Aetna considers Kineret (anakinra) medically necessary for following indications where the member has a documented negative TB test (which can include a tuberculosis skin test (PPD), an interferon-release assay (IGRA), or a chest x-ray) within 6 months of initiating therapy for persons who are naiive to biologics, and repeated yearly for members with risk factors* for TB that are continuing therapy with biologics:
Note: This note applies to the use of anakinra for rheumatoid arthritis. There are several brands of targeted immune modulators on the market. There is a lack of reliable evidence that any one brand of targeted immune modulator is superior to other brands for medically necessary indications. Enbrel (etanercept), Humira (adalimumab), Remicade (infliximab), Simponi Aria (golimumab intravenous) and Stelara (ustekinumab) brands of targeted immune modulators ("least cost brands of targeted immune modulators") are less costly to Aetna. Consequently, because other brands (e.g., Actemra (tocilizumab), Cimzia (certolizumab), Cosentyx (secukinumab), Entyvio (vedolizumab), Kineret (anakinra), Otezla (apremilast), Orencia (abatacept), Rituxan (rituximab), Simponi (golimumab), and Xeljanz (tofacitinib)) of targeted immune modulators are more costly than these least cost brands of targeted immune modulators, and least cost brands of targeted immune modulators are at least as likely to produce equivalent therapeutic results, no other brands of targeted immune modulator will be considered medically necessary unless the member has a contraindication, intolerance or incomplete response to at least 2 of the least cost brands of targeted immune modulator: Enbrel, Humira, Remicade, Simponi Aria, or Stelara, for the same medically necessary indication. If the least costly targeted immune modulator does not have the labeled indication (see appendix), then Aetna considers medically necessary another brand of targeted immune modulator that has the required labeling indication.
Aetna considers anakinra experimental and investigational for persons with active infections because its safety in active infections has not been established.
Aetna considers anakinra experimental and investigational for use in combination with TNF blocking agents (e.g., Enbrel (etanercept) or Remicade (infliximab)) because the safety and effectiveness of such combination therapy has not been established.
Aetna considers anakinra experimental and investigational for all other indications, including any of the following diseases/disorders (not an all-inclusive list), because the safety and effectiveness of anakinra for these indications has not been established.
* Risk factors for TB include: persons with close contact to people with infectious TB disease; persons who have recently emigrated from areas of the world with high rates of TB (e.g., Africa, Asia, Eastern Europe, Latin America, and Russia); children less than 5 years of age who have a positive TB test; groups with high rates of TB transmission (e.g., homeless persons, injection drug users, and persons with HIV infection); persons who work or reside with people who are at an increased risk for active TB (e.g., hospitals, long-term care facilities, correctional facilities, and homeless shelters) (CDC, 2012).
The U.S. Food and Drug Administration (FDA) approved Amgen Inc.’s Kineret (anakinra) for the treatment of moderately to severely active rheumatoid arthritis (RA) in adult patients who have failed 1 or more disease-modifying anti-rheumatic drugs (DMARDs).
Anakinra inhibits inflammation and pain by selectively blocking the protein interleukin-1, which is in excess in RA patients. Interleukin-1 production is induced in response to inflammatory stimuli and mediates various physiologic responses including inflammatory and immunological responses. Interleukin-1 has a broad range of activities including cartilage degradation by its induction of the rapid loss of proteoglycans, as well as stimulation of bone resorption. Anakinra blocks the biologic activity of interleukin-1 by competitively inhibiting interleukin-1 binding to the interleukin-1 type I receptor, which is expressed in a wide variety of tissues and organs.
The effectiveness of anakinra was evaluated in 3 randomized placebo-controlled clinical trials involving 1,392 adults (greater than or equal to18 years of age) with moderate to severe RA. Patients assigned to anakinra had significant reductions in signs and symptoms of the disease compared to patients assigned to placebo. After 6 months of treatment, 38 % of anakinra-treated patients and 22 % of placebo-treated patients showed at least a 20 % improvement in the symptoms of disease, as assessed by the American College of Rheumatology response criteria. The criteria include the number of swollen and tender joints, pain and a physician assessment of overall disease.
The recommended dose of anakinra for the treatment of patients with RA is 100 mg/day administered daily by subcutaneous injection. Higher doses did not result in a higher response.
A systematic review of the evidence for targeted immune modulators by the Drug Evaluation Review Project (Thaler et al, 2012) found a lack of reliable evidence to determine the comparative effectiveness of anakinra to other targeted immue modulators for rheumatoid arthritis. The review stated that indirect comparisons of placebo-controlled randomized controlled trials suggest that etanercept is statistically significantly more efficacious than anakinra, infliximab, tocilizumab and adalimumab for rheumatoid arthritis. No statistically significant differences in efficacy could be detected among adalimumab, anakinra, infliximab, and tocilizumab for rheumatoid arthritis.
Patients receiving anakinra may experience a decrease in neutrophil counts. In placebo-controlled studies, 8 % of patients receiving anakinra had decreases in neutrophil counts of at least 1 WHO toxicity grade compared with 2 % in the placebo control group. Six anakinra-treated patients (0.3 %) experienced neutropenia (neutrophil count less than or equal to 1 x 106/mm3). Therefore, the FDA-approved product labeling for anakinra recommends that neutrophil counts should be assessed prior to initiating anakinra treatment, and while receiving anakinra monthly for 3 months, and thereafter quarterly for a period up to 1 year.
There is some evidence from uncontrolled studies that juvenile RA may respond to anakinra (Lovell, 2004); controlled clinical studies are ongoing.
Use of Anakinra for Persons with Active Infections:
In clinical trials, anakinra was associated with a significantly greater incidence of serious infections (greater than 2 %) versus placebo (less than 1 %). Therefore, the literature states anakinra should not be used in patients with active infections, and should be discontinued if the patient develops a serious infection.
Combinational use of Anakinra and Tumor Necrosis Factor Blocking Agents:
Anakinra is indicated for use as monotherapy or in combination with other drugs except tumor necrosis factor (TNF)-blocking agents such as Enbrel (etanercept) or Remicade (infliximab).
Anakinra should not be used with other TNF blockers (e.g., etanercept, infliximab). Preliminary data has shown a higher rate of serious infection (7 %) and severe neutropenia (neutrophil count less than or equal to 1,000/mm3) (3 %) when anakinra was used with etanercept than when anakinra was used alone.
In a randomized controlled study, Genovese et al (2004) studied the potential for additive or synergistic effects of combination therapy with etanercept and anakinra in 244 patients in whom RA was active despite methotrexate therapy. Patients were treated with subcutaneous etanercept only (25 mg twice-weekly), full-dosage etanercept (25 mg twice-weekly) plus anakinra (100 mg/day), or half-dosage etanercept (25 mg once-weekly) plus anakinra (100 mg/day) for 6 months. Combination therapy with etanercept plus anakinra provided no treatment benefit over etanercept alone, regardless of the regimen, but was associated with an increased safety risk. The authors concluded that combination therapy with etanercept and anakinra provides no added benefit and an increased risk compared with etanercept alone and is not recommended for the treatment of patients with RA.
Ankylosing Spondylitis, Inflammatory Bowel Disease and Reactive Arthritis:
The U.S. Pharmacopoeial Convention (2003) concluded that "[t]here is insufficient data to establish the safety and efficacy of anakinra for the treatment of reactive arthritis, inflammatory bowel disease and ankylosing spondylitis"
Anakinra is being investigated in the treatment of severe refractory lupus arthritis. Current available evidence is limited to case reports and small case series (Ostendorf et al, 2005; Moosig et al, 2004).
In a prospective, multi-center study, Chevalier et al (2005) examined the safety of intra-articular (IA) injections of anakinra in patients with knee osteoarthritis (OA). Six doses of anakinra (0.05 to 150 mg) were considered, and the trial was double-blinded regarding the dose administered. Patients with symptomatic knee OA and without synovial fluid effusion were included. Acute inflammatory reaction (the primary endpoint defining intolerance) was recorded if pain increase over 30 mm on 100 mm visual analog scale and synovial fluid effusion occurred within 72 hours after the IA injection. As a secondary aim, effectiveness was estimated (by total pain and Western Ontario and McMaster University OA functional index [WOMAC]) until the 3rd month. One patient received 0.05 mg and 13 patients received 150 mg of anakinra. No acute reaction occurred (1 patient experienced post-injection joint swelling with no pain) and the 150-mg dose was considered the maximum tolerated dose (intolerance level 0 %; confidence interval [CI]: 0 to 9.1 %). A significant improvement was still observed until the 3rd month in the 13 patients who received 150 mg anakinra: pain improved by -20.4 +/- 23.3 mm (p = 0.008) and WOMAC global score by -19.5 +/- 20.1 (p = 0.005). The authors concluded that IA injection of anakinra in patients with knee OA was well-tolerated and did not induce any acute inflammatory reaction. The feasibility of such IA injections of anakinra opens a promising therapeutic perspective for patients with OA.
In a multi-center, double-blind, placebo-controlled study, Chevalier and colleagues (2009) evaluated the clinical response, safety, and tolerability of a single IA injection of anakinra in patients with symptomatic OA of the knee. Patients with OA of the knee were randomized 2:1:2 to receive a single IA injection of placebo, 50-mg anakinra, or 150-mg anakinra in their symptomatic knee. Patients were evaluated for 12 weeks post-injection. The primary end point was the change in the WOMAC score from baseline to week 4. Safety assessments included the evaluation of adverse events (AEs), laboratory tests, and vital signs. Pharmacokinetic parameters were assessed in a subset of patients. Of 170 patients who enrolled, 160 (94 %) completed the study. The mean improvements from baseline to week 4 in the WOMAC score were not statistically different between the placebo group and the patients who received 50-mg anakinra (p = 0.67) or 150-mg anakinra (p = 0.77). Anakinra was well-tolerated. No withdrawals due to AEs or serious AEs, and no serious infections or deaths were reported. No clinically significant trends were noted in laboratory values or vital signs. Pharmacokinetic parameters demonstrated that the mean terminal half-life of anakinra in serum after IA injection was approximately 4 hours. The authors concluded that anakinra was well-tolerated as a single 50-mg or 150-mg IA injection in patients with OA of the knee. However, anakinra was not associated with improvements in OA symptoms compared with placebo.
Systemic Lupus Erythematosus:
In a review on systemic lupus erythematosus, D'Cruz and colleagues (2007) noted that there is a range of new therapeutic approaches including biological agents (e.g., anakinra) that are being examined in animal studies or clinical trials.
In a double-blind, parallel-group, clinical study, Larsen and colleagues (2007) examined the effects of anakinra in patients with type 2 diabetes mellitus. A total of 70 patients were randomly assigned into 2 groups: (i) 34 received 100 mg of subcutaneous anakinra once-daily for 13 weeks, and (ii) 36 received placebo. At baseline and at 13 weeks, all patients underwent an oral glucose-tolerance test, followed by an intravenous bolus of 0.3 g of glucose per kilogram of body weight, 0.5 mg of glucagon, and 5 g of arginine. In addition, 35 patients underwent a hyperinsulinemic-euglycemic clamp study. The primary end point was a change in the level of glycated hemoglobin, and secondary end points were changes in beta-cell function, insulin sensitivity, and inflammatory markers. At 13 weeks, in the anakinra group, the glycated hemoglobin level was 0.46 percentage point lower than in the placebo group (p = 0.03); C-peptide secretion was enhanced (p = 0.05), and there were reductions in the ratio of pro-insulin to insulin (p = 0.005) and in levels of interleukin-6 (p < 0.001) and C-reactive protein (p = 0.002). Insulin resistance, insulin-regulated gene expression in skeletal muscle, serum adipokine levels, and the body-mass index were similar in the 2 groups. Symptomatic hypoglycemia was not observed, and there were no apparent drug-related serious adverse events. The authors concluded that the findings of this study suggested that antagonism of interleukin-1 with anakinra has possible therapeutic potential in the treatment of type 2 diabetes mellitus. They noted that further studies are needed to test higher doses of anakinra, to evaluate its long-term use, and to test interleukin-1 antagonists that have a prolonged half-life, with the aim of preventing beta-cell destruction and promoting beta-cell regeneration in type 2 diabetes. The author of an accompanying editorial (Rothman, 2007) cautioned that although anakinra treatment led to a modest improvement in the control of glycemia, the maximal effect was at 4 weeks but with an upward trend in the glycated hemoglobin level at 13 weeks. The editorialist also noted that, since the patients varied with respect to baseline blood glucose control and type of concomitant treatment, it is difficult to deduce the effectiveness of anakinra therapy in various stages of disease.
Boerschmann et al (2010) reviewed 4 recent immuno-intervention trials in patients with type 1 diabetes mellitus (T1DM); (i) the Pre-POINT study is a primary prevention trial that will test whether vaccination with oral or nasal insulin can prevent the progression of islet autoimmunity and of T1DM in autoantibody-negative children who are genetically at high diabetes risk; (ii) the Cord Blood study is a tertiary trial that will investigate whether administration of autologous umbilical cord blood to children with T1DM can lead to regeneration of pancreatic islet insulin-producing beta-cells and improved blood glucose control; (iii) the GAD Vaccination study will test whether vaccination with alum-formulated rhGAD65 (recombinant human glutamic acid decarboxylate) can preserve beta-cell function in 320 children with newly diagnosed T1DM; and (iv) the AIDA study will test the beta-cell protective effect of interleukin-1 (IL-1) receptor antagonist anakinra in 80 patients with T1DM.
Moran and colleagues (2013) examined if canakinumab or anakinra improved β-cell function in recent-onset T1DM. These researchers performed 2 randomized, placebo-controlled trials in 2 groups of patients with recent-onset T1DM and mixed-meal-tolerance-test-stimulated C peptide of at least 0.2 nM. Patients in the canakinumab trial were aged 6 to 45 years and those in the anakinra trial were aged 18 to 35 years. Patients in the canakinumab trial were enrolled at 12 sites in the U.S. and Canada and those in the anakinra trial were enrolled at 14 sites across Europe. Participants were randomly assigned by computer-generated blocked randomization to subcutaneous injection of either 2 mg/kg (maximum 300 mg) canakinumab or placebo monthly for 12 months or 100 mg anakinra or placebo daily for 9 months. Participants and carers were masked to treatment assignment. The primary end-point was baseline-adjusted 2-hr area under curve C-peptide response to the mixed meal tolerance test at 12 months (canakinumab trial) and 9 months (anakinra trial). Analyses were by intention-to-treat. Patients were enrolled in the canakinumab trial between Nov 12, 2010, and April 11, 2011, and in the anakinra trial between Jan 26, 2009, and May 25, 2011. A total of 69 patients were randomly assigned to canakinumab (n = 47) or placebo (n = 22) monthly for 12 months and 69 were randomly assigned to anakinra (n = 35) or placebo (n = 34) daily for 9 months. No interim analyses were done; 45 canakinumab-treated and 21 placebo-treated patients in the canakinumab trial; and 25 anakinra-treated and 26 placebo-treated patients in the anakinra trial were included in the primary analyses. The difference in C peptide area under curve between the canakinumab and placebo groups at 12 months was 0·01 nmol/L (95 % CI: -0.11 to 0.14; p = 0.86), and between the anakinra and the placebo groups at 9 months was 0·02 nmol/L (-0.09 to 0.15; p = 0.71). The number and severity of adverse events did not differ between groups in the canakinumab trial. In the anakinra trial, patients in the anakinra group had significantly higher grades of adverse events than the placebo group (p = 0.018), which was mainly because of a higher number of injection site reactions in the anakinra group. The authors concluded that canakinumab and anakinra were safe but were not effective as single immunomodulatory drugs in recent-onset T1DM.
In a pilot study, Abbate et al (2010) tested the safety and effects of IL-1 blockade with anakinra on left ventricular (LV) remodeling after acute myocardial infarction (AMI). A total of 10 patients with ST-segment elevation AMI were randomized to either anakinra 100 mg/day subcutaneously for 14 days or placebo in a double-blind fashion. Two cardiac magnetic resonance (CMR) imaging and echocardiographic studies were performed during a 10- to 14-week period. The primary end point was the difference in the interval change in the LV end-systolic volume index (LVESVi) between the 2 groups on CMR imaging. The secondary end points included differences in the interval changes in the LV end-diastolic volume index, and C-reactive protein levels. A +2.0 ml/m(2) median increase (inter-quartile range +1.0, +11.5) in the LVESVi on CMR imaging was seen in the placebo group and a -3.2 ml/m(2) median decrease (inter-quartile range -4.5, -1.6) was seen in the anakinra group (p = 0.033). The median difference was 5.2 ml/m(2). On echocardiography, the median difference in the LVESVi change was 13.4 ml/m(2) (p = 0.006). Similar differences were observed in the LV end-diastolic volume index on CMR imaging (7.6 ml/m(2), p = 0.033) and echocardiography (9.4 ml/m(2), p = 0.008). The change in C-reactive protein levels between admission and 72 hours after admission correlated with the change in the LVESVi (R = +0.71, p = 0.022). The authors concluded that in patients with ST-segment elevation AMI, IL-1 blockade with anakinra was safe and favorably affected by LV remodeling. They stated that if confirmed in larger trials, IL-1 blockade might represent a novel therapeutic strategy to prevent heart failure after AMI.
Wollina and Haroske (2011) discussed clinical observations as well as therapeutic interventions of pyoderma gangraenosum. Pyoderma gangraenosum is one of the most common extra-intestinal manifestations of chronic inflammatory bowel disease. In multi-variate analyses, pyoderma gangraenosum was significantly and independently associated with black African origin, familial history of ulcerative colitis, uninterrupted pancolitis as the initial location of inflammatory bowel disease, permanent stoma, eye involvement and erythema nodosum. The treatment of choice for idiopathic pyoderma gangraenosum is systemic corticosteroids, but cyclosporine A, mycophenolate mofetil and TNF-alpha inhibitors have been successful to control pyoderma gangraenosum as second line or adjuvant options. In addition, small studies have been published with successful therapeutic intervention using alefacept, visilizumab, or anakinra but controlled trials are warranted.
Anterior Cruciate Ligament Injury:
In a randomized controlled pilot study, Kraus et al (2012) evaluated the clinical effectiveness of intra-articular IL-1 receptor antagonist (IL-1Ra) for anterior cruciate ligament (ACL) tear. A total of 11 patients with acute ACL tear confirmed by magnetic resonance imaging (MRI) were randomized to receive a single intra-articular injection of IL-1Ra (anakinra 150 mg, n = 6) or equal volume of saline placebo (1 ml, n = 5). The double-blinded treatment was administered a mean 2 weeks after injury. Synovial fluid (SF) (n = 9 patients) and sera (all patients) were available at baseline (prior to injection) and immediately prior to surgery (mean 35 days later) and analyzed for SF IL-1α, IL-1β, IL-1Ra and serum hyaluronan (HA), an indicator of synovial inflammation. The primary outcome, standardized Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire, was obtained at 0 (baseline), 4, and 14 days after injection. Compared with placebo, the IL-1Ra group had substantially greater improvement in key outcomes over 14 days (KOOS pain, p = 0.001; activities of daily living, p = 0.0015; KOOS sports function, p = 0.0026; KOOS quality of life (QOL), p = 0.0048; and total KOOS, p < 0.0001). There were no adverse reactions in either group. SF IL-1α (p = 0.05) and serum HA (p = 0.03), but not IL-1β, or IL-1Ra, decreased significantly in the IL-1Ra but not the placebo-treated patients. Compared with placebo, IL-1α was borderline significantly different in the IL-1Ra-treated group (p = 0.06). The authors concluded that administered within the first month following severe knee injury, IL-1Ra reduced knee pain and improved function over a 2-week interval. They stated that this promising proof of concept study provides a new paradigm for studies of acute joint injury and suggests that a larger follow-up study is warranted.
Fatigue Associated with Sjogren's Syndrome:
Fatigue is a major cause of disability in primary Sjogren's syndrome (pSS). Fatigue has similarities with sickness behavior in animals; the latter mediated by pro-inflammatory cytokines, in particular IL-1, acting on neuronal brain cells. Norheim et al (2012) hypothesised that IL-1 inhibition might improve fatigue in pSS patients. These investigators examined the effects and safety of anakinra on fatigue. A total of 26 pSS patients participated in a double-blind, placebo-controlled parallel group study. Patients were randomized to receive either anakinra or a placebo for 4 weeks. Fatigue was evaluated by a fatigue visual analog scale (VAS) and the Fatigue Severity Scale. The primary outcome measure was a group-wise comparison of the fatigue scores at week 4, adjusted for baseline values. Secondary outcome measures included evaluation of laboratory results and safety. The proportion of patients in each group who experienced a 50 % reduction in fatigue was regarded as a post-hoc outcome. All outcomes were measured at week 4. There was no significant difference between the groups in fatigue scores at week 4 compared to baseline after treatment with anakinra. However, 6 out of 12 patients on anakinra versus 1 out of 13 patients on the placebo reported a 50 % reduction in fatigue VAS (p = 0.03). There were 2 serious adverse events in each group. The authors concluded that this randomized, double-blind, placebo-controlled trial of IL-1 blockade did not find a significant reduction in fatigue in pSS in its primary endpoint. A 50 % reduction in fatigue was analysed post-hoc, and significantly more patients on the active drug than on placebo reached this endpoint. Although not supported by the primary endpoint, this may indicate that IL-1 inhibition influences fatigue in patients with pSS.
Zong and colleagues (2014) performed a mechanistic study on the effect of anakinra in patients with refractory myositis and explored possible predictive biomarkers. A total of 15 patients with refractory myositis were treated with anakinra for 12 months. Clinical response was assessed by the 6-item core set measures of disease activity International Myositis Assessment and Clinical Studies (IMACS) and functional index (FI). Repeated muscle biopsies were investigated for cellular infiltrates, IL-1α, IL-1β, IL-1Ra and major histocompatibility complex-class I by immunohistochemistry. Serum levels of IL-1Ra and granulocyte colony-stimulating factor (G-CSF) were measured by ELISA. T-cell phenotype and functional assays were investigated by multi-color flow cytometry. Seven patients had clinical response according to IMACS, 4 of them also showed improved FI. Responders had higher baseline extra-muscular score compared with non-responders. In muscle biopsies, baseline CD163 macrophages and IL-1α expression were inversely correlated with muscle performance after 6 months treatment; all responders had IL-1Ra expression in the post-treatment biopsies but only 3/8 non-responders. In serum, IL-1Ra levels were increased and G-CSF was decreased after 6 months treatment, but their levels and changes were not related to clinical response. For T cells, an inverse correlation between baseline frequency of CD4 activated/memory T cells and decreased creatine kinase levels was observed. Five of 6 patients demonstrated less IL-17A and more IFN-γ secreting CD4 T cells after 6 months treatment. Moreover, anakinra reduced IL-17A secretion in-vitro. The authors concluded that patients with myositis may respond to anakinra. Extra-muscular score, muscle CD163 macrophages and IL-1α expression, blood CD4 activated/memory T cells might associate with anakinra treatment response. These preliminary findings need to be validated by well-designed studies.
Furthermore, an UpToDate review on “Treatment of recurrent and resistant dermatomyositis and polymyositis in adults” (Miller and Rudnicki, 2013) does not mention anakinra as a therapeutic option.
Adult-Onset Still's Disease:
Nordstrom et al (2012) examined the effectiveness of anakinra versus (DMARD in refractory adult-onset Still's disease (AOSD). In a 24-week study, 22 patients with AOSD taking prednisolone greater than or equal to 10 mg/day received anakinra (n = 12) or DMARD (n = 10). The primary end-point was achievement of remission. At 8 and 24 weeks, 7/12 and 6/12 receiving anakinra and 5/10 and 2/10 receiving DMARD achieved remission. Anakinra induced greater improvement in physical health measured by Medical Outcomes Study Short-Form 36 (SF-36; p < 0.011). During an open-label extension (OLE) of 28 weeks, 7/14 patients taking anakinra and 2/3 taking DMARD were in remission. The authors concluded that anakinra induced more beneficial responses than DMARD in patients with AOSD and was favored in the OLE phase.
Giampietro et al (2013) stated that anakinra is effective in AOSD in the short-term, but little is known regarding its effectiveness over the long-term. These researchers assessed the long-term safety and effectiveness of anakinra in AOSD. A nationwide survey was conducted between 2009 and 2010 to identify AOSD patients treated with anakinra. Collected data consisted of disease characteristics at diagnosis and at medication onset; anakinra efficacy, safety, and dose adaptation; and reasons for discontinuation, if applicable. The study included 28 AOSD patients, with a mean age of 40.3 years, and a mean disease-duration at the start of anakinra of 9.3 years. All patients had previously failed to respond to steroids and DMARDs. All patients responded to anakinra, with a rapid and sustained decrease in steroid doses. At the last follow-up (mean of 23 months), 16 patients were still being treated with anakinra: 4 had a partial response and 12 were in complete remission. Twelve patients had discontinued anakinra: 2 due to an insufficient response, 4 due to an AOSD flare after a period of complete remission, 2 due to side effects, and 1 due to a desire for pregnancy. In 3 patients, the drug discontinuation was possible because they achieved complete remission. Six additional patients experienced anakinra dose tapering, with sustained remission in 2 and relapse in the others. Anakinra was well-tolerated and adverse events were rated as mild. The authors concluded that anakinra was consistently effective in AOSD and displayed good therapeutic maintenance. Anakinra dose-tapering or discontinuation was associated with relapse in 50 % of the patients.
Iliou et al (2013) described the clinical manifestations, laboratory abnormalities and treatment of AOSD in Greek patients. This was a retrospective observational study. A total of 44 patients, diagnosed with AOSD, followed since 1985 up to June 2011, were included. The disease course and treatment were recorded and compared to previously published studies; 21 males and 23 females were identified. Mean age at diagnosis was 38.3 years. The most common clinical manifestations were fever (100 %), arthralgias (97.7 %), arthritis (93.2 %), salmon-colored rash (84 %), myalgias (50 %) and sore throat (38.6 %). Characteristic laboratory abnormalities were leucocytosis with neutrophilia (81.8 %), elevated C-reactive protein (100 %) and erythrocyte sedimentation rate (100 %). Elevated liver enzymes and hyper-ferritinemia were found in 50 % and in 59 % of the patients, respectively. Very high ferritin serum levels (greater than 5,000 μg/L) were found in 22.7 %. Rheumatoid factor and anti-nuclear antibodies were negative in all patients. Thirty patients (68.2 %) received NSAIDs or aspirin with or without corticosteroids. Response to corticosteroids was common (58.9 %). When this treatment was ineffective, a DMARD, usually methotrexate, was added with a response rate of 63.6 %. Anakinra was used in cases resistant to conventional immunosuppressive treatment. Ten out of 44 patients (22.7 %) were treated with anakinra and response was achieved in all of them. The authors concluded that these results regarding clinical manifestations and laboratory abnormalities were similar to those of previous reports. High ferritin serum levels were reported in all studies of AOSD and are considered as diagnostically valuable. When treatment with corticosteroids and DMARDS had failed, biologic agents such as anakinra were successfully applied.
An UpToDate review on “Treatment of adult Still's disease” (Mandl, 2014) states that “Resistant to first TNF inhibitor -- We use a second TNF inhibitor (as is often done in RA) or another class of agent (usually anakinra) in patients who do not respond adequately to high-dose glucocorticoids, MTX, and four to eight weeks of treatment with a TNF inhibitor. There are no comparative trials to indicate an advantage to one of these approaches in patients with ASD, and, in our experience, either of these strategies may be effective. Tocilizumab is an alternative to anakinra, especially in patients with chronic articular disease that is difficult to control or with evidence of erosive joint changes on plain radiographs or by magnetic resonance imaging, given the evidence of its efficacy in RA. However, there is less experience with this agent in ASD, and anakinra has a better adverse effect profile”.
Juvenile Idiopathic Arthritis:
Lequerre et al (2008) evaluated the safety and effectiveness of anakinra treatment in systemic-onset juvenile idiopathic arthritis (JIA). Of the 20 patients, only 5 achieved American College of Rheumatology 50 % improvement in symptoms response criteria at 6 months. Steroid dose had been decreased by 15 % to 78 % in 10 cases.
Gartlehner and colleagues (2008) stated that biologics are an important therapeutic option for treating patients with JIA. In adults, they are associated with rare but severe adverse events such as serious infections and malignancies. These researchers reviewed systematically the evidence on the safety and effectiveness of biologics for the treatment of JIA. They limited evidence to prospective studies for effectiveness, but included retrospective observational evidence for safety. Outcomes measures included clinical response, radiographical progression, quality of life, and adverse events. One randomized controlled trial (RCT) and 11 uncontrolled prospective studies provided data on effectiveness; 3 additional studies assessed safety. The only RCT and 6 uncontrolled trials support the general effectiveness of etanercept for the treatment of JIA. Internal and external validity of these studies are limited. The evidence on other biologic agents such as adalimumab, abatacept, anakinra, infliximab, rituximab, and tocilizumab is sparse or entirely missing. Because of the lack of sound long-term safety data, evidence is insufficient to draw firm conclusions about the balance of risks and benefits of any biologic agent for the treatment of JIA. Clinicians have to be aware of the lack of evidence supporting a long-term net benefit when considering biologics for patients with JIA.
Nigrovic and colleagues (2011) examined the safety and effectiveness of anakinra as first-line therapy for systemic JIA. Patients with systemic JIA receiving anakinra as part of initial DMARD therapy were identified from 11 centers in 4 countries. Medical records were abstracted using a standardized instrument, and resulting data were analyzed to characterize concomitant therapies, clinical course, adverse events, and predictors of outcome. Among 46 patients meeting inclusion criteria, anakinra monotherapy was used in 10 patients (22 %), while 67 % received corticosteroids and 33 % received additional DMARDs. Outcomes were evaluated at a median follow-up interval of 14.5 months. Fever and rash resolved within 1 month in greater than 95 % of patients, while C-reactive protein and ferritin normalized within this interval in greater than 80 % of patients. Active arthritis persisted at 1 month in 39 % of patients, at 3 months in 27 %, and at greater than 6 months of follow-up in 11 %. Approximately 60 % of patients, including 8 of 10 receiving anakinra monotherapy, attained a complete response without escalation of therapy. Disease characteristics and treatment were similar in partial and complete responders, except that partial responders were markedly younger at onset (median age of 5.2 years versus 10.2 years; p = 0.004). Associated adverse events included documented bacterial infection in 2 patients and hepatitis in 1 patient. Tachyphylaxis was not observed. The authors concluded that anakinra as first-line therapy for systemic JIA was associated with rapid resolution of systemic symptoms and prevention of refractory arthritis in almost 90 % of patients during the interval examined. These results justify further study of IL-1 inhibition as first-line, rather than rescue, therapy in systemic JIA.
The American College of Rheumatology’s update of the 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis (Ringold et al, 2013) provided the following recommendations;
The National Comprehensive Cancer Network's guideline on non-Hodgkin's lymphoma (NCCN, 2015) recommends anakinra as subsequent therapy as a single agent for multicentric Castleman's disease (CD) that has progressed following treatment of relapsed/refractory or progressive disease.
Schnitzler syndrome is a rare disorder in adults characterized by recurrent febrile rash, bone and/or joint pain, enlarged lymph nodes, fatigue, leukocytosis and systemic inflammatory response (Lipsker, 2011). A monoclonal IgM component is present in all cases. Rituximab, intravenous immunoglobulins, and TNF-blocking agents are mostly ineffective. In contrast, the IL-1 receptor antagonist anakinra relieves all symptoms within hours after the first injection, and a marked and immediate response to anakinra is supportive of the diagnosis.
Cryopyrin-Associated Periodic Syndromes (CAPS):
Neven et al (2010) stated that cryopyrin-associated periodic syndromes (CAPS) are a group of rare autoinflammatory diseases. Neonatal-onset multisystem inflammatory disease (NOMID)/chronic infantile neurologic, cutaneous, articular syndrome (CINCA syndrome) is the most severe phenotype, with fever, rash, articular manifestations, and neurologic and neurosensory involvement. CAPS are caused by mutations in CIAS1, the gene encoding NLRP3, which plays a critical role in interleukin-1 (IL-1) processing. Anakinra, an IL-1 receptor antagonist, has been shown to be an effective treatment; however, data on long-term efficacy and safety have been sparse. These investigators evaluated the long-term safety and effectiveness of anakinra treatment in patients with NOMID/CINCA syndrome. They retrospectively analyzed the medical records of NOMID/CINCA syndrome patients referred to 2 centers, who had started anakinra treatment before June 2007. There were 10 patients with NOMID/CINCA syndrome who had been treated with anakinra. The patients' ages at the time anakinra treatment was initiated ranged from 3 months to 20 years. They had been followed-up for 26 to 42 months. Sustained effectiveness in the treatment of systemic inflammation and, in some cases, neurologic involvement and growth parameters, was achieved. The dosage of anakinra required for effectiveness ranged from 1 to 3 mg/kg/day in the 8 oldest patients and from 6 to 10 mg/kg/day in the 2 youngest. Residual central nervous system inflammation and deafness persisted in some patients, especially if there had been a delay in diagnosis and treatment. Secondary amyloidosis persisted in cases in which it was present at treatment initiation, but no new lesions developed. No effect on over-growth arthropathy was observed. Adverse events consisted of mild injection-site reactions. The authors concluded that these findings indicated that anakinra treatment is effective over the long-term in NOMID/CINCA syndrome. However, treatment has to be initiated before irreversible lesions develop, and, particularly in very young patients, dosage adjustment is required.
Kuemmerle-Deschner et al (2011) stated that Muckle-Wells syndrome (MWS) is an inherited autoinflammatory disease caused by mutations in the NLRP3 gene that result in excessive IL-1 release. It is characterized by severe fevers, rashes, arthralgia, and conjunctivitis, leading to sensori-neural deafness and amyloidosis. The recombinant IL-1 receptor antagonist anakinra blocks the biologic activity of IL-1. These researchers determined the short- and long-term safety and effectiveness of anakinra therapy in children and adults with severe MWS. A single-center observational study was performed. Standardized assessments included clinical features, the Disease Activity Score (DAS) for MWS, classic and novel markers of inflammation, and patient-derived measures of health status. The primary outcome was a score of less than 10 on the DAS for MWS at 2 weeks and at the last follow-up visit. Measures of MWS disease activity were investigated using descriptive statistics and paired comparative analysis. A total of 12 patients with severe MWS (5 children and 7 adults) received anakinra for a median of 11 months (range of 5 to 14 months). The median follow-up was 11 months (range of 5 to 14 months). Disease activity was significantly lower in all patients at 2 weeks (p = 0.0005). Organ manifestations of MWS improved, as did all patient-derived measures of health status, markers of inflammation, and hearing loss in 2 of the patients. Levels of the novel neutrophil activation biomarker S100A12 followed clinical disease activity. Treatment was well-tolerated, and no serious adverse events were observed. The authors concluded that anakinra was found to be a safe and effective treatment of severe MWS, leading to a significant improvement in disease activity at 2 weeks as well as long-term. Anakinra therapy should therefore be considered in children and adults with severe MWS disease requiring IL-1 blockade.
Dhimolea (2011) noted that CAPS comprises a group of rare, but severe, inherited auto-inflammatory disorders associated with aberrant secretion of IL-1. These distinct conditions of auto-inflammatory origin include MWS, familial cold autoinflammatory syndrome, and neonatal-onset multisystem inflammatory disease (NOMID), which is also referred to as chronic infantile neurologic cutaneous and articular syndrome. Recently, this group of diseases has been associated with mutations in the NLRP3 gene that encodes for the protein cryopyrin, a component of the inflammasome complex that regulates the maturation and secretion of inflammatory cytokine IL-1β. Immune cells from patients with NOMID secrete higher levels of active IL-1β compared with monocytes from healthy subjects. Over-production of IL-1 is believed to promote aberrant inflammatory response in CAPS patients. The authors stated that evidence supporting the clinical value of IL-1β in CAPS has been provided from the complete response of patients after treatment with IL-1 blocking agents.
Sibley and colleagues (2012) stated that blocking IL-1 with anakinra in patients with the auto-inflammatory syndrome neonatal-onset multisystem inflammatory disease (NOMID) reduces systemic and organ-specific inflammation. However, the impact of long-term treatment has not been established. This study was undertaken to evaluate the long-term effect of anakinra on clinical and laboratory outcomes and safety in patients with NOMID. These researchers conducted a cohort study of 26 NOMID patients aged 0.80 to 42.17 years who were followed-up at the NIH and treated with anakinra 1-5 mg/kg/day for at least 36 months. Disease activity was assessed using daily diaries, questionnaires, and C-reactive protein level. Central nervous system (CNS) inflammation, hearing, vision, and safety were evaluated. Sustained improvements in diary scores, parent's/patient's and physician's global scores of disease activity, parent's/patient's pain scores, and inflammatory markers were observed (all p < 0.001 at 36 and 60 months). At 36 and 60 months, CNS inflammation was suppressed, with decreased cerebrospinal fluid white blood cell counts (p = 0.0026 and p = 0.0076, respectively), albumin levels, and opening pressures (p = 0.0012 and p < 0.001, respectively). Most patients showed stable or improved hearing. Cochlear enhancement on magnetic resonance imaging correlated with continued hearing loss. Visual acuity and peripheral vision were stable. Low optic nerve size correlated with poor visual field. Bony lesions progressed. Adverse events other than viral infections were rare, and all patients continued to receive the medication. The authors concluded that these findings indicated that anakinra provided sustained effectiveness in the treatment of NOMID for up to 5 years, with the requirement of dose escalation. Damage progression in the CNS, ear, and eye, but not bone, is preventable; anakinra was well-tolerated overall.
Miyamae (2012) stated that CAPS are a group of rare auto-inflammatory disorders; many cases of CAPS are caused by mutations in the NLRP3 gene. In these conditions, IL-1 is over-produced, and this over-production plays a major role in disease onset and progression. CAPS include 3 variants, ranging in order of increasing severity from familial cold auto-inflammatory syndrome, previously termed familial cold urticaria, through MWS, to CINCA syndrome, also known as NOMID. Diagnosis of CAPS is initially based on clinical manifestations and medical history, and later confirmed genetically. CAPS should be suspected when characteristic skin lesions, typical periodic fever episodes, bone/joint manifestations, and CNS involvement are recognized. The authors concluded that CAPS are life-long diseases, and early diagnosis and early treatment with IL-1-targeted therapies may improve prognosis.
Kone-Paut and Galeotti (2014) stated that CAPS is a very rare auto-inflammatory syndrome, which has recently served as a pure model of IL-1β-driven diseases. CAPS is caused by mutations into the NLRP3 gene that encodes cryopyrin, which serves as a receptor of the innate immunity that senses danger signals and pathogens. Constitutive activation of cryopyrin in CAPS leads to an excessive secretion of IL-1β. CAPS patients experience symptoms of systemic inflammation, intense fatigue and have poor quality of life. In the most severe forms, they may develop serious organ damage such as visual and hearing impairment, neurological deterioration and renal insufficiency. Anti-IL-1 drugs are effective in treating symptoms of almost all CAPS patients and have radically transformed their lives. These investigators described the history of the “revival” of CAPS patients through anti-IL-1 treatments with a special focus on anakinra, the first drug used in cohorts with variable disease severity and number of patients.
Paccaud e al (2014) noted that chronic infantile neurological cutaneous articular (CINCA) syndrome, also called neonatal onset multisystem inflammatory disease (NOMID) is a chronic disease with early onset affecting mainly the central nervous system, bones and joints and may lead to permanent damage. These researchers reported 2 preterm infants with severe CINCA syndrome treated by anti-IL-1 in the neonatal period, although, so far, no experience with this treatment in infants younger than 3 months of age has been reported. A review of the literature was performed with focus on treatment and neonatal features of CINCA syndrome. Two cases suspected to have CINCA syndrome were put on treatment with anakinra in the early neonatal period due to severe clinical presentation. These investigators observed a rapid and persistent decline of clinical signs and systemic inflammation and good drug tolerance. Diagnosis was confirmed in both cases by mutations in the NLRP3/CIAS1-gene coding for cryopyrin.. The authors concluded that they strongly suggested that specific treatment targeting IL-1 activity should be started early. Being well-tolerated, it can be introduced already in neonates presenting clinical signs of severe CINCA syndrome in order to rapidly control inflammation and to prevent life-long disability.
Headley et al (2014) stated that Muckle-Wells syndrome (MWS) is a member of the CAPS family of auto-inflammatory diseases, originally described as a triad of urticaria, sensorineural deafness and amyloidosis. Interleukin-1 blockade is a proven therapy for MWS. In this study, the clinical, laboratory and genotypic characteristics of a novel kindred of 5 individuals with Muckle-Wells syndrome were described. Response to IL-1 blockade therapy in the proband was evaluated. All 5 affected family members experienced symptoms of multi-organ inflammation. Lead time between symptom onset and diagnosis was approximately 30 years in the proband. Fever was not a universal feature in all affected family members. Anti-IL-1 therapy in the proband resulted in improvements in patient-reported symptoms, inflammatory markers, auditory acuity and reversal of her infertility. Muckle-Wells syndrome is a rare, multi-system, auto-inflammatory syndrome; delay in diagnosis prevents effective treatment.
Satoh et al (2015) noted that the bioactive form of IL-1β, a key immunoregulatory and proinflammatory cytokine, is produced by the inflammasome -- a caspase-1 activating molecular platform -- in response to selected danger-associated molecular patterns and pathogen-associated molecular patterns. Advances in understanding the role of IL-1β in inflammatory conditions has resulted in IL-1β becoming a therapeutic target for a number of inflammatory diseases beyond the rare monogenic autoinflammatory diseases characterized by aberrant inflammasome function and enhanced bioactive IL-1β production. In the monogenic autoinflammatory diseases known as CAPS, neutralization of IL-1β results in a rapid and sustained reduction in disease severity without severe side effects
Furthermore, an UpToDate review on “Cryopyrin-associated periodic syndromes and related disorders” (Nigrovic, 2015) states that “Three clinically overlapping, interleukin-1-associated, autoinflammatory disorders are known collectively as the cryopyrin-associated periodic syndromes (CAPS) or cryopyrinopathies: Familial cold autoinflammatory syndrome (FCAS), Muckle-Wells syndrome (MWS), and neonatal-onset multisystem inflammatory disorder (NOMID, also known as chronic infantile neurologic cutaneous and articular [CINCA] syndrome) …. In patients with familial cold autoinflammatory syndrome (FCAS), treatment with the IL-1 receptor antagonist, anakinra, given subcutaneously on a daily basis can prevent cold-induced attacks and markedly reduce daily symptoms. Among patients with renal secondary amyloidosis due to CAPS, anakinra has led to marked reductions in proteinuria and stabilization of serum creatinine. Treatment with anakinra can also control systemic inflammation in MWS, potentially with an effect on amyloid risk mediated through normalization of levels of serum amyloid A protein. The impact on hearing loss remains uncertain, but partial recovery has been reported. In NOMID/CINCA, treatment with anakinra has improved signs and symptoms related to inflammation in some, but not all, cases. Bone and joint abnormalities are less responsive to this agent”.
|Brand Name||Generic Name||FDA Labeled Indications|
Juvenile idiopathic arthritis
Systemic juvenile idiopathic arthritis
Juvenile idiopathic arthritis
Juvenile idiopathic arthritis
Juvenile idiopathic arthritis
|Simponi Aria||golimumab intravenous||Rheumatoid arthritis|
|CPT Codes / HCPCS Codes / ICD-9 Codes|
|There is no specific code for Kineret (Anakinra):|
|Other CPT codes related to the CPB:|
|71010 - 71035||Chest x-ray|
|86480||Tuberculosis test, cell mediated immunity antigen response measurement; gamma interferon|
|86481||Tuberculosis test, cell mediated immunity antigen response measurement; enumeration of gamma interferon – producing T cells in cell suspension|
|86580||Skin test; tuberculosis, intradermal|
|ICD-9 codes covered if selection criteria are met:|
|273.1||Monoclonal paraproteinemia [Schnitzler syndrome with documented monoclonal IgM gammopathy]|
|714.0||Rheumatoid arthritis [if the member has a contraindication, intolerance or incomplete response to at least 2 of the least cost brands of targeted immune modulators]|
|714.2||Other rheumatoid arthritis with visceral or systemic involvement [adult-onset Still's disease]|
|714.30 - 714.33||Juvenile chronic polyarthritis|
|759.89||Other specified congenital anomalies [neonatal-onset multisystem inflammatory disease (NOMID)]|
|785.6||Enlargement of lymph nodes [Castleman's disease]|
|ICD-9 codes not covered for indications listed in the CPB:|
|001.0 - 139.8||Infectious and parasitic diseases|
|249.00 - 250.93||Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled or uncontrolled|
|274.00 - 274.9||Gout|
|359.71 - 359.9||Inflammatory and immune myopathies, NEC|
|410.00 - 410.92||Acute myocardial infarction|
|412||Old myocardial infarction|
|428.0 - 428.9||Heart failure|
|555.0 - 555.9||Regional enteritis [Crohn's disease]|
|556.0 - 556.9||Ulcerative colitis|
|710.0||Systemic lupus erythematosus|
|710.2||Sicca syndrome [Sjögren's disease]|
|711.00 - 711.99||Arthropathy associated with infections|
|713.1||Arthropathy associated with gastrointestinal conditions other than infections|
|715.00 - 715.98||Osteoarthrosis and allied disorders|
|729.1||Myalgia and myositis, unspecified|
|780.79||Other malaise and fatigue [associated with Sjögren's syndrome]|
|844.2||Sprains and strains of cruciate ligament of knee|
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|There is no specific code for Kineret (Anakinra):|
|Other CPT codes related to the CPB:|
|71010 - 71035||Chest x-ray|
|86480||Tuberculosis test, cell mediated immunity antigen response measurement; gamma interferon|
|86481||Tuberculosis test, cell mediated immunity antigen response measurement; enumeration of gamma interferon – producing T cells in cell suspension|
|86580||Skin test; tuberculosis, intradermal|
|ICD-10 codes covered if selection criteria are met:|
|D47.2||Monoclonal gammopathy [Schnitzler syndrome with documented monoclonal IgM gammopathy]|
|M05.00 - M06.9||Rheumatoid arthritis [if the member has a contraindication, intolerance or incomplete response to at least 2 of the least cost brands of targeted immune modulators]|
|M08.00 - M08.99||Juvenile arthritis|
|Q87.89||Other specified congenital malformation syndromes, not elsewhere classified [neonatal-onset multisystem inflammatory disease (NOMID)]|
|R59.0 - R59.9||Enlargement of lymph nodes [Castleman’s disease]|
|ICD-10 codes not covered for indications listed in the CPB:|
|A00.0 - B99.9||Infectious and parasitic diseases|
|E08.00 - E13.9||Diabetes mellitus|
|G72.41 - G72||Inflammatory and immune myopathies, NEC|
|I21.01 - I22.9||ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardinal infarction|
|I25.2||Old myocardial infarction|
|I50.1 - I50.9||Heart failure|
|K50.00 - K50.919||Crohn's disease|
|K51.00 - K51.919||Ulcerative colitis|
|M00.00 - M01.x9||Infectious arthropathies|
|M02.00 - M02.9||Postinfective and reactive arthropathies|
|M1a.00x+ - M10.9||Gout|
|M15.0 - M19.93||Osteoarthritis|
|M32.0 - M32.9||Systemic lupus erythematosus (SLE)|
|M35.00 - M35.09||Sicca syndrome [Sjögren]|
|M45.0 - M45.9||Ankylosing spondylitis|
|M60.0 - M60.9||Myositis|
|R53.81, R53.83||Other malaise and fatigue [associated with Sjögren's syndrome]|
|S83.501+ - S83.529+||Sprain of cruciate ligament of knee|