May anakinra be used earlier in adult onset Still disease?

Interleukin-1 antagonist anakinra is increasingly used as third-line therapy in adult-onset Still disease (AoSD) after corticosteroids (CS) and immunosuppressive drugs have failed or have induced serious adverse effects. We recently had to use anakinra earlier in the course of AoSD in two patients. In both cases, the disease had a major social impact. One patient was a plane pilot, and he was forbidden to continue his job as long as he was on CS. He also had developed CS-induced central serous chorioretinopathy (CSC), and methotrexate did not allow a prompt reduction in the prednisone dosage. Anakinra had a dramatic effect and allowed the complete withdrawal of CS and methotrexate and the full remission of CSC, and the patient could pilot again. The doses of anakinra have been since then successfully reduced by two thirds. In the second case, AoSD occurred a few weeks before the patient’s A-level exams. The disease was resistant to prednisone 1 mg/kg for 15 days. Anakinra controlled all symptoms in 3 days and was stopped 3 months later. She has not relapsed since then. No adverse drug reaction has occurred. These cases suggest that a treatment by anakinra of short duration could be used early in AoSD to induce a prompt remission, to avoid the adverse effects of high dose CS and/or immunosuppressive drugs and to reduce the social impact of the disease.