptiste Quere
- Université de Bretagne Occidentale (Univ Brest), CHU Brest, INSERM (U1227), Brest, France
| | - Hélène Petit
- Service de rhumatologie, Groupement Hospitalier Rance Emeraude, CH de Dinan, Dinan, France
| | - Renaud Felten
- Service de Rhumatologie, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Sandrine Jousse-Joulin
- Université de Bretagne Occidentale (Univ Brest), CHU Brest, INSERM (U1227), Brest, France
| | - Dewi Guellec
- Université de Bretagne Occidentale (Univ Brest), CHU Brest, INSERM (U1227), Brest, France
| | - Thierry Marhadour
- Université de Bretagne Occidentale (Univ Brest), CHU Brest, INSERM (U1227), Brest, France
| | - Patrice Kervarrec
- Université de Bretagne Occidentale (Univ Brest), CHU Brest, INSERM (U1227), Brest, France
| | - Divi Cornec
- Université de Bretagne Occidentale (Univ Brest), CHU Brest, INSERM (U1227), Brest, France
| | - Solene Querellou
- Department of Nuclear Medicine, Université de Bretagne Occidentale (Univ Brest), CHU Brest, INSERM, GETBO, Brest, France
| | - Emmanuel Nowak
- Clinical Research and Innovation Department (DRCI), INSERM, CHU Brest, Brest, France; Public Agency for Clinical Research and Innovation (DRCI), Brest University Hospital, Brest, France
| | - Aghiles Souki
- Clinical Research and Innovation Department (DRCI), INSERM, CHU Brest, Brest, France; Public Agency for Clinical Research and Innovation (DRCI), Brest University Hospital, Brest, France
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Wendling D. Biological therapy in polymyalgia rheumatica. Expert Opin Biol Ther 2023; 23:1255-1263. [PMID: 37994867 DOI: 10.1080/14712598.2023.2287097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 11/20/2023] [Indexed: 11/24/2023]
Abstract
INTRODUCTION Polymyalgia rheumatica (PMR) is an inflammatory rheumatic disease of the elderly, treated mainly with systemic corticosteroids. The frequency of side effects of steroids is high in this aged population and increased due to comorbidities. The use of biological treatments could be of interest in this condition. AREAS COVERED This review takes into account literature data from the PubMed and clinical trial databases concerning the results of the use of biological treatments in PMR, in terms of efficacy and safety of these treatments. EXPERT OPINION Current data do not allow us to identify any particular efficacy of the various anti-TNF agents used in the treatment of PMR. Anti-interleukin 6 agents (tocilizumab, sarilumab) have shown consistent efficacy results, suggesting a particularly interesting steroid-sparing effect in the population under consideration. The safety profile appears acceptable. Other biologic targeted treatments are currently being evaluated. Anti-interleukin-6 agents may well have a place in the therapeutic strategy for PMR, particularly for patients with steroid-resistant disease or at high risk of complications of corticosteroid therapy.
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Affiliation(s)
- Daniel Wendling
- Rheumatology, CHU (University Teaching Hospital), Besançon, France
- EA4266 EPILAB, Université de Franche-Comté, Besançon, France
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