Receptor Antagonist Anakinra Research Articles

The use of an interleukin 1 receptor antagonist (anakinra) in the treatment of Schnitzler syndrome

The use of an interleukin 1 receptor antagonist (anakinra) in the treatment of Schnitzler syndrome

Anakinra Promotes M2 Microglia Activation during the Latent Phase of the Lithium-Pilocarpine Model of Temporal Lobe Epilepsy

Astrocytes and microglia and their polarization are thought to contribute to the progression of epilepsy. One of the processes affecting polarization is neuroinflammation, which plays an important role in epileptogenesis. However, the specific mechanisms of its involvement in shifting the pro- and anti-inflammatory reactivation of astro- and microglia have not been clarified. In this study, we examined the effect of 7-day interleukin-1 receptor antagonist (anakinra) administration on glial cell polarization during the latent phase of the lithium-pilocarpine model in 7-week-old male Wistar rats. In temporal cortex, dorsal and ventral hippocampus the mRNA expression levels of the following genes were analyzed: (i) markers of astroglia (S100b) and microglia (Aif1) activation, (ii) astrocytic proteins involved in glutamate transport and metabolism (Slc1a3, Glul, Gja1), (iii) pro-inflammatory pathway interleukin-1β (Nlrp3, Il1b, Il1rn) and transforming growth factor β1 (Tgfb1), (iv) markers of astroglia polarization (Lcn2, S100a10, Gbp2, Ptx3), and (v) microglia polarization (Nos2 and Arg1). The mRNA expression levels of S100b and Aif1 were significantly increased, and anakinra administration did not reduce their overexpression. This indicates reactivation of astroglia and microglia regardless of the anakinra administered. The expression of Slc1a3, Glul, and Gja1 genes increased in the hippocampus; anakinra administration did not affect their hyperexpression, but promoted increased expression of Gja1 in the temporal cortex. The mRNA production of Lcn2, S100a10, Gbp2, Ptx3, Nlrp3, Il1b, Il1rn and Tgfb1 increased in all structures. Administration of anakinra reduced the gene expression of Il1b. Among the markers of microglia polarization, downregulation of Arg1 expression in the dorsal hippocampus and Nos2 expression in the temporal cortex was detected. Anakinra administration enhanced the decrease in Nos2 expression and restored the level of Arg1 expression to control values. Thus, anakinra administration did not affect the intensity of glial cell reactivation, but improved M2 reactivation of microglia.

IL-1 receptor antagonism reveals a yin-yang relationship between NFκB and interferon signaling in chronic lymphocytic leukemia

Nuclear factor kappa B (NFκB) is a pathogenic factor in chronic lymphocytic leukemia (CLL) that is not addressed specifically by current therapies. NFκB is activated by inflammatory factors that stimulate toll-like receptors (TLRs) and receptors for interleukin-1 (IL-1) family members. IL-1 is considered a master regulator of inflammation, and IL-1 receptor signaling is inhibited by the IL-1 receptor antagonist anakinra. These considerations suggested that anakinra might have a role in the treatment of CLL. Consistent with this idea, anakinra inhibited spontaneous and TLR7-mediated activation of the canonical NFκB pathway in CLL cells in vitro. However, CLL cells exhibited only weak signaling responses to IL-1 itself, and anakinra was found to inhibit NFκB along with oxidative stress in an IL-1 receptor-independent manner. Anakinra was then administered with minimal toxicity to 11 previously untreated CLL patients in a phase I dose-escalation trial (NCT04691765). A stereotyped clinical response was observed in all patients. Anakinra lowered blood lymphocytes and lymph node sizes within the first month that were associated with downregulation of NFκB and oxidative stress in the leukemia cells. However, inhibition of NFκB was accompanied by upregulation of type 1 interferon (IFN) signaling, c-MYC-regulated genes and proteins, and loss of the initial clinical response. Anakinra increased IFN signaling and survival of CLL cells in vitro that were, respectively, phenocopied by mitochondrial antioxidants and reversed by IFN receptor blocking antibodies. These observations suggest that anakinra has activity in CLL and may be a useful adjunct for conventional therapies as long as compensatory IFN signaling is blocked at the same time.

Abstract 5516: Aberrant activation and perpetuation of lung wound response facilitates osteosarcoma metastasis

Abstract Introduction: The mechanisms that allow tumor cells to integrate with unfamiliar parenchymal cells within hostile distant tissues during metastatic colonization remain poorly defined. Nowhere are these mechanisms more important than in osteosarcoma-a pediatric bone tumor where metastases cause nearly all osteosarcoma related deaths and occur almost exclusively in the lung. The purpose of this study was to define the cellular and molecular events that facilitate osteosarcoma lung colonization to devise novel therapeutic strategies that prevent and treat metastasis. Experimental Approach: We generated experimental lung metastases using a panel of immunocompetent murine and human xenograft osteosarcoma models. A combination of immunohistochemistry, single cell RNA sequencing, and spatial transcriptomics were used to define the metastatic niche. Relevant findings were validated in human primary tumor, lung metastasis, and normal lung tissue specimens. Results: Disseminated osteosarcoma cells physically associate with alveolar epithelial cells and trigger changes in surrounding epithelial cells that are characteristic of the aberrant, non-resolving wound response seen in non-malignant lung diseases such as idiopathic pulmonary fibrosis (IPF). This process drives the accumulation of fibrotic epithelial cells and scar-associated macrophages confined within a dense fibronectin-based matrix. Anti-fibrotic tyrosine kinase inhibitors used to treat patients with IPF (nintedanib) prevent the observed fibrogenic changes and inhibit metastatic colonization. Epithelial-osteosarcoma paracrine signaling is dominated by an inflammatory cytokine milieu that facilitates this transition towards fibrosis. Blocking one of the dominant paracrine signals with a recombinant IL1 receptor antagonist (anakinra) has similar effects on both fibrosis and metastatic colonization. Conclusions: Our study demonstrates that tumor interactions with host stromal cells are critical for metastasis. Metastatic colonization requires transformation of the local lung microenvironment into a fibrotic, non-resolving, cytokine-rich, wound-like state that is both provoked and sustained by tumor-epithelial interactions. These insights have identified several potential therapeutic approaches to prevent metastatic colonization and treat established metastases. Citation Format: James Brandon Reinecke, Amy C. Gross, Maren Cam, Leyre Jimenez Garcia, Matthew V. Cannon, Ryan D. Roberts. Aberrant activation and perpetuation of lung wound response facilitates osteosarcoma metastasis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 5516.

Does your unwell patient have haemophagocytic lymphohistiocytosis?

Haemophagocytic lymphohistiocytosis is a severe systemic hyperinflammatory syndrome characterised by dysregulation of immune cells and excessive production of cytokines, also known as a cytokine storm. It has distinctive clinical features with fever, hyperferritinaemia and falling blood counts. In adults, this usually occurs secondary to an underlying driver or trigger including infection, malignancy or rheumatic diseases. Prompt treatment with immunomodulatory therapy, including corticosteroids and the recombinant IL-1 receptor antagonist anakinra, is recommended to switch off the cytokine storm. Etoposide-based regimens are sometimes needed, and newer therapies such as emapalumab and JAK inhibitors are increasingly being used. The incidence of haemophagocytic lymphohistiocytosis has increased significantly over the last 20 years which may partly reflect increased awareness of the condition. Although relatively rare, haemophagocytic lymphohistiocytosis can be encountered by a broad range of hospital physicians, so knowing how to diagnose and treat this condition is essential. This article reviews the pathogenesis, clinical features, causes, diagnosis and treatment of haemophagocytic lymphohistiocytosis to improve physician recognition and management of this condition to improve future patient outcomes.

Anakinra for Refractory Pseudogout in Patients with End-stage Renal Disease on Haemodialysis.

Calcium pyrophosphate deposition (CPPD) arthritis is the second most common type of crystal-induced arthritis after gout. Acute flares are commonly treated with non-steroidal anti-inflammatory drugs, intra-articular or short-term systemic glucocorticoids or colchicine. However, since there is no pharmacological treatment to reduce CPPD crystal burden, relapsing or chronic CPPD arthritis may be challenging to treat, particularly in patients with end-stage renal disease who are at risk for toxicity of the above medications. Since IL-1β appears to be driving CPPD arthritis, we treated two patients with chronic CPPD arthritis and end-stage renal disease on haemodialysis with the IL-1β receptor antagonist anakinra. In both patients, arthritis resolved quickly, while continuation of anakinra maintained remission and allowed complete glucocorticoid withdrawal. Therefore, anakinra may be a safe and effective option both for short and long-term treatment of CPPD arthritis in patients on chronic renal replacement therapy.

Germline HAVCR2/TIM-3 Checkpoint Inhibitor Receptor Deficiency in Recurrent Autoinflammatory Myocarditis

Myocarditis can be caused by viral infection, drug reaction or general inflammatory condition. To provide understanding on inflammatory myocarditis, we describe clinical, genetic, and immunological properties of a young male patient who suffered from recurrent myocarditis episodes since the age of four years. Electrocardiography, troponin I/T, echocardiography, myocardial magnetic resonance imaging and histological findings were consistent with recurrent myocarditis episodes. Homozygous c.245 A > G p.Tyr82Cys pathogenic variant in Hepatitis A Virus Cellular Receptor 2 (HAVCR2) gene encoding T cell immunoglobulin and mucin domain-containing protein 3 (TIM-3) receptor was found. Peripheral blood mononuclear cells were collected when the patient was asymptomatic; CD4+ and CD8+ T lymphoblasts, CD56+ natural killer cells and CD14+ monocytes were negative for surface TIM-3 expression. In vitro, TLR4 mediated interleukin-1β (IL-1β) response was high after LPS/ATP stimulation. Clinical symptoms responded to IL-1 receptor antagonist anakinra. TIM-3 p.Tyr82Cys CD4+ and CD8+ T cell proliferation in vitro was unrestrained. Findings on IL-2, interferon gamma, regulatory T cells, signal transducer and activator of transcription (STAT) 1, 3 and 4 phosphorylation, and PD-1 and LAG-3 checkpoint inhibitor receptor analyses were comparable to controls. We conclude that TIM-3 deficiency due to homozygous HAVCR2 c.245 A > G p.Tyr82Cys pathogenic variant in the patient described here is associated with autoinflammatory symptoms limited to early onset recurrent febrile myocarditis. Excessive IL-1β production and defective regulation of T cell proliferation may contribute to this clinical condition responsive to anakinra treatment.

A pivotal role for the IL-1β and the inflammasome in preterm labor

During labor, monocytes infiltrate massively the myometrium and differentiate into macrophages secreting high levels of reactive oxygen species and of pro-inflammatory cytokines (i.e. IL-1β), leading to myometrial contraction. Although IL-1β is clearly implicated in labor, its function and that of the inflammasome complex that cleaves the cytokine in its active form, has never been studied on steps preceding contraction. In this work, we used our model of lipopolysaccharide-induced preterm labor to highlight their role. We demonstrated that IL-1β was secreted by the human myometrium during labor or in presence of infection and was essential for myometrial efficient contractions as its blockage with an IL-1 receptor antagonist (Anakinra) or a neutralizing antibody completely inhibited the induced contractions. We evaluated the implication of the inflammasome on myometrial contractions and differentiation stages of labor onset. We showed that the effects of macrophage-released IL-1β in myometrial cell transactivation were blocked by inhibition of the inflammasome, suggesting that the inflammasome by producing IL-1β was essential in macrophage/myocyte crosstalk during labor. These findings provide novel innovative approaches in the management of preterm labor, specifically the use of an inflammasome inhibitor to block the precursor stages of labor before the acquisition of the contractile phenotype.

Phase 2 Study of Anakinra to Prevent CRS and Neurotoxicity after Treatment with Lisocabtagene Maraleucel: Planned Interim Analysis

BACKGROUND CD19 chimeric antigen receptor (CAR) T-cell therapies have transformed the treatment landscape for patients (pts) with relapsed/refractory B-cell malignancies, but they remain limited by significant toxicities: cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). While a more favorable toxicity profile had been reported with lisocabtagene maraleucel (liso-cel), based on our real-world experience CRS and ICANS are still observed in 70% and 30% of pts, respectively (Portuguese et al., ASH abstract #172978). Data from our group (Gazeau, TCT, 2023) and others (Strati, Blood, 2023; Park, Nat Med, 2023) suggested the recombinant interleukin-1 receptor antagonist anakinra may successfully prevent and treat CRS and ICANS. Thus, we conducted a phase 2 investigator-initiated clinical trial of anakinra to prevent CRS and ICANS after liso-cel (NCT04359784). We report here our planned interim analysis (n = 15). METHODS Adults ≥18 years of age with Karnofsky performance status ≥60% and B-cell non-Hodgkin lymphoma receiving liso-cel per the FDA label were eligible for this study. Anakinra was administered at 200 mg/day SC from day 0 through day +13 after liso-cel infusion, with the first dose administered approximately 2-4 hours prior to liso-cel infusion. CRS and ICANS severity were assessed per 2019 ASTCT criteria. The primary endpoint was the absence of any grade CRS assessed using the Bayesian optimal phase 2 design.The primary endpoint was not met if ≥6 of the first 15 pts developed any grade CRS. RESULTS Nineteen pts were screened for the study and 15 pts were enrolled. All 15 pts received liso-cel and all doses of SC anakinra. All pts were evaluable for toxicity assessment; 12 pts were evaluable for disease response assessment at day +28 (n = 3, no measurable disease prior to lymphodepletion [LD]). Pt and disease characteristics are shown in Table 1. Eleven pts (73%) had diffuse large B-cell lymphoma, 3 (20%) had active CNS involvement, and 5 (33%) had bulky disease (≥5 cm). Median pre-LD serum ferritin and C-reactive protein (CRP) were 153 ng/mL (IQR, 129-231) and 6.8 (IQR, 1.5-17.2), respectively. All 15 pts received anakinra as planned without dose adjustment or interruption. There were no injection-site reactions or AEs attributed to anakinra. Two pts developed infections during anakinra treatment and were both due to mild Clostridium difficile colitis requiring oral antibiotics. Eight pts (53%) developed any grade CRS, including 1 (7%) case of grade 3 CRS. Four pts (27%) developed any grade ICANS, including 3 (20%) with grade 3 (Figure 1). Median CRS onset and duration were 2 and 2.5 days, respectively, and median ICANS onset and duration were 6 and 9 days, respectively. Three pts (20%) required tocilizumab (range, 0-1 doses), 4 (50%) required dexamethasone (median total dose, 5 mg; range, 0-200 mg), and 1 (12%) required high-dose methylprednisolone. The best overall response rate (ORR) by Lugano criteria was 67% (complete response, n = 5 [42%]). Study pts were retrospectively compared to pts who received liso-cel per standard of care off trial without prophylactic anakinra at our center (n = 42). Despite higher median pre-LD CRP and IL-6 levels, the incidence of CRS was lower in anakinra-treated compared to anakinra-untreated pts (53% vs. 69%, respectively) with comparable median duration of CRS (2.5 vs. 3 days, respectively). The incidence and duration of ICANS were similar (27% vs. 28%; median 9 vs. 8 days, respectively), as was the incidence and duration of hospitalization (67% vs. 74%, median 9.5 vs. 10 days, respectively). Based on Locally Estimated Scatterplot Smoothing (LOESS) estimates, time from liso-cel infusion to CRP normalization was faster in patients receiving anakinra (9 days) compared to those receiving liso-cel alone (14 days). CONCLUSION Low-dose SC anakinra prophylaxis during liso-cel treatment was very well tolerated with preserved anti-tumor efficacy. While our primary endpoint was not reached at our planned interim analysis, we observed lower CRS rates and faster resolution of CRS in comparison to a real-world cohort of pts receiving liso-cel without prophylactic anakinra. To further enhance the preventative effects of anakinra, we plan to change the administration route from SC to intravenous, and to allow anakinra dose uptitration for the last 10 participants in the study.

Differential response to interleukin-1 blockade with anakinra on cardiorespiratory fitness in patients with heart failure with preserved ejection fraction stratified according to ejection fraction

Abstract Background Patients with heart failure with preserved ejection fraction (HFpEF) are a heterogeneous clinical population and might respond differently to pharmacologic therapies based on their baseline left ventricular EF (LVEF) (50-59% vs. ≥60%). Interleukin-1 (IL-1) is a key pro-inflammatory cytokine being explored as a therapeutic target in HFpEF for its effects on numerous outcomes including cardiorespiratory fitness (CRF). Purpose Our aim was to examine changes in CRF and C-reactive protein (CRP), a surrogate for IL-1 activity, in patients with HFpEF treated with the IL-1 recombinant human receptor antagonist anakinra, stratified according to resting LVEF. Methods We analyzed data from 32 patients (median age 55 [51-64] years, 24 (75%) female) with HFpEF, defined as a presence of HF symptoms, LVEF≥50%, and evidence of left ventricular diastolic dysfunction or elevated filling pressures. All patients were treated with anakinra 100 mg subcutaneously daily for 12 [2-12] weeks. Patients were stratified into two groups: LVEF 50-59% and LVEF ≥60%. At baseline and during treatment, patients underwent cardiopulmonary exercise testing and venipuncture to measure changes in peak oxygen consumption (peak VO2) and CRP. Categorical and continuous variables are expressed as N (%) and median (interquartile range) and were compared with the chi-square and Mann-Whitney test, respectively. The within-group paired differences were compared using the Wilcoxon signed-rank test. Results The cohort included 15 patients with LVEF 50-59% and 17 with LVEF ≥60%, without significant differences in age and sex between groups. In patients with LVEF 50-59% and ≥60%, baseline peak VO2 was 14.1 [13.1–17.3] and 13.8 [11.8-18.6] mLO2·kg-1·min-1, respectively (p = 0.82), and CRP was 6.2 [3.4-15.9] and 6.1 [3.7-17.6] mg/L, respectively (p = 0.74). A significant increase in peak VO2 (from 13.8 [11.8-18.6] to 15.8 [12.7-19.9] mLO2·kg-1·min-1, p = 0.033) and decrease in CRP (from 6.2 [3.4-15.9] mg/L to 3.4 [1.0-6.7] mg/L, p = 0.003) was seen in patients with LVEF ≥60%; whereas in those with LVEF 50-59% there were no significant changes in peak VO2 (from 14.1 [13.1–17.3] to 14.1 [11.0–17.3] mLO2·kg-1·min-1, p = 0.25) despite a significant reduction in CRP (from 6.1 [3.7-17.6] mg/L to 1.4 [0.8-11.4] mg/L, p = 0.016). We found a difference in the interval changes in peak VO2 (0 [from -1.1 to +0.3] vs +1.7 [from -0.7 to +2.3] mLO2·kg-1·min-1 in patients with LVEF 50-59% and ≥60%, respectively, p = 0.01), without differences in the interval change in CRP levels (–3.5 [from -6 to -2.1] vs –3.0 [from -11.4 to -2.1] mg/L, respectively, p = 0.91). Figure 1. Conclusions Patients with HFpEF demonstrate differential peak VO2 response to anakinra treatment based on resting LVEF, with those with a LVEF ≥60% showing greater improvement in CRF. Further randomized control trials are needed to validate these data and explore the potential underlying mechanisms.

Hypertonic saline induces inflammation in human macrophages through the NLRP1 inflammasome.

Nebulized hypertonic saline (3-7%) is commonly used to increase mucociliary clearance in patients with chronic airway disease and/or virus infections. However, altered salt concentrations may contribute to inflammatory responses. The aim of this study was to investigate whether 500 mM NaCl (3%) triggers inflammation in human macrophages and identify the molecular mechanisms involved. NaCl-induced pyroptosis, IL-1β, IL-18 and ASC speck release were measured in primary human monocyte-derived macrophages. Treatment with the recombinant IL-1 receptor antagonist anakinra or the NLRP3 inhibitor MCC950 did not affect NaCl-mediated inflammasome assembly. Knock-down of NLRP1 expression, but not of NLRP3 and NLRC4, reduced NaCl-induced pyroptosis, pro-inflammatory cytokine and ASC speck release from human THP-1-derived macrophages. Data from this study suggest that 3% NaCl-induced inflammatory responses in human macrophages depend on NLRP1 and inflammasome assembly. Targeting inflammation in addition to inhalation with hypertonic saline may benefit patients with inflammatory airway disease.

Targeting of Notch, IL-1, and leptin has therapeutic potential in xenograft colorectal cancer.

Colorectal cancer (CRC) is a fatal malignancy type and its occurence still needs to be explored mechanistically. Notch, IL-1, and leptin crosstalk is reported to play a role in the proliferation, migration, and expression of proangiogenic molecules. In this study, we aimed to investigate the effect of inhibition of Notch, IL-1, and leptin on CRC. To generate colorectal cancer tumor xenografts, 1 × 107 cells from exponentially growing cultures of HCT-15 cells were injected subcutaneously, at the axillary region of the left and right rear flanks of forty NOD.CB17-Prkdcscid/J (NOD/SCID) female mice. The mice were then monitored for the development of tumors and were randomly divided into five groups when tumor sizes reached a volume of approximately 150 mm3. Mice were used to determine the effectiveness of the gamma-secretase inhibitor (DAPT, Notch inhibitor), the interleukin-1 receptor antagonist (Anakinra) and the leptin receptor antagonist (Allo aca) against tumor growth. The mice were euthanized by CO2 inhalation immediately after the treatments finished, and all efforts were made to minimize suffering. Tumors were excissed for RT-PCR and histological analysis. There is an intact Notch, IL-1, and leptin signaling axis, and in vivo antagonism of Notch, IL-1, and leptin affects mRNA and protein expression of inflammatory and angiogenic molecules. Present data suggest that targeting Notch, IL-1, and leptin may be possesses therapeutic potential in CRC.

SIRT6 is an epigenetic repressor of thoracic aortic aneurysms via inhibiting inflammation and senescence

Thoracic aortic aneurysms (TAAs) develop asymptomatically and are characterized by dilatation of the aorta. This is considered a life-threating vascular disease due to the risk of aortic rupture and without effective treatments. The current understanding of the pathogenesis of TAA is still limited, especially for sporadic TAAs without known genetic mutation. Sirtuin 6 (SIRT6) expression was significantly decreased in the tunica media of sporadic human TAA tissues. Genetic knockout of Sirt6 in mouse vascular smooth muscle cells accelerated TAA formation and rupture, reduced survival, and increased vascular inflammation and senescence after angiotensin II infusion. Transcriptome analysis identified interleukin (IL)-1β as a pivotal target of SIRT6, and increased IL-1β levels correlated with vascular inflammation and senescence in human and mouse TAA samples. Chromatin immunoprecipitation revealed that SIRT6 bound to the Il1b promoter to repress expression partly by reducing the H3K9 and H3K56 acetylation. Genetic knockout of Il1b or pharmacological inhibition of IL-1β signaling with the receptor antagonist anakinra rescued Sirt6 deficiency mediated aggravation of vascular inflammation, senescence, TAA formation and survival in mice. The findings reveal that SIRT6 protects against TAA by epigenetically inhibiting vascular inflammation and senescence, providing insight into potential epigenetic strategies for TAA treatment.

Un caso di pericardite recidivante colchicina-resistente

A 9-year-old boy affected by colchicine-resistant idiopathic pericarditis was successfully treated with an IL-1 receptor antagonist (anakinra).

Diagnostic and therapeutic difficulties in PFAPA: a case report

Recurrent fever syndromes are autoinflammatory diseases. In their pathogenesis, no autoantibodies or autoreactive T-lymphocytes are found. Innate immunity and adaptive immunity are of great importance in this case. In the mid-latitudes, the most common syndrome is periodic fever with aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA), which mainly affects children under 5 years of age. Fevers occur cyclically, on average every 26–36 days. Characteristic features of PFAPA include the absence of any symptoms between fever episodes and undisturbed growth and development of the child. In laboratory tests, during a fever episode, elevated white blood cell count and an increase in inflammatory markers are observed. The recommended treatment is the use of glucocorticoids. In some cases, the use of colchicine or even an interleukin-1 receptor antagonist (anakinra) may be considered. The aim of this paper is to present the case of a 3.5-year-old boy hospitalised in the Department of Paediatrics, Nephrology and Paediatric Allergology of the Military Institute of Medicine due to recurrent episodes of fever with enlarged lymph nodes, occurring at regular intervals, as well as to draw attention to the difficulties encountered during the diagnosis of recurrent febrile episodes.

Adult-onset Still’s disease

Adult-onset Still's disease (AOSD) is arare autoinflammatory disease characterized by intermittent fever and acombination of symptoms, such as an evanescent rash synchronous with fever, arthralgia/arthritis, lymphadenopathy and hepatosplenomegaly. The diagnosis is based on acharacteristic constellation of symptoms and the exclusion of infections, hemato-oncological diseases, infectious diseases and alternative rheumatological causes. The systemic inflammatory reaction is reflected by high levels of ferritin and C‑reactive protein (CRP). The pharmacological treatment concept includes glucocorticoids often in combination with methotrexate (MTX) and ciclosporine (CSA) for reduction of steroids. The interleukin 1 (IL-1) receptor antagonist anakinra, the IL-1beta antibody canakinumab or an IL‑6 receptor blockage with tocilizumab (off label for AOSD) are used where there is no response to MTX or CSA. Anakinra or canakinumab can be used as aprimary option in AOSD in cases of moderate and severe disease activity.

Design of a multicenter randomized clinical trial for treatment of Alcohol-Associated Hepatitis

BackgroundMortality is high for severe alcohol-associated hepatitis (AH). Corticosteroids are the standard of care for patients without contraindications. Recent data showed that interleukin-1β receptor antagonist anakinra attenuated inflammation and liver damage. We designed a multicenter, double-blind, randomized controlled trial to assess the safety and efficacy of anakinra compared to prednisone. MethodsPatients meeting the clinical and biochemical criteria for severe AH with MELD scores between 20 and 35 were recruited at eight clinical sites. Eligible patients enrolled in the study were randomized to anakinra, 100 mg subcutaneous injection for 14 days, plus zinc sulfate 220 mg for 90 days, vs. prednisone 40 mg PO daily for 30 days. Matching placebos for anakinra, zinc, and prednisone were provided to mask the treatment. Participants were followed for 180 days. The primary outcome was overall survival at 90 days. An unadjusted log-rank test was used to compare the survival of the two treatments in the first 90 days. Between July 10, 2020, and March 4, 2022, we screened 1082 patients with severe AH, and 147 eligible patients were enrolled and randomized. The average baseline MELD score was 25 [range 20–35], Maddrey discriminant function (MDF) was 59.4 [range 20.2–197.5]. The mean aspartate transaminase (AST)-to-alanine transaminase (ALT) ratio was 3.5. The baseline characteristics were not statistically different between the two treatment groups. ConclusionsThe study provided a direct comparison of the survival benefits and safety profiles of anakinra plus zinc vs. prednisone in patients with severe AH.

The challenges of multisystem inflammatory syndrome diagnosis and treatment

A two-year-old girl with fever, diarrhea and vomiting was presented to the Emergency Department (ED). A maculopapular rash on the face, cervical lymphadenopathy and 1st degree dehydration were being noted. Laboratory results showed leukocytosis, neutrophilia and a high level of C-reactive protein (CRP). Amoxicillin was prescribed, but the patient’s state did not improve. She returned to ED with rash all over her body and 2nd degree dehydration. Laboratory results revealed thrombocytopenia and a more increased level of CRP. It was found that her mother has been diagnosed with the coronavirus disease approximately two months ago. Extended laboratory results showed signs of mild anemia, increased levels of liver enzymes, procalcitonin, troponin, N-terminal prohormone of brain natriuretic peptide, D-dimers, ferritin. Anti-SARS-CoV-2 (severe acute respiratory syndrome-coronavirus) IgG (immunoglobulin G) were detected. Multisystem inflammatory syndrome was diagnosed. Pediatric echocardiography revealed 10 mm of fluids in pericardium, I degree mitral valve regurgitation, dilated left coronary artery. She was given a treatment with intravenous Immunoglobulin G, methylprednisolone and aspirin, but her state did not improve. A treatment with Tocilizumab was given, but it did not have a much more positive effect, laboratory results showed progressed leucocytosis and neutrophilia. As the last resort, biology treatment with a recombinant form of human interleukin-1 receptor antagonist Anakinra was started and after a week all symptoms changed, and laboratory results regressed.

Adult-onset Still's disease : Diagnosis and treatment according to the new S2e guidelines of the German Society of Rheumatology (DGRh)

Adult-onset Still's disease (AOSD) is arare autoinflammatory disease characterized by intermittent fever and acombination of symptoms, such as an evanescent rash synchronous with fever, arthralgia/arthritis, lymphadenopathy and hepatosplenomegaly. The diagnosis is based on acharacteristic constellation of symptoms and the exclusion of infections, hemato-oncological diseases, infectious diseases and alternative rheumatological causes. The systemic inflammatory reaction is reflected by high levels of ferritin and C‑reactive protein (CRP). The pharmacological treatment concept includes glucocorticoids often in combination with methotrexate (MTX) and ciclosporine (CSA) for reduction of steroids. The interleukin 1 (IL-1) receptor antagonist anakinra, the IL-1beta antibody canakinumab or an IL‑6 receptor blockage with tocilizumab (off label for AOSD) are used where there is no response to MTX or CSA. Anakinra or canakinumab can be used as aprimary option in AOSD in cases of moderate and severe disease activity.

The Impact of Cytokines in Coronary Atherosclerotic Plaque: Current Therapeutic Approaches.

Coronary atherosclerosis is a chronic pathological process that involves inflammation together with endothelial dysfunction and lipoprotein dysregulation. Experimental studies during the past decades have established the role of inflammatory cytokines in coronary artery disease, namely interleukins (ILs), tumor necrosis factor (TNF)-α, interferon-γ, and chemokines. Moreover, their value as biomarkers in disease development and progression further enhance the validity of this interaction. Recently, cytokine-targeted treatment approaches have emerged as potential tools in the management of atherosclerotic disease. IL-1β, based on the results of the CANTOS trial, remains the most validated option in reducing the residual cardiovascular risk. Along the same line, colchicine was also proven efficacious in preventing major adverse cardiovascular events in large clinical trials of patients with acute and chronic coronary syndrome. Other commercially available agents targeting IL-6 (tocilizumab), TNF-α (etanercept, adalimumab, infliximab), or IL-1 receptor antagonist (anakinra) have mostly been assessed in the setting of other inflammatory diseases and further testing in atherosclerosis is required. In the future, potential targeting of the NLRP3 inflammasome, anti-inflammatory IL-10, or atherogenic chemokines could represent appealing options, provided that patient safety is proven to be of no concern.