Treatment of Adult-Onset Still's Disease with Prior Tuberculosis

Introduction to Treatment Guidelines

• The American College of Rheumatology recommends methotrexate + low-dose glucocorticoids as first-line therapy for Adult-Onset Still's Disease (AOSD) 1, 2, 4
• The European League Against Rheumatism suggests that biologic agents, such as anakinra, canakinumab, and tocilizumab, are preferred for AOSD treatment when safe to use 1, 2, 4, 5

Tuberculosis Considerations

• The Centers for Disease Control and Prevention guidelines state that anakinra and other biologic agents carry a substantial risk for tuberculosis reactivation and new infections 1, 2
• The American Thoracic Society recommends that cyclosporine does not carry the same magnitude of tuberculosis reactivation risk as biologic agents 1, 2, 3

Treatment Hierarchy

• The treatment algorithm positions methotrexate + glucocorticoids as first-line therapy, followed by biologic agents, and then cyclosporine as a second-line agent 1, 2, 4
• The American College of Rheumatology recommends reserving cyclosporine for biologic failures 1, 2

Safety Considerations

• The Centers for Disease Control and Prevention guidelines state that tuberculosis reactivation can be life-threatening and outweighs the benefit of faster AOSD control 8
• The American Association for the Study of Liver Diseases recommends monitoring for hepatitis B reactivation with any immunosuppression 1, 2, 7

Special Considerations

• The American College of Rheumatology suggests that anakinra could potentially be used in patients with prior tuberculosis only if certain conditions are met, including completed tuberculosis treatment, negative latent TB testing, and initiated TB prophylaxis 8
• The European League Against Rheumatism recommends high-dose glucocorticoids + IL-1 inhibitors for life-threatening AOSD complications, such as Macrophage Activation Syndrome (MAS) 9