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Abstract
Systemic juvenile idiopathic arthritis (sJIA) is characterized by a large range of extra-articular manifestations in addition to joint inflammation. The child with sJIA usually presents with a spiking fever pattern, evanescent rash, and arthralgias/arthritis. Other features often present are lymphadenopathy, hepatosplenomegaly, and polyserositis. The systemic manifestations are frequently more prominent and severe than the arthritis. Laboratory studies reflect systemic inflammation with significant anemia, and elevation of acute phase reactants, platelets, and white blood cell count. Ferritin level is often strikingly high. The treatment of sJIA has evolved over the past decade with the improved understanding of the role of specific inflammatory cytokines in this disease. The medications employed to treat sJIA directly inhibit the actions of these cytokines. A major cause of morbidity and mortality of children with sJIA is the development of macrophage activation syndrome, which can cause unremitting fevers, pancytopenia, coagulopathy, and hepatic dysfunction.
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Abstract
Many paediatric rheumatic diseases result from the abnormal activation or control of the immune system. Biologic drugs, which are synthesised within a biological system, have been designed to target specific molecules involved in cytokine signalling or cell-cell interactions. The past 15 years have seen a revolution in the range of effective treatments for rheumatic diseases, particularly juvenile idiopathic arthritis (JIA). As a result, the target of inactive disease and minimal long-term disease-associated damage is increasingly becoming achievable. In this article we review evidence from recent trials of the use of biologic drugs in the treatment of systemic JIA, juvenile dermatomyositis and juvenile systemic lupus erythematosus. We also highlight novel agents currently undergoing investigation which may broaden our therapeutic armamentarium over the coming decade. Key to these developments are well-designed multicentre controlled clinical trials and long-term safety monitoring as part of international drug registries.
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Affiliation(s)
- Ethan S Sen
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
| | - A V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
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203
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Abstract
Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disorder that may cause joint destruction. Biological treatments targeting specific cytokines and cell interactions have transformed the outcomes of JIA. This review focuses on the selection of patients for and the timing and selection of biological treatment in JIA. Tumor necrosis factor (TNF) inhibitors remain the first choice for polyarticular JIA, followed by abatacept and tocilizumab. Monoclonal-antibody TNF inhibitors and abatacept are usually chosen for methotrexate-resistant uveitis. Recent clinical trials of canakinumab, rilonacept, and tocilizumab have obtained great improvement in both systemic and arthritic features in chronic systemic JIA patients. Current guidelines support the early use of a short-acting IL-1 antagonist for macrophage activation syndrome, a life-threatening complication. TREAT and ACUTE studies suggest that a therapeutic window of opportunity during early disease may exist in JIA. Early initiation of biological therapy may be associated with slower progression of joint damage and longer remission.
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204
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Punaro M. Use of microarrays in the clinical practice of pediatric rheumatology: the future is now? Curr Opin Rheumatol 2015; 26:585-91. [PMID: 25014037 DOI: 10.1097/bor.0000000000000095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Systems immunology is an integrative approach that leverages high throughput technologies as well as mathematical and computational tools to investigate complex immunologic diseases by looking at the state of a system on a comprehensive scale. Gene expression profiling, also known as transcriptomics, measures the expression level of mRNAs (transcripts) in a given cell population at a specific time. Over the past decade, several major gene expression discoveries have been made in pediatric rheumatology, most notably the alpha interferon signature of systemic lupus erythematosus and the interleukin-1 signature in systemic onset juvenile idiopathic arthritis. This article reviews these discoveries, their clinical implications and the recent associated literature. RECENT FINDINGS Interferon-α has been exploited as a therapeutic target in lupus. Interleukin-1 blockade has been utilized to treat systemic onset juvenile idiopathic arthritis and related autoinflammatory diseases. SUMMARY Current gene expression studies extend our understanding of the disease pathogenesis of lupus and systemic onset juvenile idiopathic arthritis as well as related conditions. This knowledge has translated to the bedside with implications for clinical practice and direct therapeutic targeting.
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Affiliation(s)
- Marilynn Punaro
- Texas Scottish Rite Hospital, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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205
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Macrophage Activation Syndrome as Onset of Systemic Lupus Erythematosus: A Case Report and a Review of the Literature. Case Rep Med 2015; 2015:294041. [PMID: 26064125 PMCID: PMC4439481 DOI: 10.1155/2015/294041] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 04/23/2015] [Indexed: 11/23/2022] Open
Abstract
Macrophage activation syndrome (MAS) is a potentially fatal condition. It belongs to the hemophagocytic lymphohistiocytosis group of diseases. In adults, MAS is rarely associated with systemic lupus erythematosus, but it also arises as complication of several systemic autoimmune disorders, like ankylosing spondylitis, rheumatoid arthritis, and adult-onset Still's disease. Several treatment options for MAS have been reported in the literature, including a therapeutic regimen of etoposide, dexamethasone, and cyclosporine. Here we report a case of 42-year-old woman in whom MAS occurred as onset of systemic lupus erythematosus.
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206
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Gerfaud-Valentin M, Sève P, Hot A, Broussolle C, Jamilloux Y. Données actualisées sur la physiopathologie, les phénotypes et les traitements de la maladie de Still de l’adulte. Rev Med Interne 2015; 36:319-27. [DOI: 10.1016/j.revmed.2014.10.365] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 10/25/2014] [Indexed: 12/27/2022]
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207
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Darby JB, Liddell L, DeGuzman M, McClain KL, Rubenstein J, Chase L, Marquez L. A 2-year-old with 4 weeks of daily fever. Pediatrics 2015; 135:902-8. [PMID: 25917994 DOI: 10.1542/peds.2014-3692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
A 2-year-old female presents for evaluation of 4 weeks of daily fevers. When the fevers began, she had mild upper respiratory tract symptoms, which quickly resolved. The fevers persisted, however, with a maximum of 40°C. The child's review of symptoms was significant for a 1-kg weight loss over the past month. Ten months before presentation, she had moved from Saudi Arabia with her family. One week before the onset of symptoms, she had visited a petting zoo. During episodes of fever, the patient was ill-appearing and had an elevated heart rate and respiratory rate. On examination, she was found to be thin, febrile, tachycardic, and with scattered lymphadenopathy. Results of laboratory tests were remarkable for an elevated white blood cell count of 16,100 cells per uL with a neutrophilic predominance. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were elevated at 99 mm/h and 27 mg/dL, respectively. A chest radiograph indicated a small amount of fluid in the interlobar fissures. Our expert panel examines her case, offers a definition of fever of unknown origin, and makes diagnostic considerations.
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Affiliation(s)
| | - Lucette Liddell
- Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | | | - Kenneth L McClain
- Section of Pediatric Hematology and Oncology, Texas Children's Cancer and Hematology Centers, and
| | | | | | - Lucila Marquez
- Section of Hospital Medicine, Section of Infectious Disease, and
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208
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Woerner A, Uettwiller F, Melki I, Mouy R, Wouters C, Bader-Meunier B, Quartier P. Biological treatment in systemic juvenile idiopathic arthritis: achievement of inactive disease or clinical remission on a first, second or third biological agent. RMD Open 2015; 1:e000036. [PMID: 26509061 PMCID: PMC4613174 DOI: 10.1136/rmdopen-2014-000036] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 03/23/2015] [Accepted: 04/12/2015] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES To analyse the effect of biological agents (BAs) in terms of achieving inactive disease (ID) or clinical remission (CR) in patients with systemic juvenile idiopathic arthritis (SJIA), to describe effects of switching or discontinuing a BA and to assess the proportion of patients able to maintain ID or CR off steroids and after withdrawing BA therapy. METHODS Retrospective study in a French paediatric rheumatology reference centre using the CEMARA (CEntre des MAladies RAres) register. RESULTS Seventy-seven patients were included with a cumulative follow-up of 245.5 patient-years (median 1.1, range 0.5-8.0). On a first BA, ID was achieved in 37 patients, including 1 patient out of 12 patients on etanercept, 26 patients out of 51 on anakinra and 7 out of 10 on canakinumab. One patient on abatacept and two patients on tocilizumab also achieved ID. Switching of BA was common. The switch to a second (n=34), third (n=18) or fourth (n=4) BA resulted in ID in a further 13 patients, either on canakinumab (n=6) or tocilizumab (n=7). At last follow-up, 40 patients were in CR (27 patients off steroids, 5 patients having never received steroid treatment), either on (n=29) or off (n=11) BA. CONCLUSIONS In this series of patients with SJIA, interleukin-1 inhibitors were associated with a higher proportion of ID than tumour necrosis factor inhibitors when used as first BA. Switching allowed some patients to achieve ID when treated with canakinumab or tocilizumab. CR was eventually achieved in more than half of the patients.
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Affiliation(s)
- A Woerner
- Department of Paediatric Immunology, Hematology and Rheumatology and Institut IMAGINE , Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris , Paris , France ; Department of Pediatric Rheumatology , University of Basel, University Children's Hospital , Basel , Switzerland
| | - F Uettwiller
- Department of Paediatric Immunology, Hematology and Rheumatology and Institut IMAGINE , Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris , Paris , France ; Clocheville Hospital , Tours , France
| | - I Melki
- Department of Paediatric Immunology, Hematology and Rheumatology and Institut IMAGINE , Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris , Paris , France ; Department of Pediatrics , Hôpital Robert Debré, Assistance Publique Hôpitaux de Paris , Paris , France
| | - R Mouy
- Department of Paediatric Immunology, Hematology and Rheumatology and Institut IMAGINE , Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris , Paris , France
| | - C Wouters
- Department of Paediatric Immunology, Hematology and Rheumatology and Institut IMAGINE , Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris , Paris , France ; Department of Microbiology and Immunology, Pediatric Immunology and Pediatric Rheumatology , KU Leuven-University of Leuven, University Hospitals Leuven , Leuven , Belgium
| | - B Bader-Meunier
- Department of Paediatric Immunology, Hematology and Rheumatology and Institut IMAGINE , Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris , Paris , France
| | - P Quartier
- Department of Paediatric Immunology, Hematology and Rheumatology and Institut IMAGINE , Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris , Paris , France ; Université Paris-Descartes , Paris , France
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209
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Goodrich LR, Grieger JC, Phillips JN, Khan N, Gray SJ, McIlwraith CW, Samulski RJ. scAAVIL-1ra dosing trial in a large animal model and validation of long-term expression with repeat administration for osteoarthritis therapy. Gene Ther 2015; 22:536-45. [PMID: 25902762 DOI: 10.1038/gt.2015.21] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 01/22/2015] [Indexed: 11/09/2022]
Abstract
A gene therapeutic approach to treat osteoarthritis (OA) appears to be on the horizon for millions of people who suffer from this disease. Previously we described optimization of a scAAVIL-1ra gene therapeutic vector and initially tested this in an equine model verifying long-term intrasynovial IL-1ra protein at therapeutic levels. Using this vector, we carried out a dosing trial in six horses to verify protein levels and establish a dose that would express relevant levels of therapeutic protein for extended periods of time (8 months). A novel arthroscopic procedure used to detect green fluorescence protein (GFP) fluorescence intrasynovially confirmed successful transduction of the scAAVGFP vector in both the synovial and cartilage tissues. No evidence of intra-articular toxicity was detected. Immune responses to vector revealed development of neutralizing antibodies (Nabs) within 2 weeks of administration, which persisted for the duration of the study but did not lower protein expression intra-articularly. Re-dosing with a different serotype to attain therapeutic levels of protein confirmed establishment of successful transduction. This is the first study in an equine model to establish a dosing/redosing protocol, as well as examine the Nab response to capsid and supports further clinical investigation to determine the clinical efficacy of scAAVIL-1ra to treat OA.
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Affiliation(s)
- L R Goodrich
- Orthopaedic Research Center, Department of Clinical Sciences, College of Veterinary Medicine, Colorado State University, Fort Collins, CO, USA
| | - J C Grieger
- UNC Gene Therapy Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - J N Phillips
- Orthopaedic Research Center, Department of Clinical Sciences, College of Veterinary Medicine, Colorado State University, Fort Collins, CO, USA
| | - N Khan
- UNC Gene Therapy Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - S J Gray
- UNC Gene Therapy Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - C W McIlwraith
- Orthopaedic Research Center, Department of Clinical Sciences, College of Veterinary Medicine, Colorado State University, Fort Collins, CO, USA
| | - R J Samulski
- UNC Gene Therapy Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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210
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Macrophage activation syndrome in the course of monogenic autoinflammatory disorders. Clin Rheumatol 2015; 34:1333-9. [PMID: 25846831 DOI: 10.1007/s10067-015-2923-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 03/15/2015] [Accepted: 03/20/2015] [Indexed: 01/15/2023]
Abstract
An overwhelming activation of cytotoxic T cells and well-differentiated macrophages leading to systemic overload of inflammatory mediators characterizes the so-called macrophage activation syndrome (MAS); this potentially life-threatening clinical entity may derive from several genetic defects involved in granule-mediated cytotoxicity but has been largely observed in patients with juvenile idiopathic arthritis, many rheumatologic diseases, infections, and malignancies. The occurrence of MAS in the natural history or as the revealing clue of monogenic autoinflammatory disorders (AIDs), rare conditions caused by disrupted innate immunity pathways with overblown release of proinflammatory cytokines, has been only reported in few isolated patients with cryopyrin-associated periodic syndrome, mevalonate kinase deficiency, familial Mediterranean fever, and tumor necrosis factor receptor-associated periodic syndrome since 2001. All these patients displayed various clinical, laboratory, and histopathologic features of MAS and have often required intensive care support. Only one patient has died due to MAS. Defective cytotoxic cell function was documented in a minority of patients. Corticosteroids were the first-line treatment, but anakinra was clinically effective in three refractory cases. Even if MAS and AIDs share multiple clinical features as well as heterogeneous pathogenetic scenes and a potential response to anti-interleukin-1 targeted therapies, MAS requires a prompt specific recognition in the course of AIDs due to its profound severity and high mortality rate.
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211
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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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Affiliation(s)
- Andreas Woerner
- Pediatric Rheumatology, University of Basel, University Children's Hospital, Basel, Switzerland
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212
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Moghaddas F, Masters SL. Monogenic autoinflammatory diseases: Cytokinopathies. Cytokine 2015; 74:237-46. [PMID: 25814341 DOI: 10.1016/j.cyto.2015.02.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 02/06/2015] [Indexed: 12/17/2022]
Abstract
Rapid advances in genetics are providing unprecedented insight into functions of the innate immune system with identification of the mutations that cause monogenic autoinflammatory disease. Cytokine antagonism is profoundly effective in a subset of these conditions, particularly those associated with increased interleukin-1 (IL-1) activity, the inflammasomopathies. These include syndromes where the production of IL-1 is increased by mutation of innate immune sensors such as NLRP3, upstream signalling molecules such as PSTPIP1 and receptors or downstream signalling molecules, such as IL-1Ra. Another example of this is interferon (IFN) and the interferonopathies, with mutations in the sensors STING and MDA5, the upstream signalling regulator AP1S3, and a downstream inhibitor of IFN signalling, ISG15. We propose that this can be extended to cytokines such as IL-36, with mutations in IL-36Ra, and IL-10, with mutations in IL-10RA and IL-10RB, however mutations in sensors or upstream signalling molecules are yet to be described in these instances. Additionally, autoinflammatory diseases can be caused by multiple cytokines, for example with the activation of NF-κB/Rel, for which we propose the term Relopathies. This nosology is limited in that some cytokine pathways may be degenerate in their generation or execution, however provides insight into likely autoinflammatory disease candidates and the cytokines with which newly identified mutations may be associated, and therefore targeted.
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Affiliation(s)
- Fiona Moghaddas
- Inflammation Division, The Walter and Eliza Hall Institute of Medical Research, Parkville 3052, Australia; Department of Medical Biology, The University of Melbourne, Parkville 3010, Australia
| | - Seth L Masters
- Inflammation Division, The Walter and Eliza Hall Institute of Medical Research, Parkville 3052, Australia; Department of Medical Biology, The University of Melbourne, Parkville 3010, Australia.
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213
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Smith EMD, Foster HE, Beresford MW. The development and assessment of biological treatments for children. Br J Clin Pharmacol 2015; 79:379-94. [PMID: 24750505 PMCID: PMC4345949 DOI: 10.1111/bcp.12406] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 04/11/2014] [Indexed: 12/14/2022] Open
Abstract
The development of biological agents with specific immunological targets has revolutionized the treatment of a wide variety of paediatric diseases where traditional immunosuppressive agents have been partly ineffective or intolerable. The increasing requirement for pharmaceutical companies to undertake paediatric studies has provided impetus for studies of biologics in children. The assessment of biological agents in children to date has largely relied upon randomized controlled trials using a withdrawal design, rather than a parallel study design. This approach has been largely used due to ethical concerns, including use of placebo treatments in children with active chronic disease, and justified on the basis that treatments have usually already undergone robust assessment in related adult conditions. However, this study design limits the reliability of the data and can confuse the interpretation of safety results. Careful ongoing monitoring of safety and efficacy in real-world practice through national and international biologics registries and robust reporting systems is crucial. The most commonly used biological agents in children target tumour necrosis factor-α, interleukin-1, interleukin-6 and cytotoxic lymphocyte-associated antigen-4. These agents are most frequently used in paediatric rheumatic diseases. This review discusses the development and assessment of biologics within paediatric rheumatology with reference to the lessons learned from use in other subspecialties.
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Affiliation(s)
- Eve M D Smith
- Institute of Translational Medicine, University of LiverpoolLiverpool, UK
| | - Helen E Foster
- Paediatric Rheumatology, Institute of Cellular Medicine, Newcastle UniversityNewcastle upon Tyne, UK
- Great North Children's Hospital, Newcastle Hospitals NHS Foundation TrustNewcastle upon Tyne, UK
| | - Michael W Beresford
- Institute of Translational Medicine, University of LiverpoolLiverpool, UK
- Alder Hey Children's NHS Foundation TrustLiverpool, UK
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214
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Kasapçopur Ö, Barut K. Treatment in juvenile rheumatoid arthritis and new treatment options. Turk Arch Pediatr 2015; 50:1-10. [PMID: 26078691 DOI: 10.5152/tpa.2015.2229] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 10/23/2014] [Indexed: 11/22/2022]
Abstract
Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease of the childhood with the highest risk of disability. Active disease persists in the adulthood in a significant portion of children with juvenile rheumatoid arthritis despite many developments in the diagnosis and treatment. Therefore, initiation of efficient treatment in the early period of the disease may provide faster control of the inflammation and prevention of long-term harms. In recent years, treatment options have also increased in children with juvenile idiopathic arthritis owing to biological medications. All biological medications used in children have been produced to target the etiopathogenesis leading to disease including anti-tumor necrosis factor, anti-interleukin 1 and anti-interleukin 6 drugs. In this review, scientific data about biological medications used in the treatment of rheumatoid arthritis and new treatment options will be discussed.
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Affiliation(s)
- Özgür Kasapçopur
- Department of Pediatrics, Division of Pediatric Rheumatology, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
| | - Kenan Barut
- Department of Pediatrics, Division of Pediatric Rheumatology, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
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215
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Aguiar CL, Pan N, Adams A, Barinstein L, Lehman TJ. Anaphylaxis to anakinra in a pediatric patient with systemic juvenile idiopathic arthritis successfully treated with canakinumab: a case-based review. Clin Rheumatol 2015; 34:1821-4. [DOI: 10.1007/s10067-015-2889-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Revised: 01/22/2015] [Accepted: 01/25/2015] [Indexed: 10/24/2022]
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216
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Abstract
Treatment of systemic-onset juvenile idiopathic arthritis is challenging, but the availability of cytokine antagonists targeting interleukin-1 and interleukin-6 have markedly advanced the therapeutic options. In this review, we focus on the current experience with canakinumab, an interleukin-1 monoclonal human antibody for the treatment of systemic-onset juvenile idiopathic arthritis and describe its efficacy and safety. Canakinumab is an important, safe, and valid drug in the treatment of systemic-onset juvenile idiopathic arthritis.
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Affiliation(s)
- Joachim Peitz
- Pediatric Rheumatology Centre, Department of General Pediatrics and Neonatology, Asklepios Clinic, Sankt Augustin, Germany
| | - Gerd Horneff
- Pediatric Rheumatology Centre, Department of General Pediatrics and Neonatology, Asklepios Clinic, Sankt Augustin, Germany
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217
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Yokota S, Itoh Y, Morio T, Sumitomo N, Daimaru K, Minota S. Macrophage Activation Syndrome in Patients with Systemic Juvenile Idiopathic Arthritis under Treatment with Tocilizumab. J Rheumatol 2015; 42:712-22. [PMID: 25684767 DOI: 10.3899/jrheum.140288] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2014] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To identify macrophage activation syndrome (MAS) in patients with systemic juvenile idiopathic arthritis (sJIA) undergoing tocilizumab (TCZ) treatment, and to confirm laboratory marker changes and responses to treatment in patients with MAS receiving TCZ. METHODS In Japan, 394 patients with sJIA were registered in an all-patient registry surveillance of TCZ as of January 15, 2012. TCZ (8 mg/kg) was administered every 2 weeks to patients with sJIA. MAS, hemophagocytic lymphohistiocytosis, or Epstein-Barr virus-associated hemophagocytic syndrome (EB-VAHS) was reported in 23 of these patients (25 events). The Safety Evaluation Committee of Tocilizumab for JIA reviewed these cases and clinically evaluated the data and laboratory findings using their own therapeutic experience. Events were categorized into 4 groups: definitive MAS, probable MAS, EB-VAHS, and non-MAS. RESULTS The committee's review revealed 3 events of definitive MAS in 3 patients, 12 events of probable MAS in 11 patients, 2 events of EB-VAHS in 2 patients, and 8 events of non-MAS in 8 patients. There were 2 patients who developed 2 events: 2 events in 1 patient were classified into definitive MAS and probable MAS, and 2 events in another patient were classified into probable MAS. In patients with definitive or probable MAS, common clinical manifestations and laboratory findings of MAS were observed. Changes in laboratory data observed in patients with EB-VAHS were similar to those observed in patients with MAS. CONCLUSION These results suggest that the clinical/laboratory features in the course of MAS appear to be similar among patients regardless of whether TCZ is administered. Similarities in the pathophysiological background of MAS and EB-VAHS were also suggested.
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Affiliation(s)
- Shumpei Yokota
- From The Safety Evaluation Committee of Tocilizumab for JIA; Department of Pediatrics, Nippon Medical School; Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU) Graduate School of Medical and Dental Sciences; Chugai Pharmaceutical Co. Ltd., Tokyo; Department of Pediatrics, Yokohama City University School of Medicine, Kanagawa; Department of Pediatric Cardiology, Saitama Medical University International Medical Center, Saitama; Division of Rheumatology and Clinical Immunology, Jichi Medical School, Tochigi, Japan.S. Yokota, MD, PhD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatrics, Yokohama City University School of Medicine; Y. Itoh, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatrics, Nippon Medical School; T. Morio, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatrics and Developmental Biology, TMDU Graduate School of Medical and Dental Sciences; N. Sumitomo, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatric Cardiology, Saitama Medical University International Medical Center; K. Daimaru, BS, Chugai Pharmaceutical Co. Ltd.; S. Minota, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Division of Rheumatology and Clinical Immunology, Jichi Medical School.
| | - Yasuhiko Itoh
- From The Safety Evaluation Committee of Tocilizumab for JIA; Department of Pediatrics, Nippon Medical School; Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU) Graduate School of Medical and Dental Sciences; Chugai Pharmaceutical Co. Ltd., Tokyo; Department of Pediatrics, Yokohama City University School of Medicine, Kanagawa; Department of Pediatric Cardiology, Saitama Medical University International Medical Center, Saitama; Division of Rheumatology and Clinical Immunology, Jichi Medical School, Tochigi, Japan.S. Yokota, MD, PhD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatrics, Yokohama City University School of Medicine; Y. Itoh, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatrics, Nippon Medical School; T. Morio, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatrics and Developmental Biology, TMDU Graduate School of Medical and Dental Sciences; N. Sumitomo, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatric Cardiology, Saitama Medical University International Medical Center; K. Daimaru, BS, Chugai Pharmaceutical Co. Ltd.; S. Minota, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Division of Rheumatology and Clinical Immunology, Jichi Medical School
| | - Tomohiro Morio
- From The Safety Evaluation Committee of Tocilizumab for JIA; Department of Pediatrics, Nippon Medical School; Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU) Graduate School of Medical and Dental Sciences; Chugai Pharmaceutical Co. Ltd., Tokyo; Department of Pediatrics, Yokohama City University School of Medicine, Kanagawa; Department of Pediatric Cardiology, Saitama Medical University International Medical Center, Saitama; Division of Rheumatology and Clinical Immunology, Jichi Medical School, Tochigi, Japan.S. Yokota, MD, PhD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatrics, Yokohama City University School of Medicine; Y. Itoh, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatrics, Nippon Medical School; T. Morio, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatrics and Developmental Biology, TMDU Graduate School of Medical and Dental Sciences; N. Sumitomo, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatric Cardiology, Saitama Medical University International Medical Center; K. Daimaru, BS, Chugai Pharmaceutical Co. Ltd.; S. Minota, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Division of Rheumatology and Clinical Immunology, Jichi Medical School
| | - Naokata Sumitomo
- From The Safety Evaluation Committee of Tocilizumab for JIA; Department of Pediatrics, Nippon Medical School; Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU) Graduate School of Medical and Dental Sciences; Chugai Pharmaceutical Co. Ltd., Tokyo; Department of Pediatrics, Yokohama City University School of Medicine, Kanagawa; Department of Pediatric Cardiology, Saitama Medical University International Medical Center, Saitama; Division of Rheumatology and Clinical Immunology, Jichi Medical School, Tochigi, Japan.S. Yokota, MD, PhD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatrics, Yokohama City University School of Medicine; Y. Itoh, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatrics, Nippon Medical School; T. Morio, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatrics and Developmental Biology, TMDU Graduate School of Medical and Dental Sciences; N. Sumitomo, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatric Cardiology, Saitama Medical University International Medical Center; K. Daimaru, BS, Chugai Pharmaceutical Co. Ltd.; S. Minota, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Division of Rheumatology and Clinical Immunology, Jichi Medical School
| | - Kaori Daimaru
- From The Safety Evaluation Committee of Tocilizumab for JIA; Department of Pediatrics, Nippon Medical School; Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU) Graduate School of Medical and Dental Sciences; Chugai Pharmaceutical Co. Ltd., Tokyo; Department of Pediatrics, Yokohama City University School of Medicine, Kanagawa; Department of Pediatric Cardiology, Saitama Medical University International Medical Center, Saitama; Division of Rheumatology and Clinical Immunology, Jichi Medical School, Tochigi, Japan.S. Yokota, MD, PhD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatrics, Yokohama City University School of Medicine; Y. Itoh, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatrics, Nippon Medical School; T. Morio, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatrics and Developmental Biology, TMDU Graduate School of Medical and Dental Sciences; N. Sumitomo, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatric Cardiology, Saitama Medical University International Medical Center; K. Daimaru, BS, Chugai Pharmaceutical Co. Ltd.; S. Minota, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Division of Rheumatology and Clinical Immunology, Jichi Medical School
| | - Seiji Minota
- From The Safety Evaluation Committee of Tocilizumab for JIA; Department of Pediatrics, Nippon Medical School; Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU) Graduate School of Medical and Dental Sciences; Chugai Pharmaceutical Co. Ltd., Tokyo; Department of Pediatrics, Yokohama City University School of Medicine, Kanagawa; Department of Pediatric Cardiology, Saitama Medical University International Medical Center, Saitama; Division of Rheumatology and Clinical Immunology, Jichi Medical School, Tochigi, Japan.S. Yokota, MD, PhD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatrics, Yokohama City University School of Medicine; Y. Itoh, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatrics, Nippon Medical School; T. Morio, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatrics and Developmental Biology, TMDU Graduate School of Medical and Dental Sciences; N. Sumitomo, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Department of Pediatric Cardiology, Saitama Medical University International Medical Center; K. Daimaru, BS, Chugai Pharmaceutical Co. Ltd.; S. Minota, MD, the Safety Evaluation Committee of Tocilizumab for JIA, and the Division of Rheumatology and Clinical Immunology, Jichi Medical School
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Minoia F, Davì S, Horne A, Demirkaya E, Bovis F, Li C, Lehmberg K, Weitzman S, Insalaco A, Wouters C, Shenoi S, Espada G, Ozen S, Anton J, Khubchandani R, Russo R, Pal P, Kasapcopur O, Miettunen P, Maritsi D, Merino R, Shakoory B, Alessio M, Chasnyk V, Sanner H, Gao YJ, Huasong Z, Kitoh T, Avcin T, Fischbach M, Frosch M, Grom A, Huber A, Jelusic M, Sawhney S, Uziel Y, Ruperto N, Martini A, Cron RQ, Ravelli A. Clinical features, treatment, and outcome of macrophage activation syndrome complicating systemic juvenile idiopathic arthritis: a multinational, multicenter study of 362 patients. Arthritis Rheumatol 2015; 66:3160-9. [PMID: 25077692 DOI: 10.1002/art.38802] [Citation(s) in RCA: 261] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 07/24/2014] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To describe the clinical, laboratory, and histopathologic features, current treatment, and outcome of patients with macrophage activation syndrome (MAS) complicating systemic juvenile idiopathic arthritis (JIA). METHODS In this multinational, multicenter study, pediatric rheumatologists and hemato-oncologists entered patient data collected retrospectively into a web-based database. RESULTS A total of 362 patients, 22% of whom had MAS at the onset of systemic JIA, were included in the study by 95 investigators from 33 countries. The most frequent clinical manifestations were fever (96%), hepatomegaly (70%), and splenomegaly (58%). Central nervous system dysfunction and hemorrhages were recorded in 35% and 20% of the patients, respectively. Platelet count and liver transaminase, ferritin, lactate dehydrogenase, triglyceride, and d-dimer levels were the sole laboratory biomarkers showing a percentage change of >50% between the pre-MAS visit and MAS onset. Evidence of macrophage hemophagocytosis was found in 60% of the patients who underwent bone marrow aspiration. MAS occurred most frequently in the setting of active underlying disease, in the absence of a specific trigger. Nearly all patients were given corticosteroids, and 61% received cyclosporine. Biologic medications and etoposide were given to 15% and 12% of the patients, respectively. Approximately one-third of the patients required admission to the intensive care unit (ICU), and the mortality rate was 8%. CONCLUSION This study provides information on the clinical spectrum and current management of systemic JIA-associated MAS through the analysis of a very large patient sample. MAS remains a serious condition, as a sizeable proportion of patients required admission to the ICU or died.
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Sozeri B, Sevgi S, Kasapcopur O. Canakinumab: new treatment choice for systemic juvenile idiopathic arthritis. INTERNATIONAL JOURNAL OF CLINICAL RHEUMATOLOGY 2015. [DOI: 10.2217/ijr.14.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Jamilloux Y, Gerfaud-Valentin M, Henry T, Sève P. Treatment of adult-onset Still's disease: a review. Ther Clin Risk Manag 2014; 11:33-43. [PMID: 25653531 PMCID: PMC4278737 DOI: 10.2147/tcrm.s64951] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Adult-onset Still's disease (AOSD) is a rare inflammatory disorder that has been recently classified as a polygenic autoinflammatory disorder. The former classification, based on the disease course, seems to be quite dated. Indeed, there is accumulating evidence that AOSD can be divided into two distinct phenotypes based on cytokine profile, clinical presentation, and outcome, ie, a "systemic" pattern and an "articular" pattern. The first part of this review deals with the treatments that are currently available for AOSD. We then present the different strategies based on the characteristics of the disease according to clinical presentation. To do so, we focus on the two subsets of the disease. Finally, we discuss the management of life-threatening complications of AOSD, along with the therapeutic options during pregnancy.
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Affiliation(s)
- Yvan Jamilloux
- Department of Internal Medicine, Hôpital de la Croix-Rousse, Université Claude Bernard-Lyon 1, Lyon, France ; Department of Biochemistry, University of Lausanne, Epalinges, Switzerland ; International Research Center on Infectiology. INSERM U1111. Université Claude Bernard-Lyon 1, Lyon, France
| | - Mathieu Gerfaud-Valentin
- Department of Internal Medicine, Hôpital de la Croix-Rousse, Université Claude Bernard-Lyon 1, Lyon, France
| | - Thomas Henry
- International Research Center on Infectiology. INSERM U1111. Université Claude Bernard-Lyon 1, Lyon, France
| | - Pascal Sève
- Department of Internal Medicine, Hôpital de la Croix-Rousse, Université Claude Bernard-Lyon 1, Lyon, France
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Dinarello CA. An expanding role for interleukin-1 blockade from gout to cancer. Mol Med 2014; 20 Suppl 1:S43-58. [PMID: 25549233 PMCID: PMC4374514 DOI: 10.2119/molmed.2014.00232] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 11/17/2014] [Indexed: 01/08/2023] Open
Abstract
There is an expanding role for interleukin (IL)-1 in diseases from gout to cancer. More than any other cytokine family, the IL-1 family is closely linked to innate inflammatory and immune responses. This linkage is because the cytoplasmic segment of all members of the IL-1 family of receptors contains a domain, which is highly homologous to the cytoplasmic domains of all toll-like receptors (TLRs). This domain, termed "toll IL-1 receptor (TIR) domain," signals as does the IL-1 receptors; therefore, inflammation due to the TLR and the IL-1 families is nearly the same. Fundamental responses such as the induction of cyclo-oxygenase type 2, increased surface expression of cellular adhesion molecules and increased gene expression of a broad number of inflammatory molecules characterizes IL-1 signal transduction as it does for TLR agonists. IL-1β is the most studied member of the IL-1 family because of its role in mediating autoinflammatory disease. However, a role for IL-1α in disease is being validated because of the availability of a neutralizing monoclonal antibody to human IL-1α. There are presently three approved therapies for blocking IL-1 activity. Anakinra is a recombinant form of the naturally occurring IL-1 receptor antagonist, which binds to the IL-1 receptor and prevents the binding of IL-1β as well as IL-1α. Rilonacept is a soluble decoy receptor that neutralizes primarily IL-1β but also IL-1α. Canakinumab is a human monoclonal antibody that neutralizes only IL-1β. Thus, a causal or significant contributing role can be established for IL-1β and IL-1α in human disease.
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Affiliation(s)
- Charles Anthony Dinarello
- Department of Medicine, Division of Infectious Diseases, University of Colorado Denver, Aurora, Colorado, United States of America; and Department of Medicine, Radboud University, Nijmegen, the Netherlands
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Swart JF, de Roock S, Wulffraat NM. What are the immunological consequences of long-term use of biological therapies for juvenile idiopathic arthritis? Arthritis Res Ther 2014; 15:213. [PMID: 23731900 PMCID: PMC4060240 DOI: 10.1186/ar4213] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
This review summarizes the immunological consequences of biological therapies used in juvenile idiopathic arthritis (JIA). For every frequently used biological agent the characteristics are clearly specified (molecular target, isotype, registered indication for JIA, route of administration, half-life, contraindication, very common side effects, expected time of response and average cost in the first year). The emphasis of this review is on the immunological side effects that have been encountered for every separate agent in JIA populations. For each agent these adverse events have been calculated as incidence per 100 patient-years for the following categories: serious infections, tuberculosis, malignancies, response to vaccination, new-onset autoimmune diseases and development of anti-drug antibodies. There are large differences in side effects between various agents and there is a clear need for an international and standardized collection of post-marketing surveillance data of biologicals in the vulnerable group of JIA patients. Such an international pharmacovigilance database, called Pharmachild, has now been started.
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Jamilloux Y, Gerfaud-Valentin M, Martinon F, Belot A, Henry T, Sève P. Pathogenesis of adult-onset Still’s disease: new insights from the juvenile counterpart. Immunol Res 2014; 61:53-62. [DOI: 10.1007/s12026-014-8561-9] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Schulert GS, Grom AA. Pathogenesis of macrophage activation syndrome and potential for cytokine- directed therapies. Annu Rev Med 2014; 66:145-59. [PMID: 25386930 DOI: 10.1146/annurev-med-061813-012806] [Citation(s) in RCA: 250] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Macrophage activation syndrome (MAS) is an acute episode of overwhelming inflammation characterized by activation and expansion of T lymphocytes and hemophagocytic macrophages. In rheumatology, it occurs most frequently in patients with systemic juvenile idiopathic arthritis (SJIA) and systemic lupus erythematosus. The main clinical manifestations include cytopenias, liver dysfunction, coagulopathy resembling disseminated intravascular coagulation, and extreme hyperferritinemia. Clinically and pathologically, MAS bears strong similarity to hemophagocytic lymphohistiocytosis (HLH), and some authors prefer the term secondary HLH to describe it. Central to its pathogenesis is a cytokine storm, with markedly increased levels of numerous proinflammatory cytokines including IL-1, IL-6, IL-18, TNFα, and IFNγ. Although there is evidence that IFNγ may play a central role in the pathogenesis of MAS, the role of other cytokines is still not clear. There are several reports of SJIA-associated MAS dramatically benefiting from anakinra, a recombinant IL-1 receptor antagonist, but the utility of other biologics in MAS is not clear. The mainstay of treatment remains corticosteroids; other medications, including cyclosporine, are used in patients who fail to respond.
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Affiliation(s)
- Grant S Schulert
- Division of Pediatric Rheumatology, Children's Hospital Medical Center, Cincinnati, Ohio 45229; ,
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Oberle EJ, Harris JG, Verbsky JW. Polyarticular juvenile idiopathic arthritis - epidemiology and management approaches. Clin Epidemiol 2014; 6:379-93. [PMID: 25368531 PMCID: PMC4216020 DOI: 10.2147/clep.s53168] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Juvenile idiopathic arthritis (JIA) is a group of disorders characterized by arthritis persisting for at least 6 weeks with onset before the age of 16 years. Within this cluster of conditions, the polyarticular form (involving more than four joints within the first 6 months) is further divided based on the presence of rheumatoid factor. Children with polyarticular JIA pose unique diagnostic and therapeutic challenges compared to children with involvement of fewer joints. Polyarticular JIA patients tend to have a more refractory course and therefore are at increased risk for joint damage, resulting in poorer functional outcomes and decreased quality of life. Although the ability to treat this disorder continues to improve, especially with the advent of biologic agents, there is still much about the epidemiology and pathogenesis of polyarticular JIA that is unknown. The epidemiology of polyarticular JIA varies worldwide with a vast difference in reported cases between different global regions as well as within individual countries. Several genetic risk loci have been identified conferring increased susceptibility to JIA, many within the human leukocyte antigen region. Beyond the genome, environmental factors also seem to contribute to the etiology of polyarticular JIA. This review article will focus on the epidemiology and current treatments of polyarticular JIA and briefly discuss genetic and environmental influences on the pathogenesis of JIA as well as new and emerging therapies.
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Affiliation(s)
- Edward J Oberle
- Department of Pediatrics, Division of Rheumatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Julia G Harris
- Department of Pediatrics, Division of Rheumatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - James W Verbsky
- Department of Pediatrics, Division of Rheumatology, Medical College of Wisconsin, Milwaukee, WI, USA
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Grom AA. Canakinumab for the treatment of systemic juvenile idiopathic arthritis. Expert Rev Clin Immunol 2014; 10:1427-35. [DOI: 10.1586/1744666x.2014.965149] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ilowite NT, Prather K, Lokhnygina Y, Schanberg LE, Elder M, Milojevic D, Verbsky JW, Spalding SJ, Kimura Y, Imundo LF, Punaro MG, Sherry DD, Tarvin SE, Zemel LS, Birmingham JD, Gottlieb BS, Miller ML, O'Neil K, Ruth NM, Wallace CA, Singer NG, Sandborg CI. Randomized, double-blind, placebo-controlled trial of the efficacy and safety of rilonacept in the treatment of systemic juvenile idiopathic arthritis. Arthritis Rheumatol 2014; 66:2570-9. [PMID: 24839206 PMCID: PMC4314719 DOI: 10.1002/art.38699] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 05/06/2014] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To assess the efficacy and safety of rilonacept, an interleukin-1 inhibitor, in a randomized, double-blind, placebo-controlled trial. METHODS An initial 4-week double-blind placebo phase was incorporated into a 24-week randomized multicenter design, followed by an open-label phase. Seventy-one children who had active arthritis in ≥2 joints were randomized (1:1) to the 2 arms of the study. Patients in the rilonacept arm received rilonacept (loading dose 4.4 mg/kg followed by 2.2 mg/kg weekly, subcutaneously) beginning on day 0. Patients in the placebo arm received placebo for 4 weeks followed by a loading dose of rilonacept at week 4 followed by weekly maintenance doses. The primary end point was time to response, using the adapted American College of Rheumatology Pediatric 30 criteria coupled with the absence of fever and taper of the dosage of systemic corticosteroids, using prespecified criteria. RESULTS The time to response was shorter in the rilonacept arm than in the placebo arm (χ(2) = 7.235, P = 0.007). The secondary analysis, which used the same response criteria, showed that 20 (57%) of 35 patients in the rilonacept arm had a response at week 4 compared with 9 (27%) of 33 patients in the placebo arm (P = 0.016). Exacerbation of systemic juvenile idiopathic arthritis (JIA) was the most common severe adverse event. More patients in the rilonacept arm had elevated liver transaminase levels (including levels more than 3 times the upper limit of normal) compared with those in the placebo arm. Adverse events were similar in the 2 arms of the study. CONCLUSION Rilonacept was generally well tolerated and demonstrated efficacy in active systemic JIA.
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Affiliation(s)
- Norman T Ilowite
- Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
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Cantarini L, Lopalco G, Caso F, Costa L, Iannone F, Lapadula G, Anelli MG, Franceschini R, Menicacci C, Galeazzi M, Selmi C, Rigante D. Effectiveness and tuberculosis-related safety profile of interleukin-1 blocking agents in the management of Behçet's disease. Autoimmun Rev 2014; 14:1-9. [PMID: 25151975 DOI: 10.1016/j.autrev.2014.08.008] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 08/09/2014] [Indexed: 12/19/2022]
Abstract
Behçet's disease (BD) is a multi-systemic disorder of unknown etiology characterized by relapsing oral-genital ulcers, uveitis, and involvement of the articular, gastrointestinal, neurologic, and vascular systems. Although the primum movens of this condition remains unknown, a tangled plot combining autoimmune and autoinflammatory pathways has been hypothesized to explain its start and recurrence. In-depth analysis of BD pathogenetic mechanisms, involving dysfunction of multiple proinflammatory molecules, has opened new modalities of treatment: different agents targeting interleukin-1 have been studied in recent years to manage the most difficult and multi-resistant cases of BD. Growing experience with anakinra, canakinumab and gevokizumab is discussed in this review, highlighting the relative efficacy of each drug upon the protean BD clinical manifestations. Safety and tolerability of interleukin-1 antagonists in different doses have been confirmed by numerous observational studies on both large and small cohorts of patients with BD. In particular, the potential for Mycobacterium tuberculosis reactivation and tuberculosis development appears to be significantly lower with interleukin-1 blockers compared to tumor necrosis factor-α inhibitors, thus increasing the beneficial profile of this approach.
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Affiliation(s)
- Luca Cantarini
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy.
| | - Giuseppe Lopalco
- Interdisciplinary Department of Medicine, Rheumatology Unit, Policlinic Hospital, University of Bari, Bari, Italy
| | - Francesco Caso
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy; Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Padua, Padua, Italy
| | - Luisa Costa
- Rheumatology Unit, Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy
| | - Florenzo Iannone
- Interdisciplinary Department of Medicine, Rheumatology Unit, Policlinic Hospital, University of Bari, Bari, Italy
| | - Giovanni Lapadula
- Interdisciplinary Department of Medicine, Rheumatology Unit, Policlinic Hospital, University of Bari, Bari, Italy
| | - Maria Grazia Anelli
- Interdisciplinary Department of Medicine, Rheumatology Unit, Policlinic Hospital, University of Bari, Bari, Italy
| | | | - Cristina Menicacci
- Ophthalmology and Neurosurgery Department, University of Siena, Siena, Italy
| | - Mauro Galeazzi
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Padua, Padua, Italy
| | - Carlo Selmi
- Division of Rheumatology, Allergy, and Clinical Immunology, University of CA, Davis, USA; Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Donato Rigante
- Institute of Pediatrics, Università Cattolica Sacro Cuore, Rome, Italy
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Nigrovic PA. Review: is there a window of opportunity for treatment of systemic juvenile idiopathic arthritis? Arthritis Rheumatol 2014; 66:1405-13. [PMID: 24623686 DOI: 10.1002/art.38615] [Citation(s) in RCA: 135] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 02/27/2014] [Indexed: 12/13/2022]
Affiliation(s)
- Peter A Nigrovic
- Boston Children's Hospital, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts
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231
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Update on research and clinical translation on specific clinical areas: From bench to bedside: How insight in immune pathogenesis can lead to precision medicine of severe juvenile idiopathic arthritis. Best Pract Res Clin Rheumatol 2014; 28:229-46. [PMID: 24974060 DOI: 10.1016/j.berh.2014.05.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Despite the enormous progress in the treatment of juvenile idiopathic arthritis (JIA), innovations based on true bench-to-bedside research, performed in JIA patients, are still scarce. This chapter describes novel developments in which clinical innovations go hand in hand with basic discoveries. For the purpose of this review, we will mainly focus on developments in severe forms of JIA, most notably systemic JIA and polyarticular JIA. However, also in less severe forms of JIA, such as oligoarticular JIA, better insight will help to improve diagnosis and treatment. Facilitating the transition from bench to bedside will prove crucial for addressing the major challenges in JIA management. If successful, it will set new standards for a safe, targeted and personalized therapeutic approach for children with JIA.
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Abstract
The treatment of juvenile idiopathic arthritis (JIA) has substantially evolved over the past two decades. Research has been conducted and is ongoing on how therapies can best be utilized either as monotherapy or in combination for enhanced efficacy. The introduction of biologic therapies that selectively target specific cytokines has changed the acceptable clinical course of childhood arthritis. In addition to the development and utilization of new therapeutic agents, the pediatric rheumatology community has made vital progress toward defining disease activity, developing validated outcome measures, and establishing collaborative networks to assess both clinical outcomes and the long-term side effects related to therapeutics for juvenile arthritis. In this chapter, we will discuss the therapeutic evolution in JIA over the past two decades. Although the largest strides have been made with biologic agents, and these newer drugs have more rigorous data to support their use, select commonly used non-biologic therapies are included, with the discussion focused on more recent updated literature.
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Affiliation(s)
- Elizabeth A Kessler
- Division of Rheumatology, Department of Pediatrics, Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO 64108, USA.
| | - Mara L Becker
- Division of Rheumatology, Department of Pediatrics, Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO 64108, USA.
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Horneff G. Moderne Behandlung der juvenilen idiopathischen Arthritis. Monatsschr Kinderheilkd 2014. [DOI: 10.1007/s00112-014-3101-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hügle B, Hinze C, Lainka E, Fischer N, Haas JP. Development of positive antinuclear antibodies and rheumatoid factor in systemic juvenile idiopathic arthritis points toward an autoimmune phenotype later in the disease course. Pediatr Rheumatol Online J 2014; 12:28. [PMID: 25114627 PMCID: PMC4127434 DOI: 10.1186/1546-0096-12-28] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 07/10/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Systemic juvenile idiopathic arthritis (sJIA) is commonly considered an autoinflammatory disease. However, sJIA patients may develop aggressive arthritis without systemic inflammation later in the disease, resembling an autoimmune phenotype similar to other subtypes of JIA. The objective of this study was to determine whether antinuclear antibodies (ANA) and rheumatoid factor (RF) will develop in patients with sJIA over the course of the disease. FINDINGS A single center sample of sJIA patients with follow-up of more than one year was obtained. A retrospective chart survey was used to extract demographic and clinical data as well as presence and titers of ANA and RF at diagnosis and during follow-up. 32 patients were included in the study, with a median age of 4.2 years and median follow-up of 6.0 years. 8/32 patients had ANA titers ≥ 1:80 at diagnosis, with 22/32 patients showing rising ANA titers with titers ≥ 1:80 at last follow-up (p =0.001). 10/32 patients had a positive RF at least once during follow-up, compared to 0/32 at diagnosis (p = 0.001). In 5/10 patients, positive RF was documented at least twice, more than twelve weeks apart. Patients treated with TNF antagonists were not significantly more likely to develop positive ANA titers (p = 0.425) or positive RF (p = 0.703). CONCLUSIONS Patients with sJIA developed increased ANA titers and positive RF over the course of the disease, independent of treatment with TNF antagonists. This might point towards an autoimmune, rather than an autoinflammatory phenotype later in the course of sJIA.
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Affiliation(s)
- Boris Hügle
- German Center for Pediatric and Adolescent Rheumatology, Gehfeldstrasse 24, 82467 Garmisch-Partenkirchen, Germany
| | - Claas Hinze
- German Center for Pediatric and Adolescent Rheumatology, Gehfeldstrasse 24, 82467 Garmisch-Partenkirchen, Germany,Department of Pediatric Rheumatology and Immunology, University Children's Hospital Münster, Münster, Germany
| | - Elke Lainka
- Department of Pediatric Rheumatology, University Duisburg-Essen, Children’s Hospital, Essen, Germany
| | - Nadine Fischer
- German Center for Pediatric and Adolescent Rheumatology, Gehfeldstrasse 24, 82467 Garmisch-Partenkirchen, Germany
| | - Johannes-Peter Haas
- German Center for Pediatric and Adolescent Rheumatology, Gehfeldstrasse 24, 82467 Garmisch-Partenkirchen, Germany
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Abstract
Many paediatric rheumatic diseases result from the abnormal activation or control of the immune system. Biologic drugs, which are synthesised within a biological system, have been designed to target specific molecules involved in cytokine signalling or cell-cell interactions. The past 15 years have seen a revolution in the range of effective treatments for rheumatic diseases, particularly juvenile idiopathic arthritis (JIA). As a result, the target of inactive disease and minimal long-term disease-associated damage is increasingly becoming achievable. In this article we review evidence from recent trials of the use of biologic drugs in the treatment of systemic JIA, juvenile dermatomyositis and juvenile systemic lupus erythematosus. We also highlight novel agents currently undergoing investigation which may broaden our therapeutic armamentarium over the coming decade. Key to these developments are well-designed multicentre controlled clinical trials and long-term safety monitoring as part of international drug registries.
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Vastert SJ, de Jager W, Noordman BJ, Holzinger D, Kuis W, Prakken BJ, Wulffraat NM. Effectiveness of first-line treatment with recombinant interleukin-1 receptor antagonist in steroid-naive patients with new-onset systemic juvenile idiopathic arthritis: results of a prospective cohort study. Arthritis Rheumatol 2014; 66:1034-43. [PMID: 24757154 DOI: 10.1002/art.38296] [Citation(s) in RCA: 176] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 11/21/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To conduct a prospective cohort study using anakinra, a recombinant IL-1 receptor antagonist (IL-1Ra), as first-line therapy in patients with new-onset systemic juvenile idiopathic arthritis (JIA). METHODS Therapy with recombinant IL-1Ra (2 mg/kg) was initiated in 20 patients who fulfilled the International League of Associations for Rheumatology criteria for systemic JIA, before systemic steroid treatment was administered. Patients were monitored clinically and immunologically. The protocol contained a stop strategy for patients who met at least the adapted American College of Rheumatology 90% criteria for improvement in JIA (ACR Pediatric 90 [ACR Pedi 90]) after 3 months. RESULTS We included consecutive patients with new-onset systemic JIA. The mean followup period was 32 months (range 12-54 months). At the 3-month time point, 85% of the patients showed an adapted ACR Pedi 90 response or had inactive disease; 75% of the patients achieved this response while receiving recombinant IL-1Ra alone. After 1 year, 17 of the 20 patients met the criteria for clinically inactive disease, and 13 of these patients met these criteria while receiving monotherapy with recombinant IL-1Ra. However, because of persistent disease activity, 7 of the 20 patients required additional therapy besides recombinant IL-1Ra. According to our stop strategy, 73% of patients with at least an adapted ACR Pedi 90 response at 3 months could stop recombinant IL-1Ra treatment within 1 year. After 2 years, 12 (86%) of 14 patients met the criteria for disease remission, either while receiving (n = 4) or not receiving (n = 8) medication. After 3 years, 10 (91%) of 11 patients met the criteria for disease remission, either while receiving (n = 2) or not receiving (n = 8) medication. CONCLUSION This is the first prospective study in which recombinant IL-1Ra was used as first-line therapy in patients with systemic JIA. We observed excellent responses in nearly all patients within 3 months. In the majority of responding patients, treatment with recombinant IL-1Ra could be stopped within 1 year, with remission being preserved during followup. In approximately one-third of patients, concomitant therapy was required for maintenance of clinical response.
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Therapeutic role of anakinra, an interleukin-1 receptor antagonist, in the management of secondary hemophagocytic lymphohistiocytosis/sepsis/multiple organ dysfunction/macrophage activating syndrome in critically ill children*. Pediatr Crit Care Med 2014; 15:401-8. [PMID: 24583503 DOI: 10.1097/pcc.0000000000000078] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Secondary hemophagocytic lymphohistiocytosis, macrophage activating syndrome, and sepsis share the same inflammatory phenotype leading often to multiple organ dysfunction syndrome needing intensive care. The goal of this article is to describe our experience with anakinra (Kineret), a recombinant interleukin-1 receptor antagonist, in decreasing the systemic inflammation. DESIGN Retrospective case series. SETTING The PICU at the Helen DeVos Children's Hospital (Grand Rapids, MI). PATIENTS The records of eight critically ill children presumed to have secondary hemophagocytic lymphohistiocytosis at our institution between January 1, 2011, and July 31, 2012, were reviewed. INTERVENTIONS All of the patients were treated with anakinra (Kineret) and in some cases systemic corticosteroids as first-line therapy for secondary hemophagocytic lymphohistiocytosis. MEASUREMENTS AND MAIN RESULTS Patients had a median age of 14 years and a median Pediatric Risk of Mortality score of 11.5. Four were previously healthy and four had underlying diseases that could have made them susceptible to secondary hemophagocytic lymphohistiocytosis. Indications for PICU transfer were respiratory distress 50% (4 of 8), cardiovascular instability 37.5% (3 of 8), and chest pain (1 of 8). Five of the patients (62.5%) were mechanically ventilated and 62.5% (5 of 8) received vasoactive infusions. Inflammatory markers were assessed linearly at the start of therapy and 7 days later. Baseline C-reactive protein was 206 ± 50 mg/L (mean ± SEM) at the start of anakinra and decreased by 67.1% to 68 ± 36 mg/L (p = 0.03). Ferritin decreased by 63.8% to 3,210 ± 1,178 ng/mL (p = 0.30), and fibrinogen decreased by 42% to 158 ± 41 mg/dL (p = 0.03). Absolute neutrophil count (p = 0.38) and absolute lymphocyte count (p = 0.69) did not change significantly. No infections were attributed to anakinra therapy. One patient died long after treatment with anakinra while receiving pre-hematopoietic stem cell transplant chemotherapy. CONCLUSIONS Anakinra could represent a promising therapeutic approach in these life-threatening disorders that are likely underdiagnosed and often difficult to treat.
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Gilbert M, Punaro M. Blood gene expression profiling in pediatric systemic lupus erythematosus and systemic juvenile idiopathic arthritis: from bench to bedside. Pediatr Rheumatol Online J 2014; 12:16. [PMID: 24839407 PMCID: PMC4023703 DOI: 10.1186/1546-0096-12-16] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 05/01/2014] [Indexed: 12/02/2022] Open
Abstract
Blood gene expression profiling has led to major advances in the field of rheumatology over the last few decades. Specifically, DNA microarray technology has been integral in increasing our knowledge of key players in the pathogenesis of some rare pediatric rheumatic diseases. Our group, using microarray analysis, identified the interferon (IFN) gene signature in pediatric systemic lupus erythematosus (SLE) and has published data that suggest high doses of intravenous corticosteroid treatment may have benefit over strictly oral regimens. Additionally, DNA microarray technology led to our discovery that the interleukin (IL)-1 gene signature is associated with systemic juvenile idiopathic arthritis (sJIA) and to the use of IL-1 blockade with anakinra in this disease. We also reported the biologic rationale for use of anakinra early in the disease course. Anakinra is now being used as first-line treatment in sJIA in multiple centers. Herein, we review how information obtained from blood gene expression profiling has changed our clinical practice.
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Affiliation(s)
- Mileka Gilbert
- Pediatric Rheumatology, University of Texas Southwestern Medical Center, Children’s Medical Center, Texas Scottish Rite Hospital for Children, Dallas, TX, USA
| | - Marilynn Punaro
- Pediatric Rheumatology, University of Texas Southwestern Medical Center, Children’s Medical Center, Texas Scottish Rite Hospital for Children, Dallas, TX, USA
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Aoki C, Inaba Y, Choe H, Kaneko U, Hara R, Miyamae T, Imagawa T, Mori M, Oba MS, Yokota S, Saito T. Discrepancy Between Clinical and Radiological Responses to Tocilizumab Treatment in Patients with Systemic-onset Juvenile Idiopathic Arthritis. J Rheumatol 2014; 41:1171-7. [DOI: 10.3899/jrheum.130924] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Objective.Tocilizumab (TCZ), an antiinterleukin-6 receptor monoclonal antibody, is clinically beneficial in patients with systemic-onset juvenile idiopathic arthritis (sJIA). We investigated the clinical and radiological outcomes of TCZ therapy in patients with sJIA.Methods.We retrospectively evaluated 2 clinical trials (NCT00144599 and NCT00144612) involving 40 patients with sJIA who received intravenous TCZ (8 mg/kg) every 2 weeks. Clinical data and radiographs of the hands and large joints were assessed before and during TCZ treatment. The Poznanski score, modified Larsen scores of the hands and large joints, and Childhood Arthritis Radiographic Score of the Hip (CARSH) were recorded.Results.After a mean duration of 4.5 years of TCZ treatment, clinical data had improved significantly, the mean Poznanski score improved from −1.5 to −1.1, the mean Larsen score of the hands deteriorated from 7.0 to 10.0, the mean Larsen score for the large joints deteriorated from 5.9 to 6.8, and the CARSH worsened from 3.9 to 6.2. The Larsen score for the large joints improved in 11 cases (28%), remained unchanged in 8 cases (20%), and worsened in 21 cases (52%). Matrix metalloproteinase 3 (MMP-3) levels remained significantly higher (278 mg/dl) in patients with worsened Larsen scores than in patients with improved or unchanged scores (65 mg/dl). Logistic regression analysis showed that older age at disease onset was a significant risk factor for radiographic progression.Conclusion.The modified Larsen score of the large joints deteriorated in half the patients who had high MMP-3 levels during TCZ treatment and who were significantly older at disease onset.
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241
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Stoll ML, Cron RQ. Treatment of juvenile idiopathic arthritis: a revolution in care. Pediatr Rheumatol Online J 2014; 12:13. [PMID: 24782683 PMCID: PMC4003520 DOI: 10.1186/1546-0096-12-13] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 04/10/2014] [Indexed: 01/19/2023] Open
Abstract
A generation ago, children with arthritis faced a lifetime of pain and disability. Today, there are a multitude of treatment options, including a variety of biologics targeting key cytokines and other inflammatory mediators. While non-steroidal anti-inflammatory drugs and corticosteroids were once the mainstay of therapy, they are now largely used as bridge or adjunctive therapies. Among the conventional disease-modifying anti-rheumatic drugs, methotrexate remains first-line therapy for most children with juvenile idiopathic arthritis (JIA) due to its long track record of safety and effectiveness in the management of peripheral arthritis. Sulfasalazine and leflunomide may also have a secondary role. The tumor necrosis factor inhibitors (TNFi) have shown tremendous benefit in children with polyarticular JIA and likely in enthesitis-related arthritis and psoriatic JIA as well. There may be additional benefit in combining TNFi with methotrexate. Abatacept and tocilizumab also appear to benefit polyarticular JIA; the role of rituximab remains unclear. For the treatment of systemic JIA, while the TNFi are of less benefit, blockade of interleukin-1 or interleukin-6 is highly effective. Additionally, interleukin-1 blockade appears to be effective treatment of macrophage activation syndrome, one of the most dangerous complications of JIA; specifically, anakinra in combination with cyclosporine and corticosteroids may obviate the need for cytotoxic approaches. In contrast, methotrexate along with the TNFi and abatacept are effective agents for the management of uveitis, another complication of JIA. Overall, the biologics have demonstrated an impressive safety record in children with JIA, although children do need to be monitored for rare but potentially dangerous adverse events, such as tuberculosis and other infections; paradoxical development of additional autoimmune diseases; and possibly an increased risk of malignancy. Finally, there may be a window of opportunity during which children with JIA will demonstrate most optimal responses to aggressive therapy, underscoring the need for rapid diagnosis and initiation of treatment.
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Affiliation(s)
- Matthew L Stoll
- University of Alabama at Birmingham, CPP N 210 M, 1600 7th Avenue South, Birmingham, AL 35233-1711, USA
| | - Randy Q Cron
- University of Alabama at Birmingham, CPP N 210 M, 1600 7th Avenue South, Birmingham, AL 35233-1711, USA
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242
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Malattia C, Martini A. Glucocorticoids in juvenile idiopathic arthritis. Ann N Y Acad Sci 2014; 1318:65-70. [DOI: 10.1111/nyas.12436] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Clara Malattia
- Pediatria II; Istituto Giannina Gaslini, and Department of Pediatrics; University of Genova; Genova Italy
| | - Alberto Martini
- Pediatria II; Istituto Giannina Gaslini, and Department of Pediatrics; University of Genova; Genova Italy
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243
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Beukelman T. Treatment advances in systemic juvenile idiopathic arthritis. F1000PRIME REPORTS 2014; 6:21. [PMID: 24765526 PMCID: PMC3974570 DOI: 10.12703/p6-21] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Systemic juvenile idiopathic arthritis (JIA) is an autoinflammatory condition that is distinct from other forms of childhood arthritis. Recently, biologic agents that specifically inhibit the cytokines interleukin (IL)-1 and IL-6 have demonstrated remarkable clinical effectiveness and confirmed the importance of these cytokines in the disease process. Future studies are likely to optimize the care of children with systemic arthritis and further elucidate the disease pathogenesis.
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Affiliation(s)
- Timothy Beukelman
- The University of Alabama at Birmingham, Division of Pediatric Rheumatology 1600 7th Avenue South, CPP 210, Birmingham, AL, 35233-1711 USA
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244
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Abstract
Macrophage activation syndrome (MAS) is an episode of overwhelming inflammation that occurs most commonly in children with systemic juvenile idiopathic arthritis (SJIA). It is characterized by expansion and activation of T lymphocytes and hemophagocytic macrophages and bears great similarity to hemophagocytic lymphohistiocytosis (HLH). This disorder has substantial morbidity and mortality, and there is frequently a delay in recognition and initiation of treatment. Here, we will review what is known about the pathogenesis of MAS and, in particular, its similarities to HLH. The development of MAS is characterized by a cytokine storm, with the elaboration of numerous pro-inflammatory cytokines. We will examine the evidence for various cytokines in the initiation and pathogenesis of MAS and discuss how new biologic therapies may alter the risk of MAS. Finally, we will review current treatment options for MAS and examine how cytokine-directed therapy could serve as novel treatment modalities.
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Affiliation(s)
- Grant S Schulert
- Division of Pediatric Rheumatology, Children's Hospital Medical Center, MLC 4010, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
| | - Alexei A Grom
- Division of Pediatric Rheumatology, Children's Hospital Medical Center, MLC 4010, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
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Benahmed F, Chyou S, Dasoveanu D, Chen J, Kumar V, Iwakura Y, Lu TT. Multiple CD11c+ cells collaboratively express IL-1β to modulate stromal vascular endothelial growth factor and lymph node vascular-stromal growth. THE JOURNAL OF IMMUNOLOGY 2014; 192:4153-63. [PMID: 24659690 DOI: 10.4049/jimmunol.1301765] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Lymphadenopathy in autoimmune and other lymphoproliferative diseases is in part characterized by immunoblasts and vascular proliferation. The lymph node vasculature, along with the nonvascular stromal compartment, supports lymphocyte function, and targeting vascular-stromal expansion in inflamed nodes may modulate lymphocyte function in disease. CD11c(+) cells are essential for vascular-stromal proliferation and the upregulation of vascular endothelial growth factor (VEGF) needed for vascular proliferation. However, targetable CD11c(+) cell-derived molecular mediators, the identity of relevant CD11c(+) cells, and whether CD11c(+) cells directly stimulate VEGF-expressing stromal cells are poorly understood. In this study we show that CD11c(+) CD11b(+) CCR2-dependent monocytes and CCR7-dependent dendritic cells express IL-1β. IL-1β blockade, IL-1β deficiency in radiosensitive cells, and CCR2/CCR7 double deficiency but not single deficiency all attenuate immunization-induced vascular-stromal proliferation. gp38(+) stromal fibroblastic reticular cells (FRCs) that express VEGF are enriched for Thy1(+) cells and partially overlap with CCL21-expressing FRCs, and FRC VEGF is attenuated with IL-1β deficiency or blockade. IL-1β localizes to the outer borders of the T zone, where VEGF-expressing cells are also enriched. Ex vivo, CD11b(+) cells enriched for IL-1β(+) cells can directly induce cultured gp38(+)Thy1(+) FRCs to upregulate VEGF. Taken together, these results suggest a mechanism whereby multiple recruited CD11c(+) populations express IL-1β and directly modulate FRC function to help promote the initiation of vascular-stromal growth in stimulated lymph nodes. These data provide new insight into how CD11c(+) cells regulate the lymph node vascular-stromal compartment, add to the evolving understanding of functional stromal subsets, and suggest a possible utility for IL-1β blockade in preventing inflammatory lymph node growth.
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Affiliation(s)
- Fairouz Benahmed
- Autoimmunity and Inflammation Program and Pediatric Rheumatology, Hospital for Special Surgery, New York, NY 10021
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246
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Gerfaud-Valentin M, Jamilloux Y, Iwaz J, Sève P. Adult-onset Still's disease. Autoimmun Rev 2014; 13:708-22. [PMID: 24657513 DOI: 10.1016/j.autrev.2014.01.058] [Citation(s) in RCA: 358] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 01/02/2014] [Indexed: 12/17/2022]
Abstract
First described in 1971, adult-onset Still's disease (AOSD) is a rare multisystemic disorder considered as a complex (multigenic) autoinflammatory syndrome. A genetic background would confer susceptibility to the development of autoinflammatory reactions to environmental triggers. Macrophage and neutrophil activation is a hallmark of AOSD which can lead to a reactive hemophagocytic lymphohistiocytosis. As in the latter disease, the cytotoxic function of natural killer cells is decreased in patients with active AOSD. IL-18 and IL-1β, two proinflammatory cytokines processed through the inflammasome machinery, are key factors in the pathogenesis of AOSD; they cause IL-6 and Th1 cytokine secretion as well as NK cell dysregulation leading to macrophage activation. The clinico-biological picture of AOSD usually includes high spiking fever with joint symptoms, evanescent skin rash, sore throat, striking neutrophilic leukocytosis, hyperferritinemia with collapsed glycosylated ferritin (<20%), and abnormal liver function tests. According to the clinical presentation of the disease at diagnosis, two AOSD phenotypes may be distinguished: i) a highly symptomatic, systemic and feverish one, which would evolve into a systemic (mono- or polycyclic) pattern; ii) a more indolent one with arthritis in the foreground and poor systemic symptomatology, which would evolve into a chronic articular pattern. Steroid- and methotrexate-refractory AOSD cases benefit now from recent insights into autoinflammatory disorders: anakinra seems to be an efficient, well tolerated, steroid-sparing treatment in systemic patterns; tocilizumab seems efficient in AOSD with active arthritis and systemic symptoms while TNFα-blockers could be interesting in chronic polyarticular refractory AOSD.
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Affiliation(s)
- Mathieu Gerfaud-Valentin
- Hospices Civils de Lyon, Hôpital Universitaire de la Croix-Rousse, Service de médecine interne, F-69004 Lyon, France; Université Lyon I, F-69100 Villeurbanne, France; Université de Lyon, F-69000 Lyon, France
| | - Yvan Jamilloux
- Hospices Civils de Lyon, Hôpital Universitaire de la Croix-Rousse, Service de médecine interne, F-69004 Lyon, France; Inserm U1111, Centre International de Recherche en Infectiologie, F-69365 Lyon, France; Département de Biochimie, Université de Lausanne, 1006 Epalinges, Switzerland
| | - Jean Iwaz
- Université Lyon I, F-69100 Villeurbanne, France; Université de Lyon, F-69000 Lyon, France; Hospices Civils de Lyon, Service de Biostatistique, F-69000 Lyon, France; CNRS UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique Santé, F-69310 Pierre-Bénite, France
| | - Pascal Sève
- Hospices Civils de Lyon, Hôpital Universitaire de la Croix-Rousse, Service de médecine interne, F-69004 Lyon, France; Université Lyon I, F-69100 Villeurbanne, France; Université de Lyon, F-69000 Lyon, France.
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247
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Abstract
The purpose of this review is to comprehensively examine the various therapeutic agents available to treat autoimmune eye disease, their indications, clinical safety and recent developments. The stepladder approach is reviewed, including corticosteroid administration of various forms, classic immunomodulators, and newer biologic response modifiers. The authors present that corticosteroid monotherapy is almost never curative and carries significant side effects, while immunomodulatory therapy, when used appropriately as way to induce steroid-free remission, carries far less risk of causing long-term complications and provides greater potential of altering the immune system to induce a durable remission.
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248
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van Royen-Kerkhof A, Vastert BSJ, Swart JF, Wulffraat NM. Biologic treatment of pediatric rheumatic diseases: are we spoilt for choice? Immunotherapy 2014; 6:1-3. [DOI: 10.2217/imt.13.153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Annet van Royen-Kerkhof
- Department of Pediatric Immunology & Rheumatology, Wilhelmina Children’s Hospital University Medical Center, Utrecht, The Netherlands
| | - Bas SJ Vastert
- Department of Pediatric Immunology & Rheumatology, Wilhelmina Children’s Hospital University Medical Center, Utrecht, The Netherlands
| | - Joost F Swart
- Department of Pediatric Immunology & Rheumatology, Wilhelmina Children’s Hospital University Medical Center, Utrecht, The Netherlands
| | - Nico M Wulffraat
- Department of Pediatric Immunology & Rheumatology, Wilhelmina Children’s Hospital University Medical Center, Utrecht, The Netherlands
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249
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Advances in the pathogenesis and treatment of systemic juvenile idiopathic arthritis. Pediatr Res 2014; 75:176-83. [PMID: 24213625 DOI: 10.1038/pr.2013.187] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 07/11/2013] [Indexed: 11/08/2022]
Abstract
Systemic juvenile idiopathic arthritis (s-JIA) is clinically distinct from other types of JIA. It is typified by extraarticular features such as quotidian fevers, rash, splenomegaly, lymphadenopathy, laboratory abnormalities (including leukocytosis, thrombocytosis, anemia, hyperferritinemia, and elevated inflammatory markers), and a close association with the macrophage activation syndrome. Recent investigations have highlighted dysregulation of the innate immune system as the critical pathogenic driver of s-JIA. Key innate immune mediators of s-JIA are the macrophage-derived cytokines interleukin-1 (IL-1) and IL-6. Increased understanding of the roles of IL-1 and IL-6 in the pathogenesis of s-JIA has led to major changes in therapeutic options. Until recently, the most commonly used medications included corticosteroids, methotrexate, and tumor necrosis factor (TNF) inhibitors, which are incompletely effective in most cases. Newer biologic agents targeting IL-1 and IL-6 have proven very effective in treating s-JIA and in minimizing corticosteroid exposure. Here we review recent advances in the understanding of the pathogenesis of s-JIA and the recent clinical trials that have revolutionized the care of children with s-JIA.
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250
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Vastert SJ, Swart JF, Wulffraat NM. Evaluation of anakinra for the treatment of systemic juvenile idiopathic arthritis. Expert Opin Orphan Drugs 2013. [DOI: 10.1517/21678707.2014.872027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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