Of the 47 patients who received anakinra (25 anakinra with dexamethasone), progression-free survival ensued for more than three years and in 8 patients for

more than 4 years 100. Patients with a decrease in serum CRP of 15% or greater after 6 months of anakinra monotherapy resulted in progression-free survival times greater than 3 years as compared with 6 months in patients with less than a 15% fall during anakinra therapy (p<0.002). Thus, an effective reduction in IL-1β activity using CRP as the marker for IL-1β-induced IL-6 halts progression to active myeloma. Anakinra results in resolution of all signs and symptoms within hours after the first injection. However, approximately 20% of patients with Schnitzler's syndrome develop a lymphoproliferative disorder, mostly lymphoma or Waldenstrom

disease, which is similar to patients with IgM MGUS. This latter point and its consequences have been already been addressed in the Decitabine purchase literature 101. Blocking IL-1β may reduce the progression to a lymphoproliferative disorder in patients with Schnitzler’s syndrome. Similar to smoldering myeloma, the concept that IL-1β drives IL-6 production was tested in a patient with another lymphoproliferative disorder, Castleman’s selleck compound disease, which is usually treated with anti-IL-6 receptor antibodies 102. The patient failed to respond to cladribine, rituximab, steroids, etanercept and anti-IL-6 antibody but within 1 wk of anakinra treatment, the constitutional symptoms markedly improved, and anemia, thrombocytosis, leukocytosis, and elevated markers of systemic inflammation reverted to normality 103. In cytokine biology as applied to the treatment of disease, associations of elevated circulating levels of a particular cytokine with a disease do not allow for a conclusion of causation by that cytokine for the pathological process. Rather, only specific

blockade or neutralization provides the evidence. This is especially 3-mercaptopyruvate sulfurtransferase the case with IL-1β, as circulating levels, even in severe systemic inflammatory diseases, are undetectable and yet the disease manifestations are dramatically reduced upon blockade of IL-1 activity. This commonly observed therapeutic response is due to the high specific activity of IL-1β, which can be in the picomolar range in humans. Therefore, establishing a role for IL-1β in inflammatory diseases has succeeded by using short-term IL-1β-blockade and its role and usefulness will likely increase with clinical testing, facilitated by the safety of short-acting anakinra and the availability of neutralizing anti-IL-1β antibodies. Supported by NIH Grants AI-15614, CA-04 6934 and JDRF 26-2008-893. The author thanks Antonio Abbate, Mihai Netea, Leo Joosten, Anna Simon and Jos van der Meer for many helpful suggestions in the preparation of this MS. Conflict of interest: The author declares no financial or commercial conflict of interest. This article is editorially independent of Novartis.