Current evidence on switching between biologic therapies for Still's disease: A systematic literature review

Still's disease (SD) is increasingly being treated with biologic disease-modifying antirheumatic drugs (bDMARDs) according to a treat-to-target approach, with switching between these agents an integral part of this strategy. However, guidance for the clinician on switching between biologic agents in SD is limited. Here we review the evidence in the literature relating to switching between bDMARDs in SD.

A systematic review was performed for articles published since 2014 which related to the biologic treatment of SD. Case reports and studies with under 5 patients and non-English language publications were excluded. The resulting publications were reviewed for evidence on switching therapies between bDMARDs.

A total of 48 publications included for review included seven treatment guidelines, consensus statements, or best practice recommendations, and 41 publications of clinical trials, observational studies, registry studies, or case series. Interleukin (IL)-1 inhibitors are usually the recommended first-line biologics. Switching to another IL-1 inhibitor or an IL-6 inhibitor was recommended in cases of lack of tolerability, inadequate response or treatment failure. Tumour necrosis factor inhibitors and Janus kinase inhibitors were suggested for later lines of therapy. Clinical publications reported benefits of switching between bDMARDs in terms of attaining clinically inactive disease or remission, steroid-sparing effects, and reductions in treatment burden.

In patients with SD who are not meeting treatment targets, switching between bDMARDs can be a useful strategy associated with clinical benefits. However, specifically designed, controlled clinical trials (or in their absence, observational studies) are needed to determine optimal switching strategies.