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Lokhandwala S, Townsend J, Ciurtin C. Existing and Emerging Targeted Therapies in Juvenile Psoriatic Arthritis: Challenges and Unmet Needs. Paediatr Drugs 2024; 26:217-228. [PMID: 38310623 DOI: 10.1007/s40272-023-00618-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 02/06/2024]
Abstract
Juvenile psoriatic arthritis (JPsA) is a heterogeneous type of non-systemic chronic inflammatory arthritis affecting children and young people. This review focuses on highlighting challenges in harmonising recommendations for the use of available therapies in JPsA, according to its distinct clinical phenotypes, and explores the similarities and differences between the disease classification and management across age. We further explore the emerging therapeutic landscape, summarising the recently completed clinical trials in JPsA, and ongoing studies in both JPsA and adults with psoriatic arthritis, highlighting unmet needs and barriers for translational research in JPsA. The novel therapeutic agents in clinical development in JPsA range from monoclonal antibodies targeting interleukin (IL)-17, IL-12/23 and IL-23 blockades to synthetic small molecules targeting Janus kinase and tyrosine kinase and phosphodiesterase-4 inhibition. In addition, there are head-to-head clinical trials comparing tumour necrosis factor-α blockade with both IL-17 and IL-23 inhibition. Most of these new therapies have been tested in adults with psoriatic arthritis and have advanced to the phase III stage of drug development or received license for use, suggesting promising signals for efficacy and potentially acceptable safety and tolerability for JPsA. Further translational research in JPsA is required to improve our understanding of the impact of age at onset on treatment efficacy, as well as to provide opportunities for better management of refractory disease and improved long-term outcomes in JPsA, for ultimate patient benefit.
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Affiliation(s)
- Sarrah Lokhandwala
- Department of Biomedical Sciences, University College London, London, UK
| | | | - Coziana Ciurtin
- Centre for Adolescent Rheumatology, Division of Medicine, University College London, London, UK.
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2
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Shenoi S, Horneff G, Aggarwal A, Ravelli A. Treatment of non-systemic juvenile idiopathic arthritis. Nat Rev Rheumatol 2024; 20:170-181. [PMID: 38321298 DOI: 10.1038/s41584-024-01079-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2024] [Indexed: 02/08/2024]
Abstract
In the past two decades, the treatment of juvenile idiopathic arthritis (JIA) has evolved markedly, owing to the availability of a growing number of novel, potent and relatively safe therapeutic agents and the shift of management strategies towards early achievement of disease remission. However, JIA encompasses a heterogeneous group of diseases that require distinct treatment approaches. Furthermore, some old drugs, such as methotrexate, sulfasalazine and intraarticular glucocorticoids, still maintain an important therapeutic role. In the past 5 years, information on the efficacy and safety of drug therapies for JIA has been further enriched through the accomplishment of several randomized controlled trials of newer biologic and synthetic targeted DMARDs. In addition, a more rational therapeutic approach has been fostered by the promulgation of therapeutic recommendations and guidelines. A multinational collaborative effort has led to the development of the recommendations for the treat-to-target strategy in JIA. There is currently increasing interest in establishing the optimal time and modality for discontinuation of treatment in children with JIA who achieve sustained clinical remission. The aim of this Review is to summarize the current evidence and discuss the therapeutic approaches to the management of non-systemic phenotypes of JIA, including oligoarthritis, polyarthritis, enthesitis-related arthritis and psoriatic arthritis.
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Affiliation(s)
- Susan Shenoi
- Seattle Children's Hospital and Research Centre, University of Washington, Seattle, WA, USA
| | - Gerd Horneff
- Department of General Paediatrics, Asklepios Clinic Sankt Augustin, Sankt Augustin, Germany
- Department of Paediatric and Adolescents Medicine, University Hospital of Cologne, Cologne, Germany
| | - Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Angelo Ravelli
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DINOGMI), Università degli Studi di Genova, Genoa, Italy.
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3
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Hinze CH, Foell D, Kessel C. Treatment of systemic juvenile idiopathic arthritis. Nat Rev Rheumatol 2023; 19:778-789. [PMID: 37923864 DOI: 10.1038/s41584-023-01042-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2023] [Indexed: 11/06/2023]
Abstract
Systemic juvenile idiopathic arthritis (sJIA) is an inflammatory disease with hallmarks of severe systemic inflammation, which can be accompanied by arthritis. Contemporary scientific insights set this paediatric disorder on a continuum with its counterpart, adult-onset Still disease (AOSD). Patients with sJIA are prone to complications, including life-threatening hyperinflammation (macrophage activation syndrome (sJIA-MAS)) and sJIA-associated lung disease (sJIA-LD). Meanwhile, the treatment arsenal in sJIA has expanded markedly. State-of-the-art therapeutic approaches include biologic agents that target the IL-1 and IL-6 pathways. Beyond these, a range of novel agents are on the horizon, some of them already being used on a compassionate use basis, including JAK inhibitors and biologic agents that target IL-18, IFNγ, or IL-1β and IL-18 simultaneously. However, sJIA, sJIA-MAS and sJIA-LD still pose challenging conundrums to rheumatologists treating paediatric and adult patients worldwide. Although national and international consensus treatment plans exist for the treatment of 'classic' sJIA, the treatment approaches for early sJIA without arthritis, and for refractory or complicated sJIA, are not well defined. Therefore, in this Review we outline current approaches for the treatment of sJIA and provide an outlook on knowledge gaps.
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Affiliation(s)
- Claas H Hinze
- Department of Paediatric Rheumatology and Immunology, Münster University Hospital, Münster, Germany
| | - Dirk Foell
- Department of Paediatric Rheumatology and Immunology, Münster University Hospital, Münster, Germany.
| | - Christoph Kessel
- Department of Paediatric Rheumatology and Immunology, Münster University Hospital, Münster, Germany
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Tomé C, Oliveira-Ramos F, Campanilho-Marques R, Mourão AF, Sousa S, Marques C, Melo AT, Teixeira RL, Martins AP, Moeda S, Costa-Reis P, Torres RP, Bandeira M, Fonseca H, Gonçalves M, Santos MJ, Graca L, Fonseca JE, Moura RA. Children with extended oligoarticular and polyarticular juvenile idiopathic arthritis have alterations in B and T follicular cell subsets in peripheral blood and a cytokine profile sustaining B cell activation. RMD Open 2023; 9:e002901. [PMID: 37652558 PMCID: PMC10476142 DOI: 10.1136/rmdopen-2022-002901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 07/03/2023] [Indexed: 09/02/2023] Open
Abstract
OBJECTIVES The main goal of this study was to characterise the frequency and phenotype of B, T follicular helper (Tfh) and T follicular regulatory (Tfr) cells in peripheral blood and the cytokine environment present in circulation in children with extended oligoarticular juvenile idiopathic arthritis (extended oligo JIA) and polyarticular JIA (poly JIA) when compared with healthy controls, children with persistent oligoarticular JIA (persistent oligo JIA) and adult JIA patients. METHODS Blood samples were collected from 105 JIA patients (children and adults) and 50 age-matched healthy individuals. The frequency and phenotype of B, Tfh and Tfr cells were evaluated by flow cytometry. Serum levels of APRIL, BAFF, IL-1β, IL-2, IL-4, IL-6, IL-10, IL-17A, IL-21, IL-22, IFN-γ, PD-1, PD-L1, sCD40L, CXCL13 and TNF were measured by multiplex bead-based immunoassay and/or ELISA in all groups included. RESULTS The frequency of B, Tfh and Tfr cells was similar between JIA patients and controls. Children with extended oligo JIA and poly JIA, but not persistent oligo JIA, had significantly lower frequencies of plasmablasts, regulatory T cells and higher levels of Th17-like Tfh cells in circulation when compared with controls. Furthermore, APRIL, BAFF, IL-6 and IL-17A serum levels were significantly higher in paediatric extended oligo JIA and poly JIA patients when compared with controls. These immunological alterations were not found in adult JIA patients in comparison to controls. CONCLUSIONS Our results suggest a potential role and/or activation profile of B and Th17-like Tfh cells in the pathogenesis of extended oligo JIA and poly JIA, but not persistent oligo JIA.
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Affiliation(s)
- Catarina Tomé
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Filipa Oliveira-Ramos
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, EPE, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Raquel Campanilho-Marques
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, EPE, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Ana F Mourão
- Rheumatology Department, Hospital de São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, EPE, Lisbon, Portugal
| | - Sandra Sousa
- Reumatology Department, Hospital Garcia de Orta, EPE, Almada, Portugal
| | - Cláudia Marques
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Ana T Melo
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, EPE, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Rui L Teixeira
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, EPE, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Ana P Martins
- Pediatric Surgery Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, EPE, Lisbon, Portugal
| | - Sofia Moeda
- Department of Pediatrics, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, EPE, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Patrícia Costa-Reis
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Department of Pediatrics, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, EPE, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Rita P Torres
- Rheumatology Department, Hospital de São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, EPE, Lisbon, Portugal
| | - Matilde Bandeira
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, EPE, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Helena Fonseca
- Department of Pediatrics, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, EPE, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Miroslava Gonçalves
- Pediatric Surgery Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, EPE, Lisbon, Portugal
| | - Maria J Santos
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Reumatology Department, Hospital Garcia de Orta, EPE, Almada, Portugal
| | - Luis Graca
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - João E Fonseca
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, EPE, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Rita A Moura
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
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Ambler WG, Nanda K, Onel KB, Shenoi S. Refractory systemic onset juvenile idiopathic arthritis: current challenges and future perspectives. Ann Med 2022; 54:1839-1850. [PMID: 35786149 PMCID: PMC9258439 DOI: 10.1080/07853890.2022.2095431] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Systemic juvenile idiopathic arthritis (SJIA) is a rare disease with distinct features not seen in other categories of juvenile idiopathic arthritis. In recent years, advances in the understanding of disease immunopathogenesis have led to improved targeted therapies with significant improvement in patient outcomes. Despite these advances, there remain subsets of SJIA with refractory disease and severe disease-associated complications. This review highlights existing options for treatment of refractory SJIA and explores potential future therapeutics for refractory disease.Key Points:Despite targeted Interleukin IL-1 and IL-6 inhibitors a subset of SJIA remains refractory to therapy. About 1 in 7 SJIA patients will be refractory to targeted IL-1 or IL-6 therapy.There is no current agreed upon definition for refractory SJIA and we propose in this review that refractory SJIA is presence of active systemic or arthritic features despite treatment with anti-IL-1 or anti-IL-6 therapy or disease requiring glucocorticoids for control beyond 6 months.SJIA disease associated complications include presence of associated macrophage activation syndrome (MAS), interstitial lung disease (ILD) or amyloidosis and management of each differs.Refractory SJIA treatment options currently include additional conventional synthetic disease modifying anti-rheumatic drugs (csDMARDS), biologic (bDMARDS), combination biologic therapy, targeted synthetic (tsDMARDS) or other immunomodulatory therapies.
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Affiliation(s)
- William G Ambler
- Division of Pediatric Rheumatology, Hospital for Special Surgery, New York, NY, USA.,Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Kabita Nanda
- Department of Pediatrics, Division of Rheumatology, University of Washington School of Medicine & Seattle Children's Hospital, Seattle, WA, USA
| | - Karen Brandt Onel
- Division of Pediatric Rheumatology, Hospital for Special Surgery, New York, NY, USA.,Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Susan Shenoi
- Department of Pediatrics, Division of Rheumatology, University of Washington School of Medicine & Seattle Children's Hospital, Seattle, WA, USA
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Moura RA, Fonseca JE. B Cells on the Stage of Inflammation in Juvenile Idiopathic Arthritis: Leading or Supporting Actors in Disease Pathogenesis? Front Med (Lausanne) 2022; 9:851532. [PMID: 35449805 PMCID: PMC9017649 DOI: 10.3389/fmed.2022.851532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/09/2022] [Indexed: 11/13/2022] Open
Abstract
Juvenile idiopathic arthritis (JIA) is a term that collectively refers to a group of chronic childhood arthritides, which together constitute the most common rheumatic condition in children. The International League of Associations for Rheumatology (ILAR) criteria define seven categories of JIA: oligoarticular, polyarticular rheumatoid factor (RF) negative (RF-), polyarticular RF positive (RF+), systemic, enthesitis-related arthritis, psoriatic arthritis, and undifferentiated arthritis. The ILAR classification includes persistent and extended oligoarthritis as subcategories of oligoarticular JIA, but not as distinct categories. JIA is characterized by a chronic inflammatory process affecting the synovia that begins before the age of 16 and persists at least 6 weeks. If not treated, JIA can cause significant disability and loss of quality of life. Treatment of JIA is adjusted according to the severity of the disease as combinations of non-steroidal anti-inflammatory drugs (NSAIDs), synthetic and/ or biological disease modifying anti-rheumatic drugs (DMARDs). Although the disease etiology is unknown, disturbances in innate and adaptive immune responses have been implicated in JIA development. B cells may have important roles in JIA pathogenesis through autoantibody production, antigen presentation, cytokine release and/ or T cell activation. The study of B cells has not been extensively explored in JIA, but evidence from the literature suggests that B cells might have indeed a relevant role in JIA pathophysiology. The detection of autoantibodies such as antinuclear antibodies (ANA), RF and anti-citrullinated protein antibodies (ACPA) in JIA patients supports a breakdown in B cell tolerance. Furthermore, alterations in B cell subpopulations have been documented in peripheral blood and synovial fluid from JIA patients. In fact, altered B cell homeostasis, B cell differentiation and B cell hyperactivity have been described in JIA. Of note, B cell depletion therapy with rituximab has been shown to be an effective and well-tolerated treatment in children with JIA, which further supports B cell intervention in disease development.
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Affiliation(s)
- Rita A Moura
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - João Eurico Fonseca
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisbon Academic Medical Centre, Lisbon, Portugal
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Marino A, Orsini F, Pregnolato F, Cimaz R. Tumor Necrosis Factor-α Inhibition Before and After Rituximab Treatment in Juvenile Idiopathic Arthritis: What Shall We Expect? A Pilot Study. J Rheumatol 2022; 49:654-656. [DOI: 10.3899/jrheum.211039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Rituximab (RTX), a chimeric monoclonal antibody against B cell antigen CD20, has been used in patients with recalcitrant juvenile idiopathic arthritis ( JIA) with some efficacy.1,2 The resetting of peripheral B cells promoted by RTX represents quite an interesting option in autoimmune diseases such as JIA, not only for the immediate effect but also for the possible use of other therapies that might be necessary to achieve disease control.
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Reiff DD, Stoll ML, Cron RQ. Precision medicine in juvenile idiopathic arthritis-has the time arrived? THE LANCET. RHEUMATOLOGY 2021; 3:e808-e817. [PMID: 38297525 DOI: 10.1016/s2665-9913(21)00252-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/07/2021] [Accepted: 07/28/2021] [Indexed: 12/14/2022]
Abstract
The introduction of disease-modifying anti-rheumatic drug therapies for treating children and adolescents with chronic arthritis (ie, juvenile idiopathic arthritis [JIA]) has revolutionised care and outcomes. The biologic revolution continues to expand, with ever-changing immunological targets coming to market after basic research and clinical trials. The first class of biologics that was beneficial for children with JIA was tumour necrosis factor (TNF) inhibitors. If used early and aggressively, TNF inhibitors are capable of inducing disease remission for most of the seven subtypes of JIA, with the exception of systemic JIA (which more frequently responds to interleukin [IL]-1 or IL-6 inhibition). Nevertheless, there are still subsets of patients with JIA with disease that is difficult to treat or who develop extra-articular features that require a different therapeutic approach. Although finding an effective biological therapy for individual children with JIA can be trial and error, ongoing research and clinical trials are providing insight into a more personalised approach to care. In addition, redefining the JIA classification, in part based on shared similarities with various adult arthritides, could allow for extrapolation of knowledge from studies in adults with chronic arthritis.
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Affiliation(s)
- Daniel D Reiff
- Department of Pediatrics, Division of Rheumatology, University of Alabama, Birmingham, AL, USA
| | - Matthew L Stoll
- Department of Pediatrics, Division of Rheumatology, University of Alabama, Birmingham, AL, USA
| | - Randy Q Cron
- Department of Pediatrics, Division of Rheumatology, University of Alabama, Birmingham, AL, USA.
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Alzyoud RM, Alsuweiti MO, Almaaitah HQ, Aladaileh BN, Alnoubani MK, Alwahadneh AM. Juvenile idiopathic arthritis in Jordan: single center experience. Pediatr Rheumatol Online J 2021; 19:90. [PMID: 34118940 PMCID: PMC8196540 DOI: 10.1186/s12969-021-00572-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 05/20/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Juvenile idiopathic arthritis (JIA) is a heterogeneous group of disorders, including all forms of arthritis, which develops in children who are less than 16 years old. This study aimed to evaluate the clinical and laboratory features of JIA in a single center in Jordan. METHODS A retrospective analysis of the electronic medical records of Pediatric patients diagnosed with JIA based on the International League of Associations for Rheumatology (ILAR) criteria during the period from 2015 to 2019 at the Pediatric Rheumatology Clinic in the Queen Rania Children's Hospital. All patients were below the age of 14 years at the time of diagnosis and followed for at least 6 months. Collected data consisted of age, gender, age at initial presentation and diagnosis, JIA subtype, laboratory data, treatment options, and outcome. RESULTS A total of 210 patients were included in this cohort (94 males and 116 females) with the mean age at diagnosis and mean age at onset of 5.33 ± 3.40 years and 5.08 ± 3.40 years (range: 7 months - 14 years), respectively. Oligoarticular JIA was the commonest subtype (54.7%), followed by systemic arthritis (17.1%) and polyarticular arthritis (12.3%). ANA was positive in 70 patients (33.6%). Uveitis occurred in 30 (14.2%) patients. CONCLUSION To the best of our knowledge, this study on this cohort is the first report on JIA in Jordan, in comparison with other regionally and internationally published reports. Oligoarticular JIA was found to be the most common subtype. For detailed knowledge on JIA characteristics and patterns, a population-based, rather than a single center study, should be conducted in Jordan.
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Affiliation(s)
- Raed M Alzyoud
- Pediatric Immunology, Allergy and Rheumatology Division, Queen Rania Children's Hospital, Royal Medical Services, King Abdullah II St 226, P. O Box 11855, Amman, Jordan.
| | - Motasem O Alsuweiti
- Pediatric Immunology, Allergy and Rheumatology Division, Queen Rania Children's Hospital, Royal Medical Services, King Abdullah II St 226, P. O Box 11855, Amman, Jordan
| | - Heba Q Almaaitah
- Pediatric Immunology, Allergy and Rheumatology Division, Queen Rania Children's Hospital, Royal Medical Services, King Abdullah II St 226, P. O Box 11855, Amman, Jordan
| | - Bushra N Aladaileh
- Pediatric Immunology, Allergy and Rheumatology Division, Queen Rania Children's Hospital, Royal Medical Services, King Abdullah II St 226, P. O Box 11855, Amman, Jordan
| | - Mohammad K Alnoubani
- Pediatric Immunology, Allergy and Rheumatology Division, Queen Rania Children's Hospital, Royal Medical Services, King Abdullah II St 226, P. O Box 11855, Amman, Jordan
| | - Adel M Alwahadneh
- Pediatric Immunology, Allergy and Rheumatology Division, Queen Rania Children's Hospital, Royal Medical Services, King Abdullah II St 226, P. O Box 11855, Amman, Jordan
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10
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Murray GM, Sen ES, Ramanan AV. Advancing the treatment of juvenile idiopathic arthritis. THE LANCET. RHEUMATOLOGY 2021; 3:e294-e305. [PMID: 38279412 DOI: 10.1016/s2665-9913(20)30426-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/05/2020] [Accepted: 12/02/2020] [Indexed: 01/28/2024]
Abstract
Treatment for juvenile idiopathic arthritis has undergone substantial changes in recent decades. These changes are partly due to the availability of new treatments, mainly biological agents, as well as developments in treatment strategies, including a focus on concepts such as treat-to-target. In addition, the creation of large paediatric research networks has improved patient access to, and design of, clinical trials for rare paediatric diseases. Although these advances have resulted in improvements in care for most patients with juvenile idiopathic arthritis, certain subgroups of patients continue to have a poor prognosis. Further research aims to identify patients in these subgroups early, to personalise their care, improve functional outcomes, and minimise long-term damage and harm. Optimising the duration of therapy for those individuals who require systemic immunosuppression is also of importance. Incorporation of novel biomarkers in combination with validated clinical measures in an effort to predict outcomes and target therapy accordingly is an exciting development.
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Affiliation(s)
- Grainne M Murray
- Department of Paediatric Rheumatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Ethan S Sen
- Department of Paediatric Rheumatology, Great North Children's Hospital, Newcastle upon Tyne, UK; Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK; Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
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Bridges JM, Mellins ED, Cron RQ. Recent progress in the treatment of non-systemic juvenile idiopathic arthritis. Fac Rev 2021; 10:23. [PMID: 33718940 PMCID: PMC7946384 DOI: 10.12703/r/10-23] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disease affecting the joints and other organs that occurs in 1 in 1,000 children in the United States. Given the various categories of JIA, interpretation of the literature can be difficult. In this review, new developments in understanding non-systemic JIA and its treatment will be covered. Recent advances in the journey toward personalized treatment in JIA will be highlighted, including a review of currently available biologic modifiers. Uveitis and the temporomandibular joint will be discussed as particularly challenging treatment issues. Recent guideline updates and literature-guided treatment decisions will be reviewed.
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Affiliation(s)
- John M Bridges
- Children’s of Alabama/University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Elizabeth D Mellins
- Department of Pediatrics, Program in Immunology, Stanford University, Stanford, California, USA
| | - Randy Q Cron
- Children’s of Alabama/University of Alabama at Birmingham, Birmingham, Alabama, USA
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12
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Saougou IG, Markatseli TE, Voulgari PV, Drosos AA. Current Therapeutic Options for the Treatment of Juvenile Idiopathic Arthritis. Curr Rheumatol Rev 2020; 17:41-57. [PMID: 32942977 DOI: 10.2174/1573403x16999200917151805] [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] [Received: 05/24/2020] [Revised: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 12/15/2022]
Abstract
Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disease and an exclusion diagnosis that includes all forms of arthritis that persists for more than 6 weeks under the age of 16. Although there is not yet a cure for JIA, and recent advances in the therapeutic field have created a more hopeful present and future for the patients. In the past, therapies for JIA have depended on non-steroidal medication, conventional synthetic disease-modifying antirheumatic drugs and corticosteroids. However, over the last decades, the advent of biologic therapies in JIA contributed to the preservation of functional activity, control of pain, avoidance of joint damage, and extra-articular manifestations. Furthermore, over the last years, international institutions, such as the American College of Rheumatology, have released recommendations and guidelines for rheumatologists for optimal JIA management. All the above have revolutionized the treatment of JIA with promising outcomes. To this end, the relevant literature is reviewed and discussed appropriately.
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Affiliation(s)
- Ioanna G Saougou
- Department of Internal Medicine, Rheumatology Clinic, Medical School, University of Ioannina, Ioannina, Greece
| | - Theodora E Markatseli
- Department of Internal Medicine, Rheumatology Clinic, Medical School, University of Ioannina, Ioannina, Greece
| | - Paraskevi V Voulgari
- Department of Internal Medicine, Rheumatology Clinic, Medical School, University of Ioannina, Ioannina, Greece
| | - Alexandros A Drosos
- Department of Internal Medicine, Rheumatology Clinic, Medical School, University of Ioannina, Ioannina, Greece
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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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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.
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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
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15
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Kearsley-Fleet L, Sampath S, McCann LJ, Baildam E, Beresford MW, Davies R, De Cock D, Foster HE, Southwood TR, Thomson W, Hyrich KL. Use and effectiveness of rituximab in children and young people with juvenile idiopathic arthritis in a cohort study in the United Kingdom. Rheumatology (Oxford) 2019; 58:331-335. [PMID: 30358861 PMCID: PMC6343463 DOI: 10.1093/rheumatology/key306] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Indexed: 12/11/2022] Open
Abstract
Objectives Rituximab (RTX) may be a treatment option for children and young people with JIA, although it is not licensed for this indication. The aim of this study was to describe RTX use and outcomes among children with JIA. Methods This analysis included all JIA patients within the UK Biologics for Children with Rheumatic Diseases study starting RTX. Disease activity was assessed at RTX start and at follow-up. The total number of courses each patient received was assessed. Serious infections and infusion reactions occurring following RTX were reported. Results Forty-one JIA patients starting RTX were included, the majority with polyarthritis: polyarthritis RF negative [n = 14 (35%)], polyarthritis RF positive [n = 13 (33%)] and extended oligoarthritis [n = 9 (23%)]. Most were female (80%) with a median age of 15 years [interquartile range (IQR) 12–16] and a median disease duration of 9 years (IQR 5–11). The median improvement in the clinical Juvenile Arthritis Disease Activity Score (cJADAS; three-variable 71-joint JADAS) from RTX start was 9 units (n = 7; IQR −14–2). More than half reported more than one course of RTX. The median time between each course was 219 days (IQR 198–315). During follow-up, 17 (41%) patients reported switching to another biologic, including tocilizumab (n = 8), abatacept (n = 6) and TNF inhibitor (n = 3). Three patients (7%) reported a serious infection on RTX (rate of first serious infection 6.2/100 person-years). Four patients (10%) reported an infusion reaction. Conclusions This real-world cohort of children with JIA, the majority with polyarticular or extended oligoarticular JIA, showed RTX may be an effective treatment option for children who do not respond to TNF inhibitor, with a low rate of serious infections on treatment.
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Affiliation(s)
- Lianne Kearsley-Fleet
- Arthritis Research UK Centre for Epidemiology, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Sunil Sampath
- Arthritis Research UK Centre for Epidemiology, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Liza J McCann
- Clinical Academic Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, UK
| | - Eileen Baildam
- Clinical Academic Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, UK
| | - Michael W Beresford
- Clinical Academic Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, UK.,Institute of Translational Medicine (Child Health), University of Liverpool, Liverpool, UK
| | - Rebecca Davies
- Arthritis Research UK Centre for Epidemiology, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Diederik De Cock
- Arthritis Research UK Centre for Epidemiology, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Helen E Foster
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Paediatric Rheumatology, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Taunton R Southwood
- Institute of Child Health, University of Birmingham and Birmingham Children's Hospital, Birmingham, UK
| | - Wendy Thomson
- Arthritis Research UK Centre for Genetics and Genomics, Centre for Musculoskeletal Research, Faculty of Biologic, Medicine and Health, University of Manchester, Manchester, UK.,National Institute of Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Kimme L Hyrich
- Arthritis Research UK Centre for Epidemiology, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,National Institute of Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Kaegi C, Wuest B, Schreiner J, Steiner UC, Vultaggio A, Matucci A, Crowley C, Boyman O. Systematic Review of Safety and Efficacy of Rituximab in Treating Immune-Mediated Disorders. Front Immunol 2019; 10:1990. [PMID: 31555262 PMCID: PMC6743223 DOI: 10.3389/fimmu.2019.01990] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 08/06/2019] [Indexed: 12/20/2022] Open
Abstract
Background: During the past years biologic agents (also termed biologicals or biologics) have become a crucial treatment option in immunological diseases. Numerous articles have been published on biologicals, which complicates the decision making process on the use of the most appropriate biologic for a given immune-mediated disease. This systematic review is the first of a series of articles assessing the safety and efficacy of B cell-targeting biologics for the treatment of immune-mediated diseases. Objective: To evaluate rituximab's safety and efficacy for the treatment of immune-mediated disorders compared to placebo, conventional treatment, or other biologics. Methods: The PRISMA checklist guided the reporting of the data. We searched the PubMed database between 4 October 2016 and 26 July 2018 concentrating on immune-mediated disorders. Results: The literature search identified 19,665 articles. After screening titles and abstracts against the inclusion and exclusion criteria and assessing full texts, 105 articles were finally included in a narrative synthesis. Conclusions: Rituximab is both safe and effective for the treatment of acquired angioedema with C1-inhibitor deficiency, ANCA-associated vasculitis, autoimmune hemolytic anemia, Behçet's disease, bullous pemphigoid, Castleman's disease, cryoglobulinemia, Goodpasture's disease, IgG4-related disease, immune thrombocytopenia, juvenile idiopathic arthritis, relapsing-remitting multiple sclerosis, myasthenia gravis, nephrotic syndrome, neuromyelitis optica, pemphigus, rheumatoid arthritis, spondyloarthropathy, and systemic sclerosis. Conversely, rituximab failed to show an effect for antiphospholipid syndrome, autoimmune hepatitis, IgA nephropathy, inflammatory myositis, primary-progressive multiple sclerosis, systemic lupus erythematosus, and ulcerative colitis. Finally, mixed results were reported for membranous nephropathy, primary Sjögren's syndrome and Graves' disease, therefore warranting better quality trials with larger patient numbers.
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Affiliation(s)
- Celine Kaegi
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland
| | - Benjamin Wuest
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland
| | - Jens Schreiner
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland
| | - Urs C Steiner
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland
| | - Alessandra Vultaggio
- Department of Biomedicine, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Andrea Matucci
- Department of Biomedicine, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Catherine Crowley
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland
| | - Onur Boyman
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland
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Cole M, Hynes AM, Howel D, Hall L, Abinun M, Allahabadia A, Barrett T, Boelaert K, Drake AJ, Dimitri P, Kirk J, Zammitt N, Pearce S, Cheetham T. Adjuvant rituximab, a potential treatment for the young patient with Graves' hyperthyroidism (RiGD): study protocol for a single-arm, single-stage, phase II trial. BMJ Open 2019; 9:e024705. [PMID: 30670519 PMCID: PMC6347892 DOI: 10.1136/bmjopen-2018-024705] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 09/25/2018] [Accepted: 11/22/2018] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Graves' disease (Graves' hyperthyroidism) is a challenging condition for the young person and their family. The excess thyroid hormone generated by autoimmune stimulation of the thyroid stimulating hormone receptor on the thyroid gland can have a profound impact on well-being. Managing the young person with Graves' hyperthyroidism is more difficult than in older people because the side effects of conventional treatment are more significant in this age group and because the disease tends not to resolve spontaneously in the short to medium term. New immunomodulatory agents are available and the anti-B cell monoclonal antibody rituximab is of particular interest because it targets cells that manufacture the antibodies that stimulate the thyroid gland in Graves'. METHODS AND ANALYSIS The trial aims to establish whether the combination of a single dose of rituximab (500 mg) and a 12-month course of antithyroid drug (usually carbimazole) can result in a meaningful increase in the proportion of patients in remission at 2 years, the primary endpoint. A single-stage, phase II A'Hern design is used. 27 patients aged 12-20 years with newly presenting Graves' hyperthyroidism will be recruited. Markers of immune function, including lymphocyte numbers and antibody levels (total and specific), will be collected regularly throughout the trial. DISCUSSION The trial will determine whether the immunomodulatory medication, rituximab, will facilitate remission above and beyond that observed with antithyroid drug alone. A meaningful increase in the expected proportion of young patients entering remission when managed according to the trial protocol will justify consideration of a phase III trial.Ethics and dissemination The trial has received a favourable ethical opinion (North East - Tyne and Wear South Research Ethics Committee, reference 16/NE/0253, EudraCT number 2016-000209-35). The results of this trial will be distributed at international endocrine meetings, in the peer-reviewed literature and via patient support groups. TRIAL REGISTRATION NUMBER ISRCTN20381716.
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Affiliation(s)
- Michael Cole
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Ann Marie Hynes
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Denise Howel
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Lesley Hall
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Mario Abinun
- Institute of Cellular Medicine, Newcastle University, Great North Children’s Hospital, Newcastle upon Tyne, UK
| | - Amit Allahabadia
- Academic Directorate of Diabetes and Endocrinology, Royal Hallamshire Hospital, Sheffield, UK
| | - Timothy Barrett
- C/O Diabetes Unit, Birmingham Children’s Hospital, Birmingham, UK
| | - Kristien Boelaert
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, Institute of Biomedical Research, University of Birmingham, Birmingham, UK
| | - Amanda J Drake
- Centre for Cardiovascular Science, Queen’s Medical Research Institute, Edinburgh, UK
| | - Paul Dimitri
- The Academic Unit of Child Health, Sheffield Children’s NHS Trust Western Bank, Sheffield, UK
| | - Jeremy Kirk
- Department of Endocrine, Birmingham Children’s Hospital, Birmingham, UK
| | - Nicola Zammitt
- Edinburgh Centre for Endocrinology and Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Simon Pearce
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Tim Cheetham
- Department of Paediatric Endocrinology, Institute of Genetic Medicine, Newcastle University, Great North Children’s Hospital, Newcastle upon Tyne, UK
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18
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Ruiz-Medrano J, Díaz-Valle D, Cuiña R, Gegúndez J, Chhablani J, Majumder P, Gutierrez-Bonet R. The role of tocilizumab in the treatment of inflammatory diseases of the eye and orbit: A useful alternative. J Fr Ophtalmol 2018; 41:759-766. [DOI: 10.1016/j.jfo.2018.02.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 01/18/2018] [Accepted: 02/16/2018] [Indexed: 12/20/2022]
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19
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Management of Juvenile Idiopathic Arthritis in ABO-incompatible Kidney Transplantation: A Case Report. Transplant Proc 2018; 50:869-872. [PMID: 29661455 DOI: 10.1016/j.transproceed.2017.12.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 12/18/2017] [Indexed: 11/21/2022]
Abstract
Biologic agents are a beneficial therapy for juvenile idiopathic arthritis (JIA). However, there is a lack of evidence with regard to management of these agents for JIA patients who undergo kidney transplantation (KTx). A 36-year-old woman with JIA who was treated with tocilizumab targeting interleukin-6 (IL-6) receptor underwent ABO-incompatible kidney transplantation (ABOi KTx). To prevent over-immunosuppression, tocilizumab was discontinued before ABOi KTx. Rituximab, tacrolimus, mycophenolate mofetil, everolimus, and methylprednisolone were used for immunosuppression. Clinical remission of joint pain was maintained for over 3 years despite complete discontinuation of tocilizumab. Both serum IL-6 and soluble IL-6 receptor levels were markedly decreased, suggesting that multitargeted immunosuppression for ABOi KTx induced long-term clinical remission of JIA through inhibition of the IL-6 pathway. However, levels of C-reactive protein (CRP) and matrix metalloproteinase-3 (MMP-3) gradually increased thereafter and abatacept was initiated to prevent joint deterioration. These levels decreased without any adverse events. The patient's renal graft function was well maintained.
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Abstract
Juvenile idiopathic arthritis is the most common chronic rheumatic disease of unknown aetiology in childhood and predominantly presents with peripheral arthritis. The disease is divided into several subgroups, according to demographic characteristics, clinical features, treatment modalities and disease prognosis. Systemic juvenile idiopathic arthritis, which is one of the most frequent disease subtypes, is characterized by recurrent fever and rash. Oligoarticular juvenile idiopathic arthritis, common among young female patients, is usually accompanied by anti-nuclear antibodie positivity and anterior uveitis. Seropositive polyarticular juvenile idiopathic arthritis, an analogue of adult rheumatoid arthritis, is seen in less than 10% of paediatric patients. Seronegative polyarticular juvenile idiopathic arthritis, an entity more specific for childhood, appears with widespread large- and small-joint involvement. Enthesitis-related arthritis is a separate disease subtype, characterized by enthesitis and asymmetric lower-extremity arthritis. This disease subtype represents the childhood form of adult spondyloarthropathies, with human leukocyte antigen-B27 positivity and uveitis but commonly without axial skeleton involvement. Juvenile psoriatic arthritis is characterized by a psoriatic rash, accompanied by arthritis, nail pitting and dactylitis. Disease complications can vary from growth retardation and osteoporosis secondary to treatment and disease activity, to life-threatening macrophage activation syndrome with multi-organ insufficiency. With the advent of new therapeutics over the past 15 years, there has been a marked improvement in juvenile idiopathic arthritis treatment and long-term outcome, without any sequelae. The treatment of juvenile idiopathic arthritis patients involves teamwork, including an experienced paediatric rheumatologist, an ophthalmologist, an orthopaedist, a paediatric psychiatrist and a physiotherapist. The primary goals of treatment are to eliminate active disease, to normalize joint function, to preserve normal growth and to prevent long-term joint damage. Timely and aggressive treatment is important to provide early disease control. The first-line treatment includes disease-modifying anti-rheumatic drugs (methotrexate, sulphasalazine, leflunomide) in combination with corticosteroids, used in different dosages and routes (oral, intravenous, intra-articular). Intra-articular application of steroids seems to be an effective treatment modality, especially in monoarthritis. Biological agents should be added in the treatment of unresponsive patients. Anti-tumour necrosis factor agents (etanercept, infliximab, adalimumab), anti-interleukin-1 agents (anakinra, canakinumab), anti- interleukin-6 agents (tocilizumab) and T-cell regulatory agents (abatacept) have been shown to be safe and effective in childhood patients. Recent studies reported sustained reduction in joint damage with even complete clinical improvement in paediatric patients, compared to previous data.
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Affiliation(s)
- Kenan Barut
- Department of Pediatric Rheumatology, İstanbul University Cerrahpaşa Medical School, İstanbul, Turkey
| | - Amra Adrovic
- Department of Pediatric Rheumatology, İstanbul University Cerrahpaşa Medical School, İstanbul, Turkey
| | - Sezgin Şahin
- Department of Pediatric Rheumatology, İstanbul University Cerrahpaşa Medical School, İstanbul, Turkey
| | - Özgür Kasapçopur
- Department of Pediatric Rheumatology, İstanbul University Cerrahpaşa Medical School, İstanbul, Turkey
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21
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LONG-TERM OUTCOMES OF RITUXIMAB THERAPY IN PATIENTS WITH NONINFECTIOUS POSTERIOR UVEITIS REFRACTORY TO CONVENTIONAL IMMUNOSUPPRESSIVE THERAPY. Retina 2018; 38:395-402. [PMID: 28225369 DOI: 10.1097/iae.0000000000001563] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE To assess long-term effectiveness of rituximab therapy for refractory noninfectious uveitis affecting the posterior segment. METHODS Retrospective case series. Patients diagnosed with recalcitrant noninfectious posterior uveitis who were treated with rituximab intravenous infusions between 2010 and 2015 were included. Patients underwent best-corrected visual acuity testing and fluorescein angiography evidence of disk or vascular staining at 6, 12, 18, and 24 months. Patients had at least 24 months of follow-up. RESULTS Eleven patients (21 eyes) with refractory posterior uveitis treated with intravenous rituximab were included. Nine (81.8%) patients were female. Mean follow-up was 29.3 ± 7.8 months. rituximab was administered as complementary therapy because of previous inefficacy of other therapies in 7 (63.7%) patients, and it was the only treatment in four (36.3%) patients who did not tolerate other drugs. Inflammation signs by fluorescein angiography were controlled in nine (81.8%) patients at the end of follow-up. Baseline best-corrected visual acuity was 20/80 (logarithm of the minimal angle of resolution 0.6 ± 0.4), and final best-corrected visual acuity was 20/40 (0.3 ± 0.5) (P = 0.005). No significant side effects were reported. CONCLUSION Rituximab therapy was associated with stability and remission of recalcitrant noninfectious posterior uveitis in patients who did not tolerate or did not respond to other therapies.
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Ragab G, Atkinson TP, Stoll ML. Macrophage Activation Syndrome. THE MICROBIOME IN RHEUMATIC DISEASES AND INFECTION 2018. [PMCID: PMC7123081 DOI: 10.1007/978-3-319-79026-8_14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH), or termed macrophage activation syndrome (MAS) when associated with rheumatic disorders, is a frequently fatal complication of infections, rheumatic disorders, and hematopoietic malignancies. Clinically, HLH/MAS is a life-threatening condition that is usually diagnosed among febrile hospitalized patients (children and adults) who commonly present with unremitting fever and a shock-like multiorgan dysfunction scenario. Laboratory studies reveal pancytopenia, elevated liver enzymes, elevated markers of inflammation (ESR, CRP), hyperferritinemia, and features of coagulopathy. In about 60% of cases, excess hemophagocytosis (macrophages/histiocytes engulfing other hematopoietic cell types) is noted on biopsy specimens from the bone marrow, liver, lymph nodes, and other organs. HLH/MAS has been hypothesized to occur when a threshold level of inflammation has been achieved, and genetic and environmental risk factors are believed to contribute to the hyperinflammatory state. A broad variety of infections, from viruses to fungi to bacteria, have been identified as triggers of HLH/MAS, either in isolation or in addition to an underlying inflammatory disease state. Certain infections, particularly by members of the herpesvirus family, are the most notorious triggers of HLH/MAS. Treatment for infection-triggered MAS requires therapy for both the underlying infection and dampening of the hyperactive immune response.
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Affiliation(s)
- Gaafar Ragab
- Faculty of Medicine, Cairo University, Cairo, Egypt
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Abstract
The past two decades have brought immense satisfaction to pediatric rheumatologists and families of children with rheumatologic diseases. We have been able to better classify, recognize, and diagnose rheumatologic diseases, but most importantly, the discovery of biologic therapies and their efficacy and relative safety in treating multiple rheumatologic conditions, improving quality of life for the patients we care for. We will review the advances of the past two decades and discuss potential areas for new discoveries.
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Affiliation(s)
- Yonit Sterba
- Division of Pediatric Rheumatology, The Children's Hospital at Montefiore, 3415 Bainbridge Avenue, Bronx, NY, 10467, USA.
| | - Norman Ilowite
- Division of Pediatric Rheumatology, The Children's Hospital at Montefiore, 3415 Bainbridge Avenue, Bronx, NY, 10467, USA
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Vanoni F, Minoia F, Malattia C. Biologics in juvenile idiopathic arthritis: a narrative review. Eur J Pediatr 2017; 176:1147-1153. [PMID: 28725955 DOI: 10.1007/s00431-017-2960-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 06/27/2017] [Accepted: 06/29/2017] [Indexed: 12/11/2022]
Abstract
UNLABELLED In the past years, pediatric rheumatology has seen a revolution in the treatments for rheumatic diseases, particularly juvenile idiopathic arthritis. Even if nonsteroidal anti-inflammatory drugs (NSAID), intra-articular corticosteroids (IAC) injections, and methotrexate remain the mainstay of the treatment for JIA patients, in aggressive disease, these treatments may be not sufficient to reach disease remission and to prevent long-term disability. Comprehension of immunological mechanisms involved in the pathogenesis of the diseases allowed to conceive new drugs targeting specific steps of the immune response. Several cytokines, like TNF alpha and IL-1, represent a very interesting target for biologic therapies. Due to the efficacy of these therapies, nowadays, "disease remission" in pediatric rheumatology is more and more frequent, especially in juvenile idiopathic arthritis patients, and the long-term outcomes have been significantly improved. Crucial to these advancements have been multicenter controlled clinical trials and long-term safety monitoring. CONCLUSIONS Research in pediatric rheumatology has resulted in dramatic advances in diseases management. Biologic treatments have improved physical and functional outcomes and quality of life of patients with rheumatic disease. What is Known: • NSAID, intra-articular injection of corticoids, and methotrexate are the mainstay in treatment of JIA. • In aggressive JIA, these treatments may be not sufficient to reach disease remission and to prevent long term disability. What is New: • In recent years, management of JIA has significantly improved with the development of biologic therapies that allowed children with arthritis to reach a normal growth and to achieve a good long-term functional outcome.
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Affiliation(s)
- Federica Vanoni
- Department of Pediatrics, Ospedale San Giovanni, 6500, Bellinzona, Switzerland.
- Unité Romande d'Immuno-rhumatologie Pédiatrique (URIRP), Département Femme-Mère-Enfant (DFME), CHUV, University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | | | - Clara Malattia
- Istituto Giannina Gaslini and Università degli Studi di Genova, Genoa, Italy
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Alexeeva EI, Namazova-Baranova LS, Bzarova TM, Valieva SI, Denisova RV, Sleptsova TV, Isaeva KB, Chomahidze AM, Taibulatov NI, Fetisova AN, Karaseva AV, Baranov AA. Predictors of the response to etanercept in patients with juvenile idiopathic arthritis without systemic manifestations within 12 months: results of an open-label, prospective study conducted at the National Scientific and Practical Center of Children's Health, Russia. Pediatr Rheumatol Online J 2017; 15:51. [PMID: 28615036 PMCID: PMC5471744 DOI: 10.1186/s12969-017-0178-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 06/02/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the efficacy of etanercept treatment and to identify predictors of response to therapy within 12 months in patients with juvenile idiopathic arthritis (JIA) without systemic manifestations. METHODS A total of 197 juvenile patients were enrolled in this study. Response to therapy was assessed using the ACRPedi 30/50/70/90 criteria, the Wallace criteria, and the Juvenile Arthritis Disease Activity Score 71 (JADAS-71). Univariate and multivariate logistic regression analyses were performed to identify potential baseline factors associated with treatment response in different JIA categories. RESULTS One year after treatment initiation, 179 (90.9%) patients achieved ACRPedi30; 177 (89.8%) patients achieved ACRPedi50; 168 (85.3%) patients achieved ACRPedi70; and 135 (68.5%) patients achieved ACRPedi90 response. A total of 132 (67.0%) and 92 (46.7%) patients achieved inactive disease according to the Wallace criteria and the JADAS-71 cut-off point, respectively. Excellent response (achieving ACRPedi90 and clinically inactive disease according both to the Wallace criteria and the JADAS71 cut-off point) was associated with persistent oligoarticular JIA category, shorter disease duration before the start of etanercept, a lower number of DMARDs used before the introduction of etanercept, a lower number of joints with limited motion, and lower C-reactive protein at baseline. Poor response (failure to achieve ACR 70 or active disease according to both the Wallace criteria and JADAS71 even when ACR 70 was achieved) was associated with the polyarticular or enthesitis-related JIA categories, higher disease duration before the start of etanercept, and older age at disease onset. CONCLUSION Almost half (45.7%) of the patients who initiated etanercept treatment achieved an excellent response (inactive disease and ACRPedi90) after 1 year. What may be novel is our finding that the response to etanercept therapy was strongly associated with the JIA category. The response to etanercept therapy was also associated with the disease duration before the start of etanercept treatment.
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Affiliation(s)
- Ekaterina I. Alexeeva
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia ,0000 0000 9216 2496grid.415738.cFederal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia ,0000 0000 9216 2496grid.415738.cRheumatology Department, Federal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Leyla S. Namazova-Baranova
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Tatyana M. Bzarova
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia ,0000 0000 9216 2496grid.415738.cFederal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Saniya I. Valieva
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Rina V. Denisova
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Tatyana V. Sleptsova
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Kseniya B. Isaeva
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Alexandra M. Chomahidze
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Nikolay I. Taibulatov
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Anna N. Fetisova
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Anna V. Karaseva
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Alexandr A. Baranov
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
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Systemic Treatment for Noninfectious Intraocular Inflammation. CURRENT OPHTHALMOLOGY REPORTS 2017. [DOI: 10.1007/s40135-017-0127-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Ishikawa S, Shimizu M, Inoue N, Mizuta M, Nakagishi Y, Yachie A. Interleukin-33 as a marker of disease activity in rheumatoid factor positive polyarticular juvenile idiopathic arthritis. Mod Rheumatol 2016; 27:609-613. [PMID: 27785924 DOI: 10.1080/14397595.2016.1246118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To investigate clinical usefulness of serum interleukin (IL)-33 levels as an indicator of disease activity in juvenile idiopathic arthritis (JIA). METHODS We measured serum levels of IL-33 in 39 patients with JIA, including 7 patients with rheumatoid factor positive poly-JIA (RF + poly-JIA), 8 patients with RF negative poly-JIA (RF-poly-JIA), 20 patients with oligoarticular JIA (Oligo-JIA), 4 patients with enthesitis-related arthritis (ERA) and 30 age-matched healthy controls. Furthermore, we determined their correlation with measures of disease activity. RESULTS Serum IL-33 levels in patients with RF + poly-JIA were significantly elevated compared to those in patients with RF-poly-JIA, oligo-JIA and HC. Serum IL-33 levels in patients with RF-poly-JIA, oligo-JIA and ERA were not elevated compared to those in HC. Serum IL-33 levels in RF + poly-JIA patients normalized in remission phase. Serum IL-33 levels correlated positively with RF in patients with RF + poly-JIA. CONCLUSIONS These results indicate that serum IL-33 levels in RF + poly-JIA patients correlated with disease activity, suggesting a potential role of IL-33 as a promising indicator of disease activity.
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Affiliation(s)
- Sayaka Ishikawa
- a Department of Pediatrics , School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University , Kanazawa , Japan and
| | - Masaki Shimizu
- a Department of Pediatrics , School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University , Kanazawa , Japan and
| | - Natsumi Inoue
- a Department of Pediatrics , School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University , Kanazawa , Japan and
| | - Mao Mizuta
- a Department of Pediatrics , School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University , Kanazawa , Japan and.,b Department of Pediatric Rheumatology , Hyogo Prefectural Kobe Children's Hospital , Kanazawa , Japan
| | - Yasuo Nakagishi
- b Department of Pediatric Rheumatology , Hyogo Prefectural Kobe Children's Hospital , Kanazawa , Japan
| | - Akihiro Yachie
- a Department of Pediatrics , School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University , Kanazawa , Japan and
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Shenoi S, Wallace CA. Diagnosis and Treatment of Systemic Juvenile Idiopathic Arthritis. J Pediatr 2016; 177:19-26. [PMID: 27499217 DOI: 10.1016/j.jpeds.2016.06.056] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 06/03/2016] [Accepted: 06/16/2016] [Indexed: 12/23/2022]
Affiliation(s)
- Susan Shenoi
- Department of Pediatrics, Division of Rheumatology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Carol A Wallace
- Department of Pediatrics, Division of Rheumatology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
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Kearsley-Fleet L, Davies R, Baildam E, Beresford MW, Foster HE, Southwood TR, Thomson W, Hyrich KL. Factors associated with choice of biologic among children with Juvenile Idiopathic Arthritis: results from two UK paediatric biologic registers. Rheumatology (Oxford) 2016; 55:1556-65. [PMID: 26732349 PMCID: PMC4993954 DOI: 10.1093/rheumatology/kev429] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 11/25/2015] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The objectives of this study were to describe patients starting first-line biologics for JIA, to describe characteristics over time among patients starting etanercept, and to describe patterns of second biologic prescribing. METHODS The British Society for Paediatric and Adolescent Rheumatology Etanercept Cohort Study, and the Biologics for Children with Rheumatic Diseases study are ongoing prospective observational cohorts, collecting data on patients starting biologic therapy for JIA. Patients registered from 1 January 2010 starting their first biologic were compared between therapies. Patients starting etanercept before 2010 were included to analyse changes in etanercept prescribing. The pathway of patients starting a second biologic was recorded in all patients. RESULTS To 26 August 2014, 931 patients were recruited starting a first-line biologic (142 Biologics for Children with Rheumatic Diseases; 789 British Society for Paediatric and Adolescent Rheumatology Etanercept Cohort Study). From 2010, patients with systemic JIA (sJIA) were almost exclusively prescribed anakinra or tocilizumab. Choice between anti-TNF therapies was largely driven by history of chronic anterior uveitis (CAU). When investigating trends in patients starting etanercept over time, disease duration at etanercept start, patients with sJIA, a history of CAU, and those who received concomitant oral corticosteroids decreased over time. Patients who started a second biologic from 1 January 2010 showed a similar stratification. CONCLUSION Although etanercept remains the most common biologic prescribed for JIA, there has been a clear shift towards the use of alternative biologics, largely driven by disease subtype and history of CAU. This channelling of children towards specific therapies should be considered carefully in future studies and in clinical guidelines and ongoing research.
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Affiliation(s)
- Lianne Kearsley-Fleet
- Arthritis Research UK Centre for Epidemiology, Manchester Academic Health Science Centre, The University of Manchester, Manchester
| | - Rebecca Davies
- Arthritis Research UK Centre for Epidemiology, Manchester Academic Health Science Centre, The University of Manchester, Manchester
| | | | - Michael W Beresford
- Clinical Academic Department of Paediatric Rheumatology, Institute of Translational Medicine (Child Health), University of Liverpool, Alder Hey Children's NHS Foundation Trust, Liverpool
| | - Helen E Foster
- Musculoskeletal Research Group, Institute Cellular Medicine, Newcastle University, Newcastle upon Tyne
| | - Taunton R Southwood
- Department of Paediatric Rheumatology, Institute of Child Health, Birmingham Children's Hospital - NHS Trust and University of Birmingham, Birmingham
| | - Wendy Thomson
- Arthritis Research UK Centre for Genetics and Genomics, Manchester Academic Health Science Centre and NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester Partnership, Manchester, UK
| | - Kimme L Hyrich
- Arthritis Research UK Centre for Epidemiology, Manchester Academic Health Science Centre, The University of Manchester, Manchester, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester Partnership, Manchester, UK
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30
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Giancane G, Consolaro A, Lanni S, Davì S, Schiappapietra B, Ravelli A. Juvenile Idiopathic Arthritis: Diagnosis and Treatment. Rheumatol Ther 2016; 3:187-207. [PMID: 27747582 PMCID: PMC5127964 DOI: 10.1007/s40744-016-0040-4] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Indexed: 12/20/2022] Open
Abstract
Juvenile idiopathic arthritis is a broad term that describes a clinically heterogeneous group of arthritides of unknown cause, which begin before 16 years of age. This term encompasses several disease categories, each of which has distinct presentation, clinical manifestations, and, presumably, genetic background and etiopathogenesis. Although none of the available drugs has curative potential, prognosis has greatly improved as a result of substantial progresses in disease management. The most important new development has been the introduction of the biologic medications, which constitute a valuable treatment option for patients who are resistant to conventional antirheumatic agents. Further insights into the disease pathogenesis and treatment will be provided by the continuous advances in understanding of the mechanisms related to the immune response and inflammatory process, and by the development of new drugs that are capable of selectively inhibiting single molecules or pathways.
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Affiliation(s)
- Gabriella Giancane
- Istituto Giannina Gaslini, Genoa, Italy.,Università degli Studi di Genova, Genoa, Italy
| | - Alessandro Consolaro
- Istituto Giannina Gaslini, Genoa, Italy.,Università degli Studi di Genova, Genoa, Italy
| | | | | | | | - Angelo Ravelli
- Istituto Giannina Gaslini, Genoa, Italy. .,Università degli Studi di Genova, Genoa, Italy.
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31
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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.
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32
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Batu ED. Biologic therapies in systemic juvenile idiopathic arthritis. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1177511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Ezgi Deniz Batu
- Department of Pediatrics, Division of Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Steigerwald KA, Ilowite NT. Novel treatment options for juvenile idiopathic arthritis. Expert Rev Clin Pharmacol 2016; 8:559-73. [PMID: 26294075 DOI: 10.1586/17512433.2015.1061428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The purpose of this review is to summarize the newer and possible future treatments for the arthritis and systemic features in children with juvenile idiopathic arthritis (JIA), including evidence supporting their efficacy and safety.
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Affiliation(s)
- Katherine A Steigerwald
- a Children's Hospital at Montefiore, Division of Pediatric Rheumatology, Department of Pediatrics, 3415 Bainbridge Avenue, Bronx, NY 10467, USA
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Clement CC, Moncrieffe H, Lele A, Janow G, Becerra A, Bauli F, Saad FA, Perino G, Montagna C, Cobelli N, Hardin J, Stern LJ, Ilowite N, Porcelli SA, Santambrogio L. Autoimmune response to transthyretin in juvenile idiopathic arthritis. JCI Insight 2016; 1:85633. [PMID: 26973882 DOI: 10.1172/jci.insight.85633] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Juvenile idiopathic arthritis (JIA) is the most common pediatric rheumatological condition. Although it has been proposed that JIA has an autoimmune component, the autoantigens are still unknown. Using biochemical and proteomic approaches, we identified the molecular chaperone transthyretin (TTR) as an antigenic target for B and T cell immune responses. TTR was eluted from IgG complexes and affinity purified from 3 JIA patients, and a statistically significant increase in TTR autoantibodies was observed in a group of 43 JIA patients. Three cryptic, HLA-DR1-restricted TTR peptides, which induced CD4+ T cell expansion and IFN-γ and TNF-α production in 3 out of 17 analyzed patients, were also identified. Misfolding, aggregation and oxidation of TTR, as observed in the synovial fluid of all JIA patients, enhanced its immunogenicity in HLA-DR1 transgenic mice. Our data point to TTR as an autoantigen potentially involved in the pathogenesis of JIA and to oxidation and aggregation as a mechanism facilitating TTR autoimmunity.
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Affiliation(s)
- Cristina C Clement
- Department of Pathology, Albert Einstein College of Medicine, New York, New York, USA
| | - Halima Moncrieffe
- Center for Autoimmune Genomics and Etiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Aditi Lele
- Center for Autoimmune Genomics and Etiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ginger Janow
- Department of Pediatric Rheumatology, Montefiore Medical Center, New York, New York, USA
| | - Aniuska Becerra
- Department of Pathology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Francesco Bauli
- Department of Pathology, Albert Einstein College of Medicine, New York, New York, USA
| | - Fawzy A Saad
- Department of Pathology, Albert Einstein College of Medicine, New York, New York, USA
| | - Giorgio Perino
- Department of Pathology, Hospital for Special Surgery, New York, New York, USA
| | - Cristina Montagna
- Department of Genetics, Albert Einstein College of Medicine, New York, New York, USA
| | - Neil Cobelli
- Department of Orthopedic Surgery, Montefiore Medical Center, New York, New York, USA
| | - John Hardin
- Department of Orthopedic Surgery, Montefiore Medical Center, New York, New York, USA
| | - Lawrence J Stern
- Department of Pathology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Norman Ilowite
- Department of Pediatric Rheumatology, Montefiore Medical Center, New York, New York, USA
| | - Steven A Porcelli
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, New York, New York, USA
| | - Laura Santambrogio
- Department of Pathology, Albert Einstein College of Medicine, New York, New York, USA.,Department of Orthopedic Surgery, Montefiore Medical Center, New York, New York, USA.,Department of Microbiology and Immunology, Albert Einstein College of Medicine, New York, New York, USA
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Abstract
PURPOSE OF REVIEW To review recent advances in the management strategies of polyarticular course juvenile idiopathic arthritis (JIA) and identify unanswered questions and avenues for further research. RECENT FINDINGS There is evidence for an early, aggressive, treat-to-target approach for polyarticular JIA. Clinical disease activity criteria have been recently defined and validated, including criteria for inactive disease and the juvenile arthritis disease activity score (JADAS). There is a need for evidence-based, defined disease targets and biomarkers for prediction of response, including targets for remission induction, and guidelines on drug withdrawal. Recent treatment consensus plans and guidelines are discussed and compared, including the 2015 NHS England clinical policy statement, the 2014 Childhood Arthritis and Rheumatology Research Alliance (CARRA) treatment plans and the 2011 American College of Rheumatology (ACR) guidelines. Evidence for new agents such as tocilizumab, rituximab, golimumab, ustekinumab, certolizumab and tofacitinib is promising: the recent clinical trials are summarized here. Stratification of individual patient treatment remains a goal, and predictive biomarkers have been shown to predict success in the withdrawal of methotrexate therapy. SUMMARY There are promising advances in the treatment approaches, disease activity criteria, clinical guidelines, pharmaceutical choices and individually stratified therapy choices for polyarticular JIA.
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Affiliation(s)
- Kate Webb
- aDivision of Medicine, Arthritis Research UK Centre for Adolescent Rheumatology at UCL, UCLH, and GOSH, University College London bInstitute of Child Health UCL, University College London, London, UK
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Abstract
Macrophage activation syndrome (MAS) is a potentially life-threatening complication of rheumatic disorders that occurs most commonly in systemic juvenile idiopathic arthritis. In recent years, there have been several advances in the understanding of the pathophysiology of MAS. Furthermore, new classification criteria have been developed. Although the place of cytokine blockers in the management of MAS is still unclear, interleukin-1 inhibitors represent a promising adjunctive therapy, particularly in refractory cases.
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Affiliation(s)
- Angelo Ravelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Head, Center of Rheumatology, University of Genoa and G. Gaslini Institute, via G. Gaslini 5, Genoa 16147, Italy.
| | - Sergio Davì
- Second Pediatric Division and Rheumatology, G. Gaslini Institute, via G. Gaslini 5, Genoa 16147, Italy
| | - Francesca Minoia
- Second Pediatric Division and Rheumatology, G. Gaslini Institute, via G. Gaslini 5, Genoa 16147, Italy
| | - Alberto Martini
- Department of Pediatrics and Second Pediatric Division and Rheumatology, University of Genoa and G. Gaslini Institute, via G. Gaslini 5, Genoa 16147, Italy
| | - Randy Q Cron
- Director, Division of Pediatric Rheumatology, Children's Hospital of Alabama and University of Alabama at Birmingham, Children's Park Place, Ste. 210 1601 4th Avenue South Birmingham, AL 35233, USA
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Sakamoto AP, Pinheiro MM, Barbosa CMPL, Fraga MM, Len CA, Terreri MT. Rituximab use in young adults diagnosed with juvenile idiopathic arthritis unresponsive to conventional treatment: report of 6 cases. REVISTA BRASILEIRA DE REUMATOLOGIA 2015; 55:536-41. [PMID: 26066294 DOI: 10.1016/j.rbr.2014.12.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 12/10/2014] [Accepted: 12/24/2014] [Indexed: 01/19/2023] Open
Abstract
Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in childhood. Without an effective therapy, patients may progress quickly to functional disability. Recently, depletion of B cells emerged as a new approach for the treatment of autoimmune diseases, including JIA. We describe six cases of JIA patients followed at a referral center for Rheumatology and Pediatric Rheumatology, submitted to treatment with rituximab (RTX) after refractoriness to three anti-TNF agents. Patients received RTX cycles with two infusions every six months. Response to treatment was assessed by DAS28, HAQ/CHAQ, and an overall assessment by the doctor and the patient. Of our six patients, four were girls (mean age at onset of disease: 6.1 years; mean disease evolution time: 15.1 years; mean age upon receiving RTX: 21.6 years). Four patients belonged to polyarticular subtype (1 rheumatoid factor [RF]-negative, 3 FR-positive), a patient with systemic JIA subtype with a polyarticular course and arthritis related to enthesitis. Of our six patients, five responded to treatment; and during the course of 12 months, the clinical response was maintained, although not sustained. However, discontinuation by infusion reactions caused the withdrawal of RTX in two patients. The use of RTX in JIA is restricted to cases refractory to other biological agents and, even considering that this study was held in a small number of advanced patients, RTX proved to be an effective therapeutic option.
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Abstract
Many paediatric rheumatic diseases result from the abnormal activation or control of the immune system. Biologic drugs, which are synthesised within a biological system, have been designed to target specific molecules involved in cytokine signalling or cell-cell interactions. The past 15 years have seen a revolution in the range of effective treatments for rheumatic diseases, particularly juvenile idiopathic arthritis (JIA). As a result, the target of inactive disease and minimal long-term disease-associated damage is increasingly becoming achievable. In this article we review evidence from recent trials of the use of biologic drugs in the treatment of systemic JIA, juvenile dermatomyositis and juvenile systemic lupus erythematosus. We also highlight novel agents currently undergoing investigation which may broaden our therapeutic armamentarium over the coming decade. Key to these developments are well-designed multicentre controlled clinical trials and long-term safety monitoring as part of international drug registries.
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Affiliation(s)
- Ethan S Sen
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
| | - A V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
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Abstract
Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disorder that may cause joint destruction. Biological treatments targeting specific cytokines and cell interactions have transformed the outcomes of JIA. This review focuses on the selection of patients for and the timing and selection of biological treatment in JIA. Tumor necrosis factor (TNF) inhibitors remain the first choice for polyarticular JIA, followed by abatacept and tocilizumab. Monoclonal-antibody TNF inhibitors and abatacept are usually chosen for methotrexate-resistant uveitis. Recent clinical trials of canakinumab, rilonacept, and tocilizumab have obtained great improvement in both systemic and arthritic features in chronic systemic JIA patients. Current guidelines support the early use of a short-acting IL-1 antagonist for macrophage activation syndrome, a life-threatening complication. TREAT and ACUTE studies suggest that a therapeutic window of opportunity during early disease may exist in JIA. Early initiation of biological therapy may be associated with slower progression of joint damage and longer remission.
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40
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Smith EMD, Foster HE, Beresford MW. The development and assessment of biological treatments for children. Br J Clin Pharmacol 2015; 79:379-94. [PMID: 24750505 PMCID: PMC4345949 DOI: 10.1111/bcp.12406] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 04/11/2014] [Indexed: 12/14/2022] Open
Abstract
The development of biological agents with specific immunological targets has revolutionized the treatment of a wide variety of paediatric diseases where traditional immunosuppressive agents have been partly ineffective or intolerable. The increasing requirement for pharmaceutical companies to undertake paediatric studies has provided impetus for studies of biologics in children. The assessment of biological agents in children to date has largely relied upon randomized controlled trials using a withdrawal design, rather than a parallel study design. This approach has been largely used due to ethical concerns, including use of placebo treatments in children with active chronic disease, and justified on the basis that treatments have usually already undergone robust assessment in related adult conditions. However, this study design limits the reliability of the data and can confuse the interpretation of safety results. Careful ongoing monitoring of safety and efficacy in real-world practice through national and international biologics registries and robust reporting systems is crucial. The most commonly used biological agents in children target tumour necrosis factor-α, interleukin-1, interleukin-6 and cytotoxic lymphocyte-associated antigen-4. These agents are most frequently used in paediatric rheumatic diseases. This review discusses the development and assessment of biologics within paediatric rheumatology with reference to the lessons learned from use in other subspecialties.
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Affiliation(s)
- Eve M D Smith
- Institute of Translational Medicine, University of LiverpoolLiverpool, UK
| | - Helen E Foster
- Paediatric Rheumatology, Institute of Cellular Medicine, Newcastle UniversityNewcastle upon Tyne, UK
- Great North Children's Hospital, Newcastle Hospitals NHS Foundation TrustNewcastle upon Tyne, UK
| | - Michael W Beresford
- Institute of Translational Medicine, University of LiverpoolLiverpool, UK
- Alder Hey Children's NHS Foundation TrustLiverpool, UK
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Kasapçopur Ö, Barut K. Treatment in juvenile rheumatoid arthritis and new treatment options. Turk Arch Pediatr 2015; 50:1-10. [PMID: 26078691 DOI: 10.5152/tpa.2015.2229] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 10/23/2014] [Indexed: 11/22/2022]
Abstract
Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease of the childhood with the highest risk of disability. Active disease persists in the adulthood in a significant portion of children with juvenile rheumatoid arthritis despite many developments in the diagnosis and treatment. Therefore, initiation of efficient treatment in the early period of the disease may provide faster control of the inflammation and prevention of long-term harms. In recent years, treatment options have also increased in children with juvenile idiopathic arthritis owing to biological medications. All biological medications used in children have been produced to target the etiopathogenesis leading to disease including anti-tumor necrosis factor, anti-interleukin 1 and anti-interleukin 6 drugs. In this review, scientific data about biological medications used in the treatment of rheumatoid arthritis and new treatment options will be discussed.
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Affiliation(s)
- Özgür Kasapçopur
- Department of Pediatrics, Division of Pediatric Rheumatology, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
| | - Kenan Barut
- Department of Pediatrics, Division of Pediatric Rheumatology, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
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Tambralli A, Beukelman T, Cron RQ, Stoll ML. Safety and efficacy of rituximab in childhood-onset systemic lupus erythematosus and other rheumatic diseases. J Rheumatol 2015; 42:541-6. [PMID: 25593242 DOI: 10.3899/jrheum.140863] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Rituximab (RTX) has been used to treat many pediatric autoimmune conditions. We investigated the safety and efficacy of RTX in a variety of pediatric autoimmune diseases, especially systemic lupus erythematosus (SLE). METHODS Retrospective study of children treated with RTX. Effectiveness data was recorded for patients with at least 12 months of followup; safety data was recorded for all subjects. RESULTS The study included 104 children; 50 had SLE. Improvements in corticosteroid dosage, physician's global assessment of disease activity, and SLE-associated markers of disease activity were seen. The incidence of hospitalized infections was similar to previous studies of patients with childhood-onset SLE. CONCLUSION RTX can be safely administered to children and appears to contribute to decreased disease activity and steroid burden.
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Affiliation(s)
- Ajay Tambralli
- From the University of Alabama at Birmingham, Department of Pediatrics, Division of Rheumatology, Birmingham, Alabama; University of Rochester Medical Center, Department of Medicine, Rochester, New York, USA.A. Tambralli, MD, University of Rochester Medical Center, Department of Medicine; T. Beukelman, MD, MSCE; R.Q. Cron, MD, PhD; M.L. Stoll, MD, PhD, MSCS, University of Alabama at Birmingham, Department of Pediatrics, Division of Rheumatology
| | - Timothy Beukelman
- From the University of Alabama at Birmingham, Department of Pediatrics, Division of Rheumatology, Birmingham, Alabama; University of Rochester Medical Center, Department of Medicine, Rochester, New York, USA.A. Tambralli, MD, University of Rochester Medical Center, Department of Medicine; T. Beukelman, MD, MSCE; R.Q. Cron, MD, PhD; M.L. Stoll, MD, PhD, MSCS, University of Alabama at Birmingham, Department of Pediatrics, Division of Rheumatology
| | - Randy Quentin Cron
- From the University of Alabama at Birmingham, Department of Pediatrics, Division of Rheumatology, Birmingham, Alabama; University of Rochester Medical Center, Department of Medicine, Rochester, New York, USA.A. Tambralli, MD, University of Rochester Medical Center, Department of Medicine; T. Beukelman, MD, MSCE; R.Q. Cron, MD, PhD; M.L. Stoll, MD, PhD, MSCS, University of Alabama at Birmingham, Department of Pediatrics, Division of Rheumatology
| | - Matthew Laurence Stoll
- From the University of Alabama at Birmingham, Department of Pediatrics, Division of Rheumatology, Birmingham, Alabama; University of Rochester Medical Center, Department of Medicine, Rochester, New York, USA.A. Tambralli, MD, University of Rochester Medical Center, Department of Medicine; T. Beukelman, MD, MSCE; R.Q. Cron, MD, PhD; M.L. Stoll, MD, PhD, MSCS, University of Alabama at Birmingham, Department of Pediatrics, Division of Rheumatology.
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Berrada K, Abourazzak FE, El Mezouar I, Lazrak F, Aradoini N, Tahiri L, Harzy T. A successful treatment of juvenile idiopathic arthritis with rituximab: A report of two cases. Eur J Rheumatol 2014; 1:164-166. [PMID: 27708906 DOI: 10.5152/eurjrheumatol.2014.140049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 07/10/2014] [Indexed: 02/01/2023] Open
Abstract
Juvenile idiopathic arthritis (JIA) is defined as arthritis of unknown cause that starts before 16 years of age and lasts at least 6 weeks. It is the most common chronic inflammatory disease in childhood and often persists through adulthood and can lead to severe disability. Biologics are an important therapeutic option for treating patients with JIA. The efficiency of rituximab has not been proven for this indication. Its use has rarely been reported in the literature. We report two new cases of severe and refractory polyarticular JIA with positive rheumatoid factor affecting two African females aged 17 and 18 years successfully treated with rituximab. According to our experience, the use of rituximab in the treatment of JIA, especially in severe polyarticular forms with positive rheumatoid factor, might be a good alternative. Larger therapeutic trials should be conducted in this direction in order to prove the effectiveness of this biotherapy for this indication.
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Affiliation(s)
- Khadija Berrada
- Department of Rheumatology, CHU Hassan II University Hospital, Fez, Morocco
| | | | - Imane El Mezouar
- Department of Rheumatology, CHU Hassan II University Hospital, Fez, Morocco
| | - Faiza Lazrak
- Department of Rheumatology, CHU Hassan II University Hospital, Fez, Morocco
| | - Nacira Aradoini
- Department of Rheumatology, CHU Hassan II University Hospital, Fez, Morocco
| | - Latifa Tahiri
- Department of Rheumatology, CHU Hassan II University Hospital, Fez, Morocco
| | - Taoufik Harzy
- Department of Rheumatology, CHU Hassan II University Hospital, Fez, Morocco
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Swart JF, de Roock S, Wulffraat NM. What are the immunological consequences of long-term use of biological therapies for juvenile idiopathic arthritis? Arthritis Res Ther 2014; 15:213. [PMID: 23731900 PMCID: PMC4060240 DOI: 10.1186/ar4213] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
This review summarizes the immunological consequences of biological therapies used in juvenile idiopathic arthritis (JIA). For every frequently used biological agent the characteristics are clearly specified (molecular target, isotype, registered indication for JIA, route of administration, half-life, contraindication, very common side effects, expected time of response and average cost in the first year). The emphasis of this review is on the immunological side effects that have been encountered for every separate agent in JIA populations. For each agent these adverse events have been calculated as incidence per 100 patient-years for the following categories: serious infections, tuberculosis, malignancies, response to vaccination, new-onset autoimmune diseases and development of anti-drug antibodies. There are large differences in side effects between various agents and there is a clear need for an international and standardized collection of post-marketing surveillance data of biologicals in the vulnerable group of JIA patients. Such an international pharmacovigilance database, called Pharmachild, has now been started.
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Glaesener S, Quách TD, Onken N, Weller-Heinemann F, Dressler F, Huppertz HI, Thon A, Meyer-Bahlburg A. Distinct effects of methotrexate and etanercept on the B cell compartment in patients with juvenile idiopathic arthritis. Arthritis Rheumatol 2014; 66:2590-600. [PMID: 24909567 PMCID: PMC4288311 DOI: 10.1002/art.38736] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 05/29/2014] [Indexed: 12/28/2022]
Abstract
Objective B cells have been shown to play an important role in the pathogenesis of rheumatoid arthritis and juvenile idiopathic arthritis (JIA). Current treatments include the disease-modifying antirheumatic drugs methotrexate (MTX) and tumor necrosis factor α inhibition with etanercept. This study was undertaken to determine how these drugs influence the B cell compartment in patients with JIA. Methods B cell subpopulations and follicular helper T (Tfh) cells in the peripheral blood of JIA patients were investigated by multicolor flow cytometry. Serum immunoglobulin and BAFF levels were determined by enzyme-linked immunosorbent assay. Results There was a significant decrease in transitional B cells and significantly lower serum immunoglobulin levels in patients receiving MTX than in untreated patients and those receiving etanercept. In contrast, etanercept treatment had no effect on most of the B cell subpopulations, but resulted in significantly lower BAFF levels and increased numbers of Tfh cells. Thus, our findings indicate an unexpected and previously unknown direct effect of low-dose MTX on B cells, whereas etanercept had a more indirect influence. Conclusion Our results contribute to a better understanding of the potency of MTX in autoantibody-mediated autoimmune disease and present a possible mechanism of prevention of the development of drug-induced antibodies to biologic agents. The finding that MTX and etanercept affect the B cell compartment differently supports the notion that combination therapy with etanercept and MTX is more effective than monotherapy.
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Oberle EJ, Harris JG, Verbsky JW. Polyarticular juvenile idiopathic arthritis - epidemiology and management approaches. Clin Epidemiol 2014; 6:379-93. [PMID: 25368531 PMCID: PMC4216020 DOI: 10.2147/clep.s53168] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Juvenile idiopathic arthritis (JIA) is a group of disorders characterized by arthritis persisting for at least 6 weeks with onset before the age of 16 years. Within this cluster of conditions, the polyarticular form (involving more than four joints within the first 6 months) is further divided based on the presence of rheumatoid factor. Children with polyarticular JIA pose unique diagnostic and therapeutic challenges compared to children with involvement of fewer joints. Polyarticular JIA patients tend to have a more refractory course and therefore are at increased risk for joint damage, resulting in poorer functional outcomes and decreased quality of life. Although the ability to treat this disorder continues to improve, especially with the advent of biologic agents, there is still much about the epidemiology and pathogenesis of polyarticular JIA that is unknown. The epidemiology of polyarticular JIA varies worldwide with a vast difference in reported cases between different global regions as well as within individual countries. Several genetic risk loci have been identified conferring increased susceptibility to JIA, many within the human leukocyte antigen region. Beyond the genome, environmental factors also seem to contribute to the etiology of polyarticular JIA. This review article will focus on the epidemiology and current treatments of polyarticular JIA and briefly discuss genetic and environmental influences on the pathogenesis of JIA as well as new and emerging therapies.
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Affiliation(s)
- Edward J Oberle
- Department of Pediatrics, Division of Rheumatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Julia G Harris
- Department of Pediatrics, Division of Rheumatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - James W Verbsky
- Department of Pediatrics, Division of Rheumatology, Medical College of Wisconsin, Milwaukee, WI, USA
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Lee K, Bajwa A, Freitas-Neto CA, Metzinger JL, Wentworth BA, Foster CS. A comprehensive review and update on the biologic treatment of adult noninfectious uveitis: part II. Expert Opin Biol Ther 2014; 14:1651-66. [PMID: 25226284 DOI: 10.1517/14712598.2014.947957] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Treatment of adult, noninfectious uveitis remains a major challenge for ophthalmologists around the world, especially in regard to recalcitrant cases. It is reported to comprise approximately 10% of preventable blindness in the USA. The cause of uveitis can be idiopathic or associated with infectious and systemic disorders. The era of biologic medical therapies provides new options for patients with otherwise treatment-resistant inflammatory eye disease. AREAS COVERED This two-part review gives a comprehensive overview of the existing medical treatment options for patients with adult, noninfectious uveitis, as well as important advances for the treatment ocular inflammation. Part I covers classic immunomodulation and latest information on corticosteroid therapy. In part II, emerging therapies are discussed, including biologic response modifiers, experimental treatments and ongoing clinical studies for uveitis. EXPERT OPINION The hazard of chronic corticosteroid use in the treatment of adult, noninfectious uveitis is well documented. Corticosteroid-sparing therapies, which offer a very favorable risk-benefit profile when administered properly, should be substituted. Although nothing is currently approved for on-label use in this indication, many therapies, through either translation or novel basic science research, have the potential to fill the currently exposed gaps.
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Affiliation(s)
- Kyungmin Lee
- Massachusetts Eye Research and Surgery Institution (MERSI) , 5 Cambridge Center, 8th Floor, Cambridge, MA 02142 , USA +1 617 621 6377 ; +1 617 494 1430 ;
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Kalinina Ayuso V, Makhotkina N, van Tent-Hoeve M, de Groot-Mijnes JD, Wulffraat NM, Rothova A, de Boer JH. Pathogenesis of juvenile idiopathic arthritis associated uveitis: the known and unknown. Surv Ophthalmol 2014; 59:517-31. [DOI: 10.1016/j.survophthal.2014.03.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 03/24/2014] [Accepted: 03/25/2014] [Indexed: 12/17/2022]
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Abstract
The treatment of juvenile idiopathic arthritis (JIA) has substantially evolved over the past two decades. Research has been conducted and is ongoing on how therapies can best be utilized either as monotherapy or in combination for enhanced efficacy. The introduction of biologic therapies that selectively target specific cytokines has changed the acceptable clinical course of childhood arthritis. In addition to the development and utilization of new therapeutic agents, the pediatric rheumatology community has made vital progress toward defining disease activity, developing validated outcome measures, and establishing collaborative networks to assess both clinical outcomes and the long-term side effects related to therapeutics for juvenile arthritis. In this chapter, we will discuss the therapeutic evolution in JIA over the past two decades. Although the largest strides have been made with biologic agents, and these newer drugs have more rigorous data to support their use, select commonly used non-biologic therapies are included, with the discussion focused on more recent updated literature.
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Affiliation(s)
- Elizabeth A Kessler
- Division of Rheumatology, Department of Pediatrics, Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO 64108, USA.
| | - Mara L Becker
- Division of Rheumatology, Department of Pediatrics, Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO 64108, USA.
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