Biologics are more effective at treating adult-onset Still’s disease (AOSD) than are glucocorticoids or conventional disease-modifying antirheumatic drugs (DMARDs), according to a new retrospective study.
Half of the patients treated with first-line biologic DMARDs achieved sustained, event-free remission compared with 12% of patients in the conventional therapy group. In a statistical weighted analysis, the odds of reaching sustained remission on biologics was more than seven times greater than on conventional therapy.
“These data show, with a considerable effect size, that the use of biological DMARDs as a first-line therapy in patients with adult-onset Still’s disease is clearly advantageous over first-line conventional synthetic DMARD therapy,” wrote senior author Stefan Vordenbäumen, MD, PhD, of the St Elisabeth-Hospital Meerbusch-Lank in Meerbusch, Germany, and colleagues.
Still’s disease is a rare inflammatory condition characterized by fevers, rash, and joint pain. The term was previously used to describe only adult patients, whereas a similar condition in children is still often referred to as systemic juvenile idiopathic arthritis. Now, many experts agree that these diseases are “a continuum of the same disease,” the authors wrote.
Biologics are increasingly used to treat AOSD, in line with 2024 recommendations by the European Alliance of Associations for Rheumatology and the Paediatric Rheumatology European Society. However, these recommendations “rely heavily on efficacy data in children,” they explained, as clinical studies of these drugs have failed to meet their primary endpoints in adult patients.
Study Details
With a retrospective analysis, the authors aimed to determine how biologic DMARD therapy compared against conventional DMARD therapy in AOSD.
The analysis, published on March 28, 2025, in The Lancet Rheumatology, included 86 patients with AOSD. Patients were treated across 16 secondary and tertiary rheumatology centers in Germany beginning in 2007.
On average, patients were 40 years old, and 58% were women. Nearly all participants (98%) were White.
Of the 86 patients, 44 received biologic therapy; most of the patients (84%) started treatment with the interleukin-1 (IL-1) inhibitor anakinra, five patients started on the IL-6 inhibitor tocilizumab, and two patients started the IL-1 inhibitor canakinumab. (During the study, 9 of the 37 patients originally taking anakinra switched to canakinumab because of injection site reactions.) About three out of four patients in the biologic group were also concurrently taking glucocorticoids.
Of the 42 patients started on conventional synthetic DMARDs, 71% were on glucocorticoid monotherapy, 12 patients received methotrexate with steroids, and one patient received immunoglobulin therapy.
Overall, biologics were associated with a greater likelihood of achieving sustained, event-free remission, which was the primary endpoint of the study (odds ratio, 7.20; P = .0007). More patients in the biologic group (32 of 44) had also stopped glucocorticoids at week 72 than those in the conventional therapy group (18 of 42).
This finding “is particularly important given the well-documented adverse effects of long-term glucocorticoid use” Yi-Ming Chen, MD, PhD, of the Taichung Veterans General Hospital, Taichung, Taiwan, and Der-Yuan Chen, MD, PhD, of the China Medical University, Taichung, Taiwan, wrote in an accompanying editorial.
During the study period, three patients in the conventional synthetic DMARD group died — two of macrophage activation syndrome and one of unknown causes. There were no deaths in the biologic group.
Reactions to the Study
“It’s a great study,” Bella Mehta, MBBS, MS, MD, a rheumatologist at Hospital for Special Surgery in New York City, told Medscape Medical News. She was not involved with the research. “It gives you real-world evidence” of the efficacy of biologics in AOSD, which is difficult with a rare disease such as AOSD, she added.
The high prevalence of IL-1 inhibitors in the study “limits conclusions about the comparative efficacy of different biologic DMARDs,” Yi-Ming Chen and Der-Yuan Chen wrote, but comparing the efficacy of different biologic DMARDs in future studies on AOSD could be valuable, they said, “particularly given the emergence of biomarker-based approaches to treatment selection.”
Additional studies evaluating the efficacy of calcineurin inhibitors in AOSD could also be useful, Mehta added, or perhaps combining biologics and calcineurin inhibitor therapy could boost the percentage of patients reaching sustained remission.
Paired with further insights on the molecular landscape of Still’s disease, the study’s findings “support the feasibility of a more personalized, evidence-based approach to first-line biological DMARD therapy,” Yi-Ming Chen and Der-Yuan Chen noted. “This evolution in treatment strategy, driven by robust clinical evidence and advancing molecular insights, could usher in a new era in the management of Still’s disease, in which early biological DMARD therapy becomes the standard of care for appropriately selected patients.”
Study authors reported receiving grants, fees, or other support from AbbVie, AlphaSigma, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Deutsche Rheumaakademie, FOMF Akademie, GSK, Janssen, Lilly, Novartis, Pfizer, Roche/Chugai, SOBI, and UCB. Mehta is an advisory board member of Horizon Therapeutics and a consultant for BICMD and WebMD. Yi-Ming Chen and Der-Yuan Chen had no disclosures.