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Correll CK, Stryker S, Collier D, Phillips TA, Dennos AC, Balevic SJ, Beukelman T. Occurrence of adverse events and change in disease activity after initiation of etanercept in paediatric patients with juvenile psoriatic arthritis in the CARRA Registry. RMD Open 2023; 9:rmdopen-2022-002943. [PMID: 37230760 DOI: 10.1136/rmdopen-2022-002943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 05/07/2023] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVE Etanercept is commonly used to treat juvenile idiopathic arthritis, including juvenile psoriatic arthritis (JPsA); however, information on etanercept's safety and effectiveness in clinical practice is limited. We used data from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry to evaluate etanercept's safety and effectiveness in JPsA in clinical practice. METHODS We analysed safety and effectiveness data for paediatric patients enrolled in the CARRA Registry who had a JPsA diagnosis and had used etanercept. Safety was assessed by calculating rates of prespecified adverse events of special interest (AESIs) and serious adverse events (SAEs). Effectiveness was assessed by a variety of disease activity measures. RESULTS Overall, 226 patients had JPsA and received etanercept; 191 met criteria for safety analysis and 43 met criteria for effectiveness analysis. AESI and SAE incidence rates were low. There were five events: three uveitis, one new-onset neuropathy and one malignancy. Incidence rates were 0.55 (95% CI: 0.18, 1.69), 0.18 (95% CI: 0.03, 1.29) and 0.13 (95% CI: 0.02, 0.09) per 100 patient-years for uveitis, neuropathy and malignancy, respectively. Etanercept showed effectiveness for JPsA treatment; 7 of 15 (46.7%) had an American College of Rheumatology-Pediatric Response 90, 9 of 25 (36.0%) had a clinical Juvenile Arthritis Disease Activity Score 10-joint ≤1.1 and 14 of 27 (51.9%) had clinically inactive disease at the 6-month follow-up. CONCLUSION Data in the CARRA Registry showed that etanercept treatment was safe in treating children with JPsA, with low AESIs and SAEs. Etanercept was also effective, even when assessed in a small sample size.
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Affiliation(s)
- Colleen K Correll
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
| | | | | | | | - Anne C Dennos
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | - Timothy Beukelman
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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Maccora I, Marrani E, Pagnini I, Mastrolia MV, de Libero C, Caputo R, Simonini G. Challenges and management of childhood non-infectious chronic uveitis. Expert Rev Clin Immunol 2023; 19:599-611. [PMID: 36996498 DOI: 10.1080/1744666x.2023.2198210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
INTRODUCTION Childhood uveitis is a sight-threatening condition, because if not properly recognized and treated can lead to several ocular complications and blindness. It represents a real challenge not only from an etiologic/diagnostic point of view, but also for management and therapy. AREAS COVERED In this review we will discuss the main etiologies, the diagnostic approach, risk factors associated to childhood non-infectious uveitis (cNIU), and the difficulties in eye examination in childhood. Moreover, we will discuss the treatment of cNIU in term of therapeutic choice, timing of initiation and withdrawal. EXPERT OPINION Identification of specific diagnosis is mandatory to prevent severe complications, thus a thorough differential diagnosis is essential. Pediatric eye examination may be extremely challenging due to the scarce collaboration, but novel techniques and biomarkers will help in identify low grade of inflammation, eventually modify long-term outcomes. Once identified the appropriate diagnosis, recognition of children who may benefit of a systemic treatment is crucial. What, When and how long are the key questions to address in this field. Current evidence and future results of ongoing clinical trials will help in driving treatment. A proper ocular screening, not only in the context of systemic disease, should be discussed by experts.
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Affiliation(s)
- Ilaria Maccora
- Pediatric Rheumatology Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- NeuroFARBA department, University of Florence, Florence, Italy
| | - Edoardo Marrani
- Pediatric Rheumatology Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Ilaria Pagnini
- Pediatric Rheumatology Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | | | | | - Roberto Caputo
- Ophthalmology Unit, Meyer Children's Hospital, Florence, Italy
| | - Gabriele Simonini
- Pediatric Rheumatology Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- NeuroFARBA department, University of Florence, Florence, Italy
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van Straalen JW, Kearsley‐Fleet L, Klotsche J, de Roock S, Minden K, Heiligenhaus A, Hyrich KL, de Boer JH, Lamot L, Olivieri AN, Gallizzi R, Smolewska E, Faugier E, Pastore S, Hashkes PJ, Herrera CN, Emminger W, Consolini R, Wulffraat NM, Ruperto N, Swart JF. Development and External Validation of a Model Predicting New-Onset Chronic Uveitis at Different Disease Durations in Juvenile Idiopathic Arthritis. Arthritis Rheumatol 2023; 75:318-327. [PMID: 36054539 PMCID: PMC10108055 DOI: 10.1002/art.42329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/21/2022] [Accepted: 08/11/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To develop and externally validate a prediction model for new-onset chronic uveitis in children with juvenile idiopathic arthritis (JIA) for clinical application. METHODS Data from the international Pharmachild registry were used to develop a multivariable Cox proportional hazards model. Predictors were selected by backward selection, and missing values were handled by multiple imputation. The model was subsequently validated and recalibrated in 2 inception cohorts: the UK Childhood Arthritis Prospective Study (CAPS) study and the German Inception Cohort of Newly diagnosed patients with juvenile idiopathic arthritis (ICON) study. Model performance was evaluated by calibration plots and C statistics for the 2-, 4-, and 7-year risk of uveitis. A diagram and digital risk calculator were created for use in clinical practice. RESULTS A total of 5,393 patients were included for model development, and predictor variables were age at JIA onset (hazard ratio [HR] 0.83 [95% confidence interval (95% CI) 0.77-0.89]), ANA positivity (HR 1.59 [95% CI 1.06-2.38]), and International League of Associations for Rheumatology category of JIA (HR for oligoarthritis, psoriatic arthritis, and undifferentiated arthritis versus rheumatoid factor-negative polyarthritis 1.40 [95% CI 0.91-2.16]). Performance of the recalibrated prediction model in the validation cohorts was acceptable; calibration plots indicated good calibration and C statistics for the 7-year risk of uveitis (0.75 [95% CI 0.72-0.79] for the ICON cohort and 0.70 [95% CI 0.64-0.76] for the CAPS cohort). CONCLUSION We present for the first time a validated prognostic tool for easily predicting chronic uveitis risk for individual JIA patients using common clinical parameters. This model could be used by clinicians to inform patients/parents and provide guidance in choice of uveitis screening frequency and arthritis drug therapy.
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Affiliation(s)
- Joeri W. van Straalen
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Faculty of MedicineUtrecht UniversityUtrechtThe Netherlands
| | | | - Jens Klotsche
- Epidemiology UnitGerman Rheumatism Research Centre BerlinBerlinGermany
| | - Sytze de Roock
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Faculty of MedicineUtrecht UniversityUtrechtThe Netherlands
| | - Kirsten Minden
- Epidemiology Unit, German Rheumatism Research Centre Berlin, and Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Arnd Heiligenhaus
- Department of Ophthalmology, St. Franziskus Hospital, Münster, Germany, and University of Duisburg‐EssenEssenGermany
| | - Kimme L. Hyrich
- Centre for Epidemiology Versus Arthritis, The University of Manchester, and NIHR Manchester BRC, Manchester University NHS Foundation TrustManchester Academic Health Science CentreManchesterUK
| | - Joke H. de Boer
- Department of OphthalmologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Lovro Lamot
- Sestre Milosrdnice University Hospital Center Zagreb, Zagreb, Croatia, and University of Zagreb School of MedicineZagrebCroatia
| | - Alma N. Olivieri
- Dipartimento della Donna del Bambino e di Chirurgia Generale e SpecialisticaUniversità degli Studi della Campania L.VanvitelliNaplesItaly
| | - Romina Gallizzi
- Department of Medical of Health SciencesMagna Graecia UniversityCatanzaroItaly
| | - Elzbieta Smolewska
- Department of Pediatric Cardiology and RheumatologyMedical University of LodzLodzPoland
| | - Enrique Faugier
- Dipartimento della Donna del Bambino e di Chirurgia Generale e SpecialisticaUniversità degli Studi della Campania L.VanvitelliNaplesItaly
| | - Serena Pastore
- Institute for Maternal and Child Health, IRCCS Burlo GarofoloTriesteItaly
| | - Philip J. Hashkes
- Pediatric Rheumatology UnitShaare Zedek Medical Center, and Hebrew University Hadassah School of MedicineJerusalemIsrael
| | - Cristina N. Herrera
- Servicio de Reumatología, Hospital de Niños Roberto Gilbert ElizaldeGuayaquilEcuador
| | - Wolfgang Emminger
- Department of PediatricsUniversity Children's Hospital, Medical University of ViennaViennaAustria
| | - Rita Consolini
- Division of Pediatrics, Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
| | - Nico M. Wulffraat
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Faculty of MedicineUtrecht UniversityUtrechtThe Netherlands
| | - Nicolino Ruperto
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina GasliniGenoaItaly
| | - Joost F. Swart
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Faculty of MedicineUtrecht UniversityUtrechtThe Netherlands
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Hart DA. Sex differences in musculoskeletal injury and disease risks across the lifespan: Are there unique subsets of females at higher risk than males for these conditions at distinct stages of the life cycle? Front Physiol 2023; 14:1127689. [PMID: 37113695 PMCID: PMC10126777 DOI: 10.3389/fphys.2023.1127689] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/28/2023] [Indexed: 04/29/2023] Open
Abstract
Sex differences have been reported for diseases of the musculoskeletal system (MSK) as well as the risk for injuries to tissues of the MSK system. For females, some of these occur prior to the onset of puberty, following the onset of puberty, and following the onset of menopause. Therefore, they can occur across the lifespan. While some conditions are related to immune dysfunction, others are associated with specific tissues of the MSK more directly. Based on this life spectrum of sex differences in both risk for injury and onset of diseases, a role for sex hormones in the initiation and progression of this risk is somewhat variable. Sex hormone receptor expression and functioning can also vary with life events such as the menstrual cycle in females, with different tissues being affected. Furthermore, some sex hormone receptors can affect gene expression independent of sex hormones and some transitional events such as puberty are accompanied by epigenetic alterations that can further lead to sex differences in MSK gene regulation. Some of the sex differences in injury risk and the post-menopausal disease risk may be "imprinted" in the genomes of females and males during development and sex hormones and their consequences only modulators of such risks later in life as the sex hormone milieu changes. The purpose of this review is to discuss some of the relevant conditions associated with sex differences in risks for loss of MSK tissue integrity across the lifespan, and further discuss several of the implications of their variable relationship with sex hormones, their receptors and life events.
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Narayan AR, Rahi JS, Solebo AL. Temporal Trends in Childhood Uveitis: Using Administrative Health Data to Investigate the Impact of Health Policy and Clinical Practice. Ocul Immunol Inflamm 2022; 30:1931-1935. [PMID: 34648413 PMCID: PMC11166048 DOI: 10.1080/09273948.2021.1976215] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 08/30/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND We describe an investigation of temporal trends in the incidence of childhood uveitis-related hospital admissions, hospitalization being a robust indicator of disease severity. METHODS A population-based retrospective study using a hospitalization database, the Hospital Episode Statistics (HES) dataset, capturing data on care between 2013 and 2020. Primary outcomes were rates of pediatric hospital admissions for uveitis-related disorders. RESULTS During the study period, there were 3,258 reported uveitis-related hospital admissions of children aged 0 to 14 years, comprising 19% of all-age uveitis-related admissions. Anterior uveitis was the most common diagnosis. The annual incidence of childhood uveitis-related hospitalizations declined year on year from a peak incidence of 5.4 per 100,000 children (95% confidence interval 5.0-5.9) in 2015-2016 to 3.3 per 100,000 (95% CI 3.0-3.6) in 2019-2020. Over the same period, the national incidence of juvenile arthropathy-related admissions stayed stable. CONCLUSION The decline in admissions nationally may reflect reduced incidence of uveitis complications with increasing use of immunosuppressive therapies.
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Affiliation(s)
- Akshay R. Narayan
- UCL Institute of Ophthalmology, University College London, London, UK
| | - Jugnoo S. Rahi
- Population, Policy and Practice Department of Research and Teaching, UCL GOS Institute of Child Health, London, UK
- National Institute for Health Research Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital, London, UK
- Ophthalmology and Rheumatology Department, Great Ormond Street Hospital for Children NHS Trust, London, UK
- Ulverscroft Vision Research Group, Institute of Child Health, University College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Ameenat Lola Solebo
- Population, Policy and Practice Department of Research and Teaching, UCL GOS Institute of Child Health, London, UK
- National Institute for Health Research Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital, London, UK
- Ophthalmology and Rheumatology Department, Great Ormond Street Hospital for Children NHS Trust, London, UK
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6
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Lee J, Zaguia F, Minkus C, Koreishi AF, Birnbaum AD, Goldstein DA. The Role of Screening for Asymptomatic Ocular Inflammation in Sarcoidosis. Ocul Immunol Inflamm 2022; 30:1936-1939. [PMID: 34686114 DOI: 10.1080/09273948.2021.1976216] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE To determine the utility of routine screening ophthalmic exam in patients with systemic sarcoidosis and no history of uveitis. METHODS Prospective, single-center, observational study conducted at Northwestern University from October 11, 2012 to October 1, 2020 of new patients with biopsy-proven systemic sarcoidosis and no history of uveitis, referred by medical subspecialists for screening ophthalmic exam. RESULTS Forty-nine patients, with mean age of 51 ± 8.7 years, 59% female, 47% African American, 43% Caucasian, were enrolled. The majority (55%) had no ocular symptoms. The most common location of ocular involvement was the adnexa, in the form of conjunctival nodules (62%) and aqueous tear deficiency (23%). Intraocular inflammation was detected in 6 patients (13%); only 2 had active disease requiring treatment (4%). No asymptomatic patient had ocular involvement necessitating treatment. CONCLUSION Screening exams are indicated in sarcoidosis patients with ocular symptoms. No benefit of screening was demonstrated in asymptomatic patients.
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Affiliation(s)
- Jennifer Lee
- Feinberg School of Medicine, Uveitis Service, Northwestern University, Chicago, Illinois, USA
| | - Fatma Zaguia
- Feinberg School of Medicine, Uveitis Service, Northwestern University, Chicago, Illinois, USA
| | - Caroline Minkus
- Feinberg School of Medicine, Uveitis Service, Northwestern University, Chicago, Illinois, USA
| | - Anjum F Koreishi
- Feinberg School of Medicine, Uveitis Service, Northwestern University, Chicago, Illinois, USA
| | - Andrea D Birnbaum
- Feinberg School of Medicine, Uveitis Service, Northwestern University, Chicago, Illinois, USA
| | - Debra A Goldstein
- Feinberg School of Medicine, Uveitis Service, Northwestern University, Chicago, Illinois, USA
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7
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Tirelli F, Zannin ME, Vittadello F, Agnolucci J, Mazzarolo M, Zulian F. Methotrexate Monotherapy in Juvenile Idiopathic Arthritis Associated Uveitis: Myth or Reality? Ocul Immunol Inflamm 2022; 30:1763-1767. [PMID: 34287104 DOI: 10.1080/09273948.2021.1951303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate the long-term efficacy of methotrexate (MTX) monotherapy in patients with juvenile idiopathic arthritis-associated uveitis (JIA-U). METHODS We analyzed a cohort of patients with JIA-U treated with MTX monotherapy, divided into two groups depending on whether MTX was started before (on-MTX group) or after uveitis diagnosis (MTX-naïve group). The primary endpoint was the time between uveitis inactivity and first relapse. RESULTS 84 patients entered the study. The median duration of remission on MTX monotherapy resulted 8.2 months. The on-MTX group showed a significant longer time interval between arthritis and uveitis onset and higher need for biologic agents (bDMARD). During follow-up, 40 patients (47.6%) needed bDMARD due to poor control of uveitis. Clinical remission off medication was achieved in 11.9% of patients, all belonging to the MTX-naïve group. CONCLUSIONS MTX monotherapy, although effective in early stages of JIA-U, showed poor disease control in the long term.
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Affiliation(s)
- Francesca Tirelli
- Rheumatology Unit, Department of Woman's and Child's Health, University of Padova, Padua, Italy
| | - Maria Elisabetta Zannin
- Ophthalmology Unit, Department of Woman's and Child's Health, University of Padova, Padua, Italy
| | - Fabio Vittadello
- Statistician, Explora, Research and Statistical Analysis, Padua, Italy
| | - Jacopo Agnolucci
- Ophthalmology Unit, Department of Woman's and Child's Health, University of Padova, Padua, Italy
| | - Monica Mazzarolo
- Ophthalmology Unit, Department of Woman's and Child's Health, University of Padova, Padua, Italy
| | - Francesco Zulian
- Rheumatology Unit, Department of Woman's and Child's Health, University of Padova, Padua, Italy
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8
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Lee JJY, Eng SWM, Guzman J, Duffy CM, Tucker LB, Oen K, Yeung RSM, Feldman BM. A comparison of Juvenile Idiopathic Arthritis classification systems with the Research in Arthritis in Canadian Children, Emphasizing Outcomes (ReACCh-Out) cohort. Arthritis Rheumatol 2022; 74:1409-1419. [PMID: 35289119 DOI: 10.1002/art.42113] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/22/2022] [Accepted: 03/09/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To compare International League of Associations for Rheumatology (ILAR) and Paediatric Rheumatology INternational Trials Organisation (PRINTO) classifications for juvenile idiopathic arthritis (JIA) using data from the Research in Arthritis in Canadian Children emphasizing Outcomes cohort (ReACCh-Out). The aim of the PRINTO classification, still in development, is to identify homogeneous groups of patients with JIA. METHODS We used data recorded within 7 months of diagnosis in 1228 patients to assign patients according to the two classification systems by computation. We compared the proportions of patient classified and the alignment of classified categories with clinical-biological subtypes and adult types of arthritis. RESULTS The PRINTO system classified 244 patients (19.9%) as Early-onset ANA-positive (EOANA), 157 (12.8%) as Enthesitis/Spondylitis-related, 38 (3.1%) as Systemic, and 10 (0.8%) as RF-positive JIA. Twelve percent of patients were unclassifiable using ILAR while 63.3% were unclassifiable using PRINTO criteria (777 Other JIA and 2 Unclassified JIA). In sensitivity analyses, >50% remained unclassifiable by PRINTO. ILAR categories aligned better with clinical-biological subtypes in 131 patients (χ2 =44, p=0.005 versus χ2 =15, p=0.07 for PRINTO), and with adult types of arthritis in 389 evaluable patients. CONCLUSION Current identified PRINTO disorders classify a minority of patients with JIA, leaving a large proportion with Other disorders requiring further characterization. Current PRINTO classifications do not appear to improve alignment with clinical-biological subtypes or adult forms of arthritis relative to the older ILAR system.
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Affiliation(s)
- Jennifer J Y Lee
- The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Simon W M Eng
- The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Jaime Guzman
- BC Children's Hospital, Vancouver, British Columbia, Canada.,University of British Columbia, Vancouver, British Columbia, Canada
| | - Ciáran M Duffy
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,University of Ottawa, Ontario, Canada
| | - Lori B Tucker
- BC Children's Hospital, Vancouver, British Columbia, Canada.,University of British Columbia, Vancouver, British Columbia, Canada
| | - Kiem Oen
- University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rae S M Yeung
- The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Brian M Feldman
- The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
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9
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Carlsson E, Beresford MW, Ramanan AV, Dick AD, Hedrich CM. Juvenile Idiopathic Arthritis Associated Uveitis. CHILDREN-BASEL 2021; 8:children8080646. [PMID: 34438537 PMCID: PMC8393258 DOI: 10.3390/children8080646] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/20/2021] [Accepted: 07/23/2021] [Indexed: 01/31/2023]
Abstract
Juvenile idiopathic arthritis (JIA) is the most common childhood rheumatic disease. The development of associated uveitis represents a significant risk for serious complications, including permanent loss of vision. Initiation of early treatment is important for controlling JIA-uveitis, but the disease can appear asymptomatically, making frequent screening procedures necessary for patients at risk. As our understanding of pathogenic drivers is currently incomplete, it is difficult to assess which JIA patients are at risk of developing uveitis. Identification of specific risk factors for JIA-associated uveitis is an important field of research, and in this review, we highlight the genomic, transcriptomic, and proteomic factors identified as potential uveitis risk factors in JIA, and discuss therapeutic strategies.
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Affiliation(s)
- Emil Carlsson
- Department of Women’s and Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L14 5AB, UK;
- Correspondence: (E.C.); (C.M.H.); Tel.: +44-151-228-4811 (ext. 2690) (E.C.); +44-151-252-5849 (C.M.H.)
| | - Michael W. Beresford
- Department of Women’s and Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L14 5AB, UK;
- Department of Rheumatology, Alder Hey Children’s NHS Foundation Trust Hospital, Liverpool L14 5AB, UK
- National Institute for Health Research Alder Hey Clinical Research Facility, Alder Hey Children’s NHS Foundation Trust Hospital, Liverpool L14 5AB, UK
| | - Athimalaipet V. Ramanan
- Bristol Royal Hospital for Children & Translational Health Sciences, University of Bristol, Bristol BS2 8DZ, UK;
| | - Andrew D. Dick
- Translational Health Sciences, University of Bristol, Bristol BS2 8DZ, UK;
- UCL Institute of Ophthalmology, London EC1V 9EL, UK
- NIHR Biomedical Research Centre, Moorfields Eye Hospital, London EC1V 2PD, UK
| | - Christian M. Hedrich
- Department of Women’s and Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L14 5AB, UK;
- Department of Rheumatology, Alder Hey Children’s NHS Foundation Trust Hospital, Liverpool L14 5AB, UK
- National Institute for Health Research Alder Hey Clinical Research Facility, Alder Hey Children’s NHS Foundation Trust Hospital, Liverpool L14 5AB, UK
- Correspondence: (E.C.); (C.M.H.); Tel.: +44-151-228-4811 (ext. 2690) (E.C.); +44-151-252-5849 (C.M.H.)
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10
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van Straalen JW, Giancane G, Amazrhar Y, Tzaribachev N, Lazar C, Uziel Y, Telcharova-Mihaylovska A, Len CA, Miniaci A, Boteanu AL, Filocamo G, Mastri MV, Arkachaisri T, Magnolia MG, Hoppenreijs E, de Roock S, Wulffraat NM, Ruperto N, Swart JF. A clinical prediction model for estimating the risk of developing uveitis in patients with juvenile idiopathic arthritis. Rheumatology (Oxford) 2021; 60:2896-2905. [PMID: 33274366 PMCID: PMC8213427 DOI: 10.1093/rheumatology/keaa733] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 10/02/2020] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To build a prediction model for uveitis in children with JIA for use in current clinical practice. METHODS Data from the international observational Pharmachild registry were used. Adjusted risk factors as well as predictors for JIA-associated uveitis (JIA-U) were determined using multivariable logistic regression models. The prediction model was selected based on the Akaike information criterion. Bootstrap resampling was used to adjust the final prediction model for optimism. RESULTS JIA-U occurred in 1102 of 5529 JIA patients (19.9%). The majority of patients that developed JIA-U were female (74.1%), ANA positive (66.0%) and had oligoarthritis (59.9%). JIA-U was rarely seen in patients with systemic arthritis (0.5%) and RF positive polyarthritis (0.2%). Independent risk factors for JIA-U were ANA positivity [odds ratio (OR): 1.88 (95% CI: 1.54, 2.30)] and HLA-B27 positivity [OR: 1.48 (95% CI: 1.12, 1.95)] while older age at JIA onset was an independent protective factor [OR: 0.84 (9%% CI: 0.81, 0.87)]. On multivariable analysis, the combination of age at JIA onset [OR: 0.84 (95% CI: 0.82, 0.86)], JIA category and ANA positivity [OR: 2.02 (95% CI: 1.73, 2.36)] had the highest discriminative power among the prediction models considered (optimism-adjusted area under the receiver operating characteristic curve = 0.75). CONCLUSION We developed an easy to read model for individual patients with JIA to inform patients/parents on the probability of developing uveitis.
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Affiliation(s)
- Joeri W van Straalen
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital, Utrecht, Netherlands
| | - Gabriella Giancane
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DiNOGMI), Università degli Studi di Genova, Genoa, Italy
| | - Yasmine Amazrhar
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital, Utrecht, Netherlands
| | | | - Calin Lazar
- Pediatrics, Spitalul Clinic de Urgenta pentru Copii, Cluj-Napoca, Romania
| | - Yosef Uziel
- Department of Pediatrics, Pediatric Rheumatology Unit, Meir Medical Center, Kfar Saba, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Claudio A Len
- Pediatrics Department, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Angela Miniaci
- Salute della Donna, del Bambino e dell’Adolescente-Padiglione 16 Ambulatorio di reumatologia, Azienda Ospedaliero-Universitaria S. Orsola-Malpighi, Bologna, Italy
| | - Alina L Boteanu
- Pediatric Rheumatology Unit, University Hospital Ramón y Cajal, Madrid, Spain
| | - Giovanni Filocamo
- Pediatric Rheumatology, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Mariel V Mastri
- Unidad de Reumatologia, Hospital Sor Maria Ludovica, La Plata, Argentina
| | - Thaschawee Arkachaisri
- Rheumatology and Immunology Service, Department of Paediatric Subspecialties, KK Women’s and Children’s Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Maria G Magnolia
- Paediatrics, Santa Maria della Stella Hospital, Ciconia, Orvieto (TR), Italy
| | - Esther Hoppenreijs
- Pediatric Rheumatology, Radboud University Medical Center/Sint Maartenskliniek, Nijmegen, Netherlands
| | - Sytze de Roock
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital, Utrecht, Netherlands
| | - Nico M Wulffraat
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital, Utrecht, Netherlands
| | - Nicolino Ruperto
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Joost F Swart
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital, Utrecht, Netherlands
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Zhu L, Chen B, Su W. A Review of the Various Roles and Participation Levels of B-Cells in Non-Infectious Uveitis. Front Immunol 2021; 12:676046. [PMID: 34054864 PMCID: PMC8160461 DOI: 10.3389/fimmu.2021.676046] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 04/28/2021] [Indexed: 12/30/2022] Open
Abstract
Non-infectious uveitis is an inflammatory disorder of the eye that accounts for severe visual loss without evident infectious agents. While T cells are supposed to dominate the induction of inflammation in non-infectious uveitis, the role of B cells in the pathogenesis of this disease is obscure. Therefore, this review aimed to discuss diverse B-cell participation in different non-infectious uveitides and their roles in the pathogenesis of this disease as well as the mechanism of action of rituximab. Increasing evidence from experimental models and human non-infectious uveitis has suggested the participation of B cells in non-infectious uveitis. The participation levels vary in different uveitides. Furthermore, B cells play multiple roles in the pathogenic mechanisms. B cells produce autoantibodies, regulate T cell responses via antibody-independent functions, and constitute ectopic lymphoid structures. Regulatory B cells perform pivotal anti-inflammatory functions in non-infectious uveitis. Rituximab may work by depleting pro-inflammatory B cells and restoring the quantity and function of regulatory B cells in this disease. Identifying the levels of B-cell participation and the associated roles is beneficial for optimizing therapy. Diversified experimental model choices and emerging tools and/or methods are conducive for future studies on this topic.
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Affiliation(s)
- Lei Zhu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Binyao Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Wenru Su
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
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Slamang W, Tinley C, Brice N, Scott C. Paediatric non-infectious uveitis in Cape Town, South Africa: a retrospective review of disease characteristics and outcomes on immunomodulating treatment. Pediatr Rheumatol Online J 2021; 19:50. [PMID: 33794930 PMCID: PMC8017656 DOI: 10.1186/s12969-021-00537-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 03/17/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Non-infectious uveitis is a well-reported cause of blindness in more developed countries, however data from sub-Saharan Africa is lacking. Here we aim to describe the diseases associated with paediatric non-infectious uveitis and the effect of currently available treatment in this setting. METHODS A retrospective observational analysis of children with non-infectious uveitis from January 2010 to December 2017, attending the tertiary paediatric rheumatology and ophthalmology referral units in Cape Town was conducted. Statistical analysis utilising STATA13 software was performed with p < 0.05 considered significant. RESULTS Twenty-nine children were identified: median age at first visit of 74 months (IQR 49-86 months), female to male ratio of 0.9:1, predominantly of mixed ancestry (72.4%). Juvenile idiopathic arthritis associated uveitis (JIAU) (48.3%), idiopathic uveitis (41.4%), sarcoidosis (6.9%) and Behcet's disease (3.5%) were diagnosed. Chronic anterior uveitis (72.4%) was the most frequent finding. Fifty-five percent had complications at presentation and all children with idiopathic uveitis presented with cataracts. Only 6.5% of the JIA cohort had JIAU. All JIA children had chronic anterior uveitis. There were no differences between JIA children with uveitis and those without uveitis, for sex (p = 0.68) and race (p = 0.58). Significantly, children with uveitis presented at an overall younger age (p = 0.008), had oligo-articular JIA (p = 0.01) and were antinuclear antibody positive (p < 0.001). Children with idiopathic uveitis were predominantly male (66.6%) with chronic anterior uveitis (41.7%). Nineteen children (65.5%) in the cohort had inactive disease on treatment at 12 months from diagnosis, which included 10 on topical corticosteroid therapy. At the last clinical visit 17 (58.6%) on standard initial therapy, 8 (27.6%) on tumour necrosis factor inhibitors and 2 on additional DMARDs were in remission. Five of these children still required topical corticosteroids. Surgery was performed in 41.4%, primarily in the idiopathic group. Visual acuity improved or was maintained on treatment. CONCLUSION Current practice seems to detect children with potentially sight-threatening disease but the high rate of complications and the low percentage of children with JIAU raises concerns of delayed healthcare intervention. Tumour necrosis factor inhibitors have improved outcomes in refractory cases in this cohort, however further studies are needed.
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Affiliation(s)
- Waheba Slamang
- Department of Paediatric Rheumatology, Red Cross War Memorial Children's Hospital, Klipfontein Rd, Cape Town, 7700, South Africa.
- University of Cape Town South Africa, Rondebosch, Cape Town, South Africa.
| | - Christopher Tinley
- University of Cape Town South Africa, Rondebosch, Cape Town, South Africa
- Department of Paediatric Ophthalmology, Red Cross War Memorial Children's Hospital, Klipfontein Rd, Cape Town, 7700, South Africa
| | - Nicola Brice
- Department of Paediatric Rheumatology, Red Cross War Memorial Children's Hospital, Klipfontein Rd, Cape Town, 7700, South Africa
- University of Cape Town South Africa, Rondebosch, Cape Town, South Africa
| | - Christiaan Scott
- Department of Paediatric Rheumatology, Red Cross War Memorial Children's Hospital, Klipfontein Rd, Cape Town, 7700, South Africa.
- University of Cape Town South Africa, Rondebosch, Cape Town, South Africa.
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Abstract
PURPOSE OF REVIEW To give an overview of recently published articles covering risk factors, novel biomarkers and treatment for noninfectious uveitis in children. RECENT FINDINGS In the last few years, several genetic markers, serum biomarkers, aqueous humor markers, tear biomarkers and clinical factors have been identified, which are associated with childhood noninfectious uveitis. We describe the most important reports in this field that may help to tailor the screening and monitoring of this population in the future and might become the target of novel therapies. The advances in the biologic therapy of paediatric uveitis, thanks to evidence provided by the SYCAMORE, ADJUVITE and APTITUDE trials, offer new possibilities for the treatment of patients who fail methotrexate with adalimumab and tocilizumab. We discuss the importance of comprehensive outcome measures as proposed by the Multinational Interdisciplinary Working Group for Uveitis in Childhood (MIWGUC). SUMMARY Paediatric noninfectious uveitis is a sight-threatening condition and the identification of risk factors and novel biomarkers is critical for tailored management. Biologic therapies are revolutionizing the outcomes of patients resistant to conventional therapy. Increasing our knowledge of disease pathogenesis is crucial to improve targeting of screening to those at highest risk and stratification of treatments.
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Walscheid K, Glandorf K, Rothaus K, Niewerth M, Klotsche J, Minden K, Heiligenhaus A. Enthesitis-related Arthritis: Prevalence and Complications of Associated Uveitis in Children and Adolescents From a Population-based Nationwide Study in Germany. J Rheumatol 2020; 48:262-269. [DOI: 10.3899/jrheum.191085] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2020] [Indexed: 12/11/2022]
Abstract
Objective.Enthesitis-related arthritis (ERA) represents a subgroup of juvenile idiopathic arthritis (JIA) that is regularly accompanied by anterior uveitis. This study describes the prevalence and characteristics of ERA-related uveitis.Methods.Cross-sectional data from the National Pediatric Rheumatological Database (NPRD) were used to characterize ERA-related uveitis (ERA-U). In addition to sociodemographic variables, we documented the occurrence of uveitis and course of disease, including symptoms, visual acuity, and complications, as well as JIA characteristics such as disease activity (Juvenile Arthritis Disease Activity Score 10), functional ability (Childhood Health Assessment Questionnaire score), laboratory variables, and treatment.Results.In the years from 2002 to 2014, there were 3778 (15.2%) of a total of 24,841 JIA patients recorded in the NPRD who had ERA, and 280 (7.4%) of them had developed uveitis. Detailed ophthalmological documentation by a uveitis add-on module was available for 22.9% of these patients. Uveitis onset was acutely symptomatic in 63% of patients. Patients with uveitis were more frequently male, HLA-B27–positive, younger at ERA onset, and they had higher erythrocyte sedimentation rate values at first uveitis documentation than those without uveitis. Uveitis was diagnosed at a mean age of 11.5 (± 3.9) years (50% within 2 years after ERA onset). Systemic treatment with corticosteroids and synthetic and biologic disease-modifying antirheumatic drugs was associated with a (not significantly) lower risk of developing uveitis.Conclusion.The course of disease in ERA-U patients is frequently similar to HLA-B27–associated uveitis in adults; however, a subgroup of patients presents with asymptomatic uveitis.
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Rodriguez-Smith J, Yeh S, Angeles-Han S. Improving quick and accurate diagnosis of childhood JIA-uveitis from a pediatric rheumatology perspective. EXPERT REVIEW OF OPHTHALMOLOGY 2020; 15:101-109. [PMID: 32313548 PMCID: PMC7170263 DOI: 10.1080/17469899.2020.1739521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 03/04/2020] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Juvenile idiopathic arthritis (JIA) is the most common pediatric rheumatic disease associated with uveitis. JIA-associated uveitis (JIA-U) is typically asymptomatic, chronic, and can lead to sight-threatening complications. This review will provide approaches to improve the diagnosis and outcomes of children with JIA-U. AREAS COVERED We will provide updates on risk factors for uveitis onset and ocular complications, improvements in the ophthalmic screening schedule for uveitis detection, and potential strategies to advance the diagnosis and monitoring of JIA-U using advanced ophthalmic imaging and diagnostic equipment and laboratory biomarkers. EXPERT OPINION There is a lack of high-quality research in JIA-U and few randomized controlled trials, underscoring the urgent need for further studies in this population. Early uveitis diagnosis combined with timely and appropriate treatment can improve visual outcomes. Improved knowledge of uveitis pathogenesis, risk factors for uveitis onset, measurement of uveitis outcomes, and optimal treatment are crucial.
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Affiliation(s)
- Jackeline Rodriguez-Smith
- Cincinnati Children's Hospital Medical Center, Division of Rheumatology, 3333 Burnett Avenue, Cincinnati, Ohio 45229-3026, United States
| | - Steven Yeh
- Emory Eye Center, Department of Ophthalmology, Atlanta, Georgia 30322-1013, United States
| | - Sheila Angeles-Han
- Cincinnati Children's Hospital Medical Center, Division of Rheumatology, 3333 Burnett Avenue, Cincinnati, Ohio 45229-3026, United States
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Batthish M, Berard R, Cabral D, Bolaria R, Chédeville G, Duffy C, Gerhold K, Gerschman T, Huber A, Proulx-Gauthier JP, Rosenberg A, Rumsey D, Schmeling H, Shiff N, Soon G, Bruns A, Tucker L, Guzman J. A new Canadian inception cohort for juvenile idiopathic arthritis: The Canadian Alliance of Pediatric Rheumatology Investigators Registry. Rheumatology (Oxford) 2020; 59:2796-2805. [DOI: 10.1093/rheumatology/keaa006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 12/19/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objectives
The aim was to describe the design, methods and initial findings of a new Canadian inception cohort of children with JIA, The Canadian Alliance of Pediatric Rheumatology Investigators (CAPRI) JIA Registry.
Methods
The CAPRI JIA Registry was started in 2017 to collect information prospectively on children enrolled within 3 months of JIA diagnosis across Canada. The registry has a non-traditional modular design, with no artificially set times for registry visits to occur, streamlined multi-method data collection that requires 2–4 min per visit, and reports cumulative incidence of treatments, outcomes and adverse events calculated by Kaplan–Meier survival methods.
Results
A total of 166 patients, enrolled a median of 6 weeks after JIA diagnosis at 10 centres, were included. The median age at diagnosis was 9 years [interquartile range (IQR) 3, 13], 61% were female and 51% had oligoarticular JIA. The median three-variable clinical Juvenile Arthritis Disease Activity Score was 6.5 (IQR 4, 10) at enrolment, and the median time to first attainment of clinically inactive disease (CID) was 24 weeks (by 1 year, 81%). Within 1 year of diagnosis, 70% of patients had started a DMARD and 35% a biologic agent. The rates of adverse events and serious adverse events were 60 and 5.8 per 100 patient-years, respectively.
Conclusion
This streamlined and flexible registry minimizes the burden of data collection and interference with clinic operations. Initial findings suggest that treatments for newly diagnosed patients with JIA in Canada have intensified, and now 81% of patients attain CID within 1 year of diagnosis.
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Affiliation(s)
- Michelle Batthish
- Division of Rheumatology, Department of Pediatrics, McMaster University, Hamilton, Ontario
| | - Roberta Berard
- Division of Rheumatology, Department of Pediatrics, Western University, London, Ontario
| | - David Cabral
- Division of Rheumatology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia
| | - Roxana Bolaria
- Division of Rheumatology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia
| | - Gaëlle Chédeville
- Division of Rheumatology, Department of Pediatrics, McGill University, Montreal, Quebec
| | - Ciaran Duffy
- Division of Rheumatology, Department of Pediatrics, University of Ottawa, Ottawa, Ontario
| | - Kerstin Gerhold
- Division of Rheumatology, Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba
| | - Tommy Gerschman
- Division of Rheumatology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia
| | - Adam Huber
- Division of Rheumatology, Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia
| | | | - Alan Rosenberg
- Division of Rheumatology, Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan
| | - Dax Rumsey
- Division of Rheumatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta
| | - Heinrike Schmeling
- Division of Rheumatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Natalie Shiff
- Division of Rheumatology, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Gordon Soon
- Division of Rheumatology, Department of Pediatrics, University of Toronto, Toronto, Ontario
| | - Alessandra Bruns
- Division of Rheumatology, Department of Pediatrics, University de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Lori Tucker
- Division of Rheumatology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia
| | - Jaime Guzman
- Division of Rheumatology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia
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Juvenile idiopathic arthritis-associated uveitis. Clin Immunol 2019; 211:108322. [PMID: 31830532 DOI: 10.1016/j.clim.2019.108322] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 12/05/2019] [Indexed: 12/25/2022]
Abstract
Juvenile idiopathic arthritis (JIA) is the commonest rheumatic disease in children and JIA-associated uveitis its most frequent extra-articular manifestation. The uveitis is potentially sight-threatening and so carries a considerable risk of morbidity. The commonest form of uveitis seen in JIA is chronic anterior uveitis which is almost always asymptomatic in the initial stages. Therefore, screening for JIA-associated uveitis in at-risk patients is essential. The aim of early detection and treatment is to minimise intra-ocular inflammation and avoid complications leading to visual loss, resulting from both disease activity and medications. There is increasing evidence for the early introduction of systemic immunosuppressive therapies in order to reduce topical and systemic glucocorticoid use. Two randomised controlled trials of adalimumab in JIA-associated uveitis provide convincing evidence for the use of this biologic in patients who fail to respond adequately to methotrexate. Tocilizumab and baricitinib are being investigated as alternatives to anti-tumour necrosis factor drugs.
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19
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Foeldvari I, Klotsche J, Simonini G, Edelsten C, Angeles-Han ST, Bangsgaard R, de Boer J, Brumm G, Torrent RB, Constantin T, DeLibero C, Diaz J, Gerloni VM, Guedes M, Heiligenhaus A, Kotaniemi K, Leinonen S, Minden K, Miranda V, Miserocchi E, Nielsen S, Niewerth M, Pontikaki I, de Vicuna CG, Zilhao C, Yeh S, Anton J, Calzada J. Proposal for a definition for response to treatment, inactive disease and damage for JIA associated uveitis based on the validation of a uveitis related JIA outcome measures from the Multinational Interdisciplinary Working Group for Uveitis in Childhood (MIWGUC). Pediatr Rheumatol Online J 2019; 17:66. [PMID: 31575380 PMCID: PMC6774210 DOI: 10.1186/s12969-019-0345-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 07/03/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND JIA-associated uveitis (JIAU) is a serious, sight-threatening disease with significant long-term complications and risk of blindness, even with improved contemporary treatments. The MIWGUC was set up in order to propose specific JIAU activity and response items and to validate their applicability for clinical outcome studies. METHODS The group consists of 8 paediatric rheumatologists and 7 ophthalmologists. A consensus meeting took place on November 2015 in Barcelona (Spain) with the objective of validating the previously proposed measures. The validation process was based on the results of a prospective open, international, multi-centre, cohort study designed to validate the outcome measures proposed by the initial MIWGUC group meeting in 2012. The meeting used the same Delphi and nominal group technique as previously described in the first paper from the MIWGUC group (Arthritis Care Res 64:1365-72, 2012). Patients were included with a diagnosis of JIA, aged less than 18 years, and with active uveitis or an uveitis flare which required treatment with a disease-modifying anti-rheumatic drug. The proposed outcome measures for uveitis were collected by an ophthalmologist and for arthritis by a paediatric rheumatologist. Patient reported outcome measures were also measured. RESULTS A total of 82 patients were enrolled into the validation cohort. Fifty four percent (n = 44) had persistent oligoarthritis followed by rheumatoid factor negative polyarthritis (n = 15, 18%). The mean uveitis disease duration was 3.3 years (SD 3.0). Bilateral eye involvement was reported in 65 (79.3%) patients. The main findings are that the most significant changes, from baseline to 6 months, are found in the AC activity measures of cells and flare. These measures correlate with the presence of pre-existing structural complications and this has implications for the reporting of trials using a single measure as a primary outcome. We also found that visual analogue scales of disease activity showed significant change when reported by the ophthalmologist, rheumatologist and families. The measures formed three relatively distinct groups. The first group of measures comprised uveitis activity, ocular damage and the ophthalmologists' VAS. The second comprised patient reported outcomes including disruption to school attendance. The third group consisted of the rheumatologists' VAS and the joint score. CONCLUSIONS We propose distinctive and clinically significant measures of disease activity, severity and damage for JIAU. This effort is the initial step for developing a comprehensive outcome measures for JIAU, which incorporates the perspectives of rheumatologists, ophthalmologists, patients and families.
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Affiliation(s)
- Ivan Foeldvari
- Head of the Hamburg Centre for Pediatric and Adolescence Rheumatology Centre for Treatment of Scleroderma and Uveitis in Childhood and Adolescence Teaching Unit of the Asklepios Campus of the Semmelweis Medical School, Budapest An der Schön Klinik Hamburg Eilbek Dehnhaide, 120 22081, Hamburg, Germany.
| | - Jens Klotsche
- 0000 0000 9323 8675grid.418217.9German Rheumatism Research Centre, 10117 Berlin, Germany ,0000 0001 2218 4662grid.6363.0Institute for Social Medicine, Epidemiology, and Health Economics, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Gabriele Simonini
- 0000 0004 1757 2304grid.8404.8Rheumatology Unit- A. Meyer Children’s Hospital- NEUROFARBA Department, University of Florence, Florence, Italy
| | - Clive Edelsten
- grid.420468.cDept Rheumatology, Great Ormond Street Hospital, Great Ormond Street, London, UK
| | - Sheila T. Angeles-Han
- Division of Rheumatology, Cincinnati Children’s Hospital Medical Center, 3333 Burnett Avenue, Cincinnati, OH 45229; Department of Pediatrics, University of Cincinnati, Cincinnati, OH USA
| | - Regitze Bangsgaard
- Department of Ophthalmology, Copenhagen University Hospital Glostrup/Rigshospitalet, Copenhagen, Denmark
| | - Joke de Boer
- 0000000090126352grid.7692.aUMC Utrecht, Utrecht, Netherlands
| | - Gabriele Brumm
- 0000 0001 2180 3484grid.13648.38Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Rosa Bou Torrent
- 0000 0001 0663 8628grid.411160.3Pediatric Rheumatology Department, Hospital Sant Joan de Déu, Barcelona, Spain ,Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Tamas Constantin
- 0000 0001 0942 9821grid.11804.3c2nd Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | | | - Jesus Diaz
- 0000 0004 1768 8905grid.413396.aOphtalmology Department, Hospital Sant Pau, Barcelona, Spain ,0000 0001 0663 8628grid.411160.3Ophtalmology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Valeria Maria Gerloni
- 0000 0004 1757 2822grid.4708.bUniversità di Milano - Istituto Gaetano Pini, Milan, Italy
| | - Margarida Guedes
- 0000 0001 1503 7226grid.5808.5Pediatric Rheumatology Unit, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | | | - Kaisu Kotaniemi
- 0000 0000 9950 5666grid.15485.3dDepartment of Ophthalmology, Helsinki University Hospital, Helsinki, Finland
| | - Sanna Leinonen
- 0000 0000 9950 5666grid.15485.3dDepartment of Ophthalmology, Helsinki University Hospital, Helsinki, Finland
| | - Kirsten Minden
- 0000 0000 9323 8675grid.418217.9German Rheumatism Research Centre, 10117 Berlin, Germany ,Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Rheumatology and Clinical Immunology, Berlin, Germany
| | - Vasco Miranda
- 0000 0001 1503 7226grid.5808.5Pediatric Ophthalmologist at the Centro Hospitalar Universitario do Porto, Teaching Unit of the Abel Salazar Institute of Biomedical Sciences, Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
| | - Elisabetta Miserocchi
- 0000000417581884grid.18887.3eOcular Immunology and Uveitis Service, Department of Ophthalmology, San Raffaele Scientific Institute, Via Olgettina 60, 20122 Milan, Italy
| | - Susan Nielsen
- Department of Ophthalmology, Copenhagen University Hospital Glostrup/Rigshospitalet, Copenhagen, Denmark
| | - Martina Niewerth
- 0000 0000 9323 8675grid.418217.9German Rheumatism Research Centre, 10117 Berlin, Germany
| | - Irene Pontikaki
- 0000 0004 1757 2822grid.4708.bUniversità di Milano - Istituto Gaetano Pini, Milan, Italy
| | - Carmen Garcia de Vicuna
- 0000 0001 0663 8628grid.411160.3Pediatric Rheumatology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Carla Zilhao
- 0000 0001 1503 7226grid.5808.5Pediatric Rheumatology Unit, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Steven Yeh
- 0000 0004 0583 4098grid.419974.6Emory Clinic, Atlanta, USA
| | - Jordi Anton
- 0000 0001 0663 8628grid.411160.3Pediatric Rheumatology Department, Hospital Sant Joan de Déu, Barcelona, Spain ,Institut de Recerca Sant Joan de Déu, Barcelona, Spain ,0000 0004 1937 0247grid.5841.8Department of Surgery and Surgery Specializations. Universitat de Barcelona, Barcelona, Spain
| | - Joan Calzada
- 0000 0001 0663 8628grid.411160.3Pediatric Rheumatology Department, Hospital Sant Joan de Déu, Barcelona, Spain ,Institut de Recerca Sant Joan de Déu, Barcelona, Spain
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Kim L, Li A, Angeles-Han S, Yeh S, Shantha J. Update on the management of uveitis in children: an overview for the clinician. EXPERT REVIEW OF OPHTHALMOLOGY 2019; 14:211-218. [PMID: 32831897 PMCID: PMC7437956 DOI: 10.1080/17469899.2019.1663731] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 09/02/2019] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Pediatric uveitis comprises a range of ocular inflammatory diseases that may lead to vision impairment, often due to ocular complications from the disease itself or side effects of therapies. The impact on vision, visual functioning, and vision-related quality-of-life over the lifetime horizon can be substantial, underscoring the importance of appropriate ophthalmic evaluation, diagnostic testing and treatment. This review focuses on the anatomic classification, laboratory diagnosis, associated systemic diseases, and management of pediatric uveitis. AREAS COVERED A review of the literature was performed to synthesize our current understanding of the anatomic classification of pediatric uveitis, disease epidemiology, associated systemic diseases, and management principles. We also review important corticosteroid-sparing strategies including non-biologic and biologic agents such as the anti-tumor necrosis factor (TNF)-alpha family of medications, given their key role in the treatment of pediatric uveitis, particularly juvenile idiopathic arthritis (JIA). Recent advances in the assessment of vision-related quality-of-life using the Effects of Youngsters' Eyesight on Quality of Life (EYE-Q) instrument are discussed. EXPERT OPINION Pediatric uveitis can lead to long-term vision impairment if not appropriately screened and treated. JIA is the most common systemic disease associated with uveitis, is typically asymptomatic, and thus requires rigorous screening to detect uveitis and avoid secondary ocular complications. While topical and systemic corticosteroids are useful for the acute treatment of uveitis, the disease chronicity of many pediatric uveitis syndromes including JIA, often warrants early escalation of therapy to immunosuppressive medications including methotrexate (MTX) and anti-TNF-alpha inhibitors. Future directions include an improved understanding of risk factors for uveitis and better metrics to evaluate the impact of disease on vision-related quality-of-life of pediatric uveitis patients.
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Affiliation(s)
- Lucas Kim
- Mercer University School of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Alexa Li
- Emory Eye Center, Emory University School of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Sheila Angeles-Han
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Steven Yeh
- Emory Eye Center, Emory University School of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Jessica Shantha
- Emory Eye Center, Emory University School of Medicine, University of Cincinnati, Cincinnati, Ohio
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Sengler C. [New therapy approaches, better outcomes? : Results from inception cohorts for patients with juvenile idiopathic arthritis]. Z Rheumatol 2019; 78:610-619. [PMID: 31127369 DOI: 10.1007/s00393-019-0648-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Prospective cohort studies collect demographic and clinical data of newly diagnosed patients using standardized questionnaires and validated measuring instruments. Therefore, they are a valuable data source for evaluating disease progression, outcome parameters and predictors. In this article a selection of results from four inception cohorts on juvenile idiopathic arthritis (JIA) are presented. In all cohorts, one half to three quarters of the patients achieved an inactive disease within the first year under observation but there were relevant differences between the different JIA categories. The time from symptom onset to diagnosis could be identified as an important predictor of this outcome. Data from the German JIA cohort showed that the health-related quality of life of patients and healthy control subjects had largely converged 3 years after inclusion. Young children with JIA and the detection of antinuclear antibodies have an increased risk of developing JIA-associated uveitis. Of these, the uveitis was inactive in approximately 80% after 1 year; however, at the time of diagnosis, almost 30% of patients already had uveitis-related complications. The previous therapy with methotrexate proved to be preventive for the development of uveitis. The early outcome of JIA patients is generally good. The differences in the JIA categories indicate the need to further individualize the therapy and to adapt it better to the risk profile of the individual patient. Data on long-term outcomes will provide information on which factors have a decisive influence on the course of the disease and how the care of children and adolescents with JIA can be further improved.
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Affiliation(s)
- C Sengler
- Programmbereich Epidemiologie, Arbeitsgruppe Kinder- und Jugendrheumatologie, Deutsches Rheuma-Forschungszentrum Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
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