The impact of tocilizumab on physical function and quality of life in patients with rheumatoid arthritis: a systematic literature review and interpretation

Modelling the opportunity for cost-savings or patient access with biosimilar adalimumab and tocilizumab: a European perspective

OBJECTIVES

Biosimilars improve patient access by providing cost-effective treatment options. This study assessed the potential for savings and expanded patient access with increased use of two biosimilar disease modifying anti-rheumatic drugs (DMARDs): (a) approved adalimumab biosimilars and (b) the first tocilizumab biosimilar, representing an established biosimilar field and a recent biosimilar entrant in France, Germany, Italy, Spain, and the United Kingdom (UK).

METHODS

Separate ex-ante analyses were conducted for each country, parameterized using country-specific list prices, unit volumes annually, and market shares for each therapy. Discounting scenarios of 10%, 20%, and 30% were tested for tocilizumab. Outputs included direct cost-savings associated with drug acquisition or the incremental number of patients that could be treated if savings were redirected. Two biosimilar conversion scenarios were tested.

RESULTS

Savings associated with a 100% conversion to adalimumab biosimilar ranged from €10.5 to €187 million (UK and Germany, respectively), or an additional 1,096 to 19,454 patients that could be treated using the cost-savings. Introduction of a tocilizumab biosimilar provided savings up to €29.3 million in the most conservative scenario. Exclusive use of tocilizumab biosimilars (at a 30% discount) could increase savings to €28.8 to €113 million or expand access to an additional 43% of existing tocilizumab users across countries.

CONCLUSION

This study demonstrates the benefits that can be realized through increased biosimilar adoption, not only in an untapped tocilizumab market, but also through incremental increases in well-established markets such as adalimumab. As healthcare budgets continue to face downwards pressure globally, strategies to increase biosimilar market share could prove useful to help manage financial constraints.

Health-related quality of life of patients with rheumatoid arthritis on tocilizumab, adalimumab, and etanercept in Saudi Arabia: a single-center cross-sectional study

Purpose: The aim of this study was to assess the quality of life (QOL) of patients with rheumatoid arthritis (RA) on tocilizumab versus other commonly used monoclonal antibodies (mAbs) (e.g., adalimumab and etanercept). Methods: This was an interview-based cross-sectional study. Adult RA patients (≥18 years) with a disease duration of at least 1 year were included in the study. The Arabic version of EUROQOL (EQ-5D-5L) was used to assess the QOL of RA patients on mAbs. Multiple linear regression was conducted to examine the impact of tocilizumab versus other mAbs on the visual analog scale (VAS) score controlling for age, disease duration, treatment duration, gender, number of comorbidities, and the use of steroids. Results: The number of patients who met the inclusion criteria and consented to be interviewed was 105 patients (tocilizumab (n = 37), adalimumab (n = 31), and etanercept (n = 37)). No significant differences in the scores of the five EQ-5D-5L domains across different mAbs was found. Although the VAS score of patients on tocilizumab was numerically higher compared to their counterparts on adalimumab or etanercept (69.19 vs. 62.79) this was not statistically significant controlling for age, gender, disease and treatment durations, number of comorbidities, and the utilization of steroids (β = 4.26, 95% CI: [-8.84-17.36], p = 0.52). Conclusion: The use of tocilizumab did not seem to result in better QOL among RA patients. Future studies with larger sample sizes and more robust designs should be conducted to confirm or refute these findings.

Louis EK, Przybelski SA, Morgenthaler TI, Machulda MM, Boeve BF, Petersen RC, Jack CR, Graff-Radford J, Vemuri P, Mielke MM. Sleepiness in Cognitively Unimpaired Older Adults Is Associated With CSF Biomarkers of Inflammation and Axonal Integrity

Introduction

Sleepiness has been associated with cognitive decline and dementia in the elderly. Older adults with excessive daytime sleepiness appear to be more vulnerable to longitudinal amyloid PET accumulation before the onset of the dementia. However, it remains unclear whether sleepiness is similarly associated with other biomarkers of Alzheimer's disease (AD), axonal integrity, and inflammation, which may also contribute to neurodegeneration and cognitive decline.

Methods

In this cross-sectional analysis, we identified 260 cognitively unimpaired adults (>60 years) from the Mayo Clinic Study of Aging, a population-based cohort from Olmsted County (MN), who underwent CSF quantification of AD biomarkers (Aβ42, p-tau, p-tau/Aβ42) in addition to at least one of the following biomarkers [neurofilament light chain (NfL) interleukin-6 (IL-6), IL-10, and tumor necrosis factor-α (TNF-α)]. We fit linear regression models to assess associations between sleepiness, as measured by the Epworth Sleepiness Scale (ESS), and CSF biomarkers, controlling for age, sex, APOε4 status, body mass index, hypertension, dyslipidemia, and prior diagnosis of obstructive sleep apnea.

Results

Higher ESS scores were associated with higher CSF IL-6 and NfL, but not with the other CSF biomarkers. For every ESS score point increase, there was a 0.009 ([95% CI 0.001-0.016], p = 0.033) increase in the log of IL-6 and 0.01 ([95% CI 0.002-0.018], p = 0.016) increase in the log of NfL. A sensitivity analysis showed an association between ESS scores and log of p-tau/Aβ42 only in participants with an abnormal ratio (>0.023), highly predictive of amyloid positivity. For every ESS score point increase, there was a 0.006 ([95% CI 0.001-0.012], p = 0.021) increase in the log of CSF p-tau/Aβ42.

Conclusion

Sleepiness was associated with greater CSF IL-6 and NfL levels, which could contribute to neurodegeneration or alternatively cause sleepiness. Higher NfL levels may result from sleep disruption and/or contribute to sleepiness via disturbed connectivity or damage to wake-promoting centers. Associations between sleepiness and p-tau/Aβ42 in participants with abnormal ratio suggest that amyloid positivity contributes to vulnerability to sleep disturbance, which may further amyloid accumulation in a feed-forward loop process. Prospective studies of these markers are needed to determine cause-effect relationships between these associations.

Outlook of IL-6 signaling blockade for COVID-19 pneumonia

In this review article, it is highlighted the implications of pleiotropic functions of interleukin-6 (IL-6) for one of the therapeutic options targeting for COVID-19. Moreover, it is discussed how real-world data and trials with IL-6 signaling blockade will be crucial in informing the development of new treatment for COVID-19 pneumonia. Given physiological roles of IL-6 in inflammatory conditions and the data from real world, IL-6 signal inhibitors, along with standard of care (SOC) treatment, might provide efficacy, offering the potential to treat COVID-19 in hospitalized populations more effectively than current SOC alone. Therefore, on-going and planned randomized placebo-controlled studies in combination with SOC and other therapeutics to assess safety and efficacy of IL-6 signal inhibitors in hospitalized patients with severe COVID-19 pneumonia will be warranted to address the high unmet need and burden of disease in this severely ill population.

IL-6 Receptor Blockade by Tocilizumab Has Anti-absence and Anti-epileptogenic Effects in the WAG/Rij Rat Model of Absence Epilepsy

Increased expression of interleukin-6 (IL-6) both in cerebrospinal fluid (CSF) and plasma is closely associated with convulsive epilepsy and symptom severity of depression. By comparison, at present, little is known about the role of this cytokine in childhood (non-convulsive) absence epilepsy. The aim of this work was to investigate the potential effects of acute and chronic treatment with tocilizumab (TCZ, 10 and 30 mg/kg/day), on absence seizures, their development, and related psychiatric comorbidity in WAG/Rij rats. It is known that lipopolysaccharide (LPS)-induced changes in inflammatory processes increase absence epileptic activity. In order to study the central effects of TCZ, we investigated whether administration of this anti-IL-6R antibody could modulate the lipopolysaccharide (LPS) or IL-6-evoked changes in absence epileptic activity in WAG/Rij rats. Our results demonstrate that TCZ, at both doses, significantly reduced the development of absence seizures in adult WAG/Rij rats at 6 months of age (1 month after treatment suspension) compared with untreated controls, thus showing disease-modifying effects. Decreased absence seizure development at 6 months of age was also accompanied by reduced comorbid depressive-like behavior, whereas no effects were observed on anxiety-related behavior. Acute treatment with TCZ, at 30 mg/kg, had anti-absence properties lasting ~25 h. The co-administration TCZ with i.c.v. LPS or IL-6 showed that TCZ inhibited the worsening of absence seizures induced by both proinflammatory agents in the WAG/Rij rats, supporting a central anti-inflammatory-like protective action. These results suggest the possible role of IL-6 and consequent neuroinflammation in the epileptogenic process underlying the development and maintenance of absence seizures in WAG/Rij rats. Accordingly, IL-6 signaling could be a promising pharmacological target in absence epilepsy and depressive-like comorbidity.

Neuroendocrine and neurophysiological effects of interleukin 6 in rheumatoid arthritis

RA is a chronic, systemic, autoimmune disease characterized by inflammation and degradation of the joints, causing significant negative impact on quality of life. In addition to joint disease, symptoms and co-morbidities associated with RA-namely pain, fatigue and mood disorders-are often as debilitating as the disease itself. The pro-inflammatory cytokine IL-6 plays a critical role in RA-associated pathology. However, a greater understanding of the translational effects of IL-6 outside of the immune system is needed. This review discusses our current understanding of emerging aspects of IL-6 in RA-associated pain, fatigue and mood disorders such as depression and anxiety. This review also describes the clinical effects of IL-6 inhibition on these symptoms and co-morbidities in patients with RA.

Sarilumab: patient-reported outcomes in rheumatoid arthritis

In the last few decades, strategies for the management of rheumatoid arthritis (RA) have been increasingly oriented toward more comprehensive control of the disease, taking into account even RA extra-articular manifestations, comorbidities, and the patient’s perception about the disease. The need for improving the shared decision-making process suggested by European League Against Rheumatism recommendations is leading to an increasing interest in the role of patient-reported outcomes (PROs) beside the usual more objective criteria for defining clinical response based on disease-activity composite indices. Measurement of such PROs as pain or fatigue may be significantly influenced by mood disorders often complicating RA, the pathogenesis of which is deeply interconnected with phlogistic processes mediated by proinflammatory cytokines. IL6 is a pleiotropic mediator involved in neuroendocrine and neuropsychological processes, besides its well known effects on immune, cardiovascular, and metabolic systems. Therefore, there is a growing body of evidence about the efficacy of IL6 blockade in PRO improvement in RA patients. Sarilumab is a monoclonal antibody binding both soluble and membrane-bound IL6Rα, inhibiting the IL6-mediated signaling pathway with favorable efficacy and safety profile. This review analyzes the importance of PROs in strategies for the management of RA and the pathogenic mechanisms linking IL6 with the patient’s perception of the disease. Moreover, the main findings from sarilumab randomized controlled trials are summarized in detail, emphasizing the potential role of this IL6 blocker in the holistic treatment of RA.

A Review of Recent Advances Using Tocilizumab in the Treatment of Rheumatic Diseases

Tocilizumab (TCZ) is the first humanized anti-interleukin-6 (IL-6) receptor monoclonal antibody approved for the treatment of patients with rheumatoid arthritis (RA), Castleman's disease, polyarticular and systemic juvenile idiopathic arthritis, and, most recently, giant cell arteritis as well as for the treatment of chimeric antigen receptor T cell therapy-induced cytokine release syndrome. The global clinical development program for TCZ provides a wealth of clinical data on intravenous TCZ, and more recent studies in patients with RA have provided evidence characterizing the role of intravenous TCZ as monotherapy in early disease and led to the introduction of a subcutaneous formulation of TCZ. In addition, recently published open-label extension and observational studies continue to support the long-term efficacy and safety of TCZ in both clinical trial and real-world settings. Given the involvement of IL-6-mediated signaling in inflammatory disorders, TCZ is also being investigated in other immunological diseases. In particular, a phase 2 trial on the safety and efficacy of subcutaneous TCZ in adults with systemic sclerosis shows clinically relevant improvements in skin sclerosis and lung function in these patients. Another anti-IL-6 receptor agent, sarilumab, targeting the IL6 receptor alpha subunit, was recently approved for the treatment of patients with RA, although long-term data for this biologic are not yet published. In this article we review the placement of TCZ in current treatment guidelines; recent clinical trial data, including quality of life in patients with RA; recent updates to the TCZ safety profile; recent investigations of TCZ in other immunological diseases; and the clinical development of other novel IL-6-targeted agents.

Disease activity, resilience and health-related quality of life in Chinese patients with rheumatoid arthritis: a multi-center, cross-sectional study

Background

Positive psychological constructs that can moderate or mediate the negative impact of disease activity on health-related quality of life (HRQOL) in patients with rheumatoid arthritis (RA) have not been explored widely. This study aimed to assess the associations of disease activity, resilience with HRQOL and the moderating and mediating roles of resilience among Chinese RA patients.

Methods

A multi-center, cross-sectional study was conducted in RA inpatients in northeast of China. A total 298 subjects completed the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) and Ego-Resiliency Scale (ERS) to measure HRQOL and resilience. For the SF-36, physical function, physical role limitation, bodily pain and general health perception are gathered into physical component summary (PCS), while vitality, social functioning, emotional role limitation and mental health are gathered into mental component summary (MCS). Disease activity was evaluated by the Disease Activity Score 28-C-reactive protein (DAS28-CRP). Hierarchical regression analysis was applied to examine the associations of disease activity, resilience and the disease activity*resilience interaction with PCS and MCS, respectively. Asymptotic and resampling strategies were utilized to examine the mediating role of resilience.

Results

The mean scores of PCS and MCS were 40.67 and 59.14, respectively. Disease activity was negatively associated with both PCS and MCS, and resilience was only positively associated with MCS. The disease activity*resilience interaction term were significantly associated with MCS (β = 0.144, P = 0.003). The associations between disease activity and MCS were gradually reduced in low (1 SD below the mean, β = −0.369, P < 0.001), mean (β = −0.218, P < 0.001) and high (1 SD above the mean, β = −0.068, P = 0.369) groups of resilience. Resilience acted as a partial mediator in the disease activity-MCS association (effect size was −0.085, BCa 95% CI: −0.159, −0.028).

Conclusions

Disease activity was negatively associated with both physical and mental HRQOL, and resilience was only positively associated with mental HRQOL. Resilience could attenuate and mediate the association between disease activity and mental HRQOL. In addition to controlling disease activity, targeted intervention strategies designed for resilience should be strengthened to improve the HRQOL of this population.