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van Dijk BT, Bergstra SA, van den Berg JM, Schonenberg-Meinema D, van Suijlekom-Smit LWA, van Rossum MAJ, Koopman-Keemink Y, Ten Cate R, Allaart CF, Brinkman DMC, Hissink Muller PCE. Increasing the etanercept dose in a treat-to-target approach in juvenile idiopathic arthritis: does it help to reach the target? A post-hoc analysis of the BeSt for Kids randomised clinical trial. Pediatr Rheumatol Online J 2024; 22:53. [PMID: 38730442 PMCID: PMC11084083 DOI: 10.1186/s12969-024-00989-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/04/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Etanercept has been studied in doses up to 0.8 mg/kg/week (max 50 mg/week) in juvenile idiopathic arthritis (JIA) patients. In clinical practice higher doses are used off-label, but evidence regarding the relation with outcomes is lacking. We describe the clinical course of JIA-patients receiving high-dose etanercept (1.6 mg/kg/week; max 50 mg/week) in the BeSt for Kids trial. METHODS 92 patients with oligoarticular JIA, RF-negative polyarticular JIA or juvenile psoriatic arthritis were randomised across three treat-to-target arms: (1) sequential DMARD-monotherapy (sulfasalazine or methotrexate (MTX)), (2) combination-therapy MTX + 6 weeks prednisolone and (3) combination therapy MTX + etanercept. In any treatment-arm, patients could eventually escalate to high-dose etanercept alongside MTX 10mg/m2/week. RESULTS 32 patients received high-dose etanercept (69% female, median age 6 years (IQR 4-10), median 10 months (7-16) from baseline). Median follow-up was 24.6 months. Most clinical parameters improved within 3 months after dose-increase: median JADAS10 from 7.2 to 2.8 (p = 0.008), VAS-physician from 12 to 4 (p = 0.022), VAS-patient/parent from 38.5 to 13 (p = 0.003), number of active joints from 2 to 0.5 (p = 0.12) and VAS-pain from 35.5 to 15 (p = 0.030). Functional impairments (CHAQ-score) improved more gradually and ESR remained stable. A comparable pattern was observed in 11 patients (73% girls, median age 8 (IQR 6-9)) who did not receive high-dose etanercept despite eligibility (comparison group). In both groups, 56% reached inactive disease at 6 months. No severe adverse events (SAEs) occurred after etanercept dose-increase. In the comparison group, 2 SAEs consisting of hospital admission occurred. Rates of non-severe AEs per subsequent patient year follow-up were 2.27 in the high-dose and 1.43 in the comparison group. CONCLUSIONS Escalation to high-dose etanercept in JIA-patients who were treated to target was generally followed by meaningful clinical improvement. However, similar improvements were observed in a smaller comparison group who did not escalate to high-dose etanercept. No SAEs were seen after escalation to high-dose etanercept. The division into the high-dose and comparison groups was not randomised, which is a potential source of bias. We advocate larger, randomised studies of high versus regular dose etanercept to provide high level evidence on efficacy and safety. TRIAL REGISTRATION Dutch Trial Register; NTR1574; 3 December 2008; https://onderzoekmetmensen.nl/en/trial/26585 .
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Affiliation(s)
- Bastiaan T van Dijk
- Department of Paediatrics - division of Paediatric Rheumatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, the Netherlands.
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands.
| | - Sytske Anne Bergstra
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - J Merlijn van den Berg
- Department of Paediatric Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital / Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Dieneke Schonenberg-Meinema
- Department of Paediatric Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital / Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | | | - Marion A J van Rossum
- Department of Paediatrics, Emma Children's Hospital / Amsterdam University Medical Centres, Amsterdam, the Netherlands
- Department of Paediatric Rheumatology, Amsterdam Rheumatology and Immunology Centre (Reade), Amsterdam, the Netherlands
| | - Yvonne Koopman-Keemink
- Department of Paediatrics, Juliana Children's Hospital / HagaZiekenhuis, the Hague, the Netherlands
| | - Rebecca Ten Cate
- Department of Paediatrics - division of Paediatric Rheumatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, the Netherlands
| | - Cornelia F Allaart
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Daniëlle M C Brinkman
- Department of Paediatrics - division of Paediatric Rheumatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, the Netherlands
| | - Petra C E Hissink Muller
- Department of Paediatrics - division of Paediatric Rheumatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, the Netherlands
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Nicoară DM, Munteanu AI, Scutca AC, Brad GF, Jugănaru I, Bugi MA, Asproniu R, Mărginean O. Examining the Relationship between Systemic Immune-Inflammation Index and Disease Severity in Juvenile Idiopathic Arthritis. Cells 2024; 13:442. [PMID: 38474406 DOI: 10.3390/cells13050442] [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: 01/02/2024] [Revised: 02/17/2024] [Accepted: 03/02/2024] [Indexed: 03/14/2024] Open
Abstract
Juvenile Idiopathic Arthritis (JIA), the leading childhood rheumatic condition, has a chronic course in which persistent disease activity leads to long-term consequences. In the era of biologic therapy and tailored treatment, precise disease activity assessment and aggressive intervention for high disease activity are crucial for improved outcomes. As inflammation is a fundamental aspect of JIA, evaluating it reflects disease severity. Recently, there has been growing interest in investigating cellular immune inflammation indices such as the neutrophil-to-lymphocyte ratio (NLR) and systemic immune inflammation index (SII) as measures of disease severity. The aim of this retrospective study was to explore the potential of the SII in reflecting both inflammation and disease severity in children with JIA. The study comprised 74 JIA patients and 50 healthy controls. The results reveal a notable increase in median SII values corresponding to disease severity, exhibiting strong correlations with traditional inflammatory markers, including CRP and ESR (ρ = 0.714, ρ = 0.661), as well as the JADAS10 score (ρ = 0.690). Multiple regression analysis revealed the SII to be independently associated with JADAS10. Furthermore, the SII accurately distinguished patients with high disease activity from other severity groups (AUC = 0.827, sensitivity 81.5%, specificity 66%). These findings suggest that integrating the SII as an additional measure holds potential for assessing disease activity in JIA.
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Affiliation(s)
- Delia-Maria Nicoară
- Department XI Pediatrics, Discipline I Pediatrics, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Andrei-Ioan Munteanu
- Department XI Pediatrics, Discipline I Pediatrics, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
- Department of Pediatrics I, Children's Emergency Hospital "Louis Turcanu", 300011 Timisoara, Romania
- Research Center for Disturbances of Growth and Development in Children BELIVE, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Alexandra-Cristina Scutca
- Department XI Pediatrics, Discipline I Pediatrics, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
- Department of Pediatrics I, Children's Emergency Hospital "Louis Turcanu", 300011 Timisoara, Romania
| | - Giorgiana-Flavia Brad
- Department XI Pediatrics, Discipline I Pediatrics, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
- Department of Pediatrics I, Children's Emergency Hospital "Louis Turcanu", 300011 Timisoara, Romania
| | - Iulius Jugănaru
- Department XI Pediatrics, Discipline I Pediatrics, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
- Department of Pediatrics I, Children's Emergency Hospital "Louis Turcanu", 300011 Timisoara, Romania
- Research Center for Disturbances of Growth and Development in Children BELIVE, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Meda-Ada Bugi
- Department of Pediatrics I, Children's Emergency Hospital "Louis Turcanu", 300011 Timisoara, Romania
- Ph.D. School Department, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Raluca Asproniu
- Department XI Pediatrics, Discipline I Pediatrics, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
- Department of Pediatrics I, Children's Emergency Hospital "Louis Turcanu", 300011 Timisoara, Romania
| | - Otilia Mărginean
- Department XI Pediatrics, Discipline I Pediatrics, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
- Department of Pediatrics I, Children's Emergency Hospital "Louis Turcanu", 300011 Timisoara, Romania
- Research Center for Disturbances of Growth and Development in Children BELIVE, 'Victor Babeş' University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
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Shoop-Worrall SJW, Lawson-Tovey S, Wedderburn LR, Hyrich KL, Geifman N. Towards stratified treatment of JIA: machine learning identifies subtypes in response to methotrexate from four UK cohorts. EBioMedicine 2024; 100:104946. [PMID: 38194741 PMCID: PMC10792564 DOI: 10.1016/j.ebiom.2023.104946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Methotrexate (MTX) is the gold-standard first-line disease-modifying anti-rheumatic drug for juvenile idiopathic arthritis (JIA), despite only being either effective or tolerated in half of children and young people (CYP). To facilitate stratified treatment of early JIA, novel methods in machine learning were used to i) identify clusters with distinct disease patterns following MTX initiation; ii) predict cluster membership; and iii) compare clusters to existing treatment response measures. METHODS Discovery and verification cohorts included CYP who first initiated MTX before January 2018 in one of four UK multicentre prospective cohorts of JIA within the CLUSTER consortium. JADAS components (active joint count, physician (PGA) and parental (PGE) global assessments, ESR) were recorded at MTX start and over the following year. Clusters of MTX 'response' were uncovered using multivariate group-based trajectory modelling separately in discovery and verification cohorts. Clusters were compared descriptively to ACR Pedi 30/90 scores, and multivariate logistic regression models predicted cluster-group assignment. FINDINGS The discovery cohorts included 657 CYP and verification cohorts 1241 CYP. Six clusters were identified: Fast improvers (11%), Slow Improvers (16%), Improve-Relapse (7%), Persistent Disease (44%), Persistent PGA (8%) and Persistent PGE (13%), the latter two characterised by improvement in all features except one. Factors associated with clusters included ethnicity, ILAR category, age, PGE, and ESR scores at MTX start, with predictive model area under the curve values of 0.65-0.71. Singular ACR Pedi 30/90 scores at 6 and 12 months could not capture speeds of improvement, relapsing courses or diverging disease patterns. INTERPRETATION Six distinct patterns following initiation of MTX have been identified using methods in artificial intelligence. These clusters demonstrate the limitations in traditional yes/no treatment response assessment (e.g., ACRPedi30) and can form the basis of a stratified medicine programme in early JIA. FUNDING Medical Research Council, Versus Arthritis, Great Ormond Street Hospital Children's Charity, Olivia's Vision, and the National Institute for Health Research.
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Affiliation(s)
- Stephanie J W Shoop-Worrall
- Centre for Epidemiology Versus Arthritis, The University of Manchester, UK; Centre for Health Informatics, The University of Manchester, UK.
| | - Saskia Lawson-Tovey
- Centre for Genetics and Genomics Versus Arthritis, The University of Manchester, UK; National Institute for Health Research Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK.
| | - Lucy R Wedderburn
- Centre for Adolescent Rheumatology Versus Arthritis at UCL, UCLH and GOSH, London, UK; Infection, Immunity and Inflammation Research & Teaching Department, UCL GOS Institute of Child Health, London, UK; NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK.
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, The University of Manchester, UK; National Institute for Health Research Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK.
| | - Nophar Geifman
- Faculty of Health and Medical Sciences, School of Health Sciences, The University of Surrey, Surrey, UK.
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Backström M, Salo H, Kärki J, Aalto K, Rebane K, Levälampi T, Grönlund MM, Kröger L, Pohjankoski H, Hietanen M, Korkatti K, Kuusalo L, Rantalaiho V, Huhtakangas J, Relas H, Pääkkö T, Löyttyniemi E, Sokka-Isler T, Vähäsalo P. The feasibility of existing JADAS10 cut-off values in clinical practice: a study of data from The Finnish Rheumatology Quality Register. Pediatr Rheumatol Online J 2023; 21:35. [PMID: 37060076 PMCID: PMC10105448 DOI: 10.1186/s12969-023-00814-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/31/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND The ten-joint juvenile arthritis disease activity score (JADAS10) is designed to measure the level of disease activity in non-systemic juvenile idiopathic arthritis by providing a single numeric score. The clinical JADAS10 (cJADAS10) is a modification of the JADAS10 that excludes erythrocyte sedimentation rate (ESR). Three different sets of JADAS10/cJADAS10 cut-offs for disease activity states have been published, i.e., the Backström, Consolaro, and Trincianti cut-offs. The objective of this study was to investigate the performance of existing JADAS10 cut-offs in real-life settings using patient data from The Finnish Rheumatology Quality Register (FinRheuma). METHODS Data were collected from the FinRheuma register. The proportion of patients with an active joint count (AJC) above zero when classified as being in clinically inactive disease (CID) or low disease activity (LDA) groups according to existing JADAS10/cJADAS10 cut-off levels were analyzed. RESULTS A significantly larger proportion of the patients classified as being in CID had an AJC > 0 when using the JADAS10/cJADAS10 cut-offs by Trincianti et al. compared to those for the other cut-offs. In the LDA group, a significantly larger proportion of the polyarticular patients (35%/29%) had an AJC of two when Trincianti JADAS10/cJADAS10 cut-offs were used compared with when Backström (11%/10%) and Consolaro (7%/3%) JADAS10/cJADAS10 cut-offs were used. CONCLUSIONS We found the cut-offs proposed by Consolaro et al. to be the most feasible, since these cut-off levels for CID do not result in the misclassification of active disease as remission, and the proportion of patients with AJC > 1 in the LDA group is lowest using these cut-offs.
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Affiliation(s)
- M Backström
- Department of Paediatrics, The Wellbeing Services County of Ostrobothnia, Vaasa, Finland.
- PEDEGO Research Unit, University of Oulu, Oulu, Finland.
- Vaasa Central Hospital, U2, Hietalahdenkatu 2-4, 65130, Vaasa, Finland.
| | - H Salo
- Knowledge Brokers Department, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - J Kärki
- Department of Children and Adolescents, Kanta-Häme Central Hospital, Hämeenlinna, Finland
- The Finnish Institute for Welfare and Health, The Finnish Rheumatology Quality Register, Helsinki, Finland
| | - K Aalto
- New Children's Hospital, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - K Rebane
- New Children's Hospital, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - T Levälampi
- New Children's Hospital, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - M-M Grönlund
- Department of Paediatrics, Turku University Hospital, Turku, Finland
| | - L Kröger
- Department of Children and Adolescents, Kuopio University Hospital, Kuopio, Finland
| | - H Pohjankoski
- Department of Children and Adolescents, Päijät-Häme Central Hospital, Lahti, Finland
| | - M Hietanen
- Department of Children and Adolescents, Päijät-Häme Central Hospital, Lahti, Finland
| | - K Korkatti
- Department of Paediatrics, Central Ostrobothnia Central Hospital, Kokkola, Finland
| | - L Kuusalo
- Centre for Rheumatology and Clinical Immunology, Division of Medicine, University of Turku and Turku University Hospital, Turku, Finland
| | - V Rantalaiho
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Centre for Rheumatic Diseases, Tampere University Hospital, Tampere, Finland
- Centre for Rheumatic Diseases, Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | - J Huhtakangas
- Division of Rheumatology, Kuopio University Hospital, Kuopio, Finland
| | - H Relas
- Department of Rheumatology, Inflammation Center, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | - T Pääkkö
- Department of Internal Medicine, Oulu University Hospital, Oulu, Finland
| | - E Löyttyniemi
- Department of Biostatistics, University of Turku, Turku, Finland
| | - T Sokka-Isler
- University of Eastern Finland, Kuopio and Central Finland Central Hospital, Jyväskylä, Finland
| | - P Vähäsalo
- PEDEGO Research Unit, University of Oulu, Oulu, Finland
- Department of Paediatrics, Oulu University Hospital, Oulu, Finland
- Medical Research Center, Oulu University Hospital and University of Oulu, Oulu, Finland
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Vega-Fernandez P, Ting TV, Oberle EJ, McCracken C, Figueroa J, Altaye M, Cassedy A, Kaeley GS, Roth J. Musculoskeletal Ultrasound in Childhood Arthritis Limited Examination: A Comprehensive, Reliable, Time-Efficient Assessment of Synovitis. Arthritis Care Res (Hoboken) 2023; 75:401-409. [PMID: 34328679 PMCID: PMC8800943 DOI: 10.1002/acr.24759] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 07/10/2021] [Accepted: 07/27/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To develop and initially validate a comprehensive pediatric musculoskeletal ultrasound (MSUS) joint-specific scoring system, and to determine the minimum number of joints needed to identify active disease. METHODS A semiquantitative scoring system was developed by consensus and initially validated by interrater reliability using intraclass correlation coefficients (ICCs). Subsequently, newly diagnosed juvenile idiopathic arthritis patients with an active joint count of >4 had a 42-joint MSUS performed at baseline and 3 months using this protocol. A minimum set of joints needed to identify all patients with synovitis on MSUS was obtained through a data reduction process. Spearman's correlation (rs ) was calculated to determine the association between MSUS findings and clinical Juvenile Arthritis Disease Activity Score in 10 joints (cJADAS10). Standardized response means (SMRs) were used to assess change over time. RESULTS The final joint-specific scoring system revealed an excellent interrater reliability (ICC 0.81-0.96) for all joints. Thirty patients were enrolled. Scanning 5 joints bilaterally (wrists, second and third metacarpophalangeal joints, knees and ankles) captured 100% of children with B-mode synovitis and had moderate correlation with the cJADAS10 at baseline (rs = 0.45). Mean ultrasound scores at baseline and follow-up were 28.3 and 22.3, with an SRM of 0.69 (P = 0.002) for 42 joints, and 36 and 27.7, with an SRM of 0.76 (P = 0.003) for the reduced joints, respectively. CONCLUSION A limited MSUS examination called musculoskeletal ultrasound in childhood arthritis limited examination (MUSICAL) captures all patients with active synovitis, and our new joint-specific scoring system is highly reliable and sensitive to change.
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Affiliation(s)
- Patricia Vega-Fernandez
- Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 4010, Cincinnati, OH, 45229, USA
| | - Tracy V Ting
- Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 4010, Cincinnati, OH, 45229, USA
| | - Edward J. Oberle
- Nationwide Children’s Hospital and The Ohio State University, Pediatric Rheumatology, 700 Children's Drive, Columbus, Ohio, USA
| | | | - Janet Figueroa
- Emory University School of Medicine, Pediatrics, Atlanta, Georgia, USA
| | - Mekibib Altaye
- Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 4010, Cincinnati, OH, 45229, USA
| | - Amy Cassedy
- Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 4010, Cincinnati, OH, 45229, USA
| | - Gurjit S Kaeley
- University of Florida, Jacksonville, Rheumatology, Jacksonville, Florida, USA
| | - Johannes Roth
- Hebrew SeniorLife, IFAR, 1200 Centre St, Boston, Massachusetts, USA
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Juvenile idiopathic arthritis of the knee: is contrast needed to score disease activity when using an augmented MRI protocol comprising PD-weighted sequences? Eur Radiol 2022; 33:3775-3784. [PMID: 36472701 PMCID: PMC10121492 DOI: 10.1007/s00330-022-09292-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/30/2022] [Accepted: 11/09/2022] [Indexed: 12/12/2022]
Abstract
Abstract
Objective
To compare unenhanced versus enhanced knee joint magnetic resonance imaging (MRI) to assess disease activity of juvenile idiopathic arthritis (JIA).
Methods
Fifty-three knee joint MRI examinations were performed on a 3-Tesla system in 27 patients (age: 11.40 ± 3.61 years; 21 females, 6 males). MRI protocols comprised PD-weighted sequences in addition to the widely used standard protocol. JIA subgroups comprised oligoarticular arthritis (n = 16), extended oligoarthritis (n = 6), rheumatoid factor-negative polyarticular arthritis (n = 3), enthesitis-related arthritis (n = 1), and psoriatic arthritis (n = 1). MR images were retrospectively analyzed by 3 experienced radiologists in two readings, using JAMRIS (juvenile arthritis MRI scoring) system and a modified IPSG (international prophylaxis study group) classification. In the first reading session, only unenhanced MR images were evaluated. In a second reading session, all images before and after contrast medium application were included. In order to avoid bias, an interval of at least 2 weeks was set between the two readings. The clinical JADAS10 (juvenile arthritis disease activity score) was calculated including clinical assessment and laboratory workup and correlated with MRI scores. Statistical analysis comprised Pearson’s correlation for correlating two scoring results of unenhanced and the enhanced MRI, intra-class correlation coefficient (ICC) for inter- and intra-reader agreement. Diagnostic accuracy was calculated using ROC (receiver operating characteristics) curve analysis.
Results
Inter-reader agreement determined by ICC for unenhanced and enhanced MRI scores for IPSG was moderate (0.65, 95% CI 0.51–0.76, and 0.62, 95% CI 0.48–0.75) and high for JAMRIS (0.83, 95% CI 0.75–0.89, and 0.82, 95% CI 0.74–0.89). Intra-reader agreement was good to very good for JAMRIS (0.85 95% CI 0.81–0.88, 0.87 95% CI 0.83–0.89 and 0.96 95% CI 0.92–0.98) and IPSG (0.76 95% CI 0.62–0.86, 0.86 95% CI 0.77–0.92 and 0.92 95% CI 0.86–0.96). Scores of unenhanced MRI correlated with contrast-enhanced MRI: JAMRIS (r = 0.97, R2 = 0.93, p < 0.01), modified IPSG (r = 0.95, R2 = 0.91, p < 0.01). When using JADAS10 as a reference standard, moderate accuracy for both unenhanced and enhanced MRI scores was noted: JAMRIS (AUC = 0.68, 95% CI 0.51–0.85, and AUC = 0.66, 95% 0.49–0.82), IPSG score (AUC = 0.68, 95% 0.50–0.86, and AUC = 0.61, 95% 0.41–0.81).
Conclusions
Our results suggest that contrast agent application could be omitted in JIA patients with an augmented knee MRI protocol comprising PD-weighted sequence.
Key Points
• Unenhanced MRI can detect disease activity of the knee joint in patients with JIA with equally high accuracy compared to contrast-enhanced MRI.
• The intra- and inter-reader agreement was high for unenhanced and enhanced MRI JAMRIS scores, which indicate relatively good applicability of the scoring system, even for less experienced readers.
• When using the clinical JADAS10 as a reference standard for the detection of disease activity, moderate accuracy for both unenhanced and enhanced MRI scores, both JAMRIS and IPSG, was noted, which might be caused by the fact that the majority of patients had either no or minimal clinical disease activity.
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Sudhakar M, Deswal S, Sachdev N, Pal S, Pal Yadav T. The reliability of Juvenile Arthritis Magnetic Resonance Imaging Scoring system in the evaluation of the shoulder joint in juvenile idiopathic arthritis. Arch Rheumatol 2022; 37:547-558. [PMID: 36879563 PMCID: PMC9985367 DOI: 10.46497/archrheumatol.2022.9304] [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] [Received: 10/20/2021] [Accepted: 12/21/2021] [Indexed: 12/24/2022] Open
Abstract
Objectives We aimed to evaluate shoulder joint by magnetic resonance imaging (MRI) using the Juvenile Arthritis Magnetic Resonance Imaging Scoring (JAMRIS) system in children with juvenile idiopathic arthritis (JIA) and to compare clinical, laboratory parameters and disease activity scores with MRI parameters. Patients and methods A total of 32 shoulder joints of 20 patients (16 males, 4 females; mean age: 8.9±3.5 years; range, 2.5 to 14 years) with a known diagnosis of JIA and a clinical suspicion of shoulder joint involvement and underwent MRI were included. Reliability was determined by inter- and intra-observer correlation coefficients. Correlation of the clinical and laboratory parameters with JAMRIS scores was done using the non-parametric tests. Sensitivity of clinical examination to detect shoulder joint arthritis was also determined. Results Of the 32 joints, 27 joints in 17 patients showed MRI changes. Seven joints in five patients fulfilled the definition of clinical arthritis, all revealed MRI changes. In 25 joints without clinical arthritis, early and late MRI changes were seen in 19 (67%) and 12 (48%) joints, respectively. The inter- and intra-observer correlation coefficients for JAMRIS system were excellent. No correlation was found between MRI parameters, clinical, laboratory, and disease activity scores. The sensitivity of clinical examination to detect shoulder joint arthritis was 25.9%. Conclusion The JAMRIS system is reliable and reproducible to determine shoulder joint inflammation in JIA. Detection of shoulder joint arthritis by clinical examination has a poor sensitivity.
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Affiliation(s)
- Murugan Sudhakar
- Department of Pediatrics, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Shivani Deswal
- Department of Pediatrics, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Namrita Sachdev
- Department of Radiodiagnosis, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Somdipa Pal
- Department of Pediatrics, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Tribhuvan Pal Yadav
- Department of Pediatrics, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
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Yarwood A, Shoop-Worrall S, López-Isac E, Smith SL, Morris AP, Bowes JD, Tordoff M, Hyrich KL, Thomson W, Eyre S. No evidence that genetic predictors of susceptibility predict changes in core outcomes in JIA. Rheumatology (Oxford) 2022; 61:4136-4144. [PMID: 35015833 PMCID: PMC9536790 DOI: 10.1093/rheumatology/keab942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 12/15/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES The clinical progression of JIA is unpredictable. Knowing who will develop severe disease could facilitate rapid intensification of therapies. We use genetic variants conferring susceptibility to JIA to predict disease outcome measures. METHODS A total of 713 JIA patients with genotype data and core outcome variables (COVs) at diagnosis (baseline) and 1 year follow-up were identified from the Childhood Arthritis Prospective Study (CAPS). A weighted genetic risk score (GRS) was generated, including all single nucleotide polymorphisms (SNPs) previously associated with JIA susceptibility (P-value < 5×10-08). We used multivariable linear regression to test the GRS for association with COVS (limited joint count, active joint count, physician global assessment, parent/patient general evaluation, childhood HAQ and ESR) at baseline and change in COVS from baseline to 1 year, adjusting for baseline COV and International League of Associations of Rheumatology (ILAR) category. The GRS was split into quintiles to identify high (quintile 5) and low (quintile 1) risk groups. RESULTS Patients in the high-risk group for the GRS had a younger age at presentation (median low risk 7.79, median high risk 3.51). No association was observed between the GRS and any outcome measures at 1 year follow-up or baseline. CONCLUSION For the first time we have used all known JIA genetic susceptibility loci (P=<5×10-08) in a GRS to predict changes in disease outcome measured over time. Genetic susceptibility variants are poor predictors of changes in core outcome measures, it is likely that genetic factors predicting disease outcome are independent to those predicting susceptibility. The next step will be to conduct a genome-wide association analysis of JIA outcome.
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Affiliation(s)
- Annie Yarwood
- Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester
- NIHR Manchester Musculoskeletal Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust
| | - Stephanie Shoop-Worrall
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology Medicine and Health, Manchester Academic Health Science Centre
- Centre for Health Informatics, The University of Manchester, Manchester, UK
| | - Elena López-Isac
- Department of Biochemistry and Molecular Biology II, The University of Granada, Andalucía, Spain
| | - Samantha Louise Smith
- Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester
| | - Andrew P Morris
- Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester
- NIHR Manchester Musculoskeletal Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust
| | | | - John David Bowes
- Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester
- NIHR Manchester Musculoskeletal Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust
| | - Melissa Tordoff
- Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester
| | - Kimme L Hyrich
- NIHR Manchester Musculoskeletal Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology Medicine and Health, Manchester Academic Health Science Centre
| | - Wendy Thomson
- Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester
- NIHR Manchester Musculoskeletal Biomedical Research Centre, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust
| | - Stephen Eyre
- Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester
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9
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Kip MMA, de Roock S, van den Berg I, Currie G, Marshall DA, Grazziotin LR, Twilt M, Yeung RSM, Benseler SM, Vastert SJ, Wulffraat N, Swart JF, IJzerman MJ. Costs of Hospital-Associated Care for Patients With Juvenile Idiopathic Arthritis in the Dutch Health Care System. Arthritis Care Res (Hoboken) 2022; 74:1585-1592. [PMID: 33938161 PMCID: PMC9796352 DOI: 10.1002/acr.24621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 03/23/2021] [Accepted: 04/08/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The aim of this study was to quantify costs of hospital-associated care for juvenile idiopathic arthritis (JIA), provide insights in patient-level variation in costs, and investigate costs over time from the moment of JIA diagnosis. Results were reported for all JIA patients in general and by subtype. METHODS: This study was a single-center, retrospective analysis of prospective data from electronic medical records of children with JIA, ages 0-18 years, between April 1, 2011 and March 31, 2019. Patient characteristics (age, sex, JIA subtype) and hospital-based resource use (consultations, medication, radiology procedures, laboratory testing, surgeries, emergency department [ED] visits, hospital stays) were extracted and analyzed. Unit prices were obtained from Dutch reimbursement lists and pharmaceutical and hospital list prices. RESULTS The analysis included 691 patients. The mean total cost of hospital care was €3,784/patient/year, of which €2,103 (55.6%) was attributable to medication. Other costs involved pediatric rheumatologist visits (€633/patient/year [16.7%]), hospital stays (€439/patient/year [11.6%]), other within-hospital specialist visits (€324/patient/year [8.6%]), radiology procedures (€119/patient/year [3.1%]), laboratory tests (€114/patient/year [3.0%]), surgeries (€46/patient/year [1.2%]), and ED visits (€6/patient/year [0.2%]). Mean annual total costs varied between JIA subtypes and between individuals and were the highest for systemic JIA (€7,772/patient/year). Over the treatment course, costs were the highest in the first month after JIA diagnosis. CONCLUSION Hospital care costs of JIA vary substantially between individuals, between subtypes, and over the treatment course. The highest annual costs were for systemic JIA, primarily attributable to medication (i.e., biologics). Costs of other hospital-associated care were comparable regardless of subtype.
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Affiliation(s)
- Michelle M. A. Kip
- Wilhelmina Children's Hospital, Utrecht, The Netherlands, and University of TwenteEnschedeThe Netherlands
| | - Sytze de Roock
- Wilhelmina Children's Hospital and Utrecht UniversityUtrechtThe Netherlands
| | | | | | | | | | | | | | | | | | - Nico Wulffraat
- Wilhelmina Children's Hospital and Utrecht UniversityUtrechtThe Netherlands
| | - Joost F. Swart
- Wilhelmina Children's Hospital and Utrecht UniversityUtrechtThe Netherlands
| | - Maarten J. IJzerman
- University of Twente, Enschede, The Netherlands, and University of MelbourneMelbourneAustralia
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10
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Shoop-Worrall SJW, Moull L, McDonagh JE, Hyrich KL. The Role of Age in Delays to Rheumatological Care in Juvenile Idiopathic Arthritis. J Rheumatol 2022; 49:1037-1041. [PMID: 35365583 DOI: 10.3899/jrheum.211316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To investigate the relationship between age and symptom duration at initial presentation to pediatric rheumatology for juvenile idiopathic arthritis (JIA). METHODS In children and young people (CYP) enrolled in the Childhood Arthritis Prospective Study prior to March 2018, an association between age at presentation (< 5, 5-11, and > 11 yrs) and symptom duration was tested by multivariable linear regression. RESULTS In 1577 CYP, 5- to 11-year-olds took 3.2 months longer and > 11-year-olds 6.9 months longer to reach pediatric rheumatology than < 5-year-olds. CONCLUSION Adolescents take longer to reach pediatric rheumatology, potentially affecting their longer-term outcomes given the window of opportunity for JIA treatment.
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Affiliation(s)
- Stephanie J W Shoop-Worrall
- S.J.W. Shoop-Worrall, PhD, MSc, Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, and Centre for Health Informatics, The University of Manchester;
| | - Louisa Moull
- L. Moull, MBChB, School of Medical Sciences, The University of Manchester
| | - Janet E McDonagh
- J.E. McDonagh, MD, FRCP, Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester
| | - Kimme L Hyrich
- K.L Hyrich, Professor, MD, PhD, FRCPC, Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, and NIHR Manchester BRC, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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11
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Xu J, Ma J, Zeng Y, Si H, Wu Y, Zhang S, Shen B. A Cross-Tissue Transcriptome-Wide Association Study Identifies Novel Susceptibility Genes for Juvenile Idiopathic Arthritis in Asia and Europe. Front Immunol 2022; 13:941398. [PMID: 35967305 PMCID: PMC9367689 DOI: 10.3389/fimmu.2022.941398] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/22/2022] [Indexed: 12/14/2022] Open
Abstract
Background Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children, and its pathogenesis is still unclear. Genome-wide association studies (GWASs) of JIA have identified hundreds of risk factors, but few of them implicated specific biological mechanisms. Methods A cross-tissue transcriptome-wide association study (TWAS) was performed with the functional summary-based imputation software (FUSION) tool based on GWAS summary datasets (898 JIA patients and 346,102 controls from BioBank Japan (BBJ)/FinnGen). The gene expression reference weights of skeletal muscle and the whole blood were obtained from the Genotype-Tissue Expression (GTExv8) project. JIA-related genes identified by TWAS findings genes were further compared with the differentially expressed genes (DEGs) identified by the mRNA expression profile of JIA from the Gene Expression Omnibus (GEO) database (accession number: GSE1402). Last, candidate genes were analyzed using functional enrichment and annotation analysis by Metascape to examine JIA-related gene sets. Results The TWAS identified 535 significant genes with P < 0.05 and contains 350 for Asian and 195 for European (including 10 genes both expressed in Asian and European), such as CDC16 (P = 1.72E-03) and PSMD5-AS1 (P = 3.65E-02). Eight overlapping genes were identified based on TWAS results and DEGs of JIA patients, such as SIRPB1 (PTWAS = 4.21E-03, PDEG = 1.50E-04) and FRAT2 (PTWAS = 2.82E-02, PDEG = 1.43E-02). Pathway enrichment analysis of TWAS identified 183 pathways such as cytokine signaling in the immune system and cell adhesion molecules. By integrating the results of DEGs pathway and process enrichment analyses, 19 terms were identified such as positive regulation of T-cell activation. Conclusion By conducting two populations TWAS, we identified a group of JIA-associated genes and pathways, which may provide novel clues to uncover the pathogenesis of JIA.
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12
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Kip MMA, de Roock S, Currie G, Marshall DA, Grazziotin LR, Twilt M, Yeung RSM, Benseler SM, Vastert SJ, Wulffraat N, Swart JF, IJzerman MJ. Pharmacological treatment patterns in patients with juvenile idiopathic arthritis in the Netherlands: a real-world data analysis. Rheumatology (Oxford) 2022; 62:SI170-SI180. [PMID: 35583252 PMCID: PMC9949706 DOI: 10.1093/rheumatology/keac299] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 05/07/2022] [Accepted: 05/07/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate medication prescription patterns among children with JIA, including duration, sequence and reasons for medication discontinuation. METHODS This study is a single-centre, retrospective analysis of prospective data from the electronic medical records of JIA patients receiving systemic therapy aged 0-18 years between 1 April 2011 and 31 March 2019. Patient characteristics (age, gender, JIA subtype) and medication prescriptions were extracted and analysed using descriptive statistics, Sankey diagrams and Kaplan-Meier survival methods. RESULTS Over a median of 4.2 years follow-up, the 20 different medicines analysed were prescribed as monotherapy (n = 15) or combination therapy (n = 48 unique combinations) among 236 patients. In non-systemic JIA, synthetic DMARDs were prescribed to almost all patients (99.5%), and always included MTX. In contrast, 43.9% of non-systemic JIA patients received a biologic DMARD (mostly adalimumab or etanercept), ranging from 30.9% for oligoarticular persistent ANA-positive JIA, to 90.9% for polyarticular RF-positive JIA. Among systemic JIA, 91.7% received a biologic DMARD (always including anakinra). When analysing medication prescriptions according to their class, 32.6% involved combination therapy. In 56.8% of patients, subsequent treatment lines were initiated after unsuccessful first-line treatment, resulting in 68 unique sequences. Remission was the most common reason for DMARD discontinuation (44.7%), followed by adverse events (28.9%) and ineffectiveness (22.1%). CONCLUSION This paper reveals the complexity of pharmacological treatment in JIA, as indicated by: the variety of mono- and combination therapies prescribed, substantial variation in medication prescriptions between subtypes, most patients receiving two or more treatment lines, and the large number of unique treatment sequences.
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Affiliation(s)
- Michelle M A Kip
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede,Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children’s Hospital, Utrecht
| | - Sytze de Roock
- Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children’s Hospital, Utrecht,Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
| | - Gillian Currie
- Department of Community Health Sciences,Department of Paediatrics, Cumming School of Medicine,Alberta Children’s Hospital Research Institute,Department of Medicine
| | - Deborah A Marshall
- Department of Community Health Sciences,Alberta Children’s Hospital Research Institute,Department of Medicine
| | | | - Marinka Twilt
- Alberta Children’s Hospital Research Institute,Division of Rheumatology, Department of Pediatrics, Alberta Children’s Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Rae S M Yeung
- Division of Rheumatology, The Hospital for Sick Children, Department of Paediatrics, Immunology and Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Susanne M Benseler
- Alberta Children’s Hospital Research Institute,Division of Rheumatology, Department of Pediatrics, Alberta Children’s Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Sebastiaan J Vastert
- Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children’s Hospital, Utrecht,Faculty of Medicine, Utrecht University, Utrecht, The Netherlands,European Reference Network RITA (rare Immunodeficiency Autoinflammatory and Autoimmune Diseases Network)
| | - Nico Wulffraat
- Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children’s Hospital, Utrecht,Faculty of Medicine, Utrecht University, Utrecht, The Netherlands,European Reference Network RITA (rare Immunodeficiency Autoinflammatory and Autoimmune Diseases Network)
| | | | - Maarten J IJzerman
- Correspondence to: Maarten J. IJzerman, Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, PO Box 217, 7500 AE Enschede, The Netherlands. E-mail:
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13
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Jeiziner C, Allemann SS, Hersberger KE, Meyer zu Schwabedissen HE. Is Pharmacogenetic Panel Testing Applicable to Low-Dose Methotrexate in Rheumatoid Arthritis? – A Case Report. Pharmgenomics Pers Med 2022; 15:465-475. [PMID: 35586477 PMCID: PMC9109898 DOI: 10.2147/pgpm.s354011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/03/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose Pharmacogenetic (PGx) panel testing could help to determine the heritable component of a rheumatoid arthritis (RA) patient’s susceptibility for therapy failure and/or adverse drug reactions (ADRs) from methotrexate (MTX). Considering the literature mentioning the potential applicability of PGx panel testing within MTX regimens, we discuss the case of a patient who was treated with MTX, suffered from ADRs, and obtained a reactive PGx panel testing. Genotyping We used a commercial PGx panel test involving the ABC-transporters P-glycoprotein (P-gp; gene: ABCB1), and breast cancer resistance protein (BCRP; gene: ABCG2), the solute carriers reduced folate carrier 1 (RFC1; gene: SLC19A1), and organic anion transporting polypeptide 1B1 (OATP1B1; gene: SLCO1B1), and the enzymes inosine triphosphatase (ITPA), and glutathione transferase P1 (GSTP1). In addition, we genotyped the patient for the enzymes 5-aminoimidazole-4-carboxamide ribonucleotide formyltransferase (AICAR)/inosine monophosphate (IMP) cyclohydrolase (gene name: ATIC), gamma-glutamyl hydrolase (gene name: GGH) and methylenetetrahydrofolate reductase (gene name: MTHFR). Results The PGx profile of the patient revealed genetic variants in SLC19A1, ABCB1, and MTHFR, which may explain the ADRs experienced during the treatment with MTX and a potentially lower efficacy of MTX. Based on our interpretation of the PGx profile, we recommended the patient to avoid MTX in the future. Conclusion The MTX pathway is complex, which makes the interpretation of genetic variants affecting metabolism challenging. A reactive PGx panel test was applicable to explain ADRs experienced during MTX treatment for a patient with RA. However, the clinical utility of PGx-guided MTX treatment in a primary care setting is still limited. In order to base a recommendation for MTX on PGx data, we need genome-wide association studies, large prospective multicenter studies and PGx studies, which analyze different multi-gene haplotypes and gene-drug-drug interactions for MTX.
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Affiliation(s)
- Chiara Jeiziner
- Pharmaceutical Care Research Group, Department Pharmaceutical Sciences, University of Basel, Basel, Switzerland
- Correspondence: Chiara Jeiziner, Pharmaceutical Care Research Group, Department Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, Basel, 4056, Switzerland, Tel +41 61 207 61 80, Email
| | - Samuel S Allemann
- Pharmaceutical Care Research Group, Department Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Kurt E Hersberger
- Pharmaceutical Care Research Group, Department Pharmaceutical Sciences, University of Basel, Basel, Switzerland
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Abstract
Health and health care disparities in pediatric rheumatology are prevalent among socially disadvantaged and marginalized populations based on race/ethnicity, socioeconomic position, and geographic region. These groups are more likely to experience greater disease severity, morbidity, mortality, decreased quality of life, and poor mental health outcomes, which are in part due to persistent structural and institutional barriers, including decreased access to quality health care. Most of the research on health and health care disparities in pediatric rheumatology focuses on juvenile idiopathic arthritis and childhood-onset systemic lupus erythematosus; there are significant gaps in the literature assessing disparities associated with other pediatric rheumatic diseases. Understanding the underlying causes of health care disparities will ultimately inform the development and implementation of innovative policies and interventions on a federal, local, and individual level.
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Affiliation(s)
- Alisha M Akinsete
- Division of Pediatric Rheumatology, Department of Pediatrics, Children's Hospital at Montefiore/Albert Einstein College of Medicine, 3415 Bainbridge Avenue, Bronx, NY 10467, USA. https://twitter.com/@akinsetemd
| | - Jennifer M P Woo
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, 111 TW Alexander Drive, Research Triangle Park, NC 27709, USA. https://twitter.com/@jmpwoo
| | - Tamar B Rubinstein
- Division of Pediatric Rheumatology, Department of Pediatrics, Children's Hospital at Montefiore/Albert Einstein College of Medicine, 3415 Bainbridge Avenue, Bronx, NY 10467, USA.
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15
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Carlsson E, Midgley A, Perkins S, Caamano-Gutierrez E, Gritzfeld JF, Beresford MW, Hedrich CM. Serum protein signatures differentiate paediatric autoimmune/inflammatory disorders. Clin Immunol 2021; 229:108790. [PMID: 34197952 DOI: 10.1016/j.clim.2021.108790] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/25/2021] [Accepted: 06/25/2021] [Indexed: 01/04/2023]
Abstract
Because of their rarity, limited awareness among non-specialists, and significant overlaps in their clinical presentation, childhood autoimmune/inflammatory conditions represent a diagnostic and therapeutic challenge. Juvenile idiopathic arthritis (JIA), with its 7 sub-forms, is the most common paediatric "rheumatic" disease. Juvenile-onset systemic lupus erythematosus (jSLE) is a severe autoimmune/inflammatory disease that can affect any organ system and shares clinical features with JIA. To overcome issues around diagnostic approaches in the context of clinical overlap, we aimed at the definition of disease sub-form specific cytokine and chemokine profiles. Serum samples from patients with JIA (n = 77) and jSLE (n = 48), as well as healthy controls (n = 30), were collected. Samples were analysed using the Meso Scale Discovery (MSD) U-PLEX Biomarker Group 1 (hu) panel. Distinct serum protein signatures associate with JIA vs jSLE disease groups. Proteins with high discriminatory ability include IL-23, MIP-1β, MCP-1, M-CSF and MDC. Furthermore, serum IL-18, MIF, MIP-5 and YKL-40 discriminate between systemic JIA and other JIA subtypes. Thus, simultaneous quantification of serum proteins in a panel format may provide an avenue for the diagnosis and monitoring of childhood autoimmune/inflammatory conditions.
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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, United Kingdom
| | - Angela Midgley
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L14 5AB, United Kingdom
| | - Simon Perkins
- Computation Biology Facility, Technology Directorate, Faculty of Health and Life Sciences, University of Liverpool, Liverpool L69 7ZB, United Kingdom; Department of Biochemistry and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool L69 7ZB, United Kingdom
| | - Eva Caamano-Gutierrez
- Computation Biology Facility, Technology Directorate, Faculty of Health and Life Sciences, University of Liverpool, Liverpool L69 7ZB, United Kingdom; Department of Biochemistry and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool L69 7ZB, United Kingdom
| | - Jenna F Gritzfeld
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L14 5AB, United Kingdom
| | - Michael W Beresford
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L14 5AB, United Kingdom; Department of Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool L14 5AB, United Kingdom; National Institute for Health Research Alder Hey Clinical Research Facility, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool L14 5AB, United Kingdom
| | - Christian M Hedrich
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L14 5AB, United Kingdom; Department of Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool L14 5AB, United Kingdom; National Institute for Health Research Alder Hey Clinical Research Facility, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool L14 5AB, United Kingdom.
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16
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Alexeeva E, Horneff G, Dvoryakovskaya T, Denisova R, Nikishina I, Zholobova E, Malievskiy V, Santalova G, Stadler E, Balykova L, Spivakovskiy Y, Kriulin I, Alshevskaya A, Moskalev A. Early combination therapy with etanercept and methotrexate in JIA patients shortens the time to reach an inactive disease state and remission: results of a double-blind placebo-controlled trial. Pediatr Rheumatol Online J 2021; 19:5. [PMID: 33407590 PMCID: PMC7788754 DOI: 10.1186/s12969-020-00488-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 12/09/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Remission is the primary objective of treating juvenile idiopathic arthritis (JIA). It is still debatable whether early intensive treatment is superior in terms of earlier achievement of remission. The aim of this study was to evaluate the effectiveness of early etanercept+methotrexate (ETA+MTX) combination therapy versus step-up MTX monotherapy with ETA added in refractory disease. METHODS A multi-centre, double-blind, randomized study in active polyarticular JIA patients treated with either ETA+MTX (n = 35) or placebo+MTX (n = 33) for up to 24 weeks, followed by a 24-week open-label phase. The efficacy endpoints included pedACR30 criteria improvement at week 12, inactive disease at week 24, and remission at week 48. Patients who failed to achieve the endpoints at week 12 or at week 24 escaped to open-label ETA+MTX. Safety was assessed at each visit. RESULTS By intention-to-treat analysis, more patients in the ETA+MTX group reached the pedACR30 response at week 12 (33 (94.3%)) than in the placebo+MTX group (20 (60.6%); p = 0.001). At week 24, comparable percentages of patients reached inactive disease (11 (31.4%) vs 11 (33.3%)). At week 48, 11 (31.4%) and eight (24.2%) patients achieved remission. The median (+/-IQR) times to achieve an inactive disease state in the ETA+MTX and placebo+MTX groups were 24 (14-32) and 32 (24-40) weeks, respectively. Forty-four (74/100 patient-years) adverse events (AEs) were reported, leading to treatment discontinuation in 6 patients. CONCLUSIONS Early combination therapy with ETA+MTX proved to be highly effective compared to the standard step-up regimen. Compared to those treated with the standard regimen, more patients treated with a combination of ETA+MTX reached the pedACR30 response and achieved inactive disease and remission more rapidly.
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Affiliation(s)
- Ekaterina Alexeeva
- Federal State Autonomous Institution, National Medical Research Center of Children’s Health, Moscow, Russian Federation ,grid.448878.f0000 0001 2288 8774Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Gerd Horneff
- Asklepios Clinic Sankt Augustin, General Paediatrics, Arnold-Janssen-Straße 29, 53757, Sankt Augustin, Germany. .,Department of Pediatric and Adolescent medicine, Medical Faculty, University Hospital of Cologne, Cologne, Germany.
| | - Tatyana Dvoryakovskaya
- Federal State Autonomous Institution, National Medical Research Center of Children’s Health, Moscow, Russian Federation ,grid.448878.f0000 0001 2288 8774Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Rina Denisova
- Federal State Autonomous Institution, National Medical Research Center of Children’s Health, Moscow, Russian Federation ,grid.448878.f0000 0001 2288 8774Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Irina Nikishina
- grid.488825.bV.A. Nasonova Research Institute of Rheumatology, Moscow, Russian Federation
| | - Elena Zholobova
- grid.448878.f0000 0001 2288 8774Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Viktor Malievskiy
- grid.411540.50000 0001 0436 3958Federal State Educational Institution of Higher Education Bashkir State Medical University of the Ministry of Health of the Russian Federation, Ufa, Russian Federation
| | - Galina Santalova
- grid.445780.a0000 0001 0235 2817State Samara Medical University, Samara, Russian Federation
| | - Elena Stadler
- grid.445780.a0000 0001 0235 2817State Samara Medical University, Samara, Russian Federation
| | - Larisa Balykova
- grid.48430.3b0000 0001 2161 7585Medical Institute of National Research Ogarev Mordovia State University, Saransk, Russian Federation
| | - Yuriy Spivakovskiy
- grid.412420.10000 0000 8546 8761Saratov State Medical University n.a. V.I. Razumovsky, Saratov, Russian Federation
| | - Ivan Kriulin
- grid.448878.f0000 0001 2288 8774Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Alina Alshevskaya
- Biostatistics and Clinical Trials Center, Novosibirsk, Russian Federation
| | - Andrey Moskalev
- Biostatistics and Clinical Trials Center, Novosibirsk, Russian Federation
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17
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Brijendra P, Sudhakar M, Pal S, Hlawndo JL, Sachdev N, Yadav TP. Magnetic resonance imaging findings in the sternoclavicular joint in juvenile idiopathic arthritis and comparison with clinical examination. Clin Rheumatol 2021; 40:2351-2359. [PMID: 33387092 DOI: 10.1007/s10067-020-05525-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/22/2020] [Accepted: 11/24/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The sternoclavicular joint (SCJ), an important link between the appendicular and axial skeleton, though involved in 41% of rheumatoid arthritis patients, has not been studied in juvenile idiopathic arthritis (JIA). Hence, this cross-sectional study was done to delineate the magnetic resonance imaging (MRI) findings in SCJ in JIA and compare with the clinical examination to diagnose SCJ arthritis. METHODS Of the 116 JIA patients attending the pediatric rheumatology clinic, twenty-one patients (42 SC joints) were evaluated by 1.5 T MRI using the four components of early and late inflammatory changes-synovial hypertrophy, bone marrow edema (BME), cartilage lesions, and bone erosions. Results were compared with clinical assessment of SCJ arthritis. RESULTS Of the 42 SCJ evaluated (21/116 patients), MRI changes were seen in 27 SCJs (15 patients, 12.9% of 116 JIA patients). Early MRI changes were seen in 60% of joints found normal on clinical examination, with as much as 1/4th of them revealing late destructive changes. Synovial hypertrophy, BME, cartilage lesions, and bone erosions were seen in 5, 15, 4, and 10 patients, respectively. Sensitivity and specificity of clinical examinations to evaluate SC joint involvement were 55.5% and 53.3%, respectively. CONCLUSION MRI evaluation of the SCJ in JIA revealed findings in 15/21 enrolled patients. BME, bone erosions, synovial hypertrophy, and cartilage lesions were seen in 15, 10, 5, and 4 enrolled patients, respectively. Clinical examination was found to be neither sensitive nor specific. Key Points • MRI could delineate both early and late inflammatory changes in SCJ in JIA. BME, bone erosions, synovial hypertrophy, and cartilage lesions were seen in 15, 10, 5, and 4 enrolled patients, respectively. • The frequency of SC joint involvement in JIA was at least 12.9% of patients in our study. • Clinical examination for evaluating SC joint arthritis has low sensitivity (55.5%) and specificity (53.3%).
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Affiliation(s)
- Prasad Brijendra
- Department of Pediatrics, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India.,Department of Pediatrics, VMMC & SJH, New Delhi, India
| | - Murugan Sudhakar
- Department of Pediatrics, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India.,Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Somdipa Pal
- Department of Pediatrics, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Jessica Laltlansangi Hlawndo
- Department of Pediatrics, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Namrita Sachdev
- Department of Radiodiagnosis, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Tribhuvan Pal Yadav
- Department of Pediatrics, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India.
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18
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Kip MMA, de Roock S, Currie G, Marshall DA, Grazziotin LR, Twilt M, Yeung RSM, Benseler SM, Schreijer MA, Vastert SJ, Wulffraat N, van Royen-Kerkhof A, Swart JF, IJzerman MJ. Costs of medication use among patients with juvenile idiopathic arthritis in the Dutch healthcare system. Expert Rev Pharmacoecon Outcomes Res 2020; 21:975-984. [PMID: 33243033 DOI: 10.1080/14737167.2021.1857241] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background: This study aims to quantify medication costs in juvenile idiopathic arthritis (JIA), based on subtype.Research design and methods: This study is a single-center, retrospective analysis of prospective data from electronic medical records of JIA patients, aged 0-18 years between 1 April 2011 and 31 March 2019. Patient characteristics (age, gender, subtype) and medication use were extracted. Medication use and costs were reported as: 1) mean total annual costs; 2) between-patient heterogeneity in these costs; 3) duration of medication use; and, 4) costs over the treatment course.Results: The analysis included 691 patients. Mean total medication costs were €2,103/patient/year, including €1,930/patient/year (91.8%) spent on biologicals. Costs varied considerably between subtypes, with polyarticular rheumatoid-factor positive and systemic JIA patients having the highest mean costs (€5,020/patient/year and €4,790/patient/year, respectively). Mean annual medication costs over the patient's treatment course ranged from <€1,000/year (71.1% of patients) to >€11,000/year (2.5% of patients). Etanercept and adalimumab were the most commonly used biologicals. Cost fluctuations over the treatment course were primarily attributable to biological use.Conclusions: Polyarticular rheumatoid-factor positive and systemic JIA patients had the highest mean total annual medication costs, primarily attributable to biologicals. Costs varied considerably between subtypes, individuals, and over the treatment course.
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Affiliation(s)
- Michelle M A Kip
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands.,UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases)
| | - Sytze de Roock
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands.,Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
| | - Gillian Currie
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Deborah A Marshall
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Luiza R Grazziotin
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marinka Twilt
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Division of Rheumatology, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rae S M Yeung
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Division of Rheumatology, the Hospital for Sick Children, Department of Paediatrics, Immunology and Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Susanne M Benseler
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Division of Rheumatology, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Maud A Schreijer
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Sebastiaan J Vastert
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands.,Faculty of Medicine, Utrecht University, Utrecht, The Netherlands.,European Reference Network RITA (Rare Immunodeficiency Autoinflammatory and Autoimmune Diseases Network)
| | - Nico Wulffraat
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands.,Faculty of Medicine, Utrecht University, Utrecht, The Netherlands.,European Reference Network RITA (Rare Immunodeficiency Autoinflammatory and Autoimmune Diseases Network)
| | - Annet van Royen-Kerkhof
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands.,Faculty of Medicine, Utrecht University, Utrecht, The Netherlands.,European Reference Network RITA (Rare Immunodeficiency Autoinflammatory and Autoimmune Diseases Network)
| | - Joost F Swart
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands.,Faculty of Medicine, Utrecht University, Utrecht, The Netherlands.,European Reference Network RITA (Rare Immunodeficiency Autoinflammatory and Autoimmune Diseases Network)
| | - Maarten J IJzerman
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands.,UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,University of Melbourne, Melbourne School of Population and Global Health, Parkville, Melbourne, Australia
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19
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Cánovas R, Cobb J, Brozynska M, Bowes J, Li YR, Smith SL, Hakonarson H, Thomson W, Ellis JA, Abraham G, Munro JE, Inouye M. Genomic risk scores for juvenile idiopathic arthritis and its subtypes. Ann Rheum Dis 2020; 79:1572-1579. [PMID: 32887683 PMCID: PMC7677485 DOI: 10.1136/annrheumdis-2020-217421] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/14/2020] [Accepted: 08/14/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Juvenile idiopathic arthritis (JIA) is an autoimmune disease and a common cause of chronic disability in children. Diagnosis of JIA is based purely on clinical symptoms, which can be variable, leading to diagnosis and treatment delays. Despite JIA having substantial heritability, the construction of genomic risk scores (GRSs) to aid or expedite diagnosis has not been assessed. Here, we generate GRSs for JIA and its subtypes and evaluate their performance. METHODS We examined three case/control cohorts (UK, US-based and Australia) with genome-wide single nucleotide polymorphism (SNP) genotypes. We trained GRSs for JIA and its subtypes using lasso-penalised linear models in cross-validation on the UK cohort, and externally tested it in the other cohorts. RESULTS The JIA GRS alone achieved cross-validated area under the receiver operating characteristic curve (AUC)=0.670 in the UK cohort and externally-validated AUCs of 0.657 and 0.671 in the US-based and Australian cohorts, respectively. In logistic regression of case/control status, the corresponding odds ratios (ORs) per standard deviation (SD) of GRS were 1.831 (1.685 to 1.991) and 2.008 (1.731 to 2.345), and were unattenuated by adjustment for sex or the top 10 genetic principal components. Extending our analysis to JIA subtypes revealed that the enthesitis-related JIA had both the longest time-to-referral and the subtype GRS with the strongest predictive capacity overall across data sets: AUCs 0.82 in UK; 0.84 in Australian; and 0.70 in US-based. The particularly common oligoarthritis JIA also had a GRS that outperformed those for JIA overall, with AUCs of 0.72, 0.74 and 0.77, respectively. CONCLUSIONS A GRS for JIA has potential to augment clinical JIA diagnosis protocols, prioritising higher-risk individuals for follow-up and treatment. Consistent with JIA heterogeneity, subtype-specific GRSs showed particularly high performance for enthesitis-related and oligoarthritis JIA.
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Affiliation(s)
- Rodrigo Cánovas
- Cambridge Baker Systems Genomics Initiative, Baker Heart Research Institute - BHRI, Melbourne, Victoria, Australia
| | - Joanna Cobb
- Childhood Arthritis, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Marta Brozynska
- Cambridge Baker Systems Genomics Initiative, Baker Heart Research Institute - BHRI, Melbourne, Victoria, Australia
| | - John Bowes
- Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, United Kingdom.,National Institute of Health Research Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Yun R Li
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.,Helen Diller Family Comprehensive Cancer Center, Department of Radiation Oncology, University of California San Francisco, San Francisco, California, United States
| | - Samantha Louise Smith
- Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, United Kingdom
| | - Hakon Hakonarson
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Wendy Thomson
- Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, United Kingdom.,National Institute of Health Research Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Justine A Ellis
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia.,Faculty of Health, Centre for Social and Early Emotional Development, Deakin University, Burwood, Victoria, Australia
| | - Gad Abraham
- Cambridge Baker Systems Genomics Initiative, Baker Heart Research Institute - BHRI, Melbourne, Victoria, Australia.,Cambridge Baker Systems Genomics Initiative, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.,Department of Clinical Pathology, University of Melbourne, Melbourne, Victoria, Australia
| | - Jane E Munro
- Childhood Arthritis, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Paediatric Rheumatology Unit, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Michael Inouye
- Cambridge Baker Systems Genomics Initiative, Baker Heart Research Institute - BHRI, Melbourne, Victoria, Australia .,Cambridge Baker Systems Genomics Initiative, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.,Department of Clinical Pathology, University of Melbourne, Melbourne, Victoria, Australia.,British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.,British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, United Kingdom.,National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge and Cambridge University Hospitals, Cambridge, United Kingdom.,Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, United Kingdom.,The Alan Turing Institute, London, United Kingdom
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20
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Grazziotin LR, Currie G, Kip MMA, IJzerman MJ, Twilt M, Lee R, Marshall DA. Health State Utility Values in Juvenile Idiopathic Arthritis: What is the Evidence? PHARMACOECONOMICS 2020; 38:913-926. [PMID: 32390065 DOI: 10.1007/s40273-020-00921-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVES The objectives of this systematic review were to identify health state utility values (HSUV) of children and adults with juvenile idiopathic arthritis in the literature and to assess whether HSUV were appropriately reported and could be used to inform parameter inputs for a model-based cost-utility analysis to inform decision making. METHODS MEDLINE, EMBASE, PsycINFO, EconLit and CINAHL databases were searched in July 2019. Inclusion criteria were studies using preference-based instruments, targeting children or adults with juvenile idiopathic arthritis, and in the English language. The quality of studies was assessed using a modified checklist that included relevant sources of bias and assessment of quality of HSUV valuation and measurement. A descriptive analysis was conducted, including assessment on reporting of population characteristics and stratification of HSUV by potential health states or population subgroup. RESULTS From 620 identified articles, ten reported HSUV. Seven studies reported HSUV of children with juvenile idiopathic arthritis, and three of adults with a history of juvenile idiopathic arthritis. Population disease activity status and drug treatment were reported in less than half of the studies. Six (out of ten) studies stratified HSUV results for at least one of the potential health state categories, but they represent very specific situations or interventions (e.g. patients receiving different types of physiotherapy or treated with etanercept over time). CONCLUSIONS We have identified critical gaps in the literature reporting HSUV in patients with juvenile idiopathic arthritis including a lack of HSUV measures for distinct health states, particularly in adults with a history of juvenile idiopathic arthritis. The current reported HSUV data in juvenile idiopathic arthritis are insufficient for a full cost-utility analysis with a short or lifetime horizon.
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Affiliation(s)
- Luiza Raquel Grazziotin
- Department of Community Health Sciences, Room 3C56, Health Research Innovation Centre, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
| | - Gillian Currie
- Department of Community Health Sciences, Room 3C56, Health Research Innovation Centre, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michelle M A Kip
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Maarten J IJzerman
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, the Netherlands
- Faculty of Medicine, Dentistry and Health Sciences, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Australia
| | - Marinka Twilt
- Division of Rheumatology, Department of Pediatrics, Cumming School of Medicine, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Raymond Lee
- Alberta Health Services, Calgary, AB, Canada
| | - Deborah A Marshall
- Department of Community Health Sciences, Room 3C56, Health Research Innovation Centre, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada.
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.
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21
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Funk RS, Singh RK, Becker ML. Metabolomic Profiling to Identify Molecular Biomarkers of Cellular Response to Methotrexate In Vitro. Clin Transl Sci 2020; 13:137-146. [PMID: 31651077 PMCID: PMC6951846 DOI: 10.1111/cts.12694] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 08/06/2019] [Indexed: 01/21/2023] Open
Abstract
Variation in methotrexate (MTX) efficacy represents a significant barrier to early and effective disease control in the treatment of autoimmune arthritis. We hypothesize that the utilization of metabolomic techniques will allow for an improved understanding of the biochemical basis for the pharmacological activity of MTX, and can promote the identification and evaluation of novel molecular biomarkers of MTX response. In this work, erythroblastoid cells were exposed to MTX at the physiologic concentration of 1,000 nM and analyzed using three metabolomic platforms to give a broad spectrum of cellular metabolites. MTX pharmacological activity, defined as cellular growth inhibition, was associated with an altered cellular metabolomic profile based on the analysis of 724 identified metabolites. By discriminant analysis, MTX treatment was associated with increases in ketoisovaleric acid, fructose, galactose, and 2-deoxycytidine, and corresponding reductions in 2-deoxyuridine, phosphatidylinositol 32:0, orotic acid, and inosine monophosphate. Inclusion of data from analysis of folate metabolism in combination with chemometric and metabolic network analysis demonstrated that MTX treatment is associated with dysregulated folate metabolism and nucleotide biosynthesis, which is in line with its known mechanism of action. However, MTX treatment was also associated with alterations in a diversity of metabolites, including intermediates of amino acid, carbohydrate, and lipid metabolism. Collectively, these findings support a robust metabolic response following exposure to physiologic concentrations of MTX. They also identify various metabolic intermediates that are associated with the pharmacological activity of MTX, and are, therefore, potential molecular biomarker candidates in future preclinical and clinical studies of MTX efficacy in autoimmune arthritis.
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Affiliation(s)
- Ryan S. Funk
- Department of Pharmacy PracticeMedical CenterUniversity of KansasKansas CityKansasUSA
| | - Rakesh K. Singh
- Department of Pharmacy PracticeMedical CenterUniversity of KansasKansas CityKansasUSA
| | - Mara L. Becker
- Division of RheumatologyDepartment of PediatricsDuke Children's HospitalDurhamNorth CarolinaUSA
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22
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Comparison of Adults With Polyarticular Juvenile Idiopathic Arthritis to Adults With Rheumatoid Arthritis: A Cross-sectional Analysis of Clinical Features and Medication Use. J Clin Rheumatol 2019; 25:163-170. [PMID: 29781829 PMCID: PMC6240403 DOI: 10.1097/rhu.0000000000000819] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND/OBJECTIVE Many individuals with juvenile idiopathic arthritis (JIA) have persistent disease into adulthood. Polyarticular JIA (pJIA) is often mislabeled as rheumatoid arthritis (RA) in adult rheumatology clinics, and treatment for adult pJIA patients is not well defined. We aimed to describe clinical features and medication use in the adult pJIA population in relation to an RA control cohort. METHODS We performed a cross-sectional study of 45 adults with pJIA and 94 with RA seen from 2013 to 2017. Clinical characteristics including RA classification criteria were compared using χ and McNemar tests. Medication use was analyzed focusing on tumor necrosis factor inhibitor (TNFi) survival, and an accelerated failure-time model was developed for time to methotrexate initiation. RESULTS Polyarticular JIA patients were less likely to be rheumatoid factor or cyclic citrullinated peptide antibody positive; fewer than half of pJIA subjects met the RA 2010 American College of Rheumatology/European League Against Rheumatism Classification Criteria. Time from diagnosis to methotrexate initiation was associated with longer disease duration in both groups (p < 0.01). Current TNFi use was more prevalent in pJIA patients (49% vs. 18%, p < 0.01), and TNFi use, particularly for etanercept, was sustained longer with a median drug survival of 4.41 years compared with 0.70 years in RA patients (p < 0.01). CONCLUSIONS Although often considered together in adult rheumatology practice, adults with pJIA are distinct from patients with RA. Medication use markedly differed between the 2 populations with greater prevalence and duration of TNFi use in pJIA patients. Further study is needed to improve outcomes in this unique population.
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23
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Tollisen A, Flatø B, Selvaag AM, Aasland A, Ingebrigtsen T, Sagen J, Lerdal A. Treatment Satisfaction With and Adherence to Disease-Modifying Antirheumatic Drugs in Adult Patients With Juvenile Idiopathic Arthritis. Arthritis Care Res (Hoboken) 2019; 73:221-231. [PMID: 31758669 DOI: 10.1002/acr.24113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 11/19/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To examine medication satisfaction and adherence and their relationships to disease variables and health-related quality of life (HRQoL) in adults with juvenile idiopathic arthritis (JIA). METHODS Patients (n = 96, mean age 25 years, 67% female) completed questionnaires about their health status 19 years after disease onset. Patients receiving biologic disease-modifying antirheumatic drugs (bDMARDs) or methotrexate (MTX) were assessed with the 8-item Morisky Medication Adherence Scale (MMAS-8) and the Treatment Satisfaction Questionnaire for Medication (TSQM), including dimensions of effectiveness, side effects, convenience, and global satisfaction. RESULTS DMARDs were received by 52 patients (54%) (mean age 25 years, 75% female), of which 28 received MTX and 37 received bDMARDs. Patients receiving combination therapy of MTX and bDMARDs (n = 15) reported higher satisfaction with bDMARDs than MTX in the dimensions of side effects and global satisfaction (mean ± SD 92.9 ± 15.5 versus 56.2 ± 30.9, and mean ± SD 67.6 ± 19.8 versus 47.1 ± 21.7; P < 0.001 and P = 0.016, respectively). Patients receiving either bDMARDs (n = 22) or MTX (n = 13) reported higher satisfaction with bDMARDs than MTX for the dimensions of effectiveness and global satisfaction (mean ± SD 78.7 ± 15.4 versus 60.2 ± 19.9, and mean ± SD 73.6 ± 17.7 versus 52.3 ± 23.9; P = 0.004 and P = 0.005, respectively). Nearly one-half of patients (46%) reported low adherence (MMAS-8 score <6) and 25% high adherence (MMAS-8 score = 8). Higher levels of pain, psychological distress, more active joints, and current MTX use were the strongest correlates of lower medication satisfaction. Perceived medication effectiveness and global satisfaction correlated positively with physical and mental HRQoL. CONCLUSION Patients with JIA were more satisfied with bDMARDs than MTX, and 46% reported low adherence. Higher medication satisfaction was associated with better HRQoL.
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Affiliation(s)
- Anita Tollisen
- Oslo University Hospital, Rikshospitalet, Unger-Vetlesens Institute, Lovisenberg Diaconal Hospital, and University of Oslo, Oslo, Norway
| | - Berit Flatø
- Oslo University Hospital, Rikshospitalet and University of Oslo, Oslo, Norway
| | | | | | | | - Joachim Sagen
- Children and Youth Rheumatology Association, Oslo, Norway
| | - Anners Lerdal
- Lovisenberg Diaconal Hospital and University of Oslo, Oslo, Norway
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24
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Mo X, Chen X, Li H, Li J, Zeng F, Chen Y, He F, Zhang S, Li H, Pan L, Zeng P, Xie Y, Li H, Huang M, He Y, Liang H, Zeng H. Early and Accurate Prediction of Clinical Response to Methotrexate Treatment in Juvenile Idiopathic Arthritis Using Machine Learning. Front Pharmacol 2019; 10:1155. [PMID: 31649533 PMCID: PMC6791251 DOI: 10.3389/fphar.2019.01155] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/09/2019] [Indexed: 11/29/2022] Open
Abstract
Background and Aims: Accurately predicting the response to methotrexate (MTX) in juvenile idiopathic arthritis (JIA) patients before administration is the key point to improve the treatment outcome. However, no simple and reliable prediction model has been identified. Here, we aimed to develop and validate predictive models for the MTX response to JIA using machine learning based on electronic medical record (EMR) before and after administering MTX. Materials and Methods: Data of 362 JIA patients with MTX mono-therapy were retrospectively collected from EMR between January 2008 and October 2018. DAS44/ESR-3 simplified standard was used to evaluate the MTX response. Extreme gradient boosting (XGBoost), support vector machine (SVM), random forest (RF), and logistic regression (LR) algorithms were applied to develop and validate models with 5-fold cross-validation on the randomly split training and test set. Data of 13 patients additionally collected were used for external validation. Results: The XGBoost screened out the optimal 10 pre-administration features and 6 mix-variables. The XGBoost established the best model based on the 10 pre-administration variables. The performances were accuracy 91.78%, sensitivity 90.70%, specificity 93.33%, AUC 97.00%, respectively. Similarly, the XGBoost developed a better model based on the 6 mix-variables, whose performances were accuracy 94.52%, sensitivity 95.35%, specificity 93.33%, AUC 99.00%, respectively. Conclusion: Based on common EMR data, we developed two MTX response predictive models with excellent performance in JIA using machine learning. These models can predict the MTX efficacy early and accurately, which provides powerful decision support for doctors to make or adjust therapeutic scheme before or after treatment.
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Affiliation(s)
- Xiaolan Mo
- Department of Pharmacy, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.,Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, China
| | - Xiujuan Chen
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Hongwei Li
- Pediatric Allergy Immunology & Rheumatology Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jiali Li
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, China
| | - Fangling Zeng
- Department of Medical, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yilu Chen
- Department of Pharmacy, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Fan He
- Department of Pharmacy, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Song Zhang
- Pediatric Allergy Immunology & Rheumatology Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Huixian Li
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Liyan Pan
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Ping Zeng
- Pediatric Allergy Immunology & Rheumatology Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Ying Xie
- Pediatric Allergy Immunology & Rheumatology Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Huiyi Li
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, China
| | - Min Huang
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, China
| | - Yanling He
- Department of Pharmacy, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Huiying Liang
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Huasong Zeng
- Pediatric Allergy Immunology & Rheumatology Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
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25
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Backström M, Tynjälä P, Aalto K, Ylijoki H, Putto-Laurila A, Grönlund MM, Kärki J, Keskitalo P, Sard S, Pohjankoski H, Hietanen M, Witter S, Lehto H, Löyttyniemi E, Vähäsalo P. Defining new clinically derived criteria for high disease activity in non-systemic juvenile idiopathic arthritis: a Finnish multicentre study. Rheumatol Adv Pract 2019; 2:rky044. [PMID: 31431981 PMCID: PMC6649930 DOI: 10.1093/rap/rky044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 09/03/2018] [Indexed: 12/04/2022] Open
Abstract
Objectives To redefine criteria for high disease activity (HDA) in JIA, to establish HDA cut-off values for the 10-joint Juvenile Arthritis Disease Activity Score (JADAS10) and clinical JADAS10 (cJADAS10) and to describe the distribution of patients’ disease activity levels based on the JADAS cut-off values in the literature. Methods Data on 305 treatment-naïve JIA patients were collected from nine paediatric units treating JIA. The median parameters of the JADAS were proposed to be the clinical criteria for HDA. The cut-off values were assessed by using two receiver operating characteristics curve–based methods. The patients were divided into disease activity levels based on currently used JADAS cut-off values. Results We proposed new criteria for HDA. At least three of the following criteria must be satisfied in both disease courses: in oligoarthritis, two or more active joints, ESR above normal, physician global assessment (PGA) of disease activity ≥2 and parent/patient global assessment (PtGA) of well-being ≥2; in polyarthritis, six or more active joints, ESR above normal, PGA of overall disease activity ≥4 and PtGA of well-being ≥2. The HDA cut-off values for JADAS10 (cJADAS) were ≥6.7 (6.7) for oligoarticular and ≥15.3 (14.1) for polyarticular disease. The distribution of the disease activity levels based on the JADAS cut-off values in the literature varied markedly based on which cut-offs were used. Conclusion New clinically derived criteria for HDA in JIA and both JADAS and cJADAS cut-off values for HDA were proposed.
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Affiliation(s)
- Maria Backström
- Department of Pediatrics, Vaasa Central Hospital, Vaasa, Finland
| | - Pirjo Tynjälä
- Department of Pediatrics, South-Karelian Central Hospital, Lappeenranta, Finland.,Poison Information Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Kristiina Aalto
- Paediatric Department, Children's Hospital, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
| | - Heikki Ylijoki
- Department of Pediatrics, Satakunta Central Hospital, Pori, Finland
| | | | | | - Johanna Kärki
- Department of Pediatrics, Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | - Paula Keskitalo
- Department of Children and Adolescents, Medical Research Center Oulu, Oulu University Hospital and PEDEGO Research Unit, University of Oulu, Oulu, Finland
| | - Sirja Sard
- Department of Children and Adolescents, Medical Research Center Oulu, Oulu University Hospital and PEDEGO Research Unit, University of Oulu, Oulu, Finland
| | - Heini Pohjankoski
- Department of Pediatrics, Päijät-Häme Central Hospital, Lahti, Finland
| | - Maiju Hietanen
- Department of Pediatrics, Päijät-Häme Central Hospital, Lahti, Finland
| | - Silke Witter
- Department of Pediatrics, Central Finland Central Hospital, Jyväskylä, Finland
| | - Helena Lehto
- Poison Information Center, Helsinki University Central Hospital, Helsinki, Finland
| | | | - Paula Vähäsalo
- Department of Children and Adolescents, Medical Research Center Oulu, Oulu University Hospital and PEDEGO Research Unit, University of Oulu, Oulu, Finland
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26
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Pohjankoski H, Kautiainen H, Lauri JV, Puolakka K, Rantalaiho V. Trends towards more active introduction of drug therapy, emphasizing methotrexate and biologic agents, for juvenile idiopathic arthritis. Clin Rheumatol 2019; 39:263-268. [PMID: 31346886 DOI: 10.1007/s10067-019-04702-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 07/03/2019] [Accepted: 07/15/2019] [Indexed: 11/30/2022]
Abstract
To evaluate the drug treatment trends in patients with incident juvenile idiopathic arthritis (JIA) in 2006-2014. In Finland, patients are entitled to a special reimbursement for medication if their condition meets certain criteria. We gathered all reimbursement decisions with the ICD-10 diagnosis of M08 for patients under 16 years of age from a nationwide register maintained by Kela, the Social Institution of Finland. A total of 2439 incident cases of JIA were identified. We surveyed their reimbursable drugs purchased for the first time for JIA upon a doctor's prescription in 3-year cohorts (2006-2008, 2009-2011, 2012-2014). Changes of drug treatment for JIA became more active during our study years. Between 2006-2008 and 2011-2014, the introduction of methotrexate (MTX) for the first time within the first 3 months increased from 73% (2006-2008) to 90% (2011-2014) of the patients, IRR (incidence rate ratio) was 1.23 (95% CI 1.10-1.37). The use of parenteral MTX increased even more; IRR was 1.97 (95% CI 1.61-2.41). During the first 2 years of their disease, 18% of the first cohort received subcutaneous biologic agents, while the corresponding proportion in the last cohort was 31%. Biologic agents were more likely to be introduced for patients with early (3 months) MTX administration than for patients without early MTX introduction; HR (hazard ratio) 2.19 (95% CI 1.63-2.93). During the follow-up, MTX administration became more prevalent for the treatment of JIA soon after diagnosis, mostly because of the increase in the use of parenteral MTX.Key Points • The drug therapy for treating juvenile idiopathic arthritis has changed during recent years. • Methotrexate, some other conventional DMARDs, and biologic DMARDs are introduced earlier.
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Affiliation(s)
- Heini Pohjankoski
- Department of Pediatrics, Päijät-Häme Central Hospital, Lahti, Finland.
| | - Hannu Kautiainen
- Primary Health Care Unit, Kuopio University Hospital, Kuopio, Finland.,Folkhälsan Research Center, Helsinki, Finland
| | - Juhani Virta Lauri
- Kela Research, The Social Insurance Institution of Finland, Turku, Finland
| | - Kari Puolakka
- Department of Medicine, South Karelia Central Hospital, Lappeenranta, Finland
| | - Vappu Rantalaiho
- Centre for Rheumatic Diseases, Tampere University Hospital, and Faculty on Medicine and Health Technology, Tampere University, Tampere, Finland
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27
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Predicting disease outcomes in juvenile idiopathic arthritis: challenges, evidence, and new directions. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 3:725-733. [PMID: 31331873 DOI: 10.1016/s2352-4642(19)30188-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/18/2019] [Accepted: 05/31/2019] [Indexed: 12/12/2022]
Abstract
The aims of treating juvenile idiopathic arthritis are to elicit treatment response toward remission, while preventing future flares. Understanding patient and disease characteristics that predispose young people with this condition to these outcomes would allow the forecasting of disease process and the tailoring of therapies. The strongest predictor of remission is disease category, particularly oligoarthritis, although a few additional clinical predictors of treatment response have been identified. Novel evidence using biomarkers, such as S100 proteins and novel single nucleotide polymorphism data, could add value to clinical models. The future aim of personalised medicine in the treatment of juvenile idiopathic arthritis will be aided with international collaborations, allowing for the analysis of larger datasets with novel biomarker data. Combined clinical and biomarker panels will probably be required for predicting outcomes in such a complex disease.
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28
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Foley CM, Deely DA, MacDermott EJ, Killeen OG. Arthropathy of Down syndrome: an under-diagnosed inflammatory joint disease that warrants a name change. RMD Open 2019; 5:e000890. [PMID: 31245048 PMCID: PMC6560675 DOI: 10.1136/rmdopen-2018-000890] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 04/21/2019] [Accepted: 04/23/2019] [Indexed: 02/02/2023] Open
Abstract
There is an increased incidence and prevalence of arthropathy in children with Down syndrome. However, it is rarely reported or recognised at onset, and remains under-diagnosed. Children with arthropathy of Down syndrome (A-DS) are presenting with significant joint damage and disability at diagnosis.
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Affiliation(s)
- Charlene M Foley
- National Centre for Paediatric Rheumatology, Our Lady's Children's Hospital, Crumlin, Ireland.,National Children's Research Centre, Dublin, Ireland
| | - Derek A Deely
- National Centre for Paediatric Rheumatology, Our Lady's Children's Hospital, Crumlin, Ireland
| | - Emma Jane MacDermott
- National Centre for Paediatric Rheumatology, Our Lady's Children's Hospital, Crumlin, Ireland
| | - Orla G Killeen
- National Centre for Paediatric Rheumatology, Our Lady's Children's Hospital, Crumlin, Ireland.,National Children's Research Centre, Dublin, Ireland
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29
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Hissink Muller P, Brinkman DMC, Schonenberg-Meinema D, van den Bosch WB, Koopman-Keemink Y, Brederije ICJ, Bekkering PW, Kuijpers TW, Van Rossum M, van Suijlekom-Smit LWA, van den Berg JM, Boehringer S, Allaart CF, Ten Cate R. Treat to target (drug-free) inactive disease in DMARD-naive juvenile idiopathic arthritis: 24-month clinical outcomes of a three-armed randomised trial. Ann Rheum Dis 2018; 78:51-59. [PMID: 30309970 DOI: 10.1136/annrheumdis-2018-213902] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 09/11/2018] [Accepted: 09/12/2018] [Indexed: 02/07/2023]
Abstract
QUESTION Which is the best strategy to achieve (drug-free) inactive disease in juvenile idiopathic arthritis (JIA)? METHODS In a randomised, single-blinded, study in disease-modifying anti-rheumatic drug (DMARD)-naive patients with JIA, three treatment-strategies were compared: (1) sequential DMARD-monotherapy (sulfasalazine or methotrexate (MTX)), (2) combination therapy MTX + 6 weeks prednisolone and (3) combination therapy MTX +etanercept. Treatment-to-target entailed 3-monthly DMARD/biological adjustments in case of persistent disease activity, with drug tapering to nil in case of inactive disease.After 24 months, primary outcomes were time-to-inactive-disease and time-to-flare after DMARD discontinuation. Secondary outcomes were adapted ACRPedi30/50/70/90 scores, functional ability and adverse events. RESULTS 94 children (67 % girls) aged median (IQR) 9.1 (4.6-12.9) years were enrolled: 32 in arms 1 and 2, 30 in arm 3. At baseline visual analogue scale (VAS) physician was mean 49 (SD 16) mm, VAS patient 53 (22) mm, erythrocyte sedimentation rate 12.8 (14.7), active joints median 8 (5-12), limited joints 2.5 (1-4.8) and Childhood Health Assessment Questionnaire score mean 1.0 (0.6).After 24 months, 71% (arm 1), 70% (arm 2) and 72% (arm 3) of patients had inactive disease and 45% (arm 1), 31% (arm 2) and 41% (arm 3) had drug-free inactive disease. Time-to-inactive-disease was median 9.0 (5.3-15.0) months in arm 1, 9.0 (6.0-12.8) months in arm 2 and 9.0 (6.0-12.0) months in arm 3 (p=0.30). Time-to-flare was not significantly different (overall 3.0 (3.0-6.8) months, p=0.7). Adapted ACR pedi-scores were comparably high between arms. Adverse events were similar. CONCLUSION Regardless of initial specific treatments, after 24 months of treatment-to-target aimed at drug-free inactive disease, 71% of recent-onset patients with JIA had inactive disease (median onset 9 months) and 39% were drug free. Tightly controlled treatment-to-target is feasible. TRIAL REGISTRATION NUMBER 1574.
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Affiliation(s)
- Petra Hissink Muller
- Department of Paediatric Rheumatology, Leiden University Medical Center, Leiden, The Netherlands .,Department of Paediatric Rheumatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Danielle M C Brinkman
- Department of Paediatric Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Paediatrics, Alrijne Hospital Leiderdorp, Leiderdorp, The Netherlands
| | - Dieneke Schonenberg-Meinema
- Department of Paediatric Hematology, Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital AMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Yvonne Koopman-Keemink
- Department of Paediatrics, Hagaziekenhuis Juliana Children's Hospital, The Hague, The Netherlands
| | - Isabel C J Brederije
- Department of Paediatric Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Peter W Bekkering
- Princess Máxima Center, Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Taco W Kuijpers
- Department of Paediatric Hematology, Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marion Van Rossum
- Department of Paediatric Rheumatology, Amsterdam Rheumatology, Immunology Center Reade Amsterdam, Amsterdam, The Netherlands.,Department of Paediatrics, Emma Children's Hospital AMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - J Merlijn van den Berg
- Department of Paediatric Hematology, Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Stefan Boehringer
- Department of Biostatistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Cornelia F Allaart
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - R Ten Cate
- Department of Paediatric Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
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30
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Bethencourt Baute JJ, Sanchez-Piedra C, Ruiz-Montesinos D, Medrano San Ildefonso M, Rodriguez-Lozano C, Perez-Pampin E, Ortiz A, Manrique S, Roselló R, Hernandez V, Campos C, Sellas A, Sifuentes-Giraldo WA, García-González J, Sanchez-Alonso F, Díaz-González F, Gómez-Reino JJ, Bustabad Reyes S. Persistence and adverse events of biological treatment in adult patients with juvenile idiopathic arthritis: results from BIOBADASER. Arthritis Res Ther 2018; 20:227. [PMID: 30305158 PMCID: PMC6235210 DOI: 10.1186/s13075-018-1728-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 09/19/2018] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Biologic therapy has changed the prognosis of patients with juvenile idiopathic arthritis (JIA). The aim of this study was to examine the pattern of use, drug survival, and adverse events of biologics in patients with JIA during the period from diagnosis to adulthood. METHODS All patients included in BIOBADASER (Spanish Registry for Adverse Events of Biological Therapy in Rheumatic Diseases), a multicenter prospective registry, diagnosed with JIA between 2000 and 2015 were analyzed. Proportions, means, and SDs were used to describe the population. Incidence rates and 95% CIs were calculated to assess adverse events. Kaplan-Meier analysis was used to compare the drug survival rates. RESULTS A total of 469 patients (46.1% women) were included. Their mean age at diagnosis was 9.4 ± 5.3 years. Their mean age at biologic treatment initiation was 23.9 ± 13.9 years. The pattern of use of biologics during their pediatric years showed a linear increase from 24% in 2000 to 65% in 2014. Biologic withdrawal for disease remission was higher in patients who initiated use biologics prior to 16 years of age than in those who were older (25.7% vs 7.9%, p < 0.0001). Serious adverse events had a total incidence rate of 41.4 (35.2-48.7) of 1000 patient-years. Patients younger than 16 years old showed significantly increased infections (p < 0.001). CONCLUSIONS Survival and suspension by remission of biologics were higher when these compounds were initiated in patients with JIA who had not yet reached 16 years of age. The incidence rate of serious adverse events in pediatric vs adult patients with JIA treated with biologics was similar; however, a significant increase of infection was observed in patients under 16 years old.
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Affiliation(s)
| | | | | | | | - Carlos Rodriguez-Lozano
- Servicio de Reumatología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain
| | - Eva Perez-Pampin
- Servicio de Reumatología, Hospital Clínico Universitario de Santiago, A Coruña, Spain
| | - Ana Ortiz
- Servicio de Reumatología, Hospital de La Princesa, Madrid, Spain
| | - Sara Manrique
- UGC de Reumatología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga, Universidad de Málaga, Málaga, Spain
| | - Rosa Roselló
- Servicio de Reumatología, Hospital San Jorge, Huesca, Spain
| | - Victoria Hernandez
- Servicio de Reumatología, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Cristina Campos
- Servicio de Reumatología, Hospital General Universitario Valencia, Valencia, Spain
| | - Agustí Sellas
- Servicio de Reumatología, Hospital Vall d’Hebron, Barcelona, Spain
| | | | | | | | - Federico Díaz-González
- Servicio de Reumatología, Hospital Universitario de Canarias, c/Ofra s/n 38320, La Laguna, Santa Cruz de Tenerife, Spain
| | | | - Sagrario Bustabad Reyes
- Servicio de Reumatología, Hospital Universitario de Canarias, c/Ofra s/n 38320, La Laguna, Santa Cruz de Tenerife, Spain
| | - on behalf of the BIOBADASER study group
- Servicio de Reumatología, Hospital Universitario de Canarias, Tenerife, Spain
- Research Unit, Sociedad Española de Reumatología, Madrid, Spain
- Servicio de Reumatología, Hospital Universitario del Virgen Macarena, Sevilla, Spain
- Servicio de Reumatología Hospital Universitario Miguel Servet, Zaragoza, Spain
- Servicio de Reumatología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain
- Servicio de Reumatología, Hospital Clínico Universitario de Santiago, A Coruña, Spain
- Servicio de Reumatología, Hospital de La Princesa, Madrid, Spain
- UGC de Reumatología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga, Universidad de Málaga, Málaga, Spain
- Servicio de Reumatología, Hospital San Jorge, Huesca, Spain
- Servicio de Reumatología, Hospital Clinic de Barcelona, Barcelona, Spain
- Servicio de Reumatología, Hospital General Universitario Valencia, Valencia, Spain
- Servicio de Reumatología, Hospital Vall d’Hebron, Barcelona, Spain
- Servicio Reumatología, Hospital Ramón y Cajal, Madrid, Spain
- Servicio de Reumatología, Hospital 12 de Octubre, Madrid, Spain
- Servicio de Reumatología, Hospital Universitario de Canarias, c/Ofra s/n 38320, La Laguna, Santa Cruz de Tenerife, Spain
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31
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Juvenile arthritis management in less resourced countries (JAMLess): consensus recommendations from the Cradle of Humankind. Clin Rheumatol 2018; 38:563-575. [PMID: 30267356 DOI: 10.1007/s10067-018-4304-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/03/2018] [Accepted: 09/16/2018] [Indexed: 01/03/2023]
Abstract
Juvenile idiopathic arthritis (JIA) is the most prevalent chronic rheumatic disease in children and young people (CYP) and a major cause of pain and disability. The vast majority of the world's children and their families live in less resourced countries (LRCs) and face significant socioeconomic and healthcare challenges. Current recommendations for standards of care and treatment for children with JIA do not consider children living in less resourced countries. In order to develop appropriate recommendations for the care of CYP with JIA in less resourced countries a meeting of experienced pediatric rheumatologists from less resourced countries was convened with additional input from a steering group of international pediatric rheumatologists with experience in developing recommendations and standards of care for JIA. Following a needs assessment survey of healthcare workers caring for CYP with JIA in LRC, a literature review was carried out and management recommendations formulated using Delphi technique and a final consensus conference. Responses from the needs assessment were received from 121/483 (25%) practitioners from 25/49 (51%) less resourced countries. From these responses, the initial 84 recommendations were refined and expanded through a series of 3 online Delphi rounds. A final list of 90 recommendations was proposed for evaluation. Evidence for each statement was reviewed, graded, and presented to the consensus group. The degree of consensus, level of agreement, and level of evidence for these recommendations are reported. Recommendations arrived at by consensus for CYP with JIA in less resourced countries cover 5 themes: (1) diagnosis, (2) referral and monitoring, (3) education and training, (4) advocacy and networks, and (5) research. Thirty-five statements were drafted. All but one statement achieved 100% consensus. The body of published evidence was small and the quality of evidence available for critical appraisal was low. Our recommendations offer novel insights and present consensus-based strategies for the management of JIA in less resourced countries. The emphasis on communicable and endemic diseases influencing the diagnosis and treatment of JIA serves as a valuable addition to existing JIA guidelines. With increasing globalization, these recommendations as a whole provide educational and clinical utility for clinicians worldwide. The low evidence base for our recommendations reflects a shortage of research specific to less resourced countries and serves as an impetus for further inquiry towards optimizing care for children with JIA around the world.
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32
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Ferrara G, Mastrangelo G, Barone P, La Torre F, Martino S, Pappagallo G, Ravelli A, Taddio A, Zulian F, Cimaz R. Methotrexate in juvenile idiopathic arthritis: advice and recommendations from the MARAJIA expert consensus meeting. Pediatr Rheumatol Online J 2018; 16:46. [PMID: 29996864 PMCID: PMC6042421 DOI: 10.1186/s12969-018-0255-8] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 06/08/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Conventional pharmacological therapies for the treatment of juvenile idiopathic arthritis (JIA) consist of non-biological, disease-modifying antirheumatic drugs, among which methotrexate (MTX) is the most commonly prescribed. However, there is a lack of consensus-based clinical and therapeutic recommendations for the use of MTX in the management of patients with JIA. Therefore, the Methotrexate Advice and RecommendAtions on Juvenile Idiopathic Arthritis (MARAJIA) Expert Meeting was convened to develop evidence-based recommendations for the use of MTX in the treatment of JIA. METHODS The preliminary executive committee identified a total of 9 key clinical issues according to the population, intervention, comparator, outcome (PICO) approach, and performed an evidence-based, systematic, literature review. During the subsequent Expert Meeting, the relevant evidence was assessed and graded, and 10 recommendations were made. RESULTS Recommendations relating to the efficacy, optimal dosing and route of administration and duration of treatment with MTX in JIA, and to the issue of folic acid supplementation to prevent MTX side effects, use of MTX in the treatment of chronic JIA-associated uveitis, combination treatment with biologic agents, and the use of vaccinations in patients with JIA were developed. The selected topics were considered to represent clinically important issues facing clinicians caring for patients with JIA. Evidence was insufficient to formulate recommendations for the use of biomarkers predictive of treatment response. CONCLUSIONS These consensus recommendations provide balanced and evidence-based recommendations designed to have broad value for physicians and healthcare clinicians involved in the clinical management of patients with JIA.
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Affiliation(s)
| | - Greta Mastrangelo
- Rheumatology Unit, Anna Meyer Children Hospital and University of Florence, University of Florence, Florence, Italy
| | - Patrizia Barone
- Department of Pediatrics, University of Catania, Catania, Italy
| | - Francesco La Torre
- Pediatric Rheumatology Section, Pediatric Onco-Hematology Unit, Vito Fazzi Hospital, Lecce, Italy
| | - Silvana Martino
- Clinica Pediatrica Università di Torino, Day-Hospital Immunoreumatologia, Turin, Italy
| | | | - Angelo Ravelli
- Pediatria II – Reumatologia, Istituto Giannina Gaslini, and Università degli Studi di Genova, Genoa, Italy
| | - Andrea Taddio
- Institute for Maternal and Child Health - IRCCS “Burlo Garofolo”, Trieste, and University of Trieste, Trieste, Italy
| | - Francesco Zulian
- Department of Pediatrics, Rheumatology Unit, University of Padua, Padua, Italy
| | - Rolando Cimaz
- Rheumatology Unit, Anna Meyer Children Hospital and University of Florence, University of Florence, Florence, Italy
| | - On behalf of the Rheumatology Italian Study Group
- University of Trieste, Trieste, Italy
- Rheumatology Unit, Anna Meyer Children Hospital and University of Florence, University of Florence, Florence, Italy
- Department of Pediatrics, University of Catania, Catania, Italy
- Pediatric Rheumatology Section, Pediatric Onco-Hematology Unit, Vito Fazzi Hospital, Lecce, Italy
- Clinica Pediatrica Università di Torino, Day-Hospital Immunoreumatologia, Turin, Italy
- Epidemiology & Clinical Trials Office, General Hospital, Mirano VE, Italy
- Pediatria II – Reumatologia, Istituto Giannina Gaslini, and Università degli Studi di Genova, Genoa, Italy
- Institute for Maternal and Child Health - IRCCS “Burlo Garofolo”, Trieste, and University of Trieste, Trieste, Italy
- Department of Pediatrics, Rheumatology Unit, University of Padua, Padua, Italy
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33
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Rypdal V, Arnstad ED, Aalto K, Berntson L, Ekelund M, Fasth A, Glerup M, Herlin T, Nielsen S, Peltoniemi S, Zak M, Rygg M, Rypdal M, Nordal E. Predicting unfavorable long-term outcome in juvenile idiopathic arthritis: results from the Nordic cohort study. Arthritis Res Ther 2018; 20:91. [PMID: 29724248 PMCID: PMC5934822 DOI: 10.1186/s13075-018-1571-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/16/2018] [Indexed: 01/06/2023] Open
Abstract
Background The aim was to develop prediction rules that may guide early treatment decisions based on baseline clinical predictors of long-term unfavorable outcome in juvenile idiopathic arthritis (JIA). Methods In the Nordic JIA cohort, we assessed baseline disease characteristics as predictors of the following outcomes 8 years after disease onset. Non-achievement of remission off medication according to the preliminary Wallace criteria, functional disability assessed by Childhood Health Assessment Questionnaire (CHAQ) and Physical Summary Score (PhS) of the Child Health Questionnaire, and articular damage assessed by the Juvenile Arthritis Damage Index-Articular (JADI-A). Multivariable models were constructed, and cross-validations were performed by repeated partitioning of the cohort into training sets for developing prediction models and validation sets to test predictive ability. Results The total cohort constituted 423 children. Remission status was available in 410 children: 244 (59.5%) of these did not achieve remission off medication at the final study visit. Functional disability was present in 111/340 (32.7%) children assessed by CHAQ and 40/199 (20.1%) by PhS, and joint damage was found in 29/216 (13.4%). Model performance was acceptable for making predictions of long-term outcome. In validation sets, the area under the curves (AUCs) in the receiver operating characteristic (ROC) curves were 0.78 (IQR 0.72–0.82) for non-achievement of remission off medication, 0.73 (IQR 0.67–0.76) for functional disability assessed by CHAQ, 0.74 (IQR 0.65–0.80) for functional disability assessed by PhS, and 0.73 (IQR 0.63–0.76) for joint damage using JADI-A. Conclusion The feasibility of making long-term predictions of JIA outcome based on early clinical assessment is demonstrated. The prediction models have acceptable precision and require only readily available baseline variables. Further testing in other cohorts is warranted. Electronic supplementary material The online version of this article (10.1186/s13075-018-1571-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Veronika Rypdal
- Department of Pediatrics, University Hospital of North Norway, Tromsø, Norway. .,Department of Clinical Medicine, UIT the Arctic University of Norway, Tromsø, Norway.
| | - Ellen Dalen Arnstad
- Department of Clinical and Molecular Medicine, NTNU - Norwegian University of Science and Technology, Trondheim, Norway.,Department of Pediatrics, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
| | - Kristiina Aalto
- Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland
| | - Lillemor Berntson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Maria Ekelund
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Department of Pediatrics, Ryhov County Hospital, Jonkoping, Sweden
| | - Anders Fasth
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mia Glerup
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Troels Herlin
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Susan Nielsen
- Department of Pediatrics, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Suvi Peltoniemi
- Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland
| | - Marek Zak
- Department of Pediatrics, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Marite Rygg
- Department of Clinical and Molecular Medicine, NTNU - Norwegian University of Science and Technology, Trondheim, Norway.,Department of Pediatrics, St. Olavs Hospital, Trondheim, Norway
| | - Martin Rypdal
- Department of Mathematics and Statistics, UIT the Arctic University of Norway, Tromsø, Norway
| | - Ellen Nordal
- Department of Pediatrics, University Hospital of North Norway, Tromsø, Norway.,Department of Clinical Medicine, UIT the Arctic University of Norway, Tromsø, Norway
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Chen Y, Zou K, Sun J, Yang Y, Liu G. Associations between gene polymorphisms and treatment outcomes of methotrexate in patients with juvenile idiopathic arthritis. Pharmacogenomics 2018; 19:529-538. [PMID: 29589488 DOI: 10.2217/pgs-2017-0208] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Aim: Performance of a meta-analysis with respect to the genetic predictors of methotrexate (MTX) treatment outcomes, efficacy and toxicity, in patients with juvenile idiopathic arthritis (JIA). Methods: Databases of OVID MEDLINE and OVID EMBASE were searched to collect the studies addressing correlations between gene polymorphisms and efficacy and/or toxicity in MTX-treated JIA patients. Pooled odds ratios (ORs) with 95% CIs were estimated in allelic, recessive and/or dominant models. Results: With regards to efficacy, the C677T (rs1801133) polymorphism in MTHFR was associated with nonresponse to MTX treatment in a recessive model (OR: 0.40; 95% CI: 0.19–0.84). For associations with toxicity, the MTHFR C677T (rs1801133) polymorphism was associated with presenting overall adverse events in an allelic model (OR: 1.54; 95% CI: 1.07–2.22) and a dominant model (OR: 1.70; 95% CI: 1.08–2.68). Conclusion: C677T (rs1801133) polymorphism in MTHFR predicts nonresponse and/or adverse effects of MTX treatment in JIA patients.
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Affiliation(s)
- Yuehong Chen
- Department of Rheumatology & Immunology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Kun Zou
- Department of Medical Record & Statistics, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science & Technology, Chengdu, PR China
| | - Jianhong Sun
- Department of Rheumatology & Immunology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Yuan Yang
- Department of Rheumatology & Immunology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Gang Liu
- Department of Rheumatology & Immunology, West China Hospital, Sichuan University, Chengdu, PR China
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Confidence amongst Multidisciplinary Professionals in Managing Paediatric Rheumatic Disease in Australia. ARTHRITIS 2018; 2018:7807490. [PMID: 29593902 PMCID: PMC5822930 DOI: 10.1155/2018/7807490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 11/24/2017] [Accepted: 12/19/2017] [Indexed: 11/17/2022]
Abstract
Objective Interprofessional collaboration is a crucial component of care for children with rheumatic disease. Interprofessional care, when delivered appropriately, prevents disability and improves long-term prognosis in this vulnerable group. Methods The aim of this survey was to explore allied health professionals' and nurses' confidence in treating paediatric rheumatology patients. Results Overall, 117 participants were recruited, 77.9% of participants reported being “not confident at all,” “not confident,” or “neutral” in treating children with rheumatic diseases (RD) despite 65.1% of participants reporting having treated >1 paediatric rheumatology case in the past month. Furthermore, 67.2% of participants felt their undergraduate education in paediatric rheumatology was inadequate. “Journals” or “texts books” were used by 49.3% of participants as their primary source of continuing professional development (CPD) and 39.3% of participants indicated that they did not undertake any CPD related to paediatric rheumatology. Small group and online education were perceived to be potentially of “great benefit” for CPD. Conclusion This paper highlights allied health professionals' and nurses' perceived inadequacy of their undergraduate education in paediatric RD and their low confidence in recognising and treating RD. Undergraduate and postgraduate education opportunities focusing on interprofessional collaboration should be developed to address this workforce deficiency.
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36
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Nguyen JC, Lee KS, Thapa MM, Rosas HG. US Evaluation of Juvenile Idiopathic Arthritis and Osteoarticular Infection. Radiographics 2017; 37:1181-1201. [PMID: 28696851 DOI: 10.1148/rg.2017160137] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Juvenile idiopathic arthritis (JIA) and osteoarticular infection can cause nonspecific articular and periarticular complaints in children. Although contrast material-enhanced magnetic resonance imaging is the reference standard imaging modality, musculoskeletal ultrasonography (US) is emerging as an important adjunct imaging modality that can provide valuable information relatively quickly without use of radiation or the need for sedation. However, diagnostic accuracy requires a systemic approach, familiarity with various US techniques, and an understanding of maturation-related changes. Specifically, the use of dynamic, Doppler, and/or multifocal US assessments can help confirm sites of disease, monitor therapy response, and guide interventions. In patients with JIA, ongoing synovial inflammation can lead to articular and periarticular changes, including synovitis, tenosynovitis, cartilage damage, bone changes, and enthesopathy. Although these findings can manifest in adult patients with rheumatoid arthritis, important differences and pitfalls exist because of the unique changes associated with an immature and maturing skeleton. In patients who are clinically suspected of having osteoarticular infection, the inability of US to evaluate the bone marrow decreases its sensitivity. Therefore, the US findings should be interpreted with caution because juxtacortical inflammation is suggestive, but neither sensitive nor specific, for underlying osteomyelitis. Similarly, the absence of a joint effusion makes septic arthritis extremely unlikely but not impossible. US findings of JIA and osteoarticular infection often overlap. Although certain clinical scenarios, laboratory findings, and imaging appearances can favor one diagnosis over the other, fluid analysis may still be required for definitive diagnosis and optimal treatment. US is the preferred modality for fluid aspiration and administering intra-articular corticosteroid therapy. © RSNA, 2017.
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Affiliation(s)
- Jie C Nguyen
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, Madison, Wis (J.C.N., K.S.L., H.G.R.); and the Department of Radiology, Seattle Children's Hospital, Seattle, Wash (M.M.T.)
| | - Kenneth S Lee
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, Madison, Wis (J.C.N., K.S.L., H.G.R.); and the Department of Radiology, Seattle Children's Hospital, Seattle, Wash (M.M.T.)
| | - Mahesh M Thapa
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, Madison, Wis (J.C.N., K.S.L., H.G.R.); and the Department of Radiology, Seattle Children's Hospital, Seattle, Wash (M.M.T.)
| | - Humberto G Rosas
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, Madison, Wis (J.C.N., K.S.L., H.G.R.); and the Department of Radiology, Seattle Children's Hospital, Seattle, Wash (M.M.T.)
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Roszkiewicz J, Smolewska E. In the Pursuit of Methotrexate Treatment Response Biomarker in Juvenile Idiopathic Arthritis-Are We Getting Closer to Personalised Medicine? Curr Rheumatol Rep 2017; 19:19. [PMID: 28361333 DOI: 10.1007/s11926-017-0646-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW Methotrexate (MTX) is the most widely used disease-modifying antirheumatic drug (DMARD) in paediatric rheumatology and the mainstay in the therapy of juvenile idiopathic arthritis (JIA). Despite its common use, about 30% of children fail to respond to this medicine that results in potentially irreversible joint damage. RECENT FINDINGS No clinical biomarker that would predict the outcome of MTX therapy exists. Results of several studies focused on gene polymorphisms and outcome of this DMARD therapy have been published, but no reliable genetic marker useful to tailor the therapy has been discovered so far. The results of the first genome-wide association study in this field have recently revealed new genetic candidates from outside the metabolic pathway of MTX that may be associated with the efficacy of treatment. However promising, those outcomes need validation in independent prospective cohorts before we can claim that clinically useful biomarker predicting MTX treatment response is discovered.
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Affiliation(s)
- Justyna Roszkiewicz
- Department of Pediatric Rheumatology, Medical University of Lodz, Sporna 36/50, 91-738, Lodz, Poland
| | - Elzbieta Smolewska
- Department of Pediatric Rheumatology, Medical University of Lodz, Sporna 36/50, 91-738, Lodz, Poland.
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38
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Hemke R, Nusman CM, van den Berg JM, Lavini C, Schonenberg-Meinema D, Dolman KM, Kuijpers TW, Maas M. Construct validity of pixel-by-pixel DCE-MRI: Correlation with conventional MRI scores in juvenile idiopathic arthritis. Eur J Radiol 2017; 94:1-5. [PMID: 28941753 DOI: 10.1016/j.ejrad.2017.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 06/27/2017] [Accepted: 07/07/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess the capability of the pixel-by-pixel DCE-MRI time intensity curve (TIC)-shape analysis method in the evaluation of juvenile idiopathic arthritis (JIA) disease activity by correlating DCE-MRI parameters with semi-quantitative conventional-MRI scores of synovitis. METHODS Clinical, laboratory, and (DCE)-MRI datasets of 85 JIA patients were prospectively obtained. TIC-shapes of each voxel were classified into one of seven predefined color-coded TIC shape categories. Spatial information on the relative amount of TIC-shapes, maximal enhancement (ME), maximal initial slope (MIS), initial area under the curve (iAUC), time-to-peak (TTP), enhancing volume (EV) was calculated of the synovial membrane. The grade of synovitis was scored on conventional MR images by two readers using the validated JAMRIS system. The Bonferroni method was used to correct for multiple testing, therefore, a P value of <0.0056 is considered significant (0.05/9=0.0056). RESULTS The semi-quantitative JAMRIS synovitis score correlated substantially with the ME, EV, and iAUC (Rs=0.658, P<0.001; Rs=0.618, P<0.001; Rs=0.639, P<0.001), and moderately with MIS (Rs=0.453, P<0.001). A poor correlation was observed between the relative number of TIC-shapes 2-5 and the JAMRIS synovitis score (Rs=0.209, P=0.054; Rs=0.328, P=0.002; Rs=0.241, P=0.023; Rs=-0.241, P=0.026). CONCLUSION In this explorative study, both TIC shape and semi-quantitative DCE-MRI analysis methods showed moderate to substantial correlations with conventional MRI scores of disease activity, indicating that this methods are feasible. Further research is warranted whether DCE-MRI holds potential to become an objective and quantitative method for the evaluation of disease activity in JIA.
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Affiliation(s)
- Robert Hemke
- Department of Radiology and Nuclear Medicine,Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
| | - Charlotte M Nusman
- Department of Radiology and Nuclear Medicine,Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands; Department of Pediatric Hematology, Immunology, Rheumatology and Infectious Disease, Emma Children's Hospital AMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - J Merlijn van den Berg
- Department of Pediatric Hematology, Immunology, Rheumatology and Infectious Disease, Emma Children's Hospital AMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Cristina Lavini
- Department of Radiology and Nuclear Medicine,Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Dieneke Schonenberg-Meinema
- Department of Pediatric Hematology, Immunology, Rheumatology and Infectious Disease, Emma Children's Hospital AMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Koert M Dolman
- Department of Pediatric Rheumatology, Reade, Dr. Jan van Breemenstraat 2, Amsterdam, The Netherlands; Department of Pediatric Rheumatology, St. Lucas Andreas Hospital, Jan Tooropstraat 164, Amsterdam, The Netherlands
| | - Taco W Kuijpers
- Department of Pediatric Hematology, Immunology, Rheumatology and Infectious Disease, Emma Children's Hospital AMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Mario Maas
- Department of Radiology and Nuclear Medicine,Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
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Klotsche J, Raab A, Niewerth M, Sengler C, Ganser G, Kallinich T, Niehues T, Hufnagel M, Thon A, Hospach T, Horneff G, Minden K. Outcome and Trends in Treatment of Systemic Juvenile Idiopathic Arthritis in the German National Pediatric Rheumatologic Database, 2000-2013. Arthritis Rheumatol 2017; 68:3023-3034. [PMID: 27332999 DOI: 10.1002/art.39796] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 06/16/2016] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To investigate the clinical presentation and medical treatment of patients with systemic juvenile idiopathic arthritis (JIA) during the first year of illness. Our study focused on 3-year outcomes in a subsample of patients who were followed up longitudinally. METHODS From 2000 to 2013, 597 patients with systemic JIA and a disease duration of ≤12 months were recorded in the National Pediatric Rheumatologic Database. Among those patients, 3-year outcome data were available for 133. These data included the clinical Juvenile Arthritis Disease Activity Score in 10 joints (JADAS-10) and the physician's global assessment score (on a numerical rating scale), as well as assessment of joint involvement, growth retardation, and patient-reported outcomes. RESULTS The median clinical JADAS-10 declined significantly, from 7 in 2000 to 2 in 2013, while the proportion of patients with inactive disease increased from 19% in 2000 to 41% in 2013. The rate of treatment with systemic glucocorticoids and disease-modifying antirheumatic drugs (DMARDs) remained stable from 2000 to 2013. By 2013, the proportion of patients with systemic JIA who were treated with biologic DMARDs had increased to 20%. At 3-year follow-up, 72% of patients with systemic JIA had inactive disease, and 77% had no functional limitations. Growth retardation was associated with persistently high disease activity and continuing treatment with systemic glucocorticoids. At the 3-year follow-up, one-third of patients were still being treated with systemic glucocorticoids. CONCLUSION The proportion of patients with inactive disease has increased over the past decade. Possible explanations may include improved access to specialized care, additional treatment options, and earlier or faster step-up treatment. However, challenges in the management of systemic JIA remain, as ∼30% of patients continue to present with ongoing active disease.
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Affiliation(s)
- Jens Klotsche
- German Rheumatism Research Centre Berlin and Charité University Hospital Berlin, Berlin, Germany
| | - Anna Raab
- German Rheumatism Research Centre Berlin and Charité University Hospital Berlin, Berlin, Germany
| | | | | | - Gerd Ganser
- St. Josef-Stift Sendenhorst Hospital, Sendenhorst, Germany
| | | | | | | | | | - Toni Hospach
- Olgahospital, Clinical Center Stuttgart, Stuttgart, Germany
| | - Gerd Horneff
- Asklepios Clinic Sankt Augustin, St. Augustin, Germany
| | - Kirsten Minden
- German Rheumatism Research Centre Berlin and Charité University Hospital Berlin, Berlin, Germany
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Resnick CM, Vakilian PM, Breen M, Zurakowski D, Caruso P, Henderson L, Nigrovic PA, Kaban LB, Peacock ZS. Quantifying Temporomandibular Joint Synovitis in Children With Juvenile Idiopathic Arthritis. Arthritis Care Res (Hoboken) 2017; 68:1795-1802. [PMID: 27110936 PMCID: PMC5573997 DOI: 10.1002/acr.22911] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 03/02/2016] [Accepted: 04/05/2016] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Juvenile idiopathic arthritis (JIA) frequently affects the temporomandibular joints (TMJs) and is often undetected by history, examination, and plain imaging. Qualitative assessment of gadolinium-enhanced magnetic resonance images (MRIs) is currently the standard for diagnosis of TMJ synovitis associated with JIA. The purpose of this study is to apply a quantitative analysis of synovial enhancement to MRIs of patients with and without JIA to establish a disease threshold and sensitivity and specificity for the technique. METHODS This is a retrospective case-control study of children (age ≤16 years) who had MRIs with gadolinium including the TMJs. Subjects were divided into a JIA group and a control group. From a coronal T1-weighted image, a ratio (enhancement ratio [ER]) of the average pixel intensity within three 0.2-mm2 regions of interest (ROIs) in the TMJ synovium to that of a 50-mm2 ROI of the longus capitis muscle was calculated. Receiver operating characteristic curves were used to determine the sensitivity and specificity. The inter- and intraexaminer reliability was evaluated with Bland-Altman plots and 2-way mixed, absolute agreement intraclass correlation coefficients. RESULTS There were 187 and 142 TMJs included in the JIA and control groups, respectively. An ER threshold of 1.55 had a sensitivity and specificity for detecting synovitis of 91% and 96%, respectively. The inter- and intraexaminer reliability was excellent. CONCLUSION Calculating a ratio of pixel intensity between the TMJ synovium and the longus capitis muscle is a reliable way to quantify synovial enhancement. An ER of 1.55 differentiates normal TMJs from those affected by inflammatory arthritis.
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Affiliation(s)
- Cory M Resnick
- Boston Children's Hospital and Harvard School of Dental Medicine, Boston, Massachusetts
| | | | - Micheál Breen
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - David Zurakowski
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Paul Caruso
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lauren Henderson
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Peter A Nigrovic
- Harvard Medical School, Boston Children's Hospital, and Brigham and Women's Hospital, Boston, Massachusetts
| | - Leonard B Kaban
- Massachusetts General Hospital and Harvard School of Dental Medicine, Boston, Massachusetts
| | - Zachary S Peacock
- Massachusetts General Hospital and Harvard School of Dental Medicine, Boston, Massachusetts
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Zajc Avramovič M, Dolžan V, Toplak N, Accetto M, Lusa L, Avčin T. Relationship Between Polymorphisms in Methotrexate Pathway Genes and Outcome of Methotrexate Treatment in a Cohort of 119 Patients with Juvenile Idiopathic Arthritis. J Rheumatol 2017; 44:1216-1223. [PMID: 28572465 DOI: 10.3899/jrheum.160950] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To identify clinical and pharmacogenetic determinants of efficacy and toxicity of methotrexate (MTX) in juvenile idiopathic arthritis (JIA) over time. METHODS A cohort of 119 consecutive patients with JIA treated with MTX was reviewed. The Juvenile Arthritis Disease Activity Score including 71 joints was used to measure disease activity. Nonresponders were patients who did not reach a minimum of 30% improvement after 6 months of treatment or were switched to biologic drugs in the first 6 months because of inefficacy. All adverse events (AE) were noted. Genotyping of single-nucleotide polymorphisms (SNP) in the genes coding for MTX transporters, folate pathway, and adenosine pathway was performed using real-time PCR methods. Univariate and multivariable penalized logistic and Cox regression were used to analyze data. RESULTS Thirty patients (25.8%) were defined as nonresponders and 55 (47.2%) were switched to biologics during the followup. Sixty-five patients (54.5%) reported AE in a total of 405 patient-years, and 10 patients (8.4%) discontinued MTX because of AE. AMPD1 rs17602729 and MTHFD1 rs2236225 were associated with gastrointestinal AE while the latter together with MTRR rs1801394 also demonstrated associations with developing hepatoxicity. MTHFR rs1801131, ABCG2 rs2231137, wild-type of MTR rs1805087, and wild-type of ABCC2 rs2273697 were identified as potential markers for discontinuing MTX treatment because of AE. MTHFR rs1801133, MTRR rs1801394, and ABCC2 rs2273697 were associated with switching to biologics. CONCLUSION SNP in different MTX metabolic pathways influence treatment with MTX. Genetic variability is a better marker for toxicity than efficacy.
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Affiliation(s)
- Mojca Zajc Avramovič
- From the Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; Institute of Biochemistry, and Department of Pediatrics, and Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.,M. Zajc Avramovič, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; V. Dolčan, MD, PhD, Institute of Biochemistry, Medical Faculty, University of Ljubljana; N. Toplak, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana; M. Accetto, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; L. Lusa, PhD, Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana; T. Avčin, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana
| | - Vita Dolžan
- From the Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; Institute of Biochemistry, and Department of Pediatrics, and Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.,M. Zajc Avramovič, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; V. Dolčan, MD, PhD, Institute of Biochemistry, Medical Faculty, University of Ljubljana; N. Toplak, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana; M. Accetto, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; L. Lusa, PhD, Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana; T. Avčin, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana
| | - Nataša Toplak
- From the Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; Institute of Biochemistry, and Department of Pediatrics, and Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.,M. Zajc Avramovič, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; V. Dolčan, MD, PhD, Institute of Biochemistry, Medical Faculty, University of Ljubljana; N. Toplak, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana; M. Accetto, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; L. Lusa, PhD, Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana; T. Avčin, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana
| | - Meta Accetto
- From the Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; Institute of Biochemistry, and Department of Pediatrics, and Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.,M. Zajc Avramovič, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; V. Dolčan, MD, PhD, Institute of Biochemistry, Medical Faculty, University of Ljubljana; N. Toplak, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana; M. Accetto, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; L. Lusa, PhD, Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana; T. Avčin, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana
| | - Lara Lusa
- From the Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; Institute of Biochemistry, and Department of Pediatrics, and Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.,M. Zajc Avramovič, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; V. Dolčan, MD, PhD, Institute of Biochemistry, Medical Faculty, University of Ljubljana; N. Toplak, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana; M. Accetto, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; L. Lusa, PhD, Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana; T. Avčin, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana
| | - Tadej Avčin
- From the Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; Institute of Biochemistry, and Department of Pediatrics, and Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia. .,M. Zajc Avramovič, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; V. Dolčan, MD, PhD, Institute of Biochemistry, Medical Faculty, University of Ljubljana; N. Toplak, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana; M. Accetto, MD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana; L. Lusa, PhD, Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana; T. Avčin, MD, PhD, Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, and Department of Pediatrics, Medical faculty, University of Ljubljana.
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Khawaja K, Al-Maini M. Access to pediatric rheumatology care for Juvenile Idiopathic Arthritis in the United Arab Emirates. Pediatr Rheumatol Online J 2017; 15:41. [PMID: 28511684 PMCID: PMC5434612 DOI: 10.1186/s12969-017-0170-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 05/05/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND This study looks at access to care for Juvenile Idiopathic Arthritis through pediatric rheumatology in the UAE, as an example of multi-ethnic society. METHODS Patients with a diagnosis of Juvenile idiopathic arthritis were identified through the hospital electronic medical records system from January 1st 2011 to December 31st 2014. All residents of the United Arab Emirates hold an Emirates identity card. We divided our patients into two groups: Emirati-Emirates, who are native Emirati children and hold the Emirati nationality, as stated on their Emirates identity card, and who therefore have full, comprehensive access to free medical care; and non-Emirati-Emirates, who represent other nationalities, as stated on their Emirates identity card. The primary objective of this study is to look at access to care for Juvenile idiopathic arthritis through pediatric rheumatology in the two groups. The secondary objective is to look at the effect of having multiple types of healthcare insurance coverage on access to biologics. A retrospective review was carried out. RESULTS Sixty-six patients with JIA identified: 33 Emirates and 33 non-Emirates. For Emirates, the mean time from onset to first appointment with pediatric rheumatologist and diagnosis is 9 months (range: 1-48), and for non-Emirates is 12.4 months (range: 1-96). Among the Emirates, 10 patients are currently on biologic with methotrexate. Among the non-Emirates, 15 are on biologic with methotrexate. Among the Emirates, 12 are currently in remission while on treatment, as are 10 non-Emirates. Regarding disability, one Emirati patient has blindness secondary to noncompliance while under previous treatment. One Non-Emirati developed joint deformities due to periods of noncompliance and no follow up. CONCLUSIONS Delay in presentation to pediatric rheumatology has been identified as an important factor in our population, which is multi-cultural and multi-ethnic. Type of health care insurance cover did not affect number of patients getting biological therapy once patient seen in the pediatric rheumatology service.
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Affiliation(s)
- Khulood Khawaja
- Department of Rheumatology, Allergy and Immunology, Al-Mafraq Hospital, P.O. Box 2951, Abu Dhabi, United Arab Emirates.
| | - Mustafa Al-Maini
- grid.416275.3Department of Rheumatology, Allergy and Immunology, Al-Mafraq Hospital, P.O. Box 2951, Abu Dhabi, United Arab Emirates
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Aupiais C, Basmaci R, Ilharreborde B, Blachier A, Desmarest M, Job-Deslandre C, Faye A, Bonacorsi S, Alberti C, Lorrot M. Arthritis in children: comparison of clinical and biological characteristics of septic arthritis and juvenile idiopathic arthritis. Arch Dis Child 2017; 102:316-322. [PMID: 27655660 DOI: 10.1136/archdischild-2016-310594] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 07/12/2016] [Accepted: 09/03/2016] [Indexed: 11/04/2022]
Abstract
AIM Childhood arthritis arises from several causes. The aim of this observational study is to compare the clinical and biological features and short-term outcome of different types of arthritis because they have different treatment and prognoses. METHODS Children <16 years of age hospitalised in a French tertiary care centre for a first episode of arthritis lasting for less than 6 weeks who underwent joint aspiration were retrospectively included. We performed non-parametrical tests to compare groups (septic arthritis (SA), juvenile idiopathic arthritis (JIA) and arthritis with no definitive diagnosis). The time before apyrexia or C reactive protein (CRP) <10 mg/L was analysed using the Kaplan-Meier method. RESULTS We studied 125 children with a sex ratio (M/F) of 1.1 and a median age of 2.2 years (range 0.3 to 14.6). SA was associated with a lower age at onset (1.5 years, IQR 1.2-3.0 vs 3.6 years, IQR 2.2-5.6), shorter duration of symptoms before diagnosis (2 days, IQR 1-4 vs 7 days, IQR 1-19) and higher synovial white blood cell count (147 cells ×103/mm3, IQR 71-227, vs 51 cells ×103/mm3, IQR 12-113), than JIA. Apyrexia occurred later in children with JIA (40% after 2 days, 95% CI 17% to 75%) than children with SA (82%, 95% CI 68% to 92%), as did CRP<10 mg/L (18% at 7 days, 95% CI 6.3% to 29.6% vs 82.1%, 95% CI 76.1% to 89.7%, p=0.01). CONCLUSIONS There were no sufficiently reliable predictors for differentiating between SA and JIA at onset. The outcomes were different; JIA should be considered in cases of poor disease evolution after antibiotic treatment and joint aspiration.
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Affiliation(s)
- Camille Aupiais
- Unité d'Epidémiologie Clinique, AP-HP, Hôpital Robert Debré, Paris, France.,Inserm, U1123, ECEVE and CIC-EC 1426, Paris, France.,Univ Denis Diderot Paris 7, Sorbonne Paris Cité, Paris, France
| | - Romain Basmaci
- Univ Denis Diderot Paris 7, Sorbonne Paris Cité, Paris, France.,Service de Pédiatrie Générale, AP-HP, Hôpital Robert Debré, Paris, France.,Inserm, UMR1137, Infection, Antimicrobials, Modelling, Evolution (IAME), Paris, France
| | - Brice Ilharreborde
- Univ Denis Diderot Paris 7, Sorbonne Paris Cité, Paris, France.,Service d'Orthopédie Pédiatrique, AP-HP, Hôpital Robert Debré, Paris, France
| | - Audrey Blachier
- Département Informatique Médicale, Hôpital Robert Debré (APHP), Paris, France
| | - Marie Desmarest
- Service d'Accueil des Urgences Pédiatriques, AP-HP, Hôpital Robert Debré, Paris, France
| | - Chantal Job-Deslandre
- Service de Rhumatologie, AP-HP, Hôpital Cochin, Paris, France.,Université René Descartes Paris 5, Paris, France
| | - Albert Faye
- Inserm, U1123, ECEVE and CIC-EC 1426, Paris, France.,Univ Denis Diderot Paris 7, Sorbonne Paris Cité, Paris, France.,Service de Pédiatrie Générale, AP-HP, Hôpital Robert Debré, Paris, France
| | - Stéphane Bonacorsi
- Univ Denis Diderot Paris 7, Sorbonne Paris Cité, Paris, France.,Inserm, UMR1137, Infection, Antimicrobials, Modelling, Evolution (IAME), Paris, France.,Service de Microbiologie, AP-HP, Hôpital Robert Debré, Paris, France
| | - Corinne Alberti
- Unité d'Epidémiologie Clinique, AP-HP, Hôpital Robert Debré, Paris, France.,Inserm, U1123, ECEVE and CIC-EC 1426, Paris, France.,Univ Denis Diderot Paris 7, Sorbonne Paris Cité, Paris, France
| | - Mathie Lorrot
- Inserm, U1123, ECEVE and CIC-EC 1426, Paris, France.,Univ Denis Diderot Paris 7, Sorbonne Paris Cité, Paris, France.,Service de Pédiatrie Générale, AP-HP, Hôpital Robert Debré, Paris, France
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Hissink Muller PCE, Brinkman DMC, Schonenberg D, Koopman-Keemink Y, Brederije ICJ, Bekkering WP, Kuijpers TW, van Rossum MAJ, van Suijlekom-Smit LWA, van den Berg JM, Allaart CF, ten Cate R. A comparison of three treatment strategies in recent onset non-systemic Juvenile Idiopathic Arthritis: initial 3-months results of the BeSt for Kids-study. Pediatr Rheumatol Online J 2017; 15:11. [PMID: 28166785 PMCID: PMC5294738 DOI: 10.1186/s12969-017-0138-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 01/19/2017] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Combination therapy with prednisone or etanercept may induce earlier and/or more improvement in disease activity in Disease Modifying Anti Rheumatic Drug (DMARD) naïve non-systemic Juvenile Idiopathic Arthritis (JIA) patients. Here we present three months clinical outcome of initial treatments of the BeSt-for-Kids study. METHODS Included patients were randomized to either: 1. initial DMARD-monotherapy (sulfasalazine (SSZ) or methotrexate (MTX)), 2. Initial MTX / prednisolone-bridging, 3. Initial combination MTX/etanercept. Percentage inactive disease, adjusted (a) ACR Pedi30, 50 and 70 and JADAS after 6 and 12 weeks of treatment (intention to treat analysis) and side effects are reported. RESULTS 94 patients (67% girls, 32 (arm 1), 32 (arm 2) and 30 (arm 3) with median (InterQuartileRange) age of 9.1 (4.7-12.9) years were included. 38% were ANA positive, 10 had oligo-articular disease, 68 polyarticular JIA and 16 psoriatic arthritis. Baseline median (IQR) ACRpedi-scores: VAS physician 49 (40-58) mm, VAS patient 54 (37-70) mm, ESR 6.5 (2-14.8)mm/hr, active joint count 8 (5-12), limited joint count 3 (1-5), CHAQ score 0.88 (0.63-1.5). In arm 1, 17 started with MTX, 15 with SSZ. After 3 months, aACR Pedi 50 was reached by 10/32 (31%), 12/32(38%) and 16/30 (53%) (p = 0.19) and aACR Pedi 70 was reached by 8/32 (25%), 6/32(19%) and 14/30(47%) in arms 1-3 (p = 0.04). Toxicity was similar. Few serious adverse events were reported. CONCLUSION After 3 months of treatment in a randomized trial, patients with recent-onset JIA achieved significantly more clinical improvement (aACRPedi70) on initial combination therapy with MTX / etanercept than on initial MTX or SSZ monotherapy. TRIAL REGISTRATION NTR1574 . Registered 3 December 2008.
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Affiliation(s)
- P. C. E. Hissink Muller
- 0000000089452978grid.10419.3dDepartment of Pediatrics/Pediatric Rheumatology, Leiden University Medical Center, Leiden, The Netherlands ,000000040459992Xgrid.5645.2Department of Pediatrics/Pediatric Rheumatology, Erasmus MC Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - D. M. C. Brinkman
- 0000000089452978grid.10419.3dDepartment of Pediatrics/Pediatric Rheumatology, Leiden University Medical Center, Leiden, The Netherlands ,Department of Pediatrics, Alrijne Hospital Leiderdorp, Leiderdorp, The Netherlands
| | - D. Schonenberg
- Department of Pediatric Hematology, Immunology, Rheumatology and Infectious Diseases, Emma Children’s Hospital AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Y. Koopman-Keemink
- grid.414786.8Department of Pediatrics, Hagaziekenhuis Juliana Children’s Hospital, The Hague, The Netherlands
| | - I. C. J. Brederije
- 0000000089452978grid.10419.3dDepartment of Pediatrics/Pediatric Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - W. P. Bekkering
- 0000000089452978grid.10419.3dDepartment of Pediatrics/Pediatric Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - T. W. Kuijpers
- Department of Pediatric Hematology, Immunology, Rheumatology and Infectious Diseases, Emma Children’s Hospital AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M. A. J. van Rossum
- Department of Pediatric Rheumatology, Amsterdam Rheumatology and Immunology Center location Reade Amsterdam, Amsterdam, The Netherlands
| | - L. W. A. van Suijlekom-Smit
- 000000040459992Xgrid.5645.2Department of Pediatrics/Pediatric Rheumatology, Erasmus MC Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - J. M. van den Berg
- Department of Pediatric Hematology, Immunology, Rheumatology and Infectious Diseases, Emma Children’s Hospital AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - C. F. Allaart
- 0000000089452978grid.10419.3dDepartment of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - R. ten Cate
- 0000000089452978grid.10419.3dDepartment of Pediatrics/Pediatric Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
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Blazina Š, Markelj G, Avramovič MZ, Toplak N, Avčin T. Management of Juvenile Idiopathic Arthritis: A Clinical Guide. Paediatr Drugs 2016; 18:397-412. [PMID: 27484749 DOI: 10.1007/s40272-016-0186-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease of childhood. The outcome in patients with JIA has markedly improved with the advent of biologic drugs. Although early aggressive therapy with biologics seems to be very effective, this approach leads to overtreatment in patients who would respond to classic disease-modifying anti-rheumatic drugs. Therefore, methotrexate remains first-line long-term therapy for most children with polyarticular JIA. Tumor necrosis factor-α inhibitors have shown tremendous benefit in children with refractory non-systemic JIA. Similar effects have been observed with interleukin-1 and interleukin-6 blockade in patients with systemic JIA. Correct choice and timely use of available medications to achieve early and sustained remission with as few side effects as possible remain challenges for the treating physician. In this review, a practical, clinically oriented guide to the management of JIA is provided, focusing on pharmacological treatment with non-steroidal anti-inflammatory drugs, intra-articular and systemic corticosteroids, disease-modifying anti-rheumatic drugs, and biologic agents. In addition, issues regarding treatment failure, early aggressive treatment, and drug tapering are discussed, with alternative treatment options being suggested.
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Affiliation(s)
- Štefan Blazina
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Center Ljubljana, Bohoričeva 20, 1525, Ljubljana, Slovenia
| | - Gašper Markelj
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Center Ljubljana, Bohoričeva 20, 1525, Ljubljana, Slovenia
| | - Mojca Zajc Avramovič
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Center Ljubljana, Bohoričeva 20, 1525, Ljubljana, Slovenia
| | - Nataša Toplak
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Center Ljubljana, Bohoričeva 20, 1525, Ljubljana, Slovenia.,Department of Pediatrics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tadej Avčin
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Center Ljubljana, Bohoričeva 20, 1525, Ljubljana, Slovenia. .,Department of Pediatrics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
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Kessler EA, Sherman AK, Becker ML. Decreasing patient cost and travel time through pediatric rheumatology telemedicine visits. Pediatr Rheumatol Online J 2016; 14:54. [PMID: 27646340 PMCID: PMC5029100 DOI: 10.1186/s12969-016-0116-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 09/15/2016] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND There is a critical shortage of pediatric rheumatologists in the US. Substantial travel to clinics can impose time and monetary burdens on families. The aim of this study was to evaluate the cost of in-person pediatric rheumatology visits for families and determine if telemedicine clinics resulted in time and cost savings. Factors associated with interest in telemedicine were also explored. METHODS Surveys were offered to parents and guardians of patients in Pediatric Rheumatology follow-up clinics in Kansas City, Missouri, the primary site of in-person care, and at a telemedicine outreach site 160 miles away, in Joplin, Missouri. Survey questions were asked about non-medical, out-of-pocket costs associated with the appointment and interest in a telemedicine clinic. RESULTS At the primary Kansas City clinic, the median distance traveled one-way was 40 miles [IQR = 18-80]. In the Joplin sample, the median distance traveled to the telemedicine clinic was 60 miles [IQR = 20-85] compared to 175 miles [IQR = 160-200] for the same cohort of patients when seen in Kansas City (p < 0.001). When the Joplin cohort was seen via telemedicine they missed less time from work and school (p = 0.028, p = 0.003, respectively) and a smaller percentage spent money on food compared to when they had traveled to Kansas City (p < 0.001). There was no statistical difference between the Joplin cohort when they had traveled to Kansas City and the Kansas City cohort in terms of miles driven to clinic, time missed from work and school, and percentage of subjects who spent money on food. CONCLUSIONS Traditional in-person visits can result in a financial toll on families, which can be ameliorated by the use of telemedicine. Telemedicine leveled the economic burden of clinic visits so that when the Joplin cohort was seen via telemedicine, they experienced costs similar to the Kansas City cohort.
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Affiliation(s)
- Elizabeth A. Kessler
- Division of Rheumatology, Children’s Mercy, Kansas City and University of Missouri, Kansas City, 2401 Gillham Road, Kansas City, MO 64108 USA
| | - Ashley K. Sherman
- Division of Health Services and Outcomes Research, Children’s Mercy, Kansas City, 2405 Grand, Kansas City, MO 64108 USA
| | - Mara L. Becker
- Division of Rheumatology, Children’s Mercy, Kansas City and University of Missouri, Kansas City, 2401 Gillham Road, Kansas City, MO 64108 USA
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Fráňová J, Fingerhutová Š, Kobrová K, Srp R, Němcová D, Hoza J, Uher M, Saifridová M, Linková L, Doležalová P. Methotrexate efficacy, but not its intolerance, is associated with the dose and route of administration. Pediatr Rheumatol Online J 2016; 14:36. [PMID: 27301536 PMCID: PMC4908704 DOI: 10.1186/s12969-016-0099-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 06/10/2016] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND There is a lack of published evidence on the importance of methotrexate (MTX) dose and route of administration on both its efficacy and adverse events in children with Juvenile Idiopathic Arthritis (JIA). We aimed to document our clinical practice based on the treat-to-target approach in order to support the concept that better therapeutic effect achieved with an optimal dose of parenteral MTX is associated with clinically acceptable adverse effects comparable to those reported for oral treatment. METHODS Study inclusion criteria were indication of new MTX therapy for active arthritis in confirmed JIA patients younger than 18 years. Eligible patients were evaluated prospectively every 3 months for 1 year using standardized instruments for treatment response (American College of Rheumatology Pediatric (ACRPedi) response, Juvenile Arthritis Disease Activity Score (JADAS) 71, Clinically Inactive Disease (CID)) and adverse events (laboratory monitoring, Methotrexate Intolerance Severity Score (MISS)). MTX responders had to achieve at least ACRPedi 70 response. MTX intolerance was defined by MISS ≥ 6. RESULTS In 45/55 patients (81.8 %) MTX was started as subcutaneous injection. The initial median weekly dose was 14.4 mg/m(2) in parenteral and 11.7 mg/m(2) in oral administration. MTX therapy was effective in the level of ACRpedi70 and CID in 50.9 % and 30.9 % of patients at month 6 and in 70.9 % and 56.4 % after 12 months of the treatment, respectively. MTX intolerance at 6 and 12 months was noted in 25.5 % and 30.6 %, respectively. Management of intolerance included change in the dose and/or route of administration, education and councelling. Adverse events led to MTX withdrawal in 5 patients (9 %) due to toxicity (n = 3) and intolerance (n = 2). We did not find any significant predictive factors for either MTX therapeutic response or intolerance. CONCLUSION Subcutaneous MTX weekly dose around 15 mg/m(2) is associated not only with a high response rate within the first 12 months of treatment, but also with a relatively low rate of significant adverse effects that would lead to the treatment termination. It allows early recognition of MTX non-responders and addition of biologic therapy. Sustainability of therapeutic effect and longer-term evolution of adverse events will be addressed by an ongoing extension of the study.
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Affiliation(s)
- J Fráňová
- Paediatric Rheumatology Unit, Department of Paediatrics and Adolescent Medicine, General University Hospital and 1st Medical Faculty, Charles University in Prague, Ke Karlovu 2, Prague, Czech Republic
- Paediatric Rheumatology Unit, Department of Paediatrics, Children´s Medical Center, Faculty of Medicine, Masaryk University Brno and Faculty Hospital Brno, Černopolní 9, Brno, Czech Republic
| | - Š Fingerhutová
- Paediatric Rheumatology Unit, Department of Paediatrics and Adolescent Medicine, General University Hospital and 1st Medical Faculty, Charles University in Prague, Ke Karlovu 2, Prague, Czech Republic
| | - K Kobrová
- Paediatric Rheumatology Unit, Department of Paediatrics and Adolescent Medicine, General University Hospital and 1st Medical Faculty, Charles University in Prague, Ke Karlovu 2, Prague, Czech Republic
| | - R Srp
- Paediatric Rheumatology Unit, Department of Paediatrics and Adolescent Medicine, General University Hospital and 1st Medical Faculty, Charles University in Prague, Ke Karlovu 2, Prague, Czech Republic
| | - D Němcová
- Paediatric Rheumatology Unit, Department of Paediatrics and Adolescent Medicine, General University Hospital and 1st Medical Faculty, Charles University in Prague, Ke Karlovu 2, Prague, Czech Republic
| | - J Hoza
- Paediatric Rheumatology Unit, Department of Paediatrics and Adolescent Medicine, General University Hospital and 1st Medical Faculty, Charles University in Prague, Ke Karlovu 2, Prague, Czech Republic
| | - M Uher
- Institute of Biostatistics and Analyses at the Faculty of Medicine and the Faculty of Science of the Masaryk University, Brno, Czech Republic
| | - M Saifridová
- Paediatric Rheumatology Unit, Department of Paediatrics and Adolescent Medicine, General University Hospital and 1st Medical Faculty, Charles University in Prague, Ke Karlovu 2, Prague, Czech Republic
| | - L Linková
- Paediatric Rheumatology Unit, Department of Paediatrics and Adolescent Medicine, General University Hospital and 1st Medical Faculty, Charles University in Prague, Ke Karlovu 2, Prague, Czech Republic
| | - P Doležalová
- Paediatric Rheumatology Unit, Department of Paediatrics and Adolescent Medicine, General University Hospital and 1st Medical Faculty, Charles University in Prague, Ke Karlovu 2, Prague, Czech Republic.
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Aktuelle Therapie der polyartikulären Verlaufsform der juvenilen idiopathischen Arthritis. Z Rheumatol 2016; 75:284-91. [DOI: 10.1007/s00393-016-0063-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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50
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Calvo I, Antón J, López Robledillo J, de Inocencio J, Gamir M, Merino R, Lacruz L, Camacho M, Rua M, Bustabad S, Díaz Cordovés-Rego G. Recommendations for the use of methotrexate in patients with juvenile idiopathic arthritis. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.anpede.2015.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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