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Thiele F, Klein A, Windschall D, Hospach A, Foeldvari I, Minden K, Weller-Heinemann F, Horneff G. Comparative risk of infections among real-world users of biologics for juvenile idiopathic arthritis: data from the German BIKER registry. Rheumatol Int 2021; 41:751-762. [PMID: 33590331 PMCID: PMC7952348 DOI: 10.1007/s00296-020-04774-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 12/17/2020] [Indexed: 01/30/2023]
Abstract
To examine whether treatment with interleukin (IL)-1-, IL-6-, tumour necrosis factor α (TNFα)-inhibitors or Abatacept is associated with an increased risk of common infections, infections requiring hospitalization (SAE) or opportunistic infections among real-world juvenile idiopathic arthritis (JIA) patients. Furthermore, the influence of other patient-related covariates on the occurrence of infections was investigated. Patients diagnosed with JIA and treated with biologics were selected from the German BIKER registry. Incidence rates (IR) of infections per 100 person years were calculated and compared between the different cohorts. Using multivariate logistic regression, odds ratios with 95% confidence intervals (CI) were determined for the influence of patient-related covariates (age, diagnosis, laboratory data, concomitant medication, JIA activity, comorbidities, and premedication) on the occurrence of infections. 3258 patients entered the analysis. A total of 3654 treatment episodes were distributed among TNFα- (Etanercept, Adalimumab, Golimumab, Infliximab, n = 3044), IL-1- (Anakinra, Canakinumab, n = 105), IL-6- (Tocilizumab, n = 400) and T-cell activation inhibitors (Abatacept, n = 105). 813 (22.2%) patients had at least one infection, 103 (2.8%) patients suffered from an SAE infection. Both common and SAE infections were significantly more frequent in IL-1 (IR 17.3, 95% CI 12.5/24 and IR 4.3, 95% CI 2.3/8.3) and IL-6 cohort (IR 16.7, 95% CI 13.9/20 and IR 2.8, 95% CI 1.8/4.4) compared to TNFα-inhibitor cohort (IR 8.7, 95% CI 8.1/9.4 and IR 1, 95% CI 0.8/1.3). When comparing the influencing factors for various infectious diseases, the use of corticosteroids, younger age, cardiac comorbidities and higher JIA-activity are the most striking risk factors. Relative to TNFα inhibitors and Abatacept, IL-1 and IL-6 inhibitors were associated with an increased risk of common and SAE infections. The influencing covariates identified may be helpful for the choice of a suitable biologic to treat JIA.
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Affiliation(s)
- Franz Thiele
- Centre for Paediatric Rheumatology, Department of General Paediatrics, Asklepios Clinic Sankt Augustin, 53757, Sankt Augustin, Germany.
| | - Ariane Klein
- Centre for Paediatric Rheumatology, Department of General Paediatrics, Asklepios Clinic Sankt Augustin, 53757, Sankt Augustin, Germany.,Medical Faculty, University of Cologne, Cologne, Germany
| | - Daniel Windschall
- Clinic for Paediatric and Adolescent Rheumatology, St. Josef-Stift Sendenhorst, Northwest German Center for Rheumatology, Sendenhorst, Germany
| | - Anton Hospach
- Centre for Paediatric Rheumatology, Klinikum Stuttgart, Germany
| | - Ivan Foeldvari
- Hamburger Zentrum Für Kinder- Und Jugendrheumatologie, Hamburg, Germany
| | | | | | - Gerd Horneff
- Centre for Paediatric Rheumatology, Department of General Paediatrics, Asklepios Clinic Sankt Augustin, 53757, Sankt Augustin, Germany.,Medical Faculty, University of Cologne, Cologne, Germany
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2
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Schvartz A, Belot A, Kone-Paut I. Pediatric Inflammatory Multisystem Syndrome and Rheumatic Diseases During SARS-CoV-2 Pandemic. Front Pediatr 2020; 8:605807. [PMID: 33344389 PMCID: PMC7746854 DOI: 10.3389/fped.2020.605807] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 11/13/2020] [Indexed: 12/12/2022] Open
Abstract
Globally, the coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), appeared to have a milder clinical course in children compared to adults. As severe forms of COVID-19 in adults included an aberrant systemic immune response, children with chronic systemic inflammatory diseases were cautiously followed. No evidence for a specific susceptibility was identified in this pediatric population. European and US Pediatricians started to notice cases of myocarditis, sharing some features with toxic shock syndrome, Kawasaki disease, and macrophage activation syndrome in otherwise healthy patients. Multisystem Inflammatory Syndrome in Children (MIS-C) and Pediatric Inflammatory Multisystem Syndrome (PIMS) have designated this new entity in the US and Europe, respectively. The spectrum of severity ranged from standard hospitalization to pediatric intensive care unit management. Most patients had a clinical history of exposure to COVID-19 patients and/or SARS-COV2 biological diagnosis. Clinical presentations include fever, cardiac involvement, gastro-intestinal symptoms, mucocutaneous manifestations, hematological features, or other organ dysfunctions. The temporal association between the pandemic peaks and outbreaks of PIMS seems to be in favor of a post-infectious, immune-mediated mechanism. Thus, SARS-CoV2 can rarely be associated with severe systemic inflammatory manifestations in previously healthy children differently from adults highlighting the specific need for COVID-19 research in the pediatric population.
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Affiliation(s)
- Adrien Schvartz
- Service De Rhumatologie Pédiatrique, Centre De Référence Des Maladies Auto-Inflammatoires et de l'Amylose Inflammatoire, Hospital Bicêtre, Assistance Publique des Hôpitaux de Paris, Université Paris Sud Saclay, Le Kremlin-Bicêtre, France
| | - Alexandre Belot
- Service de Néphrologie, Rhumatologie, Dermatologie Pédiatriques, Centre de Référence des Rhumatismes Inflammatoires et Maladies Auto-Immunes Rares de l'Enfant (RAISE), Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Bron, France
| | - Isabelle Kone-Paut
- Service De Rhumatologie Pédiatrique, Centre De Référence Des Maladies Auto-Inflammatoires et de l'Amylose Inflammatoire, Hospital Bicêtre, Assistance Publique des Hôpitaux de Paris, Université Paris Sud Saclay, Le Kremlin-Bicêtre, France
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3
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Zhang N, Liu K, She Y, Zhao W, Zeng J, Lin G. Efficacy and safety of acupuncture and moxibustion for herpes zoster: A protocol for systematic review and network meta analysis. Medicine (Baltimore) 2020; 99:e21905. [PMID: 32899021 PMCID: PMC7478486 DOI: 10.1097/md.0000000000021905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 07/24/2020] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Herpes zoster (HZ) is currently treated primarily with antiviral drugs, yet this treatment has been debated. Acupuncture is becoming a more important treatment in this protocol. For example, pain intensity is lower among HZ patients who receive acupuncture plus moxibustion than among those who receive pharmacotherapy. There are many types of acupuncture interventions, including electroacupuncture, moxibustion, bloodletting. In this study, a network meta-analysis (NMA) is used to rank various interventions of acupuncture. METHODS AND ANALYSIS Electronic searches of abstracts and titles will be performed in MEDLINE, EMBASE, CENTRAL, CBM, CNKI, CQVIP, and Wanfang Data databases, from inception to December 31, 2019. Published and unpublished controlled trials with different acupuncture interventions will be selected, trials of antiviral drugs as the control group. All patients of HZ will be included, except for those diagnosed with PHN, immunocompromised patients, or those with complications. The effective therapy rate and the incidence of PHN are primary outcomes. The NMA will be analyzed with Stata 13.0 and GeMTC 0.14.3. DISCUSSION The NMA will be established to compare various interventions of acupuncture for the therapy of HZ, that could resolve the limitations of previous methodologies with this protocol. It will be possible to determine the best acupuncture intervention for more primary outcomes of therapy, including subgroup analysis of patients with aged ≥50 years and those of aged <50 years. ETHICS AND DISSEMINATION The NMA does not require ethical approval. The data analyzed is not personal. It is only systematically used to evaluate the effectiveness of acupuncture treatments. The results will be disseminated through international conference reports and peer-reviewed manuscripts. STRENGTH AND LIMITATIONS OF THIS STUDY A comprehensive methodology is established to rank various interventions of acupuncture by which best evidence-based intervention may be recommended for those population groups of aged ≥50 years and aged <50 years. PROSPERO REGISTRATION NUMBER CRD42019118369.
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Affiliation(s)
- Na Zhang
- Guangzhou University of Chinese Medicine
| | - Kun Liu
- Guangzhou University of Chinese Medicine
| | - Yalin She
- Guangzhou University of Chinese Medicine
| | - Weixuan Zhao
- First Affiliated Hospital of Guangdong Pharmaceutical University
| | - Jingchun Zeng
- Department of Acupuncture, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China
| | - Guohua Lin
- Department of Acupuncture, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China
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Adrovic A, Yildiz M, Köker O, Şahin S, Barut K, Kasapçopur Ö. Biologics in juvenile idiopathic arthritis-main advantages and major challenges: A narrative review. Arch Rheumatol 2020; 36:146-157. [PMID: 34046584 PMCID: PMC8140868 DOI: 10.46497/archrheumatol.2021.7953] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 01/04/2020] [Indexed: 12/26/2022] Open
Abstract
Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in childhood. The disease is divided in different subtypes based on main clinical features and disease course. Emergence of biological agents targeting specific pro-inflammatory cytokines responsible for the disease pathogenesis represents the revolution in the JIA treatment. Discovery and widespread usage of biological agents have led to significant improvement in JIA patients’ treatment, with evidently increased functionality and decreased disease sequel. Increased risk of infections remains the main discussion topic for years. Despite the slightly increased frequency of upper respiratory tract infections reported in some studies, the general safety of drugs is acceptable with rare reports of severe adverse effects (SAEs). Tuberculosis (TBC) represents the important threat in regions with increased TBC prevalence. Therefore, routine screening for TBC should not be neglected when prescribing and during the follow-up of biological treatment. Malignancy represents a hypothetical complication that sometimes causes hesitations for physicians and patients in its prescription and usage. On the other hand, current reports from the literature do not support the increased risk for malignancy among JIA patients treated with biological agents. A multidisciplinary approach including a pediatric rheumatologist and an infectious disease specialist is mandatory in the follow- up of JIA patients. Although the efficacy and safety of biological agents have been proven in different studies, there is still a need for long-term, multicentric evaluation providing relevant data.
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Affiliation(s)
- Amra Adrovic
- Department of Pediatrics, Division of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Mehmet Yildiz
- Department of Pediatrics, Division of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Oya Köker
- Department of Pediatrics, Division of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Sezgin Şahin
- Department of Pediatrics, Division of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Kenan Barut
- Department of Pediatrics, Division of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Özgür Kasapçopur
- Department of Pediatrics, Division of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
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Licciardi F, Giani T, Baldini L, Favalli EG, Caporali R, Cimaz R. COVID-19 and what pediatric rheumatologists should know: a review from a highly affected country. Pediatr Rheumatol Online J 2020; 18:35. [PMID: 32321540 PMCID: PMC7175817 DOI: 10.1186/s12969-020-00422-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/03/2020] [Indexed: 01/08/2023] Open
Abstract
On March 11th, 2020 the World Health Organization declared COVID-19 a global pandemic. The infection, transmitted by 2019 novel coronavirus (2019-nCov), was first discovered in December 2019, in Wuhan, Hubei Province, and then rapidly spread worldwide. Italy was early and severely involved, with a critical spread of the infection and a very high number of victims. Person-to-person spread mainly occurs via respiratory droplets and contact. The median incubation period is 5 days. The spectrum of respiratory symptoms may range from mild to severe, strictly depending on the age of the patient and the underlying comorbidities.In children COVID-19 related disease is less frequent and less aggressive. In Italy 1% of positive cases are under 18 years of age, and no deaths have been recorded before 29 years of age. For patients affected by rheumatic disease, despite the concerns related to the imbalance of their immune response and the effect of immunosuppressive treatments, there are still few data to understand the real consequences of this infection. Major scientific societies have issued recommendations to help rheumatologists in caring their patients. Interestingly, some of the drugs mostly used by rheumatologists appear to be promising in critical COVID-19 infected patients, where the hyperinflammation and cytokine storm seem to drive to the multiorgan failure.Pediatric rheumatologists are expected to play a supporting role in this new front of COVID-19 pandemic, both as general pediatricians treating infected children, and as rheumatologists taking care of their rheumatic patients, as well as offering their experience in the possible alternative use of immunomodulatory drugs.
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Affiliation(s)
- Francesco Licciardi
- Division of Pediatric Immunology and Rheumatology, Department of Public Health and Pediatrics, Regina Margherita Children Hospital, University of Turin, Turin, Italy
| | - Teresa Giani
- AOU Meyer, V.le Pieraccini 24, 50139, Florence, Italy.
- Department of Medical Biotechnology, University of Siena, Siena, Italy.
| | - Letizia Baldini
- Division of Pediatric Immunology and Rheumatology, Department of Public Health and Pediatrics, Regina Margherita Children Hospital, University of Turin, Turin, Italy
| | - Ennio Giulio Favalli
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO Institute, Milan, Italy
| | - Roberto Caporali
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO Institute, Milan, Italy
- Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Università degli Studi di Milano, Milan, Italy
| | - Rolando Cimaz
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO Institute, Milan, Italy
- Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Università degli Studi di Milano, Milan, Italy
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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.
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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.
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Eisert L, Augustin M, Bach S, Dittmann M, Eiler R, Fölster-Holst R, Gerdes S, Hamm H, Höger P, Horneff G, von Kiedrowski R, Philipp S, Pleimes M, Schlaeger M, Schuster V, Staubach P, Weberschock T, Werner RN, Nast A, Sticherling M. S2k guidelines for the treatment of psoriasis in children and adolescents - Short version part 2. J Dtsch Dermatol Ges 2020; 17:959-973. [PMID: 31538732 DOI: 10.1111/ddg.13936] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The present guidelines are aimed at residents and board-certified physicians in the fields of dermatology, pediatrics, pediatric dermatology and pediatric rheumatology as well as policymakers and insurance funds. They were developed by dermatologists and pediatric dermatologists in collaboration with pediatric rheumatologists using a formal consensus process (S2k). The guidelines highlight topics such as disease severity, quality of life, treatment goals as well as problems associated with off-label drug therapy in children. Trigger factors and diagnostic aspects are discussed. The primary focus is on the various topical, systemic and UV-based treatment options available and includes recommendations for use and treatment algorithms. Other aspects addressed herein include vaccinations in children and adolescents with psoriasis as well as various disease subtypes such as guttate psoriasis, diaper psoriasis, pustular psoriasis and psoriatic arthritis. Finally, we also provide recommendations for imaging studies and the diagnostic workup to rule out tuberculosis prior to initiating systemic treatment. Note: This article constitutes part 2 of the Sk2 guidelines for the treatment of psoriasis in children and adolescents. Part 1 was published in last month's issue. It contained introductory remarks and addressed aspects of diagnosis and topical treatment.
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Affiliation(s)
- Lisa Eisert
- Charité - University Medicine Berlin, Corporate Member of Freie Universität Berlin, Humboldt University of Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology und Allergology, Division of Evidence-based Medicine (dEBM), Berlin, Germany
| | - Matthias Augustin
- University Medical Center Hamburg-Eppendorf, Institute for Health Services Research in Dermatology and Nursing (IVDP), Hamburg, Germany
| | - Sabine Bach
- Patient representatives in the German Psoriasis Association
| | - Martin Dittmann
- Charité - University Medicine Berlin, Corporate Member of Freie Universität Berlin, Humboldt University of Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology und Allergology, Division of Evidence-based Medicine (dEBM), Berlin, Germany
| | - Renate Eiler
- Patient representatives in the German Psoriasis Association
| | - Regina Fölster-Holst
- Department of Dermatology, University Medical Center of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Sascha Gerdes
- Department of Dermatology, University Medical Center of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Henning Hamm
- Department of Dermatology, Venereology and Allergology, Würzburg University Medical Center, Würzburg, Germany
| | - Peter Höger
- Department of Pediatrics and Pediatric Dermatology/Allergology, Catholic Children's Hospital Wilhelmstift gGmbH, Hamburg, Germany
| | - Gerd Horneff
- Department of Pediatric and Adolescent Medicine, Asklepios Medical Center, Sankt Augustin, Germany
| | | | - Sandra Philipp
- Office-based Dermatologist (in collaboration with Markus Friedrich MD), Oranienburg, Germany
| | - Marc Pleimes
- Office-based Dermatologist specialized in Pediatric and Adolescent Skin, Heidelberg, Germany
| | | | - Volker Schuster
- Department of Pediatric and Adolescent Medicine, Leipzig University Medical Center, Leipzig, Germany
| | - Petra Staubach
- Department of Dermatology, Mainz University Medical Center, Mainz, Germany
| | - Tobias Weberschock
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Frankfurt, Frankfurt/Main.,Arbeitsgruppe EbM Frankfurt, Institut für Allgemeinmedizin, Goethe-Universität Frankfurt, Frankfurt/Main
| | - Ricardo Niklas Werner
- Charité - University Medicine Berlin, Corporate Member of Freie Universität Berlin, Humboldt University of Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology und Allergology, Division of Evidence-based Medicine (dEBM), Berlin, Germany
| | - Alexander Nast
- Charité - University Medicine Berlin, Corporate Member of Freie Universität Berlin, Humboldt University of Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology und Allergology, Division of Evidence-based Medicine (dEBM), Berlin, Germany
| | - Michael Sticherling
- Department of Dermatology, Erlangen University Medical Center, Erlangen, Germany
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8
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Eisert L, Augustin M, Bach S, Dittmann M, Eiler R, Fölster-Holst R, Gerdes S, Hamm H, Höger P, Horneff G, von Kiedrowski R, Philipp S, Pleimes M, Schlaeger M, Schuster V, Staubach P, Weberschock T, Werner RN, Nast A, Sticherling M. S2k‐Leitlinie zur Therapie der Psoriasis bei Kindern und Jugendlichen – Kurzfassung Teil 2. J Dtsch Dermatol Ges 2019; 17:959-974. [PMID: 31538739 DOI: 10.1111/ddg.13936_g] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Lisa Eisert
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology und Allergy, Division of Evidence based Medicine (dEBM)
| | - Matthias Augustin
- Universitätsklinikum Hamburg-Eppendorf, Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Hamburg
| | - Sabine Bach
- Patientenvertreterinnen des Deutschen Psoriasisbundes
| | - Martin Dittmann
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology und Allergy, Division of Evidence based Medicine (dEBM)
| | - Renate Eiler
- Patientenvertreterinnen des Deutschen Psoriasisbundes
| | | | - Sascha Gerdes
- Dermatologie des Universitätsklinikums Schleswig-Holstein, Campus Kiel, Kiel
| | - Henning Hamm
- Universitätsklinikum Würzburg, Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie, Würzburg
| | - Peter Höger
- Atholisches Kinderkrankenhaus Wilhelmstift gGmbH, Pädiatrie und Pädiatrische Dermatologie/Allergologie, Hamburg
| | - Gerd Horneff
- Asklepios Klinik Sankt Augustin, Kinder- und Jugendmedizin, Sankt Augustin
| | | | | | - Marc Pleimes
- Spezialpraxis für Kinder- und Jugendhaut, Heidelberg
| | | | - Volker Schuster
- Universitätsklinik und Poliklinik für Kinder und Jugendliche Leipzig, Leipzig
| | | | - Tobias Weberschock
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Frankfurt, Frankfurt/Main.,Arbeitsgruppe EbM Frankfurt, Institut für Allgemeinmedizin, Goethe-Universität Frankfurt, Frankfurt/Main
| | - Ricardo Niklas Werner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology und Allergy, Division of Evidence based Medicine (dEBM)
| | - Alexander Nast
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology und Allergy, Division of Evidence based Medicine (dEBM)
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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.
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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.
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Affiliation(s)
- Shinji Akioka
- a Department of Pediatrics , Kyoto Prefectural University of Medicine , Kyoto , Japan
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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.
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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
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A Dual Noradrenergic Mechanism for the Relief of Neuropathic Allodynia by the Antidepressant Drugs Duloxetine and Amitriptyline. J Neurosci 2018; 38:9934-9954. [PMID: 30249798 DOI: 10.1523/jneurosci.1004-18.2018] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/27/2018] [Accepted: 07/22/2018] [Indexed: 12/21/2022] Open
Abstract
In addition to treating depression, antidepressant drugs are also a first-line treatment for neuropathic pain, which is pain secondary to lesion or pathology of the nervous system. Despite the widespread use of these drugs, the mechanism underlying their therapeutic action in this pain context remains partly elusive. The present study combined data collected in male and female mice from a model of neuropathic pain and data from the clinical setting to understand how antidepressant drugs act. We show two distinct mechanisms by which the selective inhibitor of serotonin and noradrenaline reuptake duloxetine and the tricyclic antidepressant amitriptyline relieve neuropathic allodynia. One of these mechanisms is acute, central, and requires descending noradrenergic inhibitory controls and α2A adrenoceptors, as well as the mu and delta opioid receptors. The second mechanism is delayed, peripheral, and requires noradrenaline from peripheral sympathetic endings and β2 adrenoceptors, as well as the delta opioid receptors. We then conducted a transcriptomic analysis in dorsal root ganglia, which suggested that the peripheral component of duloxetine action involves the inhibition of neuroimmune mechanisms accompanying nerve injury, including the downregulation of the TNF-α-NF-κB signaling pathway. Accordingly, immunotherapies against either TNF-α or Toll-like receptor 2 (TLR2) provided allodynia relief. We also compared duloxetine plasma levels in the animal model and in patients and we observed that patients' drug concentrations were compatible with those measured in animals under chronic treatment involving the peripheral mechanism. Our study highlights a peripheral neuroimmune component of antidepressant drugs that is relevant to their delayed therapeutic action against neuropathic pain.SIGNIFICANCE STATEMENT In addition to treating depression, antidepressant drugs are also a first-line treatment for neuropathic pain, which is pain secondary to lesion or pathology of the nervous system. However, the mechanism by which antidepressant drugs can relieve neuropathic pain remained in part elusive. Indeed, preclinical studies led to contradictions concerning the anatomical and molecular substrates of this action. In the present work, we overcame these apparent contradictions by highlighting the existence of two independent mechanisms. One is rapid and centrally mediated by descending controls from the brain to the spinal cord and the other is delayed, peripheral, and relies on the anti-neuroimmune action of chronic antidepressant treatment.
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Abstract
Biologics target various pathways to modify immunologic activity. Biologic use to treat pediatric patients continues to expand; but limited data exist regarding infectious complications of these agents, especially for newer agents. Infectious events reported in the literature for pediatric patients indicate that a variety of bacterial, mycobacterial, viral, and fungal infections can occur. Further pediatric-specific reports are needed to fill knowledge gaps in the complications related to these agents.
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Affiliation(s)
- Lara Danziger-Isakov
- Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7017, Cincinnati, OH 45229, USA.
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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.
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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
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Groot N, Pileggi G, Sandoval CB, Grein I, Berbers G, Ferriani VPL, Wulffraat N, de Roock S. Varicella vaccination elicits a humoral and cellular response in children with rheumatic diseases using immune suppressive treatment. Vaccine 2017; 35:2818-2822. [PMID: 28412076 DOI: 10.1016/j.vaccine.2017.04.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 03/22/2017] [Accepted: 04/06/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To assess humoral and cellular responses to live-attenuated varicella zoster virus (VZV) vaccination of patients with juvenile idiopathic arthritis (JIA), juvenile dermatomyositis (JDM) or juvenile scleroderma (JScle) compared to those of healthy controls (HC). METHODS Before, 4-6weeks and one year after VZV vaccination, blood samples of patients and HC were collected. VZV-specific antibody concentrations were measured by ELISA and multiplex immune-assay. IFN-γ ELISpot assays were performed to assess VZV-specific T-cell responses. Cytokine production upon VZV stimulation were measured with a Luminex-assay. RESULTS 49 patients (39 JIA, 5 JDM, 5 JScle) and 18 HC were included. All patients used methotrexate (MTX), 16 also used corticosteroids, 3 patients used biologics. No disease flares were reported after vaccination. Antibody response to the vaccine was similar in patients and controls (p=0.139). Use of immunosuppressive drugs did not affect the response (p=0.203). A second vaccination (n=21) increased VZV-specific antibody concentrations (p=0.02). VZV-specific T-cells increased after vaccination (p=0.043), with a cytokine profile suggesting a VZV-specific Th1 and cytotoxic T-cell response. CONCLUSION The humoral response to VZV vaccination in patients with pediatric rheumatic diseases (PRD) is similar to that of HC. Generally, patients are able to mount a VZV-specific cellular response. This study has been registered in the Brazilian Clinical Trials Registry under number U1111-1189-9837.
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Affiliation(s)
- Noortje Groot
- Laboratory for Translational Immunology, Paediatric Immunology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Paediatric Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Pediatric Immunology, Sophia Children's Hospital, Erasmus University Medical Centre, The Netherlands.
| | - Gecilmara Pileggi
- Department of Pediatrics, Division of Immunology and Rheumatology, School of Medicine of Ribeirão Preto - University of São Paulo, São Paulo, Brazil
| | - Cleonice B Sandoval
- Department of Pediatrics, Division of Immunology and Rheumatology, School of Medicine of Ribeirão Preto - University of São Paulo, São Paulo, Brazil
| | - Ingrid Grein
- Department of Paediatric Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Pediatric Rheumatology, Pequeno Príncipe Hospital, Curitiba, Brazil
| | - Guy Berbers
- Centre for Infectious Disease Control, National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Virginia Paes Leme Ferriani
- Department of Pediatrics, Division of Immunology and Rheumatology, School of Medicine of Ribeirão Preto - University of São Paulo, São Paulo, Brazil
| | - Nico Wulffraat
- Department of Paediatric Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sytze de Roock
- Laboratory for Translational Immunology, Paediatric Immunology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Paediatric Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
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Becker I, Horneff G. Risk of Serious Infection in Juvenile Idiopathic Arthritis Patients Associated With Tumor Necrosis Factor Inhibitors and Disease Activity in the German Biologics in Pediatric Rheumatology Registry. Arthritis Care Res (Hoboken) 2017; 69:552-560. [DOI: 10.1002/acr.22961] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 06/06/2016] [Accepted: 06/21/2016] [Indexed: 01/01/2023]
Affiliation(s)
| | - Gerd Horneff
- Asklepios Clinic Sankt AugustinSankt Augustin Germany
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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.
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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.
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Horneff G. Safety of biologic therapies for the treatment of juvenile idiopathic arthritis. Expert Opin Drug Saf 2016; 14:1111-26. [PMID: 26084637 DOI: 10.1517/14740338.2015.1042453] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION The introduction of biological therapies opened a new era of treatment of juvenile idiopathic arthritis. After 15 years of experience with the first biologics for treatment of pediatric rheumatic disease, long-term safety effects are of great interest. AREAS COVERED This review summarizes published knowledge about safety aspects from clinical trials as well as from biologic registries in juvenile idiopathic arthritis patients. Beside infusion and injection reactions, the occurrence and aggravation of infections, the occurrence of a second autoimmune diseases, including uveitis, psoriasis, chronic inflammatory bowel disease, multiple sclerosis, diabetes mellitus, as well as cytopenias and the development of malignancies are major concerns regarding treatment with biologics. EXPERT OPINION The safety profiles of approved biologics, the TNF-α inhibitors etanercept and adalimumab, and the IL-6-inhibitor tocilizumab are highly acceptable. This conclusion is not easily expandable to the IL-1 inhibitor canakinumab as well as the T-cell-activation-inhibitor abatacept due to lack of experience; however, both have showed an excellent safety profile so far. An increase in knowledge about risk profiles in national and international collaborations, with national as well as international registries, is necessary.
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Affiliation(s)
- Gerd Horneff
- Centre for Paediatric Rheumatology, Department of Paediatrics, Asklepios Clinic Sankt Augustin , Arnold-Janssen-Str. 29, 53757 Sankt Augustin , Germany +0049 2241 249 201 ; +0049 2241 249 203 ;
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