When should we use TNF antagonists in children with rheumatic disease?

The use of biologic response modifiers in polyarticular-course juvenile idiopathic arthritis: a systematic review

OBJECTIVE

To systematically review the clinical efficacy and safety evidence of biologic drugs used to treat the polyarticular category of juvenile idiopathic arthritis (JIA).

METHODS

The literature was searched between 2000 and September 2012 for randomized controlled trials (RCTs), non-randomized comparative studies, and non-comparative observational cohort studies. The drugs evaluated included etanercept, infliximab, adalimumab, abatacept, anakinra, and ritixumab. Eligible studies included 20 or more patients with JIA, the majority of whom had polyarticular course disease. Outcomes of interest were disease improvement defined by the American College of Rheumatology criteria for Pediatrics, disease flares, rates of inactive disease, remissions, discontinuations, and adverse events (severe and non-severe).

RESULTS

Thirty-seven studies were included, the majority focused on etanercept. Seven RCTs were identified, including one each for etanercept, infliximab, adalimumab, abatacept, and anakinra, and one each looking at etanercept or infliximab as first-line therapies. There was strong evidence to support the efficacy and safety of biologics over the short-term, but a lack of long-term data for treatments other than etanercept. Several high-quality patient registries confirmed the efficacy and safety of etanercept over the long-term.

CONCLUSIONS

Current evidence shows that a short-term improvement in treatment response is achieved when patients with polyarticular JIA with an inadequate response to conventional treatment are treated with biologics. Long-term effectiveness data, however, are sparse leaving many questions regarding switches between biologics, handling patients that achieve disease remission, and long-term safety. Study designs other than RCTs may be important in understanding the role of biologics in JIA over the long-term.

[Anti-TNF-α in the treatment of uveitis in the Besançon Hospital]

BACKGROUND

Noninfectious chronic uveitis is a difficult-to-treat situation in which corticosteroids, immunosuppressive agents, and more recently, anti-tumor necrosis factor (TNF)-α are used to prevent and/or reverse severe visual impairment. This single-center retrospective study was designed to assess the use (indications, efficacy, and side effects) of anti-TNF-α agents in noninfectious uveitis.

PATIENTS AND METHODS

Eight patients were analyzed: three children (age, 7-15 years) and five adults (age, 27-44 years). Anti-TNF-α agents were etanercept (three patients), adalimumab (four patients), and infliximab (four patients). Diagnoses were Behçet's diseases (n=3), sarcoidosis (n=1), juvenile chronic arthritis (n=2), spondyloarthropathy (n=2), one of the latter two combined with Crohn disease. In all cases, anti-TNF-α therapies were prescribed because uveitis and/or associated disease were not under control.

RESULTS

Adalimumab and infliximab were effective for all patients. One patient with infliximab needed to add corticosteroids and immunosuppressive agents because of relapse. Etanercept was stopped in all cases due to a lack of effectiveness or a change in indication. In all patients, anti-TNF-α agents improved uveitis and the underlying systemic disease. In children, their use improved quality of life by corticosteroid weaning. Prescriptions did not comply with regulations for three children, because of age limits (etanercept, one; adalimumab, two). No adverse event was recorded.

CONCLUSION

In this short case series, anti-TNF-α agents were effective both on uveitis and the underlying systemic disease and were well tolerated in patients with noninfectious chronic uveitis.

Biologics in children's autoimmune disorders: efficacy and safety

Advances in understanding the pathogenesis of rheumatic diseases have led to the discovery of mechanisms of inflammation and autoimmunity and have made possible the invention of new target-specific drugs. Biologic drugs, designed to inhibit specific components of the immune system, such as cytokines, cytokine gene expression, and their complex interactions, have revolutionized the treatment options in pediatric rheumatology. Only three agents are currently available for treating juvenile idiopathic arthritis (JIA): etanercept, at the dose of 0.8 mg/kg once weekly, adalimumab at the dose of 24 mg/m(2) every 2 weeks, and abatacept at the dose of 10 mg/kg at weeks 0, 2, 4, and then every 4 weeks. They are well tolerated and relatively safe in children: Side effects are generally mild and include injection site reactions and infections. Infliximab, rilonacept, and canakinumab are also approved by the Food and Drug Administration for treatment of pediatric autoimmune disorders and are currently investigated in JIA. This review summarizes the current state of biologic drugs, their clinical application, and their efficacy and safety in the pediatric age.

Growth retardation and delayed puberty in children and adolescents with juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) is the most common joint disorder in developing children. Juvenile idiopathic arthritis is difficult to diagnose and treat. In some patients, signs and symptoms can be frustratingly inconsistent, contradictory or idiosyncratic. Short stature in patients with JIA is usually due to reduced growth in the lower extremities, and only rarely due to reduced growth in the spinal column. In some studies, children with JIA were found to have infantile body proportions. Puberty is delayed in children with JIA. In children with chronic arthritic disorders, there is a strong correlation between the activity of the disease and the age of puberty. The main goals in reducing growth retardation in children with JIA are promoting timely remission and reducing the duration and dosage of corticosteroid treatment. It is important to regularly monitor physical development. Further improvements to the treatment protocol depend on continued interdisciplinary research involving paediatricians, rheumatologists and clinical anthropologists.

Laser Doppler Perfusion Imaging Is Useful in the Study of Raynaud’s Phenomenon and Improves the Capillaroscopic Diagnosis

Objective.

To investigate capillary morphology and skin blood flow of dorsal hands by nailfold videocapillaroscopy (NVC) and laser Doppler perfusion imaging (LDPI), respectively, in patients with primary Raynaud’s phenomenon (PRP) and systemic sclerosis (SSc) and to compare the results with those obtained in healthy controls.

Methods.

The study group consisted of 142 patients with SSc, 88 patients with PRP, and 147 healthy controls. NVC was performed in all the groups examined. In patients with SSc the capillaroscopic pattern was classified as early, active, or late group pattern. A baseline skin blood flow determination of the dorsum of the subject’s hands was acquired through a low-energy 670 nm Lisca Laser Doppler Perfusion Imager.

Results.

In the healthy controls the perfusion distribution pattern was homogeneous, with a proximal-distal perfusion gradient. In patients with PRP, the perfusion distribution pattern was homogeneous, but the proximal-distal perfusion gradient was absent. Finally, in patients with SSc the perfusion distribution pattern was dyshomogeneous and a proximal-distal gradient was absent. The minimum perfusion, mean perfusion, maximum perfusion, and standard deviation, calculated as variation by means of each measurement site, were significantly different in all the groups examinated.

Conclusion.

NVC represents the best method to analyze microvascular damage in rheumatic diseases. LDPI improves the evaluation of vascular damage in patients with SSc. The LDPI and the capillaroscopic images fully matched the definition of the various stages of vascular digital damage in SSc.

Efficacy of thalidomide in systemic onset juvenile rheumatoid arthritis

Thalidomide is an immunomodulating agent which reverses many of the cytokine disturbances seen in systemic onset juvenile idiopathic arthritis (SoJIA) with inadequate response to other treatments. We report 3 cases of recalcitrant SoJIA which improved dramatically after treatment with thalidomide.

PATIENTS

Three children aged 9, 8, and 6 years diagnosed with SoJIA treated with conventional therapy including NSAIDs, corticosteroids, methotrexate and etanercept failed to respond fully and their condition worsened. Thalidomide was begun based on two previous reports showing its efficacy in recalcitrant SoJIA.

RESULTS

Thalidomide produced successful remission of the disease in all 3 patients according to the preliminary criteria for inactive disease and clinical remission of JIA.

CONCLUSION

Thalidomide may be a viable, alternative corticoid-sparing therapy in patients with recalcitrant, multidrug-resistant SoJIA.