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Pagnini I, Bertini F, Cimaz R. Difficult-To-Treat Juvenile Idiopathic Arthritis: Current and Future Options. Paediatr Drugs 2016; 18:101-8. [PMID: 26939782 DOI: 10.1007/s40272-016-0164-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in childhood and is usually treated with non-steroidal anti-inflammatory drugs or disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate or sulfasalazine. However, not all patients respond to these treatments, and toxicities may limit long-term use or diminish compliance. With advances in pharmacotherapy and the development of new therapeutic agents, there have been improvements in treatment of both systemic and non-systemic JIA, particularly with biologic agents such as anti-tumor necrosis factor (TNF)-α, anti-interleukin (IL)-1, and anti-IL6. Anti-cell therapies, such as co-stimulator blockers or anti-CD20, small molecules, and biosimilars represent new areas of interest, and, while many are not yet currently commercially available for use in children, preliminary studies appear to be promising. In the present article, the authors review therapeutic strategies for the different JIA subtypes, mainly according to guidelines and recommendations. Newer and possible future treatments for arthritis, already approved in adults but currently under study in children, are also discussed. Drugs currently in development plans for rheumatoid arthritis, which hopefully will also be useful for JIA patients in the future, are also mentioned in this paper.
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Taddio A, Cattalini M, Simonini G, Cimaz R. Recent advances in the use of Anti-TNFα therapy for the treatment of juvenile idiopathic arthritis. Expert Rev Clin Immunol 2016; 12:641-9. [DOI: 10.1586/1744666x.2016.1146132] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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203
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Ruperto N, Pistorio A, Oliveira S, Zulian F, Cuttica R, Ravelli A, Fischbach M, Magnusson B, Sterba G, Avcin T, Brochard K, Corona F, Dressler F, Gerloni V, Apaz MT, Bracaglia C, Cespedes-Cruz A, Cimaz R, Couillault G, Joos R, Quartier P, Russo R, Tardieu M, Wulffraat N, Bica B, Dolezalova P, Ferriani V, Flato B, Bernard-Medina AG, Herlin T, Trachana M, Meini A, Allain-Launay E, Pilkington C, Vargova V, Wouters C, Angioloni S, Martini A. Prednisone versus prednisone plus ciclosporin versus prednisone plus methotrexate in new-onset juvenile dermatomyositis: a randomised trial. Lancet 2016; 387:671-678. [PMID: 26645190 DOI: 10.1016/s0140-6736(15)01021-1] [Citation(s) in RCA: 135] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Most data for treatment of dermatomyositis and juvenile dermatomyositis are from anecdotal, non-randomised case series. We aimed to compare, in a randomised trial, the efficacy and safety of prednisone alone with that of prednisone plus either methotrexate or ciclosporin in children with new-onset juvenile dermatomyositis. METHODS We did a randomised trial at 54 centres in 22 countries. We enrolled patients aged 18 years or younger with new-onset juvenile dermatomyositis who had received no previous treatment and did not have cutaneous or gastrointestinal ulceration. We randomly allocated 139 patients via a computer-based system to prednisone alone or in combination with either ciclosporin or methotrexate. We did not mask patients or investigators to treatment assignments. Our primary outcomes were the proportion of patients achieving a juvenile dermatomyositis PRINTO 20 level of improvement (20% improvement in three of six core set variables at 6 months), time to clinical remission, and time to treatment failure. We compared the three treatment groups with the Kruskal-Wallis test and Friedman's test, and we analysed survival with Kaplan-Meier curves and the log-rank test. Analysis was by intention to treat. Here, we present results after at least 2 years of treatment (induction and maintenance phases). This trial is registered with ClinicalTrials.gov, number NCT00323960. FINDINGS Between May 31, 2006, and Nov 12, 2010, 47 patients were randomly assigned prednisone alone, 46 were allocated prednisone plus ciclosporin, and 46 were randomised prednisone plus methotrexate. Median duration of follow-up was 35.5 months. At month 6, 24 (51%) of 47 patients assigned prednisone, 32 (70%) of 46 allocated prednisone plus ciclosporin, and 33 (72%) of 46 administered prednisone plus methotrexate achieved a juvenile dermatomyositis PRINTO 20 improvement (p=0.0228). Median time to clinical remission was 41.9 months in patients assigned prednisone plus methotrexate but was not observable in the other two treatment groups (2.45 fold [95% CI 1.2-5.0] increase with prednisone plus methotrexate; p=0.012). Median time to treatment failure was 16.7 months in patients allocated prednisone, 53.3 months in those assigned prednisone plus ciclosporin, but was not observable in patients randomised to prednisone plus methotrexate (1.95 fold [95% CI 1.20-3.15] increase with prednisone; p=0.009). Median time to prednisone discontinuation was 35.8 months with prednisone alone compared with 29.4-29.7 months in the combination groups (p=0.002). A significantly greater proportion of patients assigned prednisone plus ciclosporin had adverse events, affecting the skin and subcutaneous tissues, gastrointestinal system, and general disorders. Infections and infestations were significantly increased in patients assigned prednisone plus ciclosporin and prednisone plus methotrexate. No patients died during the study. INTERPRETATION Combined treatment with prednisone and either ciclosporin or methotrexate was more effective than prednisone alone. The safety profile and steroid-sparing effect favoured the combination of prednisone plus methotrexate. FUNDING Italian Agency of Drug Evaluation, Istituto Giannina Gaslini (Genoa, Italy), Myositis Association (USA).
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Koné-Paut I, Shahram F, Darce-Bello M, Cantarini L, Cimaz R, Gattorno M, Anton J, Hofer M, Chkirate B, Bouayed K, Tugal-Tutkun I, Kuemmerle-Deschner J, Agostini H, Federici S, Arnoux A, Piedvache C, Ozen S. Consensus classification criteria for paediatric Behçet's disease from a prospective observational cohort: PEDBD. Ann Rheum Dis 2015; 75:958-64. [PMID: 26698843 DOI: 10.1136/annrheumdis-2015-208491] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 11/24/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND We aimed to describe the main features of Behçet's disease (BD) in children in the largest prospective cohort to date and to propose a classification. METHODS An international expert consensus group was formed to define a data set of minimal symptoms for the inclusion of patients. Patients were entered prospectively during 66 months. Experts classified patients on a consensus basis. The concordance of two international classifications was analysed in confirmed patients with BD. Comparisons of subgroups of patients helped define consensus criteria. BD-associated clinical manifestations were also investigated in three control diseases extracted from an independent data set (Eurofever). FINDINGS In total, 42 centres from 12 countries included 230 patients; data for 219 (M/F ratio=1) could be analysed. The experts classified 156 patients (71.2%) as having confirmed BD. Males more often than females showed cutaneous, ocular and vascular symptoms and females more often genital aphthosis. Age at disease onset and skin and vascular involvement were lower for European than non-European children. Oral aphthosis was the presenting sign for 81% (179/219) of patients. The mean delay to the second symptom was 2.9±2.2 years. International classifications were not concordant with the expert classification. Our paediatric classification contains six categories, a minimum of three signs (each in a distinct category) defining paediatric BD. Three clinical signs discriminated our cohort from the Eurofever cohorts. INTERPRETATION We present a comprehensive description of a large cohort of patients from both European and non-European countries and propose the first classification of paediatric BD for future therapeutic trials.
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Magnotti F, Lucherini OM, De Clemente C, Talarico R, Emmi G, Galeazzi M, Cimaz R, Cantarini L. Role of polymorphonucleates in the pathogenesis of systemic juvenile idiopathic arthritis and Still's disease: a proof of concept study. Pediatr Rheumatol Online J 2015. [PMCID: PMC4598893 DOI: 10.1186/1546-0096-13-s1-p56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Bassi A, Remaschi G, Difonzo EM, Greco A, Buccoliero AM, Giani T, Facchini F, Cimaz R, de Martino M. Idiopathic congenital atrophoderma of Pasini and Pierini. Arch Dis Child 2015; 100:1184. [PMID: 26374755 DOI: 10.1136/archdischild-2015-309498] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2015] [Indexed: 11/04/2022]
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Cattalini M, Khubchandani R, Cimaz R. When flexibility is not necessarily a virtue: a review of hypermobility syndromes and chronic or recurrent musculoskeletal pain in children. Pediatr Rheumatol Online J 2015; 13:40. [PMID: 26444669 PMCID: PMC4596461 DOI: 10.1186/s12969-015-0039-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 10/01/2015] [Indexed: 01/09/2023] Open
Abstract
Chronic or recurrent musculoskeletal pain is a common complaint in children. Among the most common causes for this problem are different conditions associated with hypermobility. Pediatricians and allied professionals should be well aware of the characteristics of the different syndromes associated with hypermobility and facilitate early recognition and appropriate management. In this review we provide information on Benign Joint Hypermobility Syndrome, Ehlers-Danlos Syndrome, Marfan Syndrome, Loeys-Dietz syndrome and Stickler syndrome, and discuss their characteristics and clinical management.
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Marrani E, Cimaz R, Lucherini OM, Caputo R, Vitale A, Cantarini L, Simonini G. The common NOD2/CARD15 variant P268S in patients with non-infectious uveitis: a cohort study. Pediatr Rheumatol Online J 2015; 13:38. [PMID: 26438151 PMCID: PMC4595328 DOI: 10.1186/s12969-015-0037-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 09/28/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The etiology of Autoimmune chronic uveitis (ACU) is still unknown; NOD2/CARD15 gene mutations are responsible for the Blau Syndrome and can induce uveitis in animal models. PRESENTATION OF THE HYPOTHESIS Aim of our study was to assess if NOD2/CARD15 variants have a role in the etiology or in the clinical course of patients with ACU, either idiopathic or associated with other inflammatory diseases. TESTING THE HYPOTHESIS We consecutively enrolled 25 patients (19 pediatric and 6 adults) affected with ACU. For each patient medical history was reviewed and clinical data were recorded. Allelic and genotypic frequencies of NOD2/CARD15 variations were calculated in patients and matched with those of 25 healthy controls. The statistical analysis was performed. Fifteen patients showed the polymorphism P268S/SNP5 (SNP rs2066842) as heterozygous carriers while two patients were homozygous for the same polymorphism; one patient carried also the variant c647 18-16 TCT on intron 3, not previously reported in the literature. Statistical analysis for NOD2/CARD15 genotyping showed significant differences between patients and controls for allelic frequencies (p = 0.04, OR: 4.03, 95 %; CI = 1.2-13.5) but not for genotypic frequencies. We could not identify a significant phenotype-genotype correlation. IMPLICATIONS OF THE HYPOTHESIS In our cohort of Italian patients, the NOD2/CARD15 common variant P268S/SNP5 could potentially be significantly associated with ACU.
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Simonini G, Cimaz R, Jones GT, Macfarlane GJ. Non-anti-TNF biologic modifier drugs in non-infectious refractory chronic uveitis: The current evidence from a systematic review. Semin Arthritis Rheum 2015; 45:238-50. [DOI: 10.1016/j.semarthrit.2015.05.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Revised: 04/29/2015] [Accepted: 05/14/2015] [Indexed: 12/14/2022]
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Pagnini I, Vitale A, Selmi C, Cimaz R, Cantarini L. Idiopathic Inflammatory Myopathies: an Update on Classification and Treatment with Special Focus on Juvenile Forms. Clin Rev Allergy Immunol 2015; 52:34-44. [DOI: 10.1007/s12016-015-8512-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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211
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Marrani E, Paganelli V, de Libero C, Cimaz R, Simonini G. Long-term efficacy of abatacept in pediatric patients with idiopathic uveitis: a case series. Graefes Arch Clin Exp Ophthalmol 2015; 253:1813-6. [DOI: 10.1007/s00417-015-3140-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 08/09/2015] [Accepted: 08/12/2015] [Indexed: 11/30/2022] Open
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Cantarini L, Talarico R, Generali E, Emmi G, Lopalco G, Costa L, Silvestri E, Caso F, Franceschini R, Cimaz R, Iannone F, Galeazzi M, Selmi C. Safety profile of biologic agents for Behçet's disease in a multicenter observational cohort study. Int J Rheum Dis 2015; 20:103-108. [DOI: 10.1111/1756-185x.12732] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Ferrari D, Zannin M, Gerloni V, Pontikaki I, Bracaglia C, Cimaz R, Simonini G, Falcini F, Corona F, Viola S, Breda L, La Torre F, Vittadello F, Martini G, Zulian F. OP0066 Safety of Anti-TNFα Agents for the Treatment of Juvenile Idiopathic Arthritis-Related Uveitis: Data from the Orchidea Registry. Ann Rheum Dis 2015. [DOI: 10.1136/annrheumdis-2015-eular.4559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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214
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Pagnini I, Bason C, Simonini G, Giani T, Brucato A, Lunardi C, Cimaz R. AB0983 Possible Correlation Between Congenital Heart Block and Autoimmune Hearing Loss. Ann Rheum Dis 2015. [DOI: 10.1136/annrheumdis-2015-eular.5041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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215
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Dei Rossi E, Taddio A, Pastore S, Lepore L, Bronzetti G, Simonini G, Cimaz R. FRI0513 Kawasaki Disease Shock Syndrome: Salient Features and Outcomes. Ann Rheum Dis 2015. [DOI: 10.1136/annrheumdis-2015-eular.4097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Giani T, Capirchio L, Marino A, Bertini F, Mauro A, Simonini G, Pagnini I, Cimaz R. AB1025 Chronic Recurrent Multifocal Osteomyelitis (CRMO): The Importance of an Accurate Differential Diagnosis. Ann Rheum Dis 2015. [DOI: 10.1136/annrheumdis-2015-eular.4710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Giani T, Mauro A, Pagnini I, Simonini G, Bertini F, Marino A, Cimaz R. AB1024 A Rare Case of Neonatal Antiphospholipid Syndrome. Ann Rheum Dis 2015. [DOI: 10.1136/annrheumdis-2015-eular.4629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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218
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Brambilla A, Cosi A, Rosati A, Guerrini R, Cimaz R, Simonini G. FRI0505 Long-Term Efficacy and Safety of Mycophenolate Mofetil in Childhood Primary Central Nervous System Vasculitis. Ann Rheum Dis 2015. [DOI: 10.1136/annrheumdis-2015-eular.4955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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219
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Magnotti F, Lucherini O, De Clemente C, Talarico R, Emmi G, Galeazzi M, Cimaz R, Cantarini L. THU0031 Role of Polymorphonucleates in the Pathogenesis of Systemic Juvenile Idiopathic Arthritis and Still's Disease: A Proof of Concept Study. Ann Rheum Dis 2015. [DOI: 10.1136/annrheumdis-2015-eular.6131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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220
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Davì S, Verazza S, Consolaro A, Insalaco A, Gerloni V, Cimaz R, Zulian F, Lepore L, Corona F, Conti G, Barone P, Cattalini M, Cortis E, Breda L, Olivieri A, Civino A, Rigante D, La Torre F, D'Angelo G, Gallizzi R, Maggio M, Consolini R, De Fanti A, Alpigiani M, Martini A, Ravelli A. AB1020 Evaluation of the Disease Course of Italian Children with Juvenile Idiopathic Arthritis Treated with Etanercept: Preliminary Results in 1019 Patients. Ann Rheum Dis 2015. [DOI: 10.1136/annrheumdis-2015-eular.4966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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221
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Foeldvari I, Katsicas M, Teresa Terreri M, Cimaz R, Kostik M, Sztajnbok F, Nemcova D, Moll M, Jose Santos M, Avcin T, Brunner J, Nielsen S, Kallinich T, Minden K, Mueller J, Janarthanan M, Uziel Y, Sifuentes-Giraldo W, Eleftheriou D, Torok K, Helmus N. THU0511 Update on the Juvenile Systemic Sclerosis Inception Cohort. www.juvenilescleroderma.com. Ann Rheum Dis 2015. [DOI: 10.1136/annrheumdis-2015-eular.1528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
Vitamin D, upon its discovery one century ago, was classified as a vitamin. This classification still greatly affects our perception about its biological role. 1,25(OH)2D (now known as the D hormone) is a pleiotropic steroid hormone that has multiple biologic effects. It is integral to the regulation of calcium homeostasis and bone turnover as well as having anti-proliferative, pro-differentiation, anti-bacterial, immunomodulatory and anti-inflammatory properties within the body in various cells and tissues. Vitamin D (cholecalciferol) should be considered a nutritional substrate that must be ingested or synthesized in sufficient amounts for the further synthesis of the very important regulatory steroid hormone (D hormone), especially in patients with pediatric rheumatic diseases (PRD). Vitamin D insufficiency or deficiency was shown to be pandemic and associated with numerous chronic inflammatory and malignant diseases and even with increased risk of mortality. Several studies have demonstrated that a high percentage of children with pediatric rheumatic diseases (PRD-e.g., JIA, jSLE) have a vitamin D deficiency or insufficiency which might correlate with disease outcome and flares. Glucocorticoids used to treat disease may have a regulatory effect on vitamin D metabolism which can additionally aggravate bone turnover in PRD. An effort to define the optimal serum 25(OH)D concentrations for healthy children and adults was launched in 2010 but as of now there are no guidelines about supplementation in PRD. In this review we have tried to summarize the strong evidence now suggesting that as the knowledge of the optimal approach to diagnosis and treatment PRD has evolved, there is also an emerging need for vitamin D supplementation as an adjunct to regular disease treatment. So in accordance with new vitamin D recommendations, we recommend that a child with rheumatic disease, especially if treated with steroids, needs at least 2-3 time higher doses of vitamin D than the dose recommended for age (approximately 2000 UI/day). Vitamin D supplementation has become an appealing and important adjunct treatment option in PRD.
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Pagnini I, Bondi T, Simonini G, Giani T, Marino A, Cimaz R. Successful treatment with canakinumab of a paediatric patient with resistant Behçet’s disease. Rheumatology (Oxford) 2015; 54:1327-8. [DOI: 10.1093/rheumatology/kev197] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Cimaz R, Cohen E, Corona F, Bonfanti C, Startari R, Bardare M. Two cases of juvenile systemic lupus erythematosus with life-threatening central nervous system involvement: striking association with antiphospholipid antibodies. CONTRIBUTIONS TO NEPHROLOGY 2015; 99:99-101. [PMID: 1458933 DOI: 10.1159/000421696] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Woerner A, von Scheven-Gête A, Cimaz R, Hofer M. Complications of systemic juvenile idiopathic arthritis: risk factors and management recommendations. Expert Rev Clin Immunol 2015; 11:575-88. [PMID: 25843554 DOI: 10.1586/1744666x.2015.1032257] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Systemic juvenile idiopathic arthritis (SJIA) is an inflammatory condition characterized by fever, lymphadenopathy, arthritis, rash and serositis. Systemic inflammation has been associated with dysregulation of the innate immune system, suggesting that SJIA is an autoinflammatory disorder. IL-1 and IL-6 play a major role in the pathogenesis of SJIA, and treatment with IL-1 and IL-6 inhibitors has shown to be highly effective. However, complications of SJIA, including macrophage activation syndrome, limitations in functional outcome by arthritis and long-term damage from chronic inflammation, continue to be a major issue in SJIA patients' care. Translational research leading to a profound understanding of the cytokine crosstalk in SJIA and the identification of risk factors for SJIA complications will help to improve long-term outcome.
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