• adult onset still's disease
• DMARDs (synthetic)
• treatment

I was pleased to read the article by Kaneko and colleagues1 on the efficacy and safety of tocilizumab in patients with adult-onset Still’s disease, because the current information on its biologic efficacy has been mainly obtained from small retrospective case series and not from prospective randomised trials. The authors have presented a randomised controlled trial in which they suggest that tocilizumab is effective in adult-onset Still’s disease refractory to glucocorticoid treatment. Information on biologic therapy for the management of adult-onset Still’s disease is scarce. In this regard, there is a noteworthy issue. At present, the treatment of patients with adult-onset Still’s disease remains empirical.2 Corticosteroids are the cornerstones of the initial treatment, and conventional disease-modifying antirheumatic drugs (DMARDs), such as methotrexate, hydroxychloroquine, leflunomide, ciclosporin, tacrolimus and azathioprine, are generally used alone or in combination. DMARDs are effective means of inducing remission, lowering the risk of relapse and minimising glucocorticoid therapy and toxicity in adult-onset Still’s disease.3 Thus, DMARDs are therapeutic options in addition to the standard-of-care treatment with glucocorticoids for this disease.4 Biologic agents are generally used as the second-line treatment because of their high cost and potential toxicity.5 Biologics may be considered in case of failure of DMARDs to control the disease. Although adult-onset Still’s disease is a rare systemic inflammatory disorder, biologic therapy represents a major breakthrough in the management of patients with adult-onset Still’s disease refractory to DMARDs. For example, anakinra induced more beneficial responses than DMARDs did in patients with refractory adult-onset Still’s disease in a randomised study.6 However, there is no strong evidence regarding the comparative efficacy of tocilizumab and DMARDs in the management of adult-onset Still’s disease. Currently, no randomised trial has shown that tocilizumab is superior to DMARDs in treating adult-onset Still’s disease refractory to glucocorticoid treatment. Thus, treatment for adult-onset Still’s disease continues to be a challenge. Further randomised studies are warranted to determine the benefits of tocilizumab in terms of its glucocorticoid-sparing effect, remission and reduction in relapse, compared with DMARD therapy.