How Physicians Manage Colchicine-Resistant Familial Mediterranean Fever: Insights From a Multinational Survey in High-Prevalence Countries

Objective. This study aimed to investigate real-world clinical practices regarding biologic therapy in colchicine-resistant familial Mediterranean fever (FMF), focusing on treatment initiation, tapering, discontinuation strategies, and related challenges. Methods. A 29-item English-language survey was distributed to pediatric and adult rheumatologists via email. The target population consisted of rheumatologists from Türkiye, Israel, and Italy (countries with a high prevalence of FMF) as well as Germany, where migrants of eastern Mediterranean origin live. The survey addressed preferences for biologic agents, colchicine compliance, tapering strategies, injection-site reaction management, and responses to trigger-related attacks. Results. A total of 126 clinicians responded. In the absence of regulatory constraints, 72.2% preferred canakinumab for colchicine-resistant FMF. The majority (94.4%) considered the standard dose of 2 mg/kg/day sufficient. Gradual extension of dose intervals was the most common tapering strategy. Whereas canakinumab was often tapered to dosing intervals of every 3-4 months, anakinra was tapered by extending the dosing interval to weekly administration in some cases. More than half (53.9%) observed a decline in colchicine compliance after starting biologics. Although 51.7% and 53.3% reported full efficacy after restarting anakinra and canakinumab, respectively, some clinicians noted reduced responses. Adult rheumatologists were more likely than pediatricians to support lifelong biologic therapy and reported greater concerns regarding colchicine compliance. Conclusion. Pediatric rheumatologists tended to favor discontinuation of biologic therapy rather than lifelong use. On-demand use of biologics also emerged as a treatment approach among treating physicians. Issues such as colchicine compliance, disease-specific triggers, and the potential to maintain efficacy upon reintroduction of interleukin 1 inhibitors after discontinuation should be prioritized in future research.