1
|
Brunner HI, Akikusa JD, Al-Abadi E, Bohnsack JF, Boteanu AL, Chedeville G, Cuttica R, De La Pena W, Jung L, Kasapcopur O, Kobusinska K, Schulert GS, Neiva C, Rivas-Chacon R, Rizo Rodriguez JC, Vazquez-Del Mercado M, Wagner-Weiner L, Weiss JE, Wouters C, Posner H, Wouters A, Chang C, White C, Kanik K, Liu S, Martini A, Lovell DJ, Ruperto N. Safety and efficacy of tofacitinib for the treatment of patients with juvenile idiopathic arthritis: preliminary results of an open-label, long-term extension study. Ann Rheum Dis 2024:ard-2023-225094. [PMID: 38849152 DOI: 10.1136/ard-2023-225094] [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: 10/03/2023] [Accepted: 05/22/2024] [Indexed: 06/09/2024]
Abstract
OBJECTIVES We report the safety, tolerability and efficacy of tofacitinib in patients with juvenile idiopathic arthritis (JIA) in an ongoing long-term extension (LTE) study. METHODS Patients (2-<18 years) with JIA who completed phase 1/3 index studies or discontinued for reasons excluding treatment-related serious adverse events (AEs) entered the LTE study and received tofacitinib 5 mg two times per day or equivalent weight-based doses. Safety outcomes included AEs, serious AEs and AEs of special interest. Efficacy outcomes included improvement since tofacitinib initiation per the JIA-American College of Rheumatology (ACR)70/90 criteria, JIA flare rate and disease activity measured by Juvenile Arthritis Disease Activity Score (JADAS)27, with inactive disease corresponding to JADAS ≤1.0. RESULTS Of 225 patients with JIA (median (range) duration of treatment, 41.6 (1-103) months), 201 (89.3%) had AEs; 34 (15.1%) had serious AEs. 10 patients developed serious infections; three had herpes zoster. Two patients newly developed uveitis. Among patients with polyarticular course JIA, JIA-ACR70/90 response rates were 60.0% (78 of 130) and 33.6% (47 of 140), respectively, at month 1, and generally improved over time. JIA flare events generally occurred in <5% of patients through to month 48. Observed mean (SE) JADAS27 was 22.0 (0.6) at baseline, 6.2 (0.7) at month 1 and 2.8 (0.5) at month 48, with inactive disease in 28.8% (36 of 125) of patients at month 1 and 46.8% (29 of 82) at month 48. CONCLUSIONS In this interim analysis of LTE study data in patients with JIA, safety findings were consistent with the known profile of tofacitinib, and efficacy was maintained up to month 48. TRIAL REGISTRATION NUMBER NCT01500551.
Collapse
Affiliation(s)
- Hermine I Brunner
- Division of Rheumatology and Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jonathan D Akikusa
- Paediatric Rheumatology Service, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Eslam Al-Abadi
- Paediatric and Adolescent Rheumatology Service, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - John F Bohnsack
- Division of Allergy and Immunology, Primary Children's Hospital, Salt Lake City, Utah, USA
| | | | - Gaelle Chedeville
- Department of Pediatrics, Division of Rheumatology, McGill University Health Centre, Glen Site, Montreal, Quebec, Canada
| | - Ruben Cuttica
- Paediatric Rheumatology, Hospital Britanico de Buenos Aires, Buenos Aires, Argentina
| | - Wendy De La Pena
- Pediatric Rheumatology, Loma Linda University Children's Hospital, Loma Linda, California, USA
| | - Lawrence Jung
- Department of Pediatrics, School of Medicine, George Washington University, Washington, District of Columbia, USA
| | - Ozgur Kasapcopur
- Department of Paediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Katarzyna Kobusinska
- Department of Paediatrics, Haematology, Oncology and Rheumatology, Wojewodzki Szpital Dzieciecy im J Brudzinskiego, Bydgoszcz, Poland
| | - Grant S Schulert
- Division of Rheumatology and Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Claudia Neiva
- Paediatric Rheumatology Network, Santa Casa de Misericórdia de Belo Horizonte, Minas Gerais, Brazil
| | | | - Juan Cruz Rizo Rodriguez
- Centro de Alta Especialidad en Reumatología e Investigación del Potosí, SC, San Luis Potosí, Mexico
| | | | - Linda Wagner-Weiner
- Pediatric Rheumatology, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Jennifer E Weiss
- Pediatric Rheumatology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Carine Wouters
- Paediatric Rheumatology, Department of Paediatrics, UZ Leuven-Gasthuisberg, Leuven, Belgium
| | | | | | | | | | | | | | - Alberto Martini
- Paediatric Rheumatology, Department of Paediatrics, University of Genova, Genova, Italy
| | - Daniel J Lovell
- Division of Rheumatology and Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Nicolino Ruperto
- Pediatric and Rheumatology Clinic, IRCCS Istituto Giannina Gaslini, Genova, Italy
| |
Collapse
|
2
|
Akgün Ö, Demirkan FG, Kavrul Kayaalp G, Erdemir M, Akay N, Çakmak F, Önel M, Keskindemirci G, Eker Ömeroğlu R, Gökçay EG, Aktay Ayaz N. Vaccination coverage of children with rheumatic diseases compared with healthy controls: a retrospective case-control study. Postgrad Med 2023; 135:824-830. [PMID: 37997766 DOI: 10.1080/00325481.2023.2287988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 11/22/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE To reveal the vaccination status of patients with pediatric rheumatic disease (PedRD) and to compare this with healthy controls. METHODS The electronic health records of the Ministry of Health regarding the vaccination status of children with PedRD followed in a tertiary hospital were analyzed cross-sectionally and compared with their healthy controls. The missing vaccines were reported according to individual, age-appropriate schedule and causes of skipped vaccines in both groups were investigated with an online survey. RESULTS The vaccination rate of patients in the last examination was 71.4% (90/126) and 95.7% (110/115) in healthy controls (p < 0.001). Measles-mumps-rubella vaccine, diphtheria, the administration rates of the second dose of tetanus-acellular pertussis-inactivated polio and Haemophilus influenzae type B, chickenpox, and hepatitis A vaccines were significantly lower in patients than in controls (p values 0.004, 0.02, 0.01, 0.013, respectively). The pre-diagnosis incomplete vaccination proportion was significantly higher in the patient group (16.6%) than in healthy controls (4.3%) (p = 0.002). In the patient group, the proportion of incomplete live-attenuated vaccines after diagnosis (25%) was more than pre-diagnosis (61.1%) (p = 0.04), while the proportion of incomplete non-live vaccines before and after diagnosis was similar (47.2% and 50%, respectively) (p = 0.73). The major reasons for missed vaccines were physicians' recommendations (15.6%), the presence of PedRD diagnosis (12.5%), and the drugs used (12.5%). CONCLUSION Vaccination coverage of PedRD patients has been shown to lag behind the routine vaccination schedule (71.4%). In addition to new recommendations, electronic health system records for vaccination may be appropriate for the follow-up of these patients, and the addition of reminder alerts may be useful to reduce the rate of missed vaccinations.
Collapse
Affiliation(s)
- Özlem Akgün
- Department of Pediatric Rheumatology, İstanbul Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | - Fatma Gül Demirkan
- Department of Pediatric Rheumatology, İstanbul Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | - Gülşah Kavrul Kayaalp
- Department of Pediatric Rheumatology, İstanbul Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | - Merve Erdemir
- Social Pediatrics Doctoral Program, Istanbul University Institute of Health Sciences Institute of Child Health, Istanbul, Turkey
| | - Nergis Akay
- Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Figen Çakmak
- Department of Pediatric Rheumatology, İstanbul Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | - Mustafa Önel
- Department of Microbiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Gonca Keskindemirci
- Department of Social Pediatrics, Institute of Child Health, Istanbul University, Istanbul, Turkey
- Division of Social Pediatrics, Department of Child Health and Diseases, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Rukiye Eker Ömeroğlu
- Department of Pediatric Rheumatology, İstanbul Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | - Emine Gülbin Gökçay
- Department of Social Pediatrics, Institute of Child Health, Istanbul University, Istanbul, Turkey
- Division of Social Pediatrics, Department of Child Health and Diseases, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Nuray Aktay Ayaz
- Department of Pediatric Rheumatology, İstanbul Faculty of Medicine, İstanbul University, İstanbul, Turkey
| |
Collapse
|
3
|
Marinho AKBB. Vaccination in children with immune-mediated disorders. J Pediatr (Rio J) 2023; 99 Suppl 1:S62-S69. [PMID: 36566017 PMCID: PMC10066448 DOI: 10.1016/j.jped.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To present an updated review of recommendations for the vaccination of children with immune-mediated diseases, with an emphasis on rheumatic and inflammatory diseases. SOURCE OF DATA Studies published in the PubMed and Scielo databases between 2002 and 2022, Guidelines of Brazilian Scientific Societies, Manuals and Technical Notes of the Ministry of Health of Brazil, on current immunization schedules for special populations. DATA SYNTHESIS Immunosuppressive drugs and biological agents reduce the immunogenicity of vaccines and favor susceptibility to infections. The safety and efficacy of immunogens are important points for vaccination in children with immune-mediated diseases. The safety threshold of a vaccine applied to immunocompromised individuals can be reduced when compared to healthy individuals. Very often, the recommendations for the immunization of children with immune-mediated diseases follow the recommendations for immunocompromised patients. Vaccination against COVID-19, on the other hand, should ideally occur when the disease is stabilized and in the absence of a low degree of immunosuppression. The patients should be informed about the possibility that the immunization may fail during treatment with immunosuppressants. Specific vaccination schedules should be considered to ensure better protection. CONCLUSIONS Recent studies have allowed updating the recommendations on the safety and immunogenicity of vaccination in children with immune-mediated diseases, especially for live attenuated vaccines. There is a scarcity of data on the safety and efficacy of COVID-19 vaccines in patients, particularly pediatric patients, with rheumatic diseases. The completion of ongoing studies is expected to help guide recommendations on COVID-19 vaccines in this group of patients.
Collapse
Affiliation(s)
- Ana Karolina Barreto Berselli Marinho
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Serviço de Imunologia Clínica e Alergia, São Paulo, SP, Brazil.
| |
Collapse
|
4
|
Cunninghame J, Wen S, Dufficy M, Ullman A, Takashima M, Cann M, Doyle R. Immunogenicity and safety of vaccination in children with paediatric rheumatic diseases: a scoping review. Ther Adv Vaccines Immunother 2023; 11:25151355231167116. [PMID: 37124959 PMCID: PMC10131534 DOI: 10.1177/25151355231167116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/01/2023] [Indexed: 05/02/2023] Open
Abstract
Children with paediatric rheumatic diseases (PRDs) are at increased risk of vaccine-preventable disease. Safe and effective vaccination is central to preventive care in PRD patients; however, uncertainty surrounding immunogenicity and safety has contributed to suboptimal vaccination. The aim of this study was to evaluate treatment effect on immunogenicity to vaccination in PRD patients and assess vaccine safety, specifically adverse events following immunisation (AEFI) and disease flare. Scoping review. In this scoping review, a systematic search of PubMed, CINAHL and Embase databases was conducted from 2014 to 23 August 2022 to identify observational studies evaluating the immunogenicity and safety of commonly used vaccinations in PRD patients. The primary outcome was immunogenicity (defined as seroprotection and protective antibody concentrations), with secondary outcomes describing AEFI and disease flare also extracted. Due to extensive heterogeneity related to diagnostic and vaccination variability, narrative synthesis was used to describe the findings of each study. Study quality was assessed via the Mixed Methods Appraisal Tool. The review was prospectively registered with PROSPERO (CRD42022307212). The search yielded 19 studies evaluating immunogenicity to vaccination and incidence of AEFI and disease flares in this population, which were of acceptable quality. Corticosteroids did not have deleterious effects on vaccine response. Treatment with conventional disease-modifying antirheumatic drugs (DMARDs) and biologic DMARDs generally had no effect immunogenicity in PRD patients. While patients exhibited adequate seroprotection, protective antibody levels were lower in patients on some immunosuppressant agents. Varicella infections were recorded post vaccination in several patients with low protective antibody levels undergoing treatment with DMARDs and corticosteroids. Most vaccines appear safe and effective in PRD patients, despite immunosuppressant treatment. Booster vaccinations should be considered with some studies highlighting inadequate seroprotection following primary course of vaccinations with acceleration of antibody decline over time. There was limited evidence to support avoiding live vaccines in PRD patients.
Collapse
Affiliation(s)
| | - Sophie Wen
- Centre for Children’s Health Research,
Children’s Health Queensland Hospital and Health Service, South Brisbane,
QLD, Australia
- Centre for Clinical Research, The University of
Queensland, Brisbane, QLD, Australia
| | - Mitchell Dufficy
- School of Nursing, Midwifery and Social Work,
The University of Queensland, Brisbane, QLD, Australia
| | - Amanda Ullman
- School of Nursing, Midwifery and Social Work,
The University of Queensland, Brisbane, QLD, Australia
- Centre for Children’s Health Research,
Children’s Health Queensland Hospital and Health Service, South Brisbane,
QLD, Australia
| | - Mari Takashima
- School of Nursing, Midwifery and Social Work,
The University of Queensland, Brisbane, QLD, Australia
- Centre for Children’s Health Research,
Children’s Health Queensland Hospital and Health Service, South Brisbane,
QLD, Australia
| | - Megan Cann
- Centre for Children’s Health Research,
Children’s Health Queensland Hospital and Health Service, South Brisbane,
QLD, Australia
| | - Rebecca Doyle
- School of Nursing, Midwifery and Social Work,
The University of Queensland, Brisbane, QLD, Australia
- Centre for Children’s Health Research,
Children’s Health Queensland Hospital and Health Service, South Brisbane,
QLD, Australia
| |
Collapse
|
5
|
Ferrari J. Verrucae pedis in children with juvenile idiopathic arthritis and other paediatric rheumatic diseases: a cross-sectional study. J Foot Ankle Res 2022; 15:29. [PMID: 35449072 PMCID: PMC9026681 DOI: 10.1186/s13047-022-00526-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Verrucae pedis (verrucae / VPs) are a common viral infection of the skin seen in children. There are limited studies of the prevalence, duration and impact of verrucae pedis in children who are immunosuppressed. The studies available suggest that, in these children, the warts are more widespread and are more long-standing. The primary aim of this study was to determine the prevalence of verrucae pedis in children attending rheumatology clinics who may have some degree of immunosuppression due to their prescribed medication and compare this to the reported prevalence in the healthy population. METHOD Children attending out-patient rheumatology appointments were recruited. The young people were aged between four and 17 years old. A visual inspection of both feet was used to identify potential verrucae. Diagnosis of a verruca pedis was confirmed on observation of the typical clinical features. The location, duration of presence, previous treatments, presence of verrucae in other family members and psychological impact was recorded. RESULTS A total of 71 children were included. Of the group, 55 children had no verrucae present, 16 children had one or more verrucae. The prevalence of verrucae was 22.5%. Medication impacting on the immune system was prescribed in 80% of the group. There appeared to be no greater chance of having verrucae if taking immunosuppressive medication than compared to having no medication (OR = 1.1, 95%CI 0.26 to 4.48, p = 0.46). Children with verrucae tended to be between 9 and 12 years old. In total, 37.5% of the young people with verrucae had lesions reportedly present for 24 months or more. Two-thirds of the participants were not concerned about verrucae being present and most participants with a verruca were not aware of what a verruca was, but despite this the majority of participants (81%) had sought treatment for the verrucae. CONCLUSION Children with Juvenile Idiopathic Arthritis and other rheumatic conditions have no greater prevalence of verrucae compared to the general population. The verrucae present were of a similar clinical type and did not seem to be more widespread or have atypical features, which has been reported in other immunocompromised populations. The percentage of lesions remaining beyond 24 months was found to be slightly greater than has been reported in other healthy populations. The children in this study seemed to be less emotionally concerned about their verrucae, despite this most families had sought treatment for the verrucae.
Collapse
Affiliation(s)
- Jill Ferrari
- University of East London, Stratford, London, UK.
| |
Collapse
|
6
|
Udaondo C, Núñez Cuadros E, Murias S, Remesal A, Alcobendas R, Guerrero C, Guillen-Martin S, Escuredo M, Aleo E, Alonso D, Tagarro A, De Santiago E, Camacho-Lovillo M, Diaz F, Arenas D, Camacho P, Lirola MJ, Díaz Almirón M, Calvo C. Are infections in children with juvenile idiopathic arthritis more frequent than in healthy children? A prospective multicenter observational study. Front Pediatr 2022; 10:917731. [PMID: 36034561 PMCID: PMC9403004 DOI: 10.3389/fped.2022.917731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/26/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Children with juvenile idiopathic arthritis (JIA) might be at a higher risk of infection. Our objectives are to describe and compare infection rates in patients with JIA vs. healthy patients. METHODS A prospective, multicenter observational study was performed in Spain from January 2017 to June 2019. Patients with JIA from 7 participating hospitals and children without JIA (siblings of patients with JIA, and non-JIA children from primary health centers) were followed up with quarterly questionnaires to record infection episodes. Tuberculosis, herpes zoster, and infections requiring hospital admission were considered severe infections. Rates of infection (episodes/patient/year) were compared using a generalized estimating equations model. RESULTS A total of 371 children (181 with and 190 without JIA) were included. The median age was 8.8 years (IQR 5.5-11.3); 75% of the patients with JIA received immunosuppressive treatment (24% methotrexate, 22% biologic, 26% both). A total of 667 infections were recorded; 15 (2.2%) were considered severe. The infection rate was 1.31 (95%CI 1.1-1.5) in JIA and 1.12 (95%CI 0.9-1.3) in non-JIA participants (p = 0.19). Age <4 years increased the infection rate by 2.5 times (2.72 vs. 1.12, p < 0.001) in both groups. The most frequent infection sites were upper respiratory (62.6% vs. 74.5%) and gastrointestinal (18.8% vs. 11.4%). There were no differences in severe infections (2.5% vs. 2%, p = 0.65) between the groups. In children with JIA, younger age and higher disease activity (JADAS71) were associated with a higher infection rate. CONCLUSION We found no differences in the infection rate or infection severity between patients with and without JIA. Most infections were mild. An age younger than 4 years increased the infection risk in both groups. Higher disease activity was associated with a higher infection rate.
Collapse
Affiliation(s)
- Clara Udaondo
- Pediatric Rheumatology Unit, University Hospital La Paz, Madrid, Spain.,La Paz Research Institute (IDIPaz), Madrid, Spain.,CIBERINFEC ISCIII, Madrid, Spain
| | - Esmeralda Núñez Cuadros
- Pediatric Rheumatology Unit, UCG Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Sara Murias
- Pediatric Rheumatology Unit, University Hospital La Paz, Madrid, Spain
| | - Agustin Remesal
- Pediatric Rheumatology Unit, University Hospital La Paz, Madrid, Spain
| | - Rosa Alcobendas
- Pediatric Rheumatology Unit, University Hospital La Paz, Madrid, Spain
| | | | - Sara Guillen-Martin
- Pediatric Rheumatology Unit, UCG Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain.,Pediatrics, Hospital de Getafe, Madrid, Spain
| | | | - Esther Aleo
- Pediatrics, Fundación para la Investigación del Hospital Clínico San Carlos, Hospital Clinico San Carlos, Madrid, Spain
| | | | - Alfredo Tagarro
- Fundación de Investigación Biomédica Hospital 12 de Octubre. Instituto de Investigación 12 de Octubre (imas12), Madrid, Spain.,Department of Pediatrics, Infanta Sofía University Hospital, Madrid, Spain.,Infanta Sofia University Hospital and Henares University Hospital Foundation for Biomedical Research and Innovation (FIIB HUIS HHEN), Madrid, Spain.,Facultad de Medicina, Universidad Europea de Madrid, Madrid, Spain
| | | | - Marisol Camacho-Lovillo
- Pediatric Immunology, Rheumatology and Infectious Diseases Department, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | | | - Pilar Camacho
- Pediatrics, Centro Alcala de Guadaira, Seville, Spain
| | - Maria Jose Lirola
- Pediatric Rheumatology, Grupo IHP - Instituto Hispalense de Pediatría, Seville, Spain
| | - Mariana Díaz Almirón
- CIBERINFEC ISCIII, Madrid, Spain.,Biostatistics, Investigation department, IDIPaz, University Hospital La Paz, Madrid, Spain
| | - Cristina Calvo
- CIBERINFEC ISCIII, Madrid, Spain.,Pediatric Rheumatology Unit, UCG Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain.,Pediatric Infectious Diseases Department, University Hospital La Paz, Madrid, Spain
| |
Collapse
|
7
|
Balažiová B, Kuková Z, Mišíková D, Novosedlíková K, Dallos T. Real-life vaccination coverage in Slovak children with rheumatic diseases. Front Pediatr 2022; 10:956136. [PMID: 36034574 PMCID: PMC9412159 DOI: 10.3389/fped.2022.956136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 07/13/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Evidence-based recommendations for vaccination of patients with pediatric rheumatic diseases (PRDs) are available, their implementation in practice is unknown. OBJECTIVES To analyze real-life vaccination coverage in children with PRDs and identify reasons for incomplete vaccination. METHODS Up-to-date information on vaccination status of Slovak children followed at a tertiary pediatric rheumatology center was retrieved from pediatricians over an 18-month period and compared to the standard Slovak Immunization Schedule. Reasons for missed vaccinations were analyzed retrospectively. RESULTS Vaccination records of 156 patients (median age 10 years, 2-18) with PRDs (JIA n = 108, systemic diseases n = 21, autoinflammatory diseases n = 16, uveitis n = 9, others n = 2) were available for analysis. 117 (75.0%) were completely vaccinated, 2 (1.3%) had not received any vaccine due to reasons unrelated to PRD. 37 (23.7%) remaining patients missed altogether 48 mandatory vaccinations. In 58.3% (n = 28, in 24 patients) no PRD related reasons for missing vaccinations were identified. Only 20 vaccinations (18 live-attenuated and 2 non-live in 19 patients) were missed due to ongoing immunosuppressive treatment or PRD activity. Patients aged 11-14 years were more likely to be incompletely vaccinated than other age groups (48.8% vs. 15.9%, p < 0.001), mainly due to missed MMR booster. Systemic immunosuppressive treatment was a significant predictor for incomplete vaccination status (OR 5.03, 95% CI 1.13-22.31, p = 0.03). CONCLUSION Full vaccination is possible in a high proportion of PRD patients. In addition to immunosuppressive therapy, reasons unrelated to PRDs are a frequent and possibly inadequate cause of missed vaccinations. Periodic vaccination status assessments are needed in pediatric rheumatology care.
Collapse
Affiliation(s)
- Barbora Balažiová
- Department of Pediatrics, National Institute for Children's Diseases, Comenius University Medical School in Bratislava, Bratislava, Slovakia
| | - Zuzana Kuková
- Department of Pediatrics, National Institute for Children's Diseases, Comenius University Medical School in Bratislava, Bratislava, Slovakia
| | - Daša Mišíková
- Department of Pediatrics, National Institute for Children's Diseases, Comenius University Medical School in Bratislava, Bratislava, Slovakia
| | - Katarína Novosedlíková
- Department of Pediatrics, National Institute for Children's Diseases, Comenius University Medical School in Bratislava, Bratislava, Slovakia
| | - Tomáš Dallos
- Department of Pediatrics, National Institute for Children's Diseases, Comenius University Medical School in Bratislava, Bratislava, Slovakia
| |
Collapse
|
8
|
Freudenhammer M, Hufnagel M. [Travelling with children and adolescents with rheumatic diseases]. Z Rheumatol 2021; 80:620-628. [PMID: 33904986 PMCID: PMC8077853 DOI: 10.1007/s00393-021-01002-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2021] [Indexed: 10/27/2022]
Abstract
Due to the underlying disease and immunosuppressive treatment, pediatric patients with rheumatic diseases are at increased risk for (long distance) travel-related health problems. A pretravel comprehensive consultation is therefore strongly recommended. Whether a child with rheumatic disease is sufficiently fit for travel essentially depends on the disease activity, the age of the child and the intended travel destination. Depending on the level of immunosuppression, the risks for this patient group include (travel-related) infections and the possibility of disease activity flares. Of particular importance is adequate exposure prevention: standard vaccinations should be updated and indications for travel vaccinations evaluated in advance of travelling. In this context, potential contraindications, especially for live vaccines, in the case of specific immunosuppressive treatment should be considered. In the event of travel to malaria endemic areas, the necessity for chemoprophylaxis or stand-by medication must be evaluated but caution is needed regarding potential drug interactions. Detailed education about careful hand, food and contact hygiene is critical. Because photosensitivity may be increased in some rheumatic diseases and/or medications, UV protection is crucial. Barriers (clothes and mosquito nets) and age-appropriate chemical insect repellents should be used to prevent insect-borne diseases. Before start of travel, possibilities for on-site medical help in the event of disease deterioration and/or infection should be evaluated. This should be included in the assessment of the patient's ability to travel. Travelers with rheumatic disease should carry a first aid kit that includes both a sufficient supply of regular antirheumatic medication and supplemental medication in case of a disease flare. Storage conditions must be taken ínto account for some medications. Ultimately, the success of a journey depends on the planning from the perspective of the child with its specific needs.
Collapse
Affiliation(s)
- M Freudenhammer
- Abteilung für Pädiatrische Infektiologie und Rheumatologie, Klinik für Allgemeine Kinder- und Jugendmedizin, Universitätsklinikum Freiburg, Mathildenstr. 1, 79106, Freiburg, Deutschland.
- IMM-PACT Clinician Scientist Programm, Medizinische Fakultät, Universität Freiburg, Freiburg, Deutschland.
| | - M Hufnagel
- Abteilung für Pädiatrische Infektiologie und Rheumatologie, Klinik für Allgemeine Kinder- und Jugendmedizin, Universitätsklinikum Freiburg, Mathildenstr. 1, 79106, Freiburg, Deutschland.
| |
Collapse
|
9
|
Rutstein BH, Gmuca S, Gerber JS, Lim T, Argraves M, Ogdie A. Validation of coding algorithms for the identification of herpes zoster among children. Pharmacoepidemiol Drug Saf 2021; 30:1162-1167. [PMID: 33960541 DOI: 10.1002/pds.5264] [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: 03/03/2021] [Revised: 04/28/2021] [Accepted: 05/03/2021] [Indexed: 11/08/2022]
Abstract
PURPOSE To examine the validity of International Classification of Diseases, 10th Revision, (ICD-10) code-based algorithms for herpes zoster (HZ) in the electronic medical record (EMR) of a large, integrated pediatric healthcare network and to examine baseline demographics and chronic comorbidities associated with HZ in a representative pediatric population. METHODS We reviewed the electronic charts of all patients with a single ICD-10 for HZ (B02.xx) as their primary or secondary diagnosis in the EMR of the Children's Hospital of Philadelphia (CHOP) healthcare network from January 2010-March 2019. The positive predictive value (PPV) for a single code for HZ was calculated and alternative algorithms were examined to determine which method resulted in the highest PPV. RESULTS The PPV for a single ICD-10 code was 91.7% (95% CI 80.8-95.4) for definitive and/or probable cases of HZ and 63.9% (95% CI 53.4%-75.5%) for definitive cases alone. Adding a prescription for an antiviral did not improve the PPV. However, adding a new code for rash entered within 1 week of the HZ code increased the PPV to 100% for definitive and/or probable cases but with substantial loss of sensitivity. A high proportion of children with HZ who required inpatient hospitalization had chronic disease (70%) and were on systemic immunomodulatory therapy (50%). CONCLUSIONS HZ can be identified with a high PPV in electronic medical records of children using ICD-10 code alone. These findings lay the foundation for future pharmacoepidemiologic research to better understand risk factors for HZ infection.
Collapse
Affiliation(s)
- Beth H Rutstein
- Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sabrina Gmuca
- Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeffrey S Gerber
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Tristan Lim
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Melissa Argraves
- Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alexis Ogdie
- Department of Medicine, Division of Rheumatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
10
|
Hepatitis B vaccination response of treatment-naive patients with juvenile idiopathic arthritis. Rheumatol Int 2021; 42:1199-1205. [PMID: 33738550 DOI: 10.1007/s00296-021-04833-3] [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: 02/15/2021] [Accepted: 03/02/2021] [Indexed: 10/21/2022]
Abstract
To evaluate the vaccine response of treatment-naive juvenile idiopathic arthritis (JIA) patients who were fully vaccinated against Hepatitis B Virus (HBV) and then compare their antibody status with healthy controls. In this multicenter study, initial visit hepatitis B surface antigen (HbsAg) and anti-hepatitis B surface antibody (anti-Hbs) titers of 262 treatment-naive JIA patients who were followed up regularly between May 2015 and October 2019 were evaluated retrospectively from patients' medical records and compared with 276 healthy peers. Both HbsAg and anti-Hbs antibody titers were tested by the ELISA technique. Anti-HBs titers ≥ 10 IU/L were considered as reactive indicating seroprotection against HBV. In the JIA group, seropositivity rate was 59.1% while 72.9% of the control group were immune against HBV (p = 0.002). The median titer for anti-Hbs was 14 (range: 0-1000) IU/L in the patient group and 43.3 (range: 0-1000) IU/L in the control group (p = 0.01). Neither JIA patients nor healthy controls were positive for HbsAg. Patients with JIA vaccinated according to the national vaccination schedule were evaluated at their first visit in pediatric rheumatology outpatient clinics for anti-Hbs presence and it was found that they have lesser seroprotectivity than their age and sex-matched routinely vaccinated, healthy peers. So, to complete missing vaccines and booster vaccine doses, assessing the immune status of the patients at the time of diagnosis against HBV should be in the check-list of physicians dealing with pediatric rheumatic diseases.
Collapse
|
11
|
Horton DB, Salas J, Wec A, Kohlheim M, Kapadia P, Beukelman T, Boneparth A, Haverkamp K, Mannion ML, Moorthy LN, Ringold S, Rosenthal M. Making Decisions About Stopping Medicines for Well-Controlled Juvenile Idiopathic Arthritis: A Mixed-Methods Study of Patients and Caregivers. Arthritis Care Res (Hoboken) 2021; 73:374-385. [PMID: 31880862 PMCID: PMC7319899 DOI: 10.1002/acr.24129] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 12/17/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Improved treatments for juvenile idiopathic arthritis (JIA) have increased remission rates. We conducted this study to investigate how patients and caregivers make decisions about stopping medications when JIA is inactive. METHODS We performed a mixed-methods study of caregivers and patients affected by JIA, recruited through social media and flyers, and selected by purposive sampling. Participants discussed their experiences with JIA, medications, and decision-making through recorded telephone interviews. Of 44 interviewees, 20 were patients (50% ages <18 years), and 24 were caregivers (50% caring for children ages ≤10 years). We evaluated characteristics associated with high levels of reported concerns about JIA or medicines using Fisher's exact testing. RESULTS Decisions about stopping medicines were informed by competing risks between disease activity and treatment. Participants who expressed more concerns about JIA were more likely to report disease-related complications (P = 0.002) and more motivated to continue treatment. However, participants expressing more concern about medicines were more likely to report treatment-related complications (P = 0.04) and felt more compelled to stop treatment. Additionally, participants considered how JIA or treatments facilitated or interfered with their sense of normalcy and safety, expressed feelings of guilt and regret about previous or potential adverse events, and reflected on uncertainty and unpredictability of future harms. Decision-making was also informed by trust in rheumatologists and other information sources (e.g., family and online support groups). CONCLUSION When deciding whether to stop medicines whenever JIA is inactive, patients and caregivers weigh competing risks between disease activity and treatment. Based on our results, we suggest specific approaches for clinicians to perform shared decision-making regarding stopping medicines for JIA.
Collapse
Affiliation(s)
- Daniel B. Horton
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Jomaira Salas
- Department of Sociology, Rutgers University, New Brunswick, NJ, USA
| | | | - Melanie Kohlheim
- Pediatric Rheumatology Care and Outcomes Improvement Network, Cincinnati, OH, USA
| | - Pooja Kapadia
- Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | | | | | - Ky Haverkamp
- University of Washington School of Medicine, Seattle, WA, USA
| | | | - L. Nandini Moorthy
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | | | - Marsha Rosenthal
- Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ, USA
| |
Collapse
|
12
|
Rollet-Cohen V, Mirete J, Dingulu G, Hofer F, Hofer M, Woerner A, Dommergues MA, Hentgen V. Suboptimal vaccination coverage of recommended vaccines among French children with recurrent autoinflammatory fever syndromes: a study from the Juvenile Inflammatory Rheumatism cohort. Clin Rheumatol 2021; 40:2855-2864. [PMID: 33439385 DOI: 10.1007/s10067-020-05553-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/08/2020] [Accepted: 12/16/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION/OBJECTIVES To determine vaccination coverage among a French cohort of children with recurrent autoinflammatory fever syndromes (RFS). METHOD All RFS children aged 2 to 19 years from the Juvenile Inflammatory Rheumatism cohort and followed at the French Reference Center for Autoinflammatory Diseases, Versailles Hospital, were included in our observational study. Immunisation status at ages 2, 7 and 15 years and at the last outpatient visit was evaluated according to the standard French vaccine schedule and recommended supplementary vaccines for patients with immunosuppressive therapy. RESULTS Of 200 patients, 90 (45%) had periodic fever, aphthous stomatitis, pharyngitis and adenitis syndrome; 52 (26%) had familial Mediterranean fever and 50 (25%) had undefined recurrent fever. Complete immunisation as per the standard schedule was obtained by 32% of patients at 2 years, 28% at 7 years, 6% at 15 years and 44% at the last outpatient visit. Similar or higher coverage was obtained by the last outpatient visit for most vaccines, compared to immunisation coverage at 2 years: pneumococcus (91% vs 88%), diphtheria tetanus poliomyelitis (82% vs 86%), hepatitis B (79% vs 69%) and measles, mumps, rubella (91% vs 50%). No patients with immunosuppressive therapy (n = 14) were up to date for all supplementary immunisations recommended for them. CONCLUSION Vaccination coverage for RFS children is suboptimal, especially for infants who present with recurrent febrile episodes. The initial vaccination delay is partially corrected through specialist follow-up in later years. Coverage according to the supplementary vaccine recommendations for immunosuppressed patients is poor. Key Points • Vaccination coverage for RFS children is suboptimal, especially at 2 years of age which is likely due to the prevalence of early recurrent febrile symptoms. • The initial vaccination delay is partially recovered during later follow-up at an expert rheumatology center. • Specific recommendations are particularly difficult to apply to patients on immunosuppressive therapy.
Collapse
Affiliation(s)
- Virginie Rollet-Cohen
- Department of General Pediatrics, Versailles Hospital, 177 rue de Versailles, 78150, Le Chesnay, Paris, France.
| | - Justine Mirete
- Department of General Pediatrics, Versailles Hospital, 177 rue de Versailles, 78150, Le Chesnay, Paris, France
| | - Glory Dingulu
- Reference Center for Autoinflammatory Diseases and Amyloidosis, Versailles Hospital-CEREMAIA, 78150, Le Chesnay, Paris, France
| | - François Hofer
- Fondation Rhumatismes-Enfants-Suisse, 1163, Etoy, Switzerland
| | - Michael Hofer
- Paediatric Rheumatology Western Switzerland, Centre Hospitalier Universitaire Vaudois (CHUV), 1011, Lausanne, Switzerland.,Hospital Universitaire Genève (HUG), 1206, Geneva, Switzerland
| | - Andreas Woerner
- Paediatric Rheumatology, University of Basel, University Children's Hospital, 4031, Basel, Switzerland
| | - Marie-Aliette Dommergues
- Department of General Pediatrics, Versailles Hospital, 177 rue de Versailles, 78150, Le Chesnay, Paris, France
| | - Véronique Hentgen
- Department of General Pediatrics, Versailles Hospital, 177 rue de Versailles, 78150, Le Chesnay, Paris, France.,Reference Center for Autoinflammatory Diseases and Amyloidosis, Versailles Hospital-CEREMAIA, 78150, Le Chesnay, Paris, France
| |
Collapse
|
13
|
Abstract
PURPOSE OF REVIEW Several biologic drugs are available for treatment of immune-mediated diseases, and the number of children treated with biologics is increasing. This review summarises current knowledge about the safety and immunogenicity of vaccines in children treated with biologic therapy. RECENT FINDINGS A recent retrospective, multicentre study reported that the booster dose of live-attenuated vaccine (MMR/V) was safe for patients with rheumatic diseases treated with biologic therapy. Recent publications revealed that immunogenicity of vaccines in children treated with biologics was lower than in the healthy population, especially on long-term follow-up. Children treated with biologic therapy are at greater danger of infections, compared to the healthy population. Therefore, they should be vaccinated according to national guidelines. Regardless of the therapy, non-live vaccines are recommended. However, it is common practice to advise postponing vaccination with live-attenuated vaccines in children while they are on immunosuppressive therapy. Newly published data suggest that booster dose MMR/V is safe for children treated with biologic therapy.
Collapse
Affiliation(s)
- Nataša Toplak
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre Ljubljana, Bohoričeva 20, 1000, Ljubljana, Slovenia. .,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
| | - Yosef Uziel
- Pediatric Rheumatology Unit, Department of Pediatrics, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
14
|
Giancane G, Swart JF, Castagnola E, Groll AH, Horneff G, Huppertz HI, Lovell DJ, Wolfs T, Herlin T, Dolezalova P, Sanner H, Susic G, Sztajnbok F, Maritsi D, Constantin T, Vargova V, Sawhney S, Rygg M, K Oliveira S, Cattalini M, Bovis F, Bagnasco F, Pistorio A, Martini A, Wulffraat N, Ruperto N. Opportunistic infections in immunosuppressed patients with juvenile idiopathic arthritis: analysis by the Pharmachild Safety Adjudication Committee. Arthritis Res Ther 2020; 22:71. [PMID: 32264969 PMCID: PMC7136994 DOI: 10.1186/s13075-020-02167-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/27/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND To derive a list of opportunistic infections (OI) through the analysis of the juvenile idiopathic arthritis (JIA) patients in the Pharmachild registry by an independent Safety Adjudication Committee (SAC). METHODS The SAC (3 pediatric rheumatologists and 2 pediatric infectious disease specialists) elaborated and approved by consensus a provisional list of OI for use in JIA. Through a 5 step-procedure, all the severe and serious infections, classified as per MedDRA dictionary and retrieved in the Pharmachild registry, were evaluated by the SAC by answering six questions and adjudicated with the agreement of 3/5 specialists. A final evidence-based list of OI resulted by matching the adjudicated infections with the provisional list of OI. RESULTS A total of 772 infectious events in 572 eligible patients, of which 335 serious/severe/very severe non-OI and 437 OI (any intensity/severity), according to the provisional list, were retrieved. Six hundred eighty-two of 772 (88.3%) were adjudicated as infections, of them 603/682 (88.4%) as common and 119/682 (17.4%) as OI by the SAC. Matching these 119 opportunistic events with the provisional list, 106 were confirmed by the SAC as OI, and among them infections by herpes viruses were the most frequent (68%), followed by tuberculosis (27.4%). The remaining events were divided in the groups of non-OI and possible/patient and/or pathogen-related OI. CONCLUSIONS We found a significant number of OI in JIA patients on immunosuppressive therapy. The proposed list of OI, created by consensus and validated in the Pharmachild cohort, could facilitate comparison among future pharmacovigilance studies. TRIAL REGISTRATION Clinicaltrials.gov NCT01399281; ENCePP seal: awarded on 25 November 2011.
Collapse
Affiliation(s)
- Gabriella Giancane
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO, Genoa, Italy
| | - Joost F Swart
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, University Utrecht, European Reference Network-RITA, Utrecht, The Netherlands
| | - Elio Castagnola
- Department of Infectious Diseases, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andreas H Groll
- Infectious Disease Research Program, Department of Pediatric Hematology and Oncology, University Children's Hospital, Münster, Germany
| | - Gerd Horneff
- Asklepios Clinic Sankt Augustin, Department of General Paediatrics, Sankt Augustin, Germany
- Medical Faculty, Department of Paediatric and Adolescents Medicine, University Hospital of Cologne, Cologne, Germany
| | - Hans-Iko Huppertz
- Clinic Bremen-Mitte, Prof.-Hesse Children's Hospital and Pediatric Intensive Care Medicine, Bremen, Germany
| | - Daniel J Lovell
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tom Wolfs
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, University Utrecht, European Reference Network-RITA, Utrecht, The Netherlands
| | - Troels Herlin
- Pediatric Rheumatology Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Pavla Dolezalova
- 1st Faculty of Medicine, Department of Pediatrics and Adolescent Medicine, Charles University in Prague and General University Hospital, Praha, Czech Republic
| | - Helga Sanner
- Department of Rheumatology, Oslo University Hospital, Oslo, Norway
- Norwegian National Advisory Unit on Rheumatic Diseases in Children and Adolescents, Oslo, Norway
| | - Gordana Susic
- Institute of Rheumatology of Belgrade, Division of Pediatric Rheumatology, Belgrade, Serbia
| | - Flavio Sztajnbok
- Hospital Universitario Pedro Ernesto, Nucleo de Estudos da Saúde do Adolescente, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Despoina Maritsi
- 2nd Department of Pediatrics Athens Medical School, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Tamas Constantin
- Unit of Pediatric Rheumatology-Immunology, Second Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Veronika Vargova
- Faculty of Medicine, Department of Paediatrics and Adolescent Medicine, Pavol Jozef Šafárik University in Košice, Kosice, Slovakia
| | - Sujata Sawhney
- Sir Ganga Ram Hospital Marg, Centre for Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Marite Rygg
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
- Department of Pediatrics, St. Olavs University Hospital of Trondheim, Trondheim, Norway
| | - Sheila K Oliveira
- Instituto de Puericultura e Pediatria Martagao Gesteira (IPPMG), Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marco Cattalini
- Clinica Pediatrica dell'Università di Brescia, Spedali Civili, Unità di Immunologia e Reumatologia Pediatrica, Brescia, Italy
| | - Francesca Bovis
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO, Genoa, Italy
| | - Francesca Bagnasco
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO, Genoa, Italy
| | - Angela Pistorio
- IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy
| | - Alberto Martini
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DiNOGMI), Università degli Studi di Genova, Genoa, Italy
| | - Nico Wulffraat
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, University Utrecht, European Reference Network-RITA, Utrecht, The Netherlands
| | - Nicolino Ruperto
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO, Genoa, Italy.
| |
Collapse
|
15
|
Cimaz R, Maioli G, Calabrese G. Current and emerging biologics for the treatment of juvenile idiopathic arthritis. Expert Opin Biol Ther 2020; 20:725-740. [PMID: 32116038 DOI: 10.1080/14712598.2020.1733524] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The management of a child with juvenile idiopathic arthritis (JIA) requires a combination of pharmacological, physical, and psychosocial therapies in order to induce disease remission, by controlling articular and systemic inflammation. This review aims to provide a comprehensive discussion on the biological therapies currently in use in the treatment of JIA referring to existing recommendations and clinical evidence. We also discuss on the emerging biological drugs actually under consideration. AREAS COVERED Recent findings on immunological mechanisms involved in the pathogenesis of the disease allowed us to identify several specific targets for biologic therapies. A systematic literature review was conducted between January 1997 and January 2020 on PubMed including national and international guidelines and recommendations, trials and case-control studies. EXPERT OPINION There is now a plethora of therapies that are directed against variable targets, and the physician has to choose the most appropriate available medication in order to achieve early and sustained remission with as few side effects as possible. Research is advancing very fast in order to be more and more specific in suppressing inflammatory pathways without harming natural defenses. Finally, pharmacoeconomic considerations will also be very important to deal with, considering the high cost of most of these molecules.
Collapse
Affiliation(s)
- Rolando Cimaz
- Pediatric Rheumatology Department, ASST-Gaetano Pini-CTO, Department of Clinical Sciences and Community Health, University of Milan , Milan, Italy.,Pediatric Rheumatology Department, ASST-Gaetano Pini-CTO, University of Milan , Milan, Italy
| | | | | |
Collapse
|
16
|
Infectious adverse events in children with Juvenile Idiopathic Arthritis treated with Biological Agents in a real-life setting: Data from the JIRcohorte. Joint Bone Spine 2019; 87:49-55. [PMID: 31369865 DOI: 10.1016/j.jbspin.2019.07.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 07/17/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The main objective of our study is to assess the infectious adverse events occurring in juvenile idiopathic arthritis (JIA) children treated with biological agents. METHODS Patients were selected from the retrospective module of the JIRcohorte, data concerning the period between January 2001 and August 2015. All infectious adverse events (IAE) were retrieved. For every infectious side effect, the date, the severity, the need for a hospitalization, the type of pathogen and the affected organ were noted. Incidence rates were expressed in number of events per 100 person-years (100p-y), and OR were calculated. RESULTS Six hundred seventy-seven patients with JIA were included in the study. A total of 3075.4 person-years of exposure were analyzed. One hundred eighty-four infectious events were described (6.0 events/100 p-y): 15.5/100 p-y with tocilizumab (TCZ), 9.6/100 p-y with Canakinumab (CAN), 7.4/100 p-y with abatacept (ABA), 6.9/100 p-y with Golimumab (GOL), 6.7/100 p-y with Anakinra (ANA), 6.3/100 p-y with Infliximab, 4.8/100 p-y with Etanercept, and 3.7/100 p-y with Adalimumab. Risk of developing an infection was significantly higher with IL-6 antagonists or IL-1 antagonists than with TNF-inhibitor. Forty point eight percent of the infectious adverse events (IAE) affected the upper respiratory tract or the Ear, nose and throat (ENT) system. Twelve infectious adverse events were described as severe or very severe (0.4/100p-y). No case of tuberculosis or death was reported. CONCLUSION Infectious complications with biologics occurring in children treated for JIA are rare, and in most of the cases have a mild or moderate severity, affecting mainly the upper respiratory tract or the ENT.
Collapse
|
17
|
|
18
|
Abstract
Juvenile idiopathic arthritis (JIA) is a chronic childhood arthritis. Its pathogenesis is very complicated, with the involvement of not only immune cells but various types of parenchymal cells, and is affected by both genetic and environmental predispositions. The clinical spectrum from inflammation to related conditions is largely mediated by cytokines including interleukin (IL)-6. Fluctuations in IL-6 and its related molecules can modulate the pathogenesis and the clinical presentation positively or negatively. The recent clinical impact of IL-6 blockade on JIA has begun a therapeutic paradigm shift. This review describes the characteristics of JIA, mainly focused on IL-6 with the current therapeutic perspective.
Collapse
Affiliation(s)
- Shinji Akioka
- a Department of Pediatrics , Kyoto Prefectural University of Medicine , Kyoto , Japan
| |
Collapse
|
19
|
Basiaga ML, Ross ME, Gerber JS, Ogdie A. Incidence of Pneumocystis jirovecii and Adverse Events Associated With Pneumocystis Prophylaxis in Children Receiving Glucocorticoids. J Pediatric Infect Dis Soc 2018; 7:283-289. [PMID: 28992298 PMCID: PMC6276024 DOI: 10.1093/jpids/pix052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 06/02/2017] [Indexed: 11/14/2022]
Abstract
BACKGROUND Antimicrobial prophylaxis is indicated to prevent Pneumocystis jirovecii pneumonia (PJP) in profoundly immunosuppressed children. The incidence of PJP infection in children with chronic glucocorticoid exposure is unknown, and PJP prophylaxis has been associated with adverse events. We hypothesized that PJP infection is rare in children without human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), cancer, or a transplant history who are using chronic glucocorticoids and that those exposed to PJP prophylaxis are more likely to experience a cutaneous hypersensitivity reaction or myelosuppression than unexposed patients. METHODS This study involved a retrospective cohort from the Clinformatics Data Mart Database (OptumInsight, Eden Prairie, MN). We identified patients ≤18 years of age who received at least 2 prescriptions for a systemic glucocorticoid within a 60-day period and excluded patients with a history of PJP infection, an oncologic diagnosis, transplant, or HIV/AIDS. PJP prophylaxis exposure was identified by using national drug codes. Cutaneous hypersensitivity reaction or myelosuppression was identified by using International Classification of Diseases, 9th Revision (ICD-9), codes. We used a discrete time-failure model to examine the association between exposure and outcome. RESULTS We identified 119399 children on glucocorticoids, 10% of whom received PJP prophylaxis. The incidences of PJP were 0.61 and 0.53 per 10000 patient-years in children exposed and those unexposed to PJP prophylaxis, respectively. In a multivariable model, trimethoprim-sulfamethoxazole was associated with cutaneous hypersensitivity reaction (odds ratio, 3.20; 95% confidence interval, 2.62-3.92) and myelosuppression (odds ratio, 1.85; 95% confidence interval, 1.56-2.20). CONCLUSIONS PJP infection was rare in children using glucocorticoids chronically, and PJP prophylaxis-associated cutaneous hypersensitivity reactions and myelosuppression are more common. The use of PJP chemoprophylaxis in children without HIV/AIDS, cancer, or a transplant history who are taking glucocorticoids chronically should be considered carefully.
Collapse
Affiliation(s)
- Matthew L Basiaga
- Division of Rheumatology, Department of Pediatrics, Seattle Children’s Hospital, University of Washington School of Medicine,Correspondence: M. L. Basiaga, DO, MSCE, Seattle Children’s Hospital, 4800 Sand Point Way NE, M.A.7.110, Seattle, WA 98107 ()
| | - Michelle E Ross
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine
| | - Jeffrey S Gerber
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine,Division of Infectious Diseases, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine
| | - Alexis Ogdie
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine,Division of Rheumatology, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine
| |
Collapse
|
20
|
Marino A, Giani T, Cimaz R. Risks associated with use of TNF inhibitors in children with rheumatic diseases. Expert Rev Clin Immunol 2018; 15:189-198. [PMID: 30451548 DOI: 10.1080/1744666x.2019.1550359] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction: Tumor necrosis factor alpha (TNF-α) is a pro-inflammatory cytokine involved in the pathogenesis of many inflammatory diseases. Several drugs blocking TNF-α are employed in clinical practice in pediatrics. Given their action on the immune system, TNF-α inhibitors have raised concerns on their safety profile since their introduction. A broad spectrum of side effects related to TNF inhibition has been reported: immunogenicity, infectious diseases, malignancies, and others. Areas covered: In order to assess the risk related to the use of anti-TNF-α agents in children with rheumatic diseases we analyzed data obtained from retrospective and prospective safety studies, case reports and case series, and controlled trials. Expert commentary: Anti-TNF-α agents have shown a remarkably good safety profile in the pediatric population so far. However, there are lots of questions to be answered and maintaining active surveillance on these drugs is necessary in order to not overlook any possible unexpected adverse effects.
Collapse
Affiliation(s)
- Achille Marino
- a Department of Pediatrics, Desio Hospital , ASST Monza , Desio (MB) , Italy.,b PhD student in Biomedical Sciences , University of Florence , Florence , Italy
| | - Teresa Giani
- c Department of Medical Biotechnology , University of Siena , Siena , Italy.,d Rheumatology Unit, Meyer Children's Hospital , University of Florence , Florence , Italy
| | - Rolando Cimaz
- e Department of Neurosciences, Psychology, Drug Research and Child Health, Rheumatology Unit, Meyer Children's Hospital , University of Florence , Florence , Italy
| |
Collapse
|
21
|
The frequency of infections in patients with juvenile idiopathic arthritis on biologic agents: 1-year prospective study. Clin Rheumatol 2018; 38:1025-1030. [PMID: 30448935 DOI: 10.1007/s10067-018-4367-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 11/02/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
|
22
|
Mehta J, Beukelman T. Biologic Agents in the Treatment of Childhood-Onset Rheumatic Disease. J Pediatr 2017; 189:31-39. [PMID: 28711176 DOI: 10.1016/j.jpeds.2017.06.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 06/05/2017] [Accepted: 06/15/2017] [Indexed: 12/22/2022]
Affiliation(s)
- Jay Mehta
- Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Timothy Beukelman
- Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, Birmingham, AL.
| |
Collapse
|
23
|
Brunelli JB, Schmidt AR, Sallum AME, Goldenstein-Schainberg C, Bonfá E, Silva CA, Aikawa NE. High rate of serious infection in juvenile idiopathic arthritis patients under biologic therapy in a real-life setting. Mod Rheumatol 2017; 28:264-270. [PMID: 28949278 DOI: 10.1080/14397595.2017.1349059] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES To assess the rate of serious and/or opportunistic infections in juvenile idiopathic arthritis (JIA) patients from a single tertiary center under biologic therapy and to identify possible risk factors associated to these complications. METHODS A total of 107 JIA patients followed at the biologic therapy center of our tertiary university hospital using a standardized electronic database protocol including demographic data, clinical and laboratorial findings and treatment at baseline and at the moment of infection. Opportunistic infections included tuberculosis, herpes zoster and systemic mycosis. RESULTS A total of 398 patient-yrs(py) were included. The median time of biologic exposure was 3.0 years (0.15-11.5). We observed 35 serious/opportunistic infectious events in 27 (25%) patients: 31(88.6%) were serious infections and four (11.4%) opportunistic infections. Serious/opportunistic infections rates were 10.6/100py for ETN, 10.9/100py for ADA, 2.6/100py for ABA and 14.8/100py for TCZ. Comparison of 27 patients with and 80 without infection showed a higher frequency of systemic-onset JIA, lower age at biologic therapy initiation and a history of previous serious infection (p < .05) in the former group. CONCLUSIONS This study demonstrated a high rate of serious infections in JIA patients under biologic therapy in a real-life setting. Systemic-onset JIA, lower age at biologic therapy start and history of previous serious infections were important risk factors for these complications. Also, higher rates of severe infections comparing to the former studies was possibly due to elevated MTX doses in our patients.
Collapse
Affiliation(s)
- Juliana Barbosa Brunelli
- a Pediatric Rheumatology Unit, Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , São Paulo , Brazil
| | - Ana Renata Schmidt
- a Pediatric Rheumatology Unit, Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , São Paulo , Brazil
| | - Adriana Maluf Elias Sallum
- a Pediatric Rheumatology Unit, Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , São Paulo , Brazil
| | - Claudia Goldenstein-Schainberg
- b Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , São Paulo , Brazil
| | - Eloisa Bonfá
- b Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , São Paulo , Brazil
| | - Clovis A Silva
- a Pediatric Rheumatology Unit, Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , São Paulo , Brazil
| | - Nádia Emi Aikawa
- a Pediatric Rheumatology Unit, Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , São Paulo , Brazil.,b Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , São Paulo , Brazil
| |
Collapse
|
24
|
Lawrence SJ, Sadarangani M, Jacobson K. Pneumocystis jirovecii Pneumonia in Pediatric Inflammatory Bowel Disease: A Case Report and Literature Review. Front Pediatr 2017; 5:161. [PMID: 28791279 PMCID: PMC5522842 DOI: 10.3389/fped.2017.00161] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 07/06/2017] [Indexed: 01/15/2023] Open
Abstract
Immunosuppressive therapy is a known risk factor for opportunistic infections. We report the first case of severe Pneumocystis jirovecii infection requiring intensive care in a pediatric patient with inflammatory bowel disease (IBD). The literature was reviewed and there were 92 reported cases of Pneumocystis pneumonia (PCP) in patients with IBD. Most sources were case reports and there was likely reporting bias toward patients receiving immunomodulators, anti-tumor necrosis factor (anti-TNF) therapy, and those who died. Overall, 56% of patients were males and 58% had Crohn's disease. The median age was 45 years (interquartile range 30-68, range 8-78) and 86% of patients were lymphopenic. The case-fatality rate was 23%. Corticosteroids were used as IBD treatment in 88% of patients who subsequently developed PCP, 42% received thiopurines, 44% used anti-TNF therapy, and 15% received either cyclosporine or tacrolimus. Rates of mono, dual, triple, and quadruple immunosuppression therapy were 35, 35, 29, and 2%, respectively. This report highlights the importance of considering PCP in immunosuppressed lymphopenic pediatric IBD patients who present with unusual symptoms. Moreover, it should give gastroenterologists the impetus to limit immunosuppressive therapy to its minimal effective dose and consider options such as exclusive enteral nutrition wherever possible. Although there is no place for global PCP prophylaxis in IBD given the low incidence, in an era when there is increasing use of biologic agents with combination immunosuppressive therapy, the risk-benefit profile of PCP chemoprophylaxis should be revisited in selected cohorts such as patients on triple immunosuppression with corticosteroids, thiopurines, and a biological agent or calcineurin inhibitor, especially in lymphopenic individuals.
Collapse
Affiliation(s)
- Sally J Lawrence
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Manish Sadarangani
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Kevan Jacobson
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
25
|
Verazza S, Davì S, Consolaro A, Bovis F, Insalaco A, Magni-Manzoni S, Nicolai R, Marafon DP, De Benedetti F, Gerloni V, Pontikaki I, Rovelli F, Cimaz R, Marino A, Zulian F, Martini G, Pastore S, Sandrin C, Corona F, Torcoletti M, Conti G, Fede C, Barone P, Cattalini M, Cortis E, Breda L, Olivieri AN, Civino A, Podda R, Rigante D, La Torre F, D’Angelo G, Jorini M, Gallizzi R, Maggio MC, Consolini R, De Fanti A, Muratore V, Alpigiani MG, Ruperto N, Martini A, Ravelli A. Disease status, reasons for discontinuation and adverse events in 1038 Italian children with juvenile idiopathic arthritis treated with etanercept. Pediatr Rheumatol Online J 2016; 14:68. [PMID: 27993144 PMCID: PMC5170898 DOI: 10.1186/s12969-016-0126-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 11/24/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Data from routine clinical practice are needed to further define the efficacy and safety of biologic medications in children with juvenile idiopathic arthritis (JIA). The aim of this analysis was to investigate the disease status, reasons for discontinuation and adverse events in Italian JIA patients treated with etanercept (ETN). METHODS In 2013, all centers of the Italian Pediatric Rheumatology Study Group were asked to make a census of patients given ETN after January 2000. Patients were classified in three groups: group 1 = patients still taking ETN; group 2 = patients discontinued from ETN for any reasons; group 3 = patients lost to follow-up while receiving ETN. All three groups received a retrospective assessment; patients in group 1 also underwent a cross-sectional assessment. RESULTS 1038 patients were enrolled by 23 centers: 422 (40.7%) were in group 1, 462 (44.5%) in group 2, and 154 (14.8%) in group 3. Median duration of ETN therapy was 2.5 years. At cross-sectional assessment, 41.8% to 48.6% of patients in group 1 met formal criteria for inactive disease, whereas 52.4% of patients in group 2 and 55.8% of patients in group 3 were judged in clinical remission by their caring physician at last visit. A relatively greater proportion of patients with systemic arthritis were discontinued or lost to follow-up. Parent evaluations at cross-sectional visit in group 1 showed that 52.4% of patients had normal physical function, very few had impairment in quality of life, 51.2% had no pain, 76% had no morning stiffness, and 82.7% of parents were satisfied with their child's illness outcome. Clinically significant adverse events were reported for 27.8% of patients and ETN was discontinued for side effects in 9.5%. The most common adverse events were new onset or recurrent uveitis (10.2%), infections (6.6%), injection site reactions (4.4%), and neuropsychiatric (3.1%), gastrointestinal (2.4%), and hematological disorders (2.1%). Ten patients developed an inflammatory bowel disease and 2 had a malignancy. One patient died of a fulminant streptococcal sepsis. CONCLUSIONS Around half of the patients achieved complete disease quiescence under treatment with ETN. The medication was overall well tolerated, as only one quarter of patients experienced clinically significant adverse events and less than 10% had treatment discontinued for toxicity.
Collapse
Affiliation(s)
| | | | - Alessandro Consolaro
- Università degli Studi di Genova, Genova, Italy ,Istituto Giannina Gaslini, Genova, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Fabrizia Corona
- Fondazione IRCCS Cà Granda – Ospedale Maggiore Policlinico, Milano, Italy
| | - Marta Torcoletti
- Fondazione IRCCS Cà Granda – Ospedale Maggiore Policlinico, Milano, Italy
| | - Giovanni Conti
- Azienda Ospedaliera Universitaria Policlinico G. Martino, Messina, Italy
| | - Claudia Fede
- Azienda Ospedaliera Universitaria Policlinico G. Martino, Messina, Italy
| | - Patrizia Barone
- Azienda Ospedaliero-Universitaria Policlinico Vittorio Emanuele, Catania, Italy
| | | | | | | | | | - Adele Civino
- Azienda Ospedaliera Card. G. Panico, Tricase, Italy
| | - Rosanna Podda
- Ospedale Regionale per le Microcitemie, Cagliari, Italy
| | | | | | | | | | | | | | | | | | | | | | | | - Alberto Martini
- Università degli Studi di Genova, Genova, Italy ,Istituto Giannina Gaslini, Genova, Italy
| | - Angelo Ravelli
- Università degli Studi di Genova, Genova, Italy. .,Istituto Giannina Gaslini, Genova, Italy. .,Pediatria II-Reumatologia, Istituto G. Gaslini, Largo G. Gaslini 5, 16147, Genova, Italy.
| | | |
Collapse
|
26
|
Nozawa T, Nishimura K, Ohara A, Hara R, Ito S. Primary varicella infection in children with systemic juvenile idiopathic arthritis under tocilizumab therapy. Mod Rheumatol 2016; 29:558-562. [DOI: 10.1080/14397595.2016.1254314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Tomo Nozawa
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama City, Japan
| | - Kenichi Nishimura
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama City, Japan
| | - Asami Ohara
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama City, Japan
| | - Ryoki Hara
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama City, Japan
| | - Shuichi Ito
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama City, Japan
| |
Collapse
|
27
|
Tragiannidis A, Kyriakidis I, Zündorf I, Groll AH. Invasive fungal infections in pediatric patients treated with tumor necrosis alpha (TNF-α) inhibitors. Mycoses 2016; 60:222-229. [DOI: 10.1111/myc.12576] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 09/17/2016] [Accepted: 09/17/2016] [Indexed: 01/09/2023]
Affiliation(s)
- Athanasios Tragiannidis
- Second Department of Pediatrics; AHEPA University General Hospital; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Ioannis Kyriakidis
- Second Department of Pediatrics; AHEPA University General Hospital; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Ilse Zündorf
- Institute of Pharmaceutical Biology; Goethe-University of Frankfurt; Frankfurt am Main Germany
| | - Andreas H. Groll
- Department of Pediatric Hematology and Oncology; Center for Bone Marrow Transplantation; Infectious Disease Research Program; University Childrens Hospital; Muenster Germany
| |
Collapse
|
28
|
Mannion ML, Xie F, Baddley J, Chen L, Curtis JR, Saag K, Zhang J, Beukelman T. Analysis of health care claims during the peri-transfer stage of transition from pediatric to adult care among juvenile idiopathic arthritis patients. Pediatr Rheumatol Online J 2016; 14:49. [PMID: 27596158 PMCID: PMC5012002 DOI: 10.1186/s12969-016-0107-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 08/20/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To investigate the utilization of health care services before and after transfer from pediatric to adult rheumatology care in clinical practice. METHODS Using US commercial claims data from January 2005 through August 2012, we identified individuals with a JIA diagnosis code from a pediatric rheumatologist followed by any diagnosis code from an adult rheumatologist. Individuals had 6 months observable time before the last pediatric visit and 6 months after the first adult visit. Medication, emergency room, physical therapy use, and diagnosis codes were compared between the pediatric and adult interval using McNemar's test. The proportion of days covered (PDC) of TNFi for the time between last pediatric and first adult visit was calculated. RESULTS We identified 58 individuals with JIA who transferred from pediatric to adult rheumatology care after the age of 14. The median age at the last pediatric rheumatology visit was 18.1 years old and the median transfer interval was 195 days. 29 % of patients received NSAIDs in the adult interval compared to 43 % in the pediatric interval (p = 0.06). In the pediatric interval, 71 % received a JRA and 0 % received an RA physician diagnosis code compared to 28 and 45 %, respectively, in the adult interval. The median PDC for patients receiving a TNFi was 0.75 during the transfer interval. CONCLUSION Individuals with JIA who transferred to adult care were more likely receive a diagnosis of RA instead of JRA and were less likely to receive NSAIDs, but had no significant immediate changes to other medication use.
Collapse
Affiliation(s)
- Melissa L. Mannion
- Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, 1600 7th Ave S, CPPN M10, Birmingham, AL 35209 USA
| | - Fenglong Xie
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 510 20th St South, FOT 802, Birmingham, AL 35294 USA
| | - John Baddley
- Department of Medicine, Division of Infectious Disease, University of Alabama at Birmingham, 1900 University Blvd, THT 229, Birmingham, AL 35294 USA
| | - Lang Chen
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 510 20th St South, FOT 802, Birmingham, AL 35294 USA
| | - Jeffrey R. Curtis
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 510 20th St South, FOT 802, Birmingham, AL 35294 USA
| | - Kenneth Saag
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 510 20th St South, FOT 802, Birmingham, AL 35294 USA
| | - Jie Zhang
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 510 20th St South, FOT 802, Birmingham, AL 35294 USA
| | - Timothy Beukelman
- Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, 1600 7th Ave S, CPPN M10, Birmingham, AL 35209 USA
| |
Collapse
|
29
|
Davies HD. Infectious Complications With the Use of Biologic Response Modifiers in Infants and Children. Pediatrics 2016; 138:peds.2016-1209. [PMID: 27432853 DOI: 10.1542/peds.2016-1209] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Biologic response modifiers (BRMs) are substances that interact with and modify the host immune system. BRMs that dampen the immune system are used to treat conditions such as juvenile idiopathic arthritis, psoriatic arthritis, or inflammatory bowel disease and often in combination with other immunosuppressive agents, such as methotrexate and corticosteroids. Cytokines that are targeted include tumor necrosis factor α; interleukins (ILs) 6, 12, and 23; and the receptors for IL-1α (IL-1A) and IL-1β (IL-1B) as well as other molecules. Although the risk varies with the class of BRM, patients receiving immune-dampening BRMs generally are at increased risk of infection or reactivation with mycobacterial infections (Mycobacterium tuberculosis and nontuberculous mycobacteria), some viral (herpes simplex virus, varicella-zoster virus, Epstein-Barr virus, hepatitis B) and fungal (histoplasmosis, coccidioidomycosis) infections, as well as other opportunistic infections. The use of BRMs warrants careful determination of infectious risk on the basis of history (including exposure, residence, and travel and immunization history) and selected baseline screening test results. Routine immunizations should be given at least 2 weeks (inactivated or subunit vaccines) or 4 weeks (live vaccines) before initiation of BRMs whenever feasible, and inactivated influenza vaccine should be given annually. Inactivated and subunit vaccines should be given when needed while taking BRMs, but live vaccines should be avoided unless under special circumstances in consultation with an infectious diseases specialist. If the patient develops a febrile or serious respiratory illness during BRM therapy, consideration should be given to stopping the BRM while actively searching for and treating possible infectious causes.
Collapse
|
30
|
Leuvenink R, Aeschlimann F, Baer W, Berthet G, Cannizzaro E, Hofer M, Kaiser D, Schroeder S, Heininger U, Woerner A. Clinical course and therapeutic approach to varicella zoster virus infection in children with rheumatic autoimmune diseases under immunosuppression. Pediatr Rheumatol Online J 2016; 14:34. [PMID: 27256096 PMCID: PMC4890263 DOI: 10.1186/s12969-016-0095-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 05/16/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND To analyze the clinical presentation and complications of varicella zoster virus (VZV) infection in children with rheumatic diseases treated with immunosuppressive medication such as biological disease-modifying antirheumatic drugs (bDMARDs) and/or conventional disease-modifying antirheumatic drugs (cDMARDs), and to analyze the therapeutic approach to VZV infections with respect to the concomitant immunosuppressive treatment. METHODS Retrospective multicenter study using the Swiss Pediatric Rheumatology registry. Children with rheumatic diseases followed in a Swiss center for pediatric rheumatology and treated with cDMARD and/or bDMARD with a clinical diagnosis of varicella or herpes zoster between January 2004 and December 2013 were included. RESULTS Twenty-two patients were identified, of whom 20 were treated for juvenile idiopathic arthritis, 1 for a polyglandular autoimmune syndrome type III, and 1 for uveitis. Of these 22 patients, 16 had varicella and 6 had herpes zoster. Median age at VZV disease was 7.6 years (range 2 to 17 years), with 6.3 years (range 2 to 17 years) for those with varicella and 11.6 years (range 5 to 16 years) for those with herpes zoster. The median interval between start of immunosuppression and VZV disease was 14.1 months (range 1 to 63 months). Two patients had received varicella vaccine (1 dose each) prior to start of immunosuppression. Concomitant immunosuppressive therapy was methotrexate (MTX) monotherapy (n = 9) or bDMARD monotherapy (n = 2), or a combination of bDMARD with prednisone, MTX or Leflunomide (n = 11). Four patients experienced VZV related complications: cellulitis in 1 patient treated with MTX, and cellulitis, sepsis and cerebellitis in 3 patients treated with biological agents and MTX combination therapy. Six children were admitted to hospital (range of duration: 4 to 9 days) and 12 were treated with valaciclovir or aciclovir. CONCLUSION The clinical course of varicella and herpes zoster in children under immunosuppression is variable, with 4 (18 %) of 22 children showing a complicated course. Thorough assessment of VZV disease and vaccination history and correct VZV vaccination according to national guidelines at diagnosis of a rheumatic autoimmune disease is essential to minimize VZV complications during a later immunosuppressive treatment.
Collapse
Affiliation(s)
- Raphael Leuvenink
- University of Basel Medical School, Basel, Switzerland ,Pediatric Rheumatology, University of Basel Children’s Hospital, Spitalstrasse 33, CH – 4031 Basel, Switzerland
| | | | - Walter Baer
- Department of Pediatrics, Hospital of Chur, Chur, Switzerland
| | - Gerald Berthet
- Department of Pediatrics, Hospital of Aarau, Aarau, Switzerland
| | | | - Michael Hofer
- Unité romande de rhumatologie pédiatrique, CHUV, University of Lausanne and HUG, Geneva, Switzerland
| | - Daniela Kaiser
- Department of Pediatrics, Hospital of Lucerne, Lucerne, Switzerland
| | | | - Ulrich Heininger
- Pediatric Rheumatology, University of Basel Children’s Hospital, Spitalstrasse 33, CH – 4031 Basel, Switzerland
| | - Andreas Woerner
- Pediatric Rheumatology, University of Basel Children's Hospital, Spitalstrasse 33, CH - 4031, Basel, Switzerland.
| |
Collapse
|
31
|
Nicolai R, Cortis E, Ravà L, Bracaglia C, Pardeo M, Insalaco A, Buonuomo PS, Tozzi AE, De Benedetti F. Herpes Virus Infections During Treatment With Etanercept in Juvenile Idiopathic Arthritis. J Pediatric Infect Dis Soc 2016; 5:76-9. [PMID: 26908493 DOI: 10.1093/jpids/piu078] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 06/18/2014] [Indexed: 11/14/2022]
Abstract
Incidence rates for varicella and herpes zoster were similar in patients with juvenile idiopathic arthritis receiving etanercept/methotrexate (n = 85, 184.9 patient-years [PY]) or methotrexate alone (n = 71, 199.4 PY); no complicated varicella or herpes zoster cases were reported; herpes labialis incidence was higher in patients receiving etanercept/methotrexate versus methotrexate alone (0.38 vs. 0.24 PY).
Collapse
Affiliation(s)
| | - E Cortis
- Division of Pediatrics, Ospedale Santa Maria della Stella, Orvieto, Italy
| | - L Ravà
- Division of Epidemiology, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | | | | | | | - P S Buonuomo
- Division of Rare Diseases, Department of Pediatric Medicine
| | - A E Tozzi
- Division of Epidemiology, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | | |
Collapse
|
32
|
Hügle B, Horneff G. The role of synthetic drugs in the biologic era: therapeutic strategies for treating juvenile idiopathic arthritis. Expert Opin Pharmacother 2016; 17:703-14. [PMID: 26678914 DOI: 10.1517/14656566.2016.1133592] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Juvenile idiopathic arthritis is the most frequent chronic rheumatic disease in childhood. Synthetic disease modifying drugs (DMARDs) have been used in its treatment since the 1980s and have led to substantial improvement of quality of life and disease outcome. Recent pharmacological research has focused on newer medications, especially biologic agents. AREAS COVERED Synthetic DMARDS, especially methotrexate, rightfully remain the first-line treatment of most categories of juvenile arthritis, as attested by several international guidelines. A substantial body of evidence supports these medications, and recent research tries to clarify their optimal use in the clinical setting, both as monotherapy and in combination with biologics. In addition, new forms of synthetic DMARDs are in the research pipeline, or are already used for rheumatoid arthritis. EXPERT OPINION Methotrexate remains the preferred first-line medication for polyarticular arthritis, with leflunomide as a viable alternative in case of intolerance or toxicity, despite lack of approval in Europe and the US. Sulfasalazine and hydroxychloroquine are used only rarely in clinical practice, considered in combination with methotrexate if biologics are not available. New synthetic DMARDS are in the research pipeline for JIA, in the form of small molecules.
Collapse
Affiliation(s)
- Boris Hügle
- a German Center for Pediatric Rheumatology , Garmisch-Partenkirchen , Germany
| | - Gerd Horneff
- b Department of Pediatrics , Asklepios Clinic Sankt Augustin , Sankt Augustin , Germany
| |
Collapse
|
33
|
Winthrop KL, Novosad SA, Baddley JW, Calabrese L, Chiller T, Polgreen P, Bartalesi F, Lipman M, Mariette X, Lortholary O, Weinblatt ME, Saag M, Smolen J. Opportunistic infections and biologic therapies in immune-mediated inflammatory diseases: consensus recommendations for infection reporting during clinical trials and postmarketing surveillance. Ann Rheum Dis 2015; 74:2107-16. [DOI: 10.1136/annrheumdis-2015-207841] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 08/28/2015] [Indexed: 12/27/2022]
Abstract
No consensus has previously been formed regarding the types and presentations of infectious pathogens to be considered as ‘opportunistic infections’ (OIs) within the setting of biologic therapy. We systematically reviewed published literature reporting OIs in the setting of biologic therapy for inflammatory diseases. The review sought to describe the OI definitions used within these studies and the types of OIs reported. These findings informed a consensus committee (infectious diseases and rheumatology specialists) in deliberations regarding the development of a candidate list of infections that should be considered as OIs in the setting of biologic therapy. We reviewed 368 clinical trials (randomised controlled/long-term extension), 195 observational studies and numerous case reports/series. Only 11 observational studies defined OIs within their methods; no consistent OI definition was identified across studies. Across all study formats, the most numerous OIs reported were granulomatous infections. The consensus group developed a working definition for OIs as ‘indicator’ infections, defined as specific pathogens or presentations of pathogens that ‘indicate’ the likelihood of an alteration in host immunity in the setting of biologic therapy. Using this framework, consensus was reached upon a list of OIs and case-definitions for their reporting during clinical trials and other studies. Prior studies of OIs in the setting of biologic therapy have used inconsistent definitions. The consensus committee reached agreement upon an OI definition, developed case definitions for reporting of each pathogen, and recommended these be used in future studies to facilitate comparison of infection risk between biologic therapies.
Collapse
|
34
|
Berard RA, Laxer RM. Early aggressive therapy for patients with juvenile idiopathic arthritis: are we there yet? J Rheumatol 2015; 41:2343-6. [PMID: 25452178 DOI: 10.3899/jrheum.141051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Roberta A Berard
- Pediatric Rheumatologist, Children's Hospital, London Health Sciences Centre; Assistant Professor of Pediatrics, Western University
| | - Ronald M Laxer
- Professor of Pediatrics and Medicine, University of Toronto, Staff Rheumatologist, The Hospital for Sick Children, Toronto, Ontario, Canada.
| |
Collapse
|
35
|
Osterman MT, Haynes K, Delzell E, Zhang J, Bewtra M, Brensinger CM, Chen L, Xie F, Curtis JR, Lewis JD. Effectiveness and Safety of Immunomodulators With Anti-Tumor Necrosis Factor Therapy in Crohn's Disease. Clin Gastroenterol Hepatol 2015; 13:1293-1301.e5; quiz e70, e72. [PMID: 25724699 PMCID: PMC4475667 DOI: 10.1016/j.cgh.2015.02.017] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 01/28/2015] [Accepted: 02/10/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The benefit of continuing immunomodulators when "stepping up" to anti-tumor necrosis factor (anti-TNF) therapy for Crohn's disease (CD) is uncertain. This study assessed the effectiveness and safety of immunomodulators with anti-TNF therapy in CD. METHODS We conducted a retrospective cohort study of new users of anti-TNF therapy for CD in Medicare. Users of anti-TNF combination therapy with immunomodulators were matched to up to 3 users of anti-TNF monotherapy via propensity score and compared by using 3 metrics of effectiveness-surgery, hospitalization, and discontinuation of anti-TNF therapy or surgery-and 2 metrics of safety-serious infection and non-Candida opportunistic infection. Cox regression was used for all analyses. RESULTS Among new users of infliximab, we matched 381 users of combination therapy to 912 users of monotherapy; among new users of adalimumab, we matched 196 users of combination therapy to 505 users of monotherapy. Combination therapy occurred predominantly as "step up" after thiopurine therapy. The rates of surgery (hazard ratio [HR], 1.20; 95% confidence interval, 0.73-1.96), hospitalization (HR, 0.82; 0.57-1.19), discontinuation of anti-TNF therapy or surgery (HR, 1.09; 0.88-1.34), and serious infection (HR, 0.93; 0.88-1.34) did not differ between users of anti-TNF combination therapy and monotherapy. However, the risks of opportunistic infection (HR, 2.64; 1.21-5.73) and herpes zoster (HR, 3.16; 1.25-7.97) were increased with combination therapy. CONCLUSIONS We found that continuation of immunomodulators after "stepping up" to anti-TNF therapy did not improve outcomes but was associated with an increased risk of opportunistic infection.
Collapse
Affiliation(s)
- Mark T Osterman
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Kevin Haynes
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Pharmacoepidemiology Research and Teaching, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth Delzell
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham, Alabama
| | - Jie Zhang
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham, Alabama
| | - Meenakshi Bewtra
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Colleen M Brensinger
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lang Chen
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Fenglong Xie
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jeffrey R Curtis
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham, Alabama; Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - James D Lewis
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Pharmacoepidemiology Research and Teaching, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
36
|
Hsin YC, Zhuang LZ, Yeh KW, Chang CW, Horng JT, Huang JL. Risk of Tuberculosis in Children with Juvenile Idiopathic Arthritis: A Nationwide Population-Based Study in Taiwan. PLoS One 2015; 10:e0128768. [PMID: 26047099 PMCID: PMC4457914 DOI: 10.1371/journal.pone.0128768] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Accepted: 05/01/2015] [Indexed: 11/29/2022] Open
Abstract
Objective We aimed to determine the risk of tuberculosis in children with juvenile idiopathic arthritis (JIA) in Taiwan. Methods We used the Taiwan National Health Insurance Research Database (NHIRD) to conduct a nested case-control study. We identified a JIA cohort and matched each JIA child with non-JIA children for comparison. Methotrexate (MTX), tumor necrosis factor (TNF) inhibitor administration, and new tuberculosis cases were determined during our study period. To compare tuberculosis (TB) risk among our study groups, Cox proportional regression models were used to determine adjusted hazard ratios (aHRs). Results We identified 1495 children with JIA and 11592 non-JIA children. Majority (68.7%) children with JIA had not received MTX or TNF inhibitors; 23.9% used MTX without TNF inhibitors, and 7.4% received TNF inhibitors, irrespective of MTX administration. In total, 43 children developed tuberculosis. The overall tuberculosis infection rate for children with JIA was two times higher than that for non-JIA children. Compared with non-JIA children, children with JIA who used MTX without TNF inhibitors revealed a significantly increased of tuberculosis infection rate (aHR = 4.67; 95% CI: 1.65–13.17; P = 0.004). Children with JIA who either received TNF inhibitors or never used MTX and TNF inhibitors revealed a tuberculosis infection rate comparable to that of non-JIA children. Conclusions Analysis of nationwide data of Taiwan suggested that children with JIA were at higher risk of tuberculosis compared with those without JIA.
Collapse
Affiliation(s)
- Yi-Chen Hsin
- Department of Pediatric Allergy Immunology and Rheumatology, Division of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Lai-Zhen Zhuang
- Department of Computer Science and Information Engineering, National Central University, Chungli, Taiwan
| | - Kuo-Wei Yeh
- Department of Pediatric Allergy Immunology and Rheumatology, Division of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Cheng-Wei Chang
- Department of Information Management, Hsing Wu University, New Taipei City, Taiwan
| | - Jorng-Tzong Horng
- Department of Computer Science and Information Engineering, National Central University, Chungli, Taiwan
- Department of Biomedical Informatics, Asia University, Taichung, Taiwan
- * E-mail: (JLH); (JTH)
| | - Jing-Long Huang
- Department of Pediatric Allergy Immunology and Rheumatology, Division of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- * E-mail: (JLH); (JTH)
| |
Collapse
|
37
|
Grubbs JA, Baddley JW. Pneumocystis jirovecii pneumonia in patients receiving tumor-necrosis-factor-inhibitor therapy: implications for chemoprophylaxis. Curr Rheumatol Rep 2015; 16:445. [PMID: 25182673 DOI: 10.1007/s11926-014-0445-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Pneumocystis jirovecii pneumonia (PJP) is an important opportunistic infection that has been increasingly reported in patients with rheumatic disease. Reported incidence among patients taking TNF inhibitors (TNFi) has varied, but has usually been low. Still, disease causes significant mortality among those affected and must be considered in patients with rheumatological disease presenting with dyspnea and cough. Diagnosis can be difficult in the non-HIV population, and our understanding of the epidemiology and natural history after exposure is changing. Trimethoprim-sulfamethoxazole is believed to be the most effective agent for treatment and prophylaxis, but is associated with significant adverse effects. Given the low incidence reported in most studies of patients on TNFi, prophylaxis is probably not beneficial for this patient population as a whole.
Collapse
Affiliation(s)
- James A Grubbs
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, 1900 University Boulevard, 229 Tinsley Harrison Tower, Birmingham, AL, 35294-0006, USA
| | | |
Collapse
|
38
|
Klotsche J, Niewerth M, Haas JP, Huppertz HI, Zink A, Horneff G, Minden K. Long-term safety of etanercept and adalimumab compared to methotrexate in patients with juvenile idiopathic arthritis (JIA). Ann Rheum Dis 2015; 75:855-61. [DOI: 10.1136/annrheumdis-annrheumdis-2014-206747] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 04/05/2015] [Indexed: 12/20/2022]
|
39
|
Gundacker ND, Baddley JW. Fungal Infections in the Era of Biologic Therapies. CURRENT CLINICAL MICROBIOLOGY REPORTS 2015. [DOI: 10.1007/s40588-015-0018-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
|
40
|
Nimmrich S, Horneff G. Incidence of herpes zoster infections in juvenile idiopathic arthritis patients. Rheumatol Int 2015; 35:465-70. [PMID: 25583050 DOI: 10.1007/s00296-014-3197-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 12/18/2014] [Indexed: 12/19/2022]
Abstract
The risk of herpes zoster among patients with juvenile idiopathic arthritis (JIA) exposed to biologics has not been evaluated. We determined incidence rates of herpes zoster among children with JIA in correlation with medication at time of occurrence and total drug exposure. The German biologics register database was used to identify patients with herpes zoster. Crude infection rates and incidence ratios (IRR) were compared to published rates. Demographics and overall exposure and particular exposure time to corticosteroids, immunosuppressive drugs and biologics were analyzed. The JIA cohort included 3,042 patients with 5,557.9 person-years of follow-up; 1,628 have used corticosteroids, 2,930 methotrexate and 1,685 etanercept. In total, 17 herpes zoster events have been documented [6/1,000 patients (3.5-9.0); 3.1/1,000 patient-years (1.9-4.9)]. Thus, the incidence rate in JIA patients was higher than expected [IRR 2.9 (1.8-4.5), p < 0.001]. In all patients, the event resolved completely. There were two complications, one patient developed intercostal neuralgia, and one had a recurrent herpes zoster. Compared to the healthy population, a significant higher IRR is observed in JIA patients who received a monotherapy with etanercept or in combination with steroids and methotrexate, but not in JIA patients exposed to methotrexate without biologics. In comparison with our control group of patients treated with methotrexate, the IRR was higher for exposure to etanercept monotherapy and combination of etanercept and corticosteroids irrespective of methotrexate use. A generally higher incidence rate in JIA patients treated with etanercept was observed. No serious or refractory manifestations occurred.
Collapse
Affiliation(s)
- S Nimmrich
- Department of Pediatrics and Neonatology, Asklepios Clinics, Arnold Janssen Str. 29, 53757, Sankt Augustin, Germany,
| | | |
Collapse
|
41
|
Swart JF, de Roock S, Wulffraat NM. What are the immunological consequences of long-term use of biological therapies for juvenile idiopathic arthritis? Arthritis Res Ther 2014; 15:213. [PMID: 23731900 PMCID: PMC4060240 DOI: 10.1186/ar4213] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
This review summarizes the immunological consequences of biological therapies used in juvenile idiopathic arthritis (JIA). For every frequently used biological agent the characteristics are clearly specified (molecular target, isotype, registered indication for JIA, route of administration, half-life, contraindication, very common side effects, expected time of response and average cost in the first year). The emphasis of this review is on the immunological side effects that have been encountered for every separate agent in JIA populations. For each agent these adverse events have been calculated as incidence per 100 patient-years for the following categories: serious infections, tuberculosis, malignancies, response to vaccination, new-onset autoimmune diseases and development of anti-drug antibodies. There are large differences in side effects between various agents and there is a clear need for an international and standardized collection of post-marketing surveillance data of biologicals in the vulnerable group of JIA patients. Such an international pharmacovigilance database, called Pharmachild, has now been started.
Collapse
|
42
|
Stringer E, Bernatsky S. Validity of juvenile idiopathic arthritis diagnoses using administrative health data. Rheumatol Int 2014; 35:575-9. [PMID: 25270916 DOI: 10.1007/s00296-014-3142-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 09/20/2014] [Indexed: 10/24/2022]
Abstract
Administrative health databases are valuable sources of data for conducting research including disease surveillance, outcomes research, and processes of health care at the population level. There has been limited use of administrative data to conduct studies of pediatric rheumatic conditions and no studies validating case definitions in Canada. We report a validation study of incident cases of juvenile idiopathic arthritis in the Canadian province of Nova Scotia. Cases identified through administrative data algorithms were compared to diagnoses in a clinical database. The sensitivity of algorithms that included pediatric rheumatology specialist claims was 81-86%. However, 35-48% of cases that were identified could not be verified in the clinical database depending on the algorithm used. Our case definitions would likely lead to overestimates of disease burden. Our findings may be related to issues pertaining to the non-fee-for-service remuneration model in Nova Scotia, in particular, systematic issues related to the process of submitting claims.
Collapse
Affiliation(s)
- Elizabeth Stringer
- Division of Rheumatology, Department of Pediatrics, Dalhousie University, IWK Health Centre, 5850 University Avenue, Halifax, NS, B3K 6R8, Canada,
| | | |
Collapse
|
43
|
Walters HM, Pan N, Lehman TJA, Adams A, Huang WT, Sitaras L, Cunningham-Rundles S, Walsh TJ, Toussi SS. A prospective study comparing infection risk and disease activity in children with juvenile idiopathic arthritis treated with and without tumor necrosis factor-alpha inhibitors. Clin Rheumatol 2014; 34:457-64. [PMID: 25227771 DOI: 10.1007/s10067-014-2779-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 08/25/2014] [Accepted: 09/07/2014] [Indexed: 12/19/2022]
Abstract
Tumor necrosis factor-alpha (TNF-α) inhibitors are effective treatment for juvenile idiopathic arthritis (JIA) but may increase infection rates. However, active JIA may also render patients vulnerable to infection. In this study, we prospectively assessed infection rates in JIA patients treated with and without TNF-α inhibitors and correlated disease activity with infection risk. TNF-α inhibitor-naïve JIA subjects were followed up for 12 months. Subjects initiated on TNF-α inhibitors after enrollment were analyzed in the TNF group. Subjects treated without TNF-α inhibitors were analyzed in the non-TNF group. Questionnaires captured mild or severe infections. JIA disease activity by Childhood Health Assessment Questionnaire (CHAQ) disability index/pain score and physician joint count/global assessment was recorded. Twenty TNF and 36 non-TNF subjects were analyzed. The total infection rate ratio for TNF versus non-TNF group subjects was 1.14 (95% CI, 0.78-1.66; p = 0.51). The average rate of infections per month was 0.29 for TNF and 0.24 for non-TNF subjects. No severe infections or hospitalizations occurred in either group. Secondary infectious outcomes were also similar between groups. Controlling for study group, an increase in CHAQ pain score correlated with an increase in several infectious outcome measures. Our results suggest no difference in infection rates between JIA subjects treated with and without TNF-α inhibitors. Additionally, JIA disease activity may have contributed to infection risk in our cohort, irrespective of immunosuppressive therapy. Future analysis of the relationship between treatment regimens, disease activity, and infection rates may help to further delineate predictors of infection risk in JIA patients.
Collapse
Affiliation(s)
- Heather M Walters
- Department of Pediatric Rheumatology, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA,
| | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Pipolo C, Turati F, Cressoni P, Farronato G, Angiero F, Garagiola U, Di Pasquale D, Saibene AM, Lenzi R, Felisati G. Prevalence of sinonasal disease in children with Juvenile idiopathic arthritis. Laryngoscope 2014; 125:291-5. [PMID: 25125135 DOI: 10.1002/lary.24881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 07/04/2014] [Accepted: 07/21/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in children and is caused by a multitude of well-studied disorders. However, the association between JIA and/or its treatment and sinonasal inflammatory disease (SNID) has never been studied. We therefore investigated this relationship to gain more insight into burdening pathologies connected to JIA. STUDY DESIGN Retrospective evaluation. METHODS A retrospective evaluation according to the Lund-Mackay score of cone-beam computed tomography scans (CBCT) performed in 70 children affected by JIA and compared to CBCT scans of 124 healthy controls was conducted. The prevalence of sinonasal opacification and adenoid hypertrophy in patients affected with JIA was compared with findings obtained in unaffected children. RESULTS JIA was significantly associated with SNID (P = .030). Of patients with JIA, 18.6% had SNID, whereas in children without JIA, only 8.1% had SNID. The odds ratio values were 5.38 (95% confidence interval [CI]: 1.90-15.26) for treated and 0.92 (95% CI: 0.18-4.83) for untreated JIA. No clear difference was found depending on the duration of JIA. No association was found between adenoid hypertrophy and SNID (P = .816). CONCLUSIONS Our data suggest that JIA patients, especially when undergoing immunosuppressive therapy, should be subjected to an ear, nose, and throat evaluation. A prospective study including clinical evaluation would be of the utmost importance to provide evidence on which to base comprehensive healthcare for these patients. LEVEL OF EVIDENCE 3b.
Collapse
Affiliation(s)
- Carlotta Pipolo
- Otorhinolaryngology Unit, Head and Neck Department, San Paolo Hospital, University of Milan, Milan, Italy; Department of Epidemiology, Institutes for Research, Hospitalization and Health Care-Mario Negri Institute for Pharmacological Research, Milan, Italy
| | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Zhu Z, Kang Y, Lin Z, Huang Y, Lv H, Li Y. X-linked agammaglobulinemia combined with juvenile idiopathic arthritis and invasive Klebsiella pneumoniae polyarticular septic arthritis. Clin Rheumatol 2014; 34:397-401. [PMID: 24567239 DOI: 10.1007/s10067-014-2537-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 01/29/2014] [Accepted: 02/09/2014] [Indexed: 11/25/2022]
Abstract
X-linked agammaglobulinemia (XLA) is a primary immunodeficiency disease caused by mutations in the Bruton's tyrosine kinase (BTK) gene. XLA can also present in combination with juvenile idiopathic arthritis (JIA), the major chronic rheumatologic disease in children. We report herein the first known case of a juvenile patient diagnosed with XLA combined with JIA that later developed into invasive Klebsiella pneumoniae polyarticular septic polyarthritis. An additional comprehensive review of XLA combined with JIA and invasive K. pneumoniae septic arthritis is also presented. XLA was identified by the detection of BTK mutations while the diagnosis of JIA was established by clinical and laboratory assessments. Septic arthritis caused by invasive K. pneumoniae was confirmed by culturing of the synovia and gene detection of the isolates. Invasive K. pneumoniae infections can not only result in liver abscesses but also septic arthritis, although this is rare. XLA combined with JIA may contribute to invasive K. pneumoniae infection.
Collapse
Affiliation(s)
- Zaihua Zhu
- Department of Rheumatology, Zhejiang Provincial People's Hospital, 158 Shangtang Rd, Hangzhou, 310014, Zhejiang, China
| | | | | | | | | | | |
Collapse
|
46
|
Berard RA, Laxer RM. Etanercept (Enbrel) in the treatment of juvenile idiopathic arthritis. Expert Opin Biol Ther 2013; 13:1623-30. [DOI: 10.1517/14712598.2013.840580] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
47
|
Abstract
Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease of childhood. Many questions regarding the risk of infection associated with JIA and with the immunosuppressant therapeutic agents commonly used to treat JIA are currently unanswered. It appears likely that JIA itself increases the background rate of serious bacterial infections, irrespective of immunosuppressant use. The available evidence suggests that treatment with methotrexate or tumor necrosis factor inhibitors only modestly increases the risk of serious infections and may not increase the risk at all. Opportunistic infections are very uncommon among children with JIA, but they likely occur at an increased rate compared to children without JIA. Intra-articular glucocorticoid injections almost never result in infectious complications in the treatment of JIA when performed carefully. Additional controlled studies of the risks of infection among children with JIA are needed, particularly comparative studies of newer therapeutic agents.
Collapse
|