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Efficacy of canakinumab as first-line biologic agent in adult-onset Still’s disease

A Correction to this article was published on 25 February 2019

This article has been updated

Adult-onset Still’s disease (AOSD) is a rare condition characterized by fever, arthritis, skin rash, and multi-organ inflammation. The pathogenesis is mediated by the pro-inflammatory cytokine interleukin (IL)-1β, as confirmed by the clinical efficacy of selective blockade. Anakinra, a recombinant inhibitor of the IL-1β receptor, currently represents the cornerstone of biologic therapy [1].

More recently, a monoclonal antibody blocking IL-1β, canakinumab, entered the clinical arena and became available for the treatment of AOSD. The efficacy of canakinumab in AOSD is being evaluated in a clinical trial (NCT022042939). At present, evidence from several case reports or series suggest good efficacy in AOSD (reviewed in [2, 3]): of note, in all published cases, canakinumab was used following failure of one or more biologics, including anakinra.

Here, we report the efficacy of canakinumab as a first-line biologic agent in AOSD. Four patients with severe DMARD-refractory AOSD received canakinumab (4 mg/kg/4 weeks) following failure of conventional treatment with corticosteroids and methotrexate. Patient characteristics and response to therapy are shown in Table 1. In all patients, treatment with canakinumab led to striking clinical responses, within days of initiation. Fever and skin rash disappeared first, followed by progressive improvement in arthritis. If present, inflammatory organ involvement also responded to treatment, as confirmed by resolution of pericardial inflammation and hepatosplenomegaly in two and one patients, respectively. Marked reductions in CRP, ESR, and serum ferritin mirrored the efficacy on clinical manifestations. Reduced disease severity allowed for robust tapering of corticosteroid therapy, which was discontinued in two patients and substantially reduced in two patients (Table 1).

Table 1 Patient characteristics and response to therapy

Biologic therapy with IL-1 inhibitors should be instituted earlier in AOSD course for more favorable outcomes [2]. Both IL-1 blocking agents anakinra and canakinumab received EMA approval for the treatment of AOSD. Although anakinra and canakinumab block the same target, they have different mechanisms of action. Anakinra, a recombinant inhibitor of the IL-1 receptor, requires daily injections due to a short half-life of 6 h. Canakinumab, a fully human monoclonal antibody selectively blocking IL-1β, has a longer half-life and is administered monthly [4].

In this study, first-line biologic therapy of AOSD with canakinumab resulted in rapid and marked efficacy, ultimately leading to full clinical remissions in all patients and allowing for robust steroid-sparing effects. Canakinumab in AOSD is often used as a last line of treatment following failure of multiple other agents, including anakinra [2]. Early treatment is nevertheless advisable and may reduce chances of chronic disease and permanent damage [2, 5].

Change history

  • 25 February 2019

    Following publication of the original article [1], the authors reported an error in the spelling of Lorenzo Dagna’s name.



Adult-onset Still’s disease


C-reactive protein


Disease-modifying anti-rheumatic drug


Erythrocyte sedimentation rate




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Not applicable to this article as no datasets were generated or analyzed during the current study.


GC has received funding from AIRC under MFAG 2018 - ID. 22136 project – P.I. Cavalli Giulio. CAD is supported by NIH grant AI-15614.

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GC, AT, GDL, CC, EB, and LD took care of patients; GC performed the statistical analysis and drafted the paper; CAD participated in the design of the study and helped to draft the manuscript. All authors read and approved the final manuscript.

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Correspondence to Giulio Cavalli.

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Need for approval waived as canakinumab is approved by Italian regulating bodies for the treatment of AOSD. Patients gave their consent to drug administration and utilization of data in anonymous form for research purposes.

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Not applicable.

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The authors declare that they have no competing interests.

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The original version of this article was revised: Lorenzo Dagna's name was corrected.

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Cavalli, G., Tomelleri, A., De Luca, G. et al. Efficacy of canakinumab as first-line biologic agent in adult-onset Still’s disease. Arthritis Res Ther 21, 54 (2019).

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