• Mounica Vallurupalli, Jean G MacFadyen, Robert J Glynn, Tom Thuren, Peter Libby, Nancy Berliner, and Paul M Ridker.
• Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (M.V., J.G.M., R.J.G., P.L., N.B., P.M.R.).
• Ann. Intern. Med. 2020 Apr 21; 172 (8): 523-532.

BackgroundInflammatory cytokines, such as interleukin (IL)-1β, alter iron homeostasis and erythropoiesis, resulting in anemia, but whether inhibition of IL-1β can reverse these effects is unclear.ObjectiveTo determine whether IL-1β inhibition with canakinumab reduces incident anemia and improves hemoglobin levels among those with prevalent anemia.DesignExploratory analysis of a randomized controlled trial. (ClinicalTrials.gov: NCT01327846).SettingMany clinical sites in 39 countries.Participants8683 CANTOS (Canakinumab Anti-inflammatory Thrombosis Outcomes Study) participants without anemia at trial entry and 1303 with prevalent anemia at trial entry.InterventionRandom assignment to receive placebo or canakinumab (50, 150, or 300 mg) subcutaneously once every 3 months.MeasurementsPrimary outcome was incident anemia (hemoglobin level <130 g/L in men or <120 g/L in women).ResultsAnemia incidence increased with rising baseline levels of high-sensitivity C-reactive protein (hsCRP), and both hsCRP and IL-6 decreased among participants receiving canakinumab compared with the placebo group. During a median follow-up of 3.7 years, participants without baseline anemia who received canakinumab at any dosage had significantly less incident anemia than those who received placebo (hazard ratio, 0.84 [95% CI, 0.77 to 0.93]; P < 0.001). Compared with placebo, the greatest benefits of IL-1β inhibition on incident anemia were observed among participants with the most robust anti-inflammatory response, an effect corroborated in formal mediation analyses. Among those with baseline anemia, canakinumab increased mean hemoglobin levels by 11.3 g/L (P < 0.001) compared with placebo after 2 years of treatment. Canakinumab increased the risk for infection and was associated with mild cases of thrombocytopenia and neutropenia, none of which was grade 3 or higher.LimitationCANTOS was not designed to assess the cause of anemia in individual trial participants.ConclusionThese exploratory analyses of randomized trial data provide proof of principle that inflammation inhibition, at least through the IL-1β/IL-6 signaling pathway, reduces the incidence of anemia and improves hemoglobin levels in patients with anemia.Primary Funding SourceNovartis Pharmaceuticals.

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