What is the treatment approach for Rheumatoid Arthritis (RA) with interleukin involvement?

From the Guidelines

The treatment approach for Rheumatoid Arthritis (RA) with interleukin involvement should primarily focus on targeted biologic therapies that inhibit specific interleukin pathways, with methotrexate as the first-line therapy, and interleukin inhibitors added for inadequate response, as recommended by the 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis 1. The treatment of RA with interleukin involvement typically begins with conventional disease-modifying antirheumatic drugs (DMARDs) like methotrexate, starting at 7.5-10 mg weekly, increasing to 15-25 mg weekly.

• Interleukin inhibitors, particularly IL-6 inhibitors like tocilizumab (Actemra) and sarilumab (Kevzara), are effective options when DMARDs have failed to adequately control disease activity.
• Tocilizumab is typically administered at 4-8 mg/kg intravenously every 4 weeks or 162 mg subcutaneously weekly, while sarilumab is given as 200 mg subcutaneously every two weeks.
• These biologics work by blocking specific inflammatory cytokines that drive joint inflammation and destruction in RA, reducing joint damage, pain, and improving physical function.
• Regular monitoring of liver function, blood counts, and lipid profiles is essential during treatment, and patients should be screened for tuberculosis and other infections before initiating therapy, as these medications can increase infection risk, as stated in the 2020 EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update 1. Key considerations in the treatment approach include:
• Early evaluation, diagnosis, and management of RA, with treatment decisions following a shared decision-making process, as emphasized in the 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis 1.
• Treatment decisions should be reevaluated within a minimum of 3 months based on efficacy and tolerability of the DMARD(s) chosen.
• Disease activity levels should be calculated using RA disease activity measures endorsed by the ACR, with the goal of reaching a predefined target of low disease activity or remission.

From the FDA Drug Label

AVTOZMA® (tocilizumab-anoh) is an interleukin-6 (IL-6) receptor antagonist indicated for treatment of: Rheumatoid Arthritis (RA) (1.1) Adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more Disease-Modifying Anti-Rheumatic Drugs (DMARDs). For RA, pJIA and sJIA, AVTOZMA may be used alone or in combination with methotrexate: and in RA, other non-biologic DMARDs may be used.

The treatment approach for Rheumatoid Arthritis (RA) with interleukin involvement is to use AVTOZMA (tocilizumab-anoh), an interleukin-6 (IL-6) receptor antagonist, alone or in combination with methotrexate and/or other non-biologic DMARDs. The recommended dosage is:

• Intravenous: 4 mg per kg every 4 weeks, followed by an increase to 8 mg per kg every 4 weeks based on clinical response.
• Subcutaneous: 162 mg administered every other week, followed by an increase to every week based on clinical response for patients less than 100 kg weight, and 162 mg administered every week for patients at or above 100 kg weight. 2

From the Research

Treatment Approach for Rheumatoid Arthritis (RA) with Interleukin Involvement

• The treatment approach for RA with interleukin involvement typically involves the use of disease-modifying anti-rheumatic drugs (DMARDs) and biologics, which can help to reduce inflammation and slow disease progression 3, 4.
• Biologics such as abatacept, adalimumab, anakinra, certolizumab pegol, etanercept, golimumab, infliximab, rituximab, and tocilizumab have been shown to be effective in reducing symptoms and improving function in patients with RA who have failed to respond to methotrexate or other DMARDs 4.
• Intra-articular therapy with methotrexate or tumor necrosis factor inhibitors may also be used to treat persistent monoarthritis in patients with RA, although the optimal dose and frequency of injections is yet unknown 5.
• The management of RA-associated interstitial lung disease (RA-ILD) is challenging, but emerging data suggest that controlling RA disease activity may reduce RA-ILD risk, and immunomodulatory and antifibrotic drugs may also be effective in treating RA-ILD 6.

Pharmacologic Treatment

• Methotrexate is a commonly used DMARD for the treatment of RA, but its use has been associated with an increased risk of malignancies, including breast, ovarian, and lung cancers 7.
• The concomitant use of biologics and methotrexate may further increase the risk of certain malignancies, such as breast, ovarian, and lung cancers 7.
• Tumor necrosis factor inhibitors (TNFi) have been shown to be effective in reducing symptoms and improving function in patients with RA, and may also be used to treat RA-ILD 3, 5.

Considerations

• The treatment approach for RA with interleukin involvement should be individualized based on the patient's specific needs and medical history.
• Patients with RA should be closely monitored for potential side effects of treatment, including malignancies and infections.
• Further research is needed to fully understand the risks and benefits of different treatment approaches for RA with interleukin involvement.