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Kearsley-Fleet L, Baildam E, Beresford MW, Douglas S, Foster HE, Southwood TR, Hyrich KL. Outcomes after anti-tumour necrosis factor originator to biosimilar switching in children and young people with juvenile idiopathic arthritis in the UK: a national cohort study. THE LANCET. RHEUMATOLOGY 2024; 6:e438-e446. [PMID: 38843858 DOI: 10.1016/s2665-9913(24)00087-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND For cost-saving purposes, children and young people with juvenile idiopathic arthritis (JIA) are being switched (for non-medical reasons) from biological originators to biosimilars. Here, we aimed to investigate those who switched from an anti-tumour necrosis factor (TNF) originator to a biosimilar, regarding drug survival and disease activity, compared with a matched cohort who continued the originator. METHODS This analysis included all patients in the UK JIA Biologics Register switching directly from an anti-TNF originator to a biosimilar of the same product. All patients were matched (age, sex, disease duration, calendar year of when patients started originator therapy, line of therapy, and International League of Associations for Rheumatology [ILAR] category) to patients continuing the originator. For those matched successfully, a Cox proportional hazard model assessed whether drug persistence differed between those who switched compared with those who continued the originator. Overall change in the 71-joint juvenile arthritis disease activity score and the proportion of patients with a clinically important worsening score (by ≥1·7 units) after 6 months was compared between cohorts. This analysis was designed to address a priority research area set by our patient partners. FINDINGS There were 224 children and young people with non-systemic JIA (139 [62%] were female, and 85 [38%] were male) identified as switching from a biological originator to a biosimilar of the same product from Jan 1, 2017, to July 7, 2023. 143 (64%) patients were originally on adalimumab, 56 (25%) on etanercept, and 25 (11%) on infliximab. Of these, 164 patients were matched successfully to those continuing the originator. There was no evidence that patients switching were more likely to stop treatment compared with those continuing the originator, with a hazard ratio of 1·46 (95% CI 0·93-2·30). Of the 51 patients in the biosimilar group who stopped treatment, 18 (35%) switched back to the originator (14 in the first year), 28 (55%) started a different biological drug, and five (10%) discontinued all treatment by the last follow-up. Of the 87 matched patients with available disease activity, there was no evidence that JADAS-71 worsened more after 6 months, with an odds ratio of 0·71 (95% CI 0·34-1·51; p=0·38). INTERPRETATION In this matched comparative effectiveness analysis, children and young people with JIA switched from originators to biosimilars. Disease activity was similar between patients switching compared with those continuing the originator. Three quarters of patients were still receiving their biosimilar after 1 year, with switching back to originator uncommon, at only 9% after 1 year, suggesting good tolerability of non-medical switching in this patient population. This information is reassuring to clinicians and patients regarding the effect of non-medical biological switching. FUNDING British Society for Rheumatology, Versus Arthritis, and National Institutes for Health Research Manchester Biomedical Research Centre.
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Affiliation(s)
- Lianne Kearsley-Fleet
- Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
| | | | - Michael W Beresford
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK; Institute of Life Course and Medical Specialities, University of Liverpool, Liverpool, UK
| | - Sharon Douglas
- Scottish Network for Arthritis in Children, Edinburgh, UK
| | - Helen E Foster
- Population and Health Institute, Newcastle University, Newcastle, UK
| | | | - Kimme L Hyrich
- Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, The 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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Sener S, Aliyev E, Batu ED, Balik Z, Bayindir Y, Cam V, Basaran O, Bilginer Y, Ozen S. Factors determining resistance to conventional disease-modifying anti-rheumatic drug treatment in oligoarticular juvenile idiopathic arthritis. Clin Rheumatol 2024; 43:2021-2026. [PMID: 38683443 DOI: 10.1007/s10067-024-06925-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/26/2024] [Accepted: 02/29/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVE Our study was designed to investigate the reasons for starting the conventional disease-modifying anti-rheumatic drugs (DMARDs) and the variables that impact the response to DMARD treatment in oligoarticular juvenile idiopathic arthritis (JIA) patients. METHODS Oligoarticular JIA patients (n = 187) were categorized into two groups: Group A consisted of patients who achieved remission with DMARD, and Group B comprised those who did not respond to DMARD therapy. RESULTS DMARDs were initiated for various reasons: 68 (36.4%) due to active disease despite nonsteroidal anti-inflammatory drugs (± intra-articular corticosteroid) treatment, 59 (31.6%) due to uveitis, 49 (26.2%) due to extended oligoarticular JIA, and 11 (5.9%) due to inflammatory bowel disease. One hundred twenty-three patients (65.8%) achieved remission with DMARDs (Group A), while 64 patients (34.2%) did not respond to DMARD therapy (Group B). In Group B, patients had higher C-reactive protein (CRP) levels as well as higher Juvenile Idiopathic Arthritis Disease Activity Scores-71 (JADAS-71) at diagnosis (both p < 0.001). Moreover, extended oligoarticular JIA subtype (p = 0.017) and involvement of small joints at diagnosis (p = 0.043) were more prevalent among these patients. Group A exhibited a higher frequency of antinuclear antibody positivity (p = 0.014). Elevated CRP levels (> 1.1 mg/dL) (OR 1.308, 95% CI 1.203-3.574; p < 0.001) and high JADAS-71 at diagnosis (> 15.8) (OR 1.659, 95% CI 1.179-2.941; p < 0.001) were associated with DMARD resistance. CONCLUSION Elevated CRP and high JADAS-71 at diagnosis were the main factors associated with DMARD resistance in oligoarticular JIA. Prospective long-term studies may help verify the role of these factors associated with DMARD resistance in oligoarticular JIA. Key Points • Conventional DMARDs were most commonly started due to active disease despite NSAID (± intra-articular corticosteroids). • Remission was achieved with DMARD in 65.8% of oligoarticular JIA patients. • Elevated CRP and high JADAS-71 at diagnosis were associated with DMARD resistance.
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Affiliation(s)
- Seher Sener
- Division of Pediatric Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Sihhiye Campus, 06100, Ankara, Turkey
| | - Emil Aliyev
- Division of Pediatric Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Sihhiye Campus, 06100, Ankara, Turkey
| | - Ezgi Deniz Batu
- Division of Pediatric Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Sihhiye Campus, 06100, Ankara, Turkey
| | - Zeynep Balik
- Division of Pediatric Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Sihhiye Campus, 06100, Ankara, Turkey
| | - Yagmur Bayindir
- Division of Pediatric Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Sihhiye Campus, 06100, Ankara, Turkey
| | - Veysel Cam
- Division of Pediatric Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Sihhiye Campus, 06100, Ankara, Turkey
| | - Ozge Basaran
- Division of Pediatric Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Sihhiye Campus, 06100, Ankara, Turkey
| | - Yelda Bilginer
- Division of Pediatric Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Sihhiye Campus, 06100, Ankara, Turkey
| | - Seza Ozen
- Division of Pediatric Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Sihhiye Campus, 06100, Ankara, Turkey.
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van Dijk BT, Bergstra SA, van den Berg JM, Schonenberg-Meinema D, van Suijlekom-Smit LWA, van Rossum MAJ, Koopman-Keemink Y, Ten Cate R, Allaart CF, Brinkman DMC, Hissink Muller PCE. Increasing the etanercept dose in a treat-to-target approach in juvenile idiopathic arthritis: does it help to reach the target? A post-hoc analysis of the BeSt for Kids randomised clinical trial. Pediatr Rheumatol Online J 2024; 22:53. [PMID: 38730442 PMCID: PMC11084083 DOI: 10.1186/s12969-024-00989-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/04/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Etanercept has been studied in doses up to 0.8 mg/kg/week (max 50 mg/week) in juvenile idiopathic arthritis (JIA) patients. In clinical practice higher doses are used off-label, but evidence regarding the relation with outcomes is lacking. We describe the clinical course of JIA-patients receiving high-dose etanercept (1.6 mg/kg/week; max 50 mg/week) in the BeSt for Kids trial. METHODS 92 patients with oligoarticular JIA, RF-negative polyarticular JIA or juvenile psoriatic arthritis were randomised across three treat-to-target arms: (1) sequential DMARD-monotherapy (sulfasalazine or methotrexate (MTX)), (2) combination-therapy MTX + 6 weeks prednisolone and (3) combination therapy MTX + etanercept. In any treatment-arm, patients could eventually escalate to high-dose etanercept alongside MTX 10mg/m2/week. RESULTS 32 patients received high-dose etanercept (69% female, median age 6 years (IQR 4-10), median 10 months (7-16) from baseline). Median follow-up was 24.6 months. Most clinical parameters improved within 3 months after dose-increase: median JADAS10 from 7.2 to 2.8 (p = 0.008), VAS-physician from 12 to 4 (p = 0.022), VAS-patient/parent from 38.5 to 13 (p = 0.003), number of active joints from 2 to 0.5 (p = 0.12) and VAS-pain from 35.5 to 15 (p = 0.030). Functional impairments (CHAQ-score) improved more gradually and ESR remained stable. A comparable pattern was observed in 11 patients (73% girls, median age 8 (IQR 6-9)) who did not receive high-dose etanercept despite eligibility (comparison group). In both groups, 56% reached inactive disease at 6 months. No severe adverse events (SAEs) occurred after etanercept dose-increase. In the comparison group, 2 SAEs consisting of hospital admission occurred. Rates of non-severe AEs per subsequent patient year follow-up were 2.27 in the high-dose and 1.43 in the comparison group. CONCLUSIONS Escalation to high-dose etanercept in JIA-patients who were treated to target was generally followed by meaningful clinical improvement. However, similar improvements were observed in a smaller comparison group who did not escalate to high-dose etanercept. No SAEs were seen after escalation to high-dose etanercept. The division into the high-dose and comparison groups was not randomised, which is a potential source of bias. We advocate larger, randomised studies of high versus regular dose etanercept to provide high level evidence on efficacy and safety. TRIAL REGISTRATION Dutch Trial Register; NTR1574; 3 December 2008; https://onderzoekmetmensen.nl/en/trial/26585 .
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Affiliation(s)
- Bastiaan T van Dijk
- Department of Paediatrics - division of Paediatric Rheumatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, the Netherlands.
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands.
| | - Sytske Anne Bergstra
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - J Merlijn van den Berg
- Department of Paediatric Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital / Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Dieneke Schonenberg-Meinema
- Department of Paediatric Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital / Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | | | - Marion A J van Rossum
- Department of Paediatrics, Emma Children's Hospital / Amsterdam University Medical Centres, Amsterdam, the Netherlands
- Department of Paediatric Rheumatology, Amsterdam Rheumatology and Immunology Centre (Reade), Amsterdam, the Netherlands
| | - Yvonne Koopman-Keemink
- Department of Paediatrics, Juliana Children's Hospital / HagaZiekenhuis, the Hague, the Netherlands
| | - Rebecca Ten Cate
- Department of Paediatrics - division of Paediatric Rheumatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, the Netherlands
| | - Cornelia F Allaart
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Daniëlle M C Brinkman
- Department of Paediatrics - division of Paediatric Rheumatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, the Netherlands
| | - Petra C E Hissink Muller
- Department of Paediatrics - division of Paediatric Rheumatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, the Netherlands
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Polat MC, Çelikel E, Tekin ZE, Kurt T, Kaplan MM, Güngörer V, Tekgöz N, Sezer M, Karagöl C, Coşkun S, Öner N, Sezer S, Acar BÇ. When should the use of biological agents be considered in persistent oligoarticular juvenile idiopathic arthritis patients? Eur J Pediatr 2024:10.1007/s00431-024-05538-y. [PMID: 38554171 DOI: 10.1007/s00431-024-05538-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/19/2024] [Accepted: 03/21/2024] [Indexed: 04/01/2024]
Abstract
The purpose of this study was to compare the demographic and clinical characteristics of the groups with and without bDMARDs added to the treatment of persistent oligoarticular juvenile idiopathic arthritis (JIA) patients on methotrexate (MTX) and also to determine the predictors of adding bDMARDs to treatment. This study included 86 oligoarticular JIA patients on MTX. Patients were divided into two groups receiving MTX (n = 69) and MTX plus bDMARD (n = 17). Predictors of adding bDMARDs were investigated by comparing demographic, clinical features and laboratory findings. Gender, age at diagnosis, time elapsed from the onset of symptoms to diagnosis, and disease duration, the number and distribution of affected joint at the time of diagnosis were similar in both groups. The mean JADAS10 at the time of diagnosis were 18.8 ± 4.2 and 19.5 ± 6.4 in the MTX and MTX plus bDMARDs groups, respectively (p = 0.68). JADAS10 at 3rd and 6th month were significantly higher in patients on MTX plus bDMARDs (p = 0.001, p = 0.004, respectively). In multivariate analysis, the risk of adding bDMARD was shown to increase 1.24-fold (p = 0.004, 95% CI: 1.07-1.43) for each point increase on the JADAS 10 at 3rd months. The number (p = 0.64) or type (p = 0.18) of joint involvement at disease onset were not predictors of adding a bDMARD. CONCLUSION JADAS10 indicating ongoing severe disease activity at 3rd and 6th months rather than baseline JADAS10 is associated with the addition of bDMARDs. WHAT IS KNOWN • Oligoarticular JIA patients have the best outcomes among JIA categories and respond favorably to first-line therapies such as non-steroidal anti-inflammatory drugs and intraarticular corticosteroid injections. • Clinically inactive disease rates have increased with the widespread use of biological agents in oligoarticular JIA patients who have not responded to initial therapies. WHAT IS NEW • Approximately one-fifth of patients with persistent oligoarticular JIA on methotrexate may require the addition of a biological disease modifying anti-rheumatic drug during follow-up. • The JADAS10 calculated at 3 and 6 months is a valuable tool to identify patients who should be added biological disease modifying anti-rheumatic drugs in persistent oligoarticular JIA.
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Affiliation(s)
- Merve Cansu Polat
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey.
| | - Elif Çelikel
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
| | - Zahide Ekici Tekin
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
| | - Tuba Kurt
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
| | - Melike Mehveş Kaplan
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
| | - Vildan Güngörer
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
| | - Nilüfer Tekgöz
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
| | - Müge Sezer
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
| | - Cüneyt Karagöl
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
| | - Serkan Coşkun
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
| | - Nimet Öner
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
| | - Serdar Sezer
- Division of Rheumatology, Department of Internal Medicine, Ankara Training and Research Hospital, 06230-Altındağ, Ankara, Turkey
| | - Banu Çelikel Acar
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
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Wedderburn LR, Ramanan AV, Croft AP, Hyrich KL, Dick AD. Towards molecular-pathology informed clinical trials in childhood arthritis to achieve precision medicine in juvenile idiopathic arthritis. Ann Rheum Dis 2023; 82:449-456. [PMID: 36600186 PMCID: PMC10086280 DOI: 10.1136/ard-2022-222553] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022]
Abstract
In childhood arthritis, collectively known as Juvenile idiopathic arthritis (JIA), the rapid rise of available licensed biological and targeted small molecule treatments in recent years has led to improved outcomes. However, real-world data from multiple countries and registries show that despite a large number of available drugs, many children and young people continue to suffer flares and experience significant periods of time with active disease for many years. More than 50% of young people with JIA require ongoing immune suppression well into adult life, and they may have to try multiple different treatments in that time. There are currently no validated tools with which to select specific treatments, nor biomarkers of response to assist in such choices, therefore, current management uses essentially a trial-and-error approach. A further consequence of recent progress is a reducing pool of available children or young people who are eligible for new trials. In this review we consider how progress towards a molecular based approach to defining treatment targets and informing trial design in JIA, combined with novel approaches to clinical trials, could provide strategies to maximise discovery and progress, in order to move towards precision medicine for children with arthritis.
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Affiliation(s)
- Lucy R Wedderburn
- UCL GOS Institute of Child Health, University College London, London, UK
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, UCL, London, UK
- National Institute of Health Research Biomedical Research Centre at GOSH London UK, Great Ormond Street Hospital, London, UK
| | - Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
| | - Adam P Croft
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- National Institute of Health Research Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, The 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, UK
| | - Andrew D Dick
- Translational Health Sciences, University of Bristol, Bristol, UK
- UCL Institute of Ophthalmology, University College London, London, UK
- National Institute of Health Research Biomedical Research Centre, Moorfields and UCL Institute of Ophthalmology, London, UK
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Kearsley-Fleet L, Baildam E, Beresford MW, Douglas S, Foster HE, Southwood TR, Hyrich KL, Ciurtin C. Successful stopping of biologic therapy for remission in children and young people with juvenile idiopathic arthritis. Rheumatology (Oxford) 2022; 62:1926-1935. [PMID: 36104094 PMCID: PMC10152290 DOI: 10.1093/rheumatology/keac463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/07/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Clinicians concerned about long-term safety of biologics in JIA may consider tapering or stopping treatment once remission is achieved despite uncertainty in maintaining drug-free remission. This analysis aims to (i) calculate how many patients with JIA stop biologics for remission, (ii) calculate how many later re-start therapy and after how long, and (iii) identify factors associated with re-starting biologics. METHODS Patients starting biologics between 1 January 2010 and 7 September 2021 in the UK JIA Biologics Register were included. Patients stopping biologics for physician-reported remission, those re-starting biologics and factors associated with re-starting, were identified. Multiple imputation accounted for missing data. RESULTS Of 1451 patients with median follow-up of 2.7 years (IQR 1.4, 4.0), 269 (19%) stopped biologics for remission after a median of 2.2 years (IQR 1.7, 3.0). Of those with follow-up data (N = 220), 118 (54%) later re-started therapy after a median of 4.7 months, with 84% re-starting the same biologic. Patients on any-line tocilizumab (prior to stopping) were less likely to re-start biologics (vs etanercept; odds ratio [OR] 0.3; 95% CI: 0.2, 0.7), while those with a longer disease duration prior to biologics (OR 1.1 per year increase; 95% CI: 1.0, 1.2) or prior uveitis were more likely to re-start biologics (OR 2.5; 95% CI: 1.3, 4.9). CONCLUSIONS This analysis identified factors associated with successful cessation of biologics for remission in JIA as absence of uveitis, prior treatment with tocilizumab and starting biologics earlier in the disease course. Further research is needed to guide clinical recommendations.
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Affiliation(s)
- Lianne Kearsley-Fleet
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester Academic Health Science Centre, Manchester
| | - Eileen Baildam
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust
| | - Michael W Beresford
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust.,Institute of Life Course and Medical Specialities, University of Liverpool, Liverpool
| | - Sharon Douglas
- Scottish Network for Arthritis in Children (SNAC), Edinburgh
| | - Helen E Foster
- Population and Health Institute, Newcastle University, Newcastle upon Tyne
| | | | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester Academic Health Science Centre, Manchester.,National Institute of Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester
| | - Coziana Ciurtin
- Centre for Adolescent Rheumatology, Division of Medicine, University College London, London, UK
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Park J, Batthish M, Berard RA, Chédeville G, Proulx-Gauthier JP, Rumsey DG, Tucker LB, Wong S, Guzman J. Comparing Canadian pediatric rheumatology practice to the 2019 ACR Juvenile Idiopathic Arthritis guidelines. Results from the CAPRI Registry. Rheumatology (Oxford) 2022; 62:1616-1620. [PMID: 35977388 DOI: 10.1093/rheumatology/keac468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 08/09/2022] [Accepted: 08/09/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To identify differences between baseline Canadian JIA practices and the 2019 American College of Rheumatology guidelines for juvenile idiopathic arthritis (JIA Guidelines). METHODS Canadian pediatric rheumatologists were surveyed for their opinion on reasonable a priori target adherence rates for JIA Guideline recommendations. Then, prospectively collected data for 266 newly diagnosed children from 2017 to 2019 were analyzed to calculate observed adherence rates. Kaplan Meier survival curves were used to estimate the cumulative incidence of starting synthetic or biologic DMARDs for different patient groups. RESULTS Twenty-five of 61 (41%) eligible physicians answered the survey. Most survey respondents (64%) felt that adherence targets should vary depending on the strength of recommendation and quality of evidence, from a mean of 84% for strong recommendations with high quality evidence, to 29% for conditional recommendations with very low-quality evidence. Data showed 13/19 (68%) recommendations would have met proposed targets and 10/19 (53%) had ≥80% observed adherence. Exceptions were the use of subcutaneous over oral methotrexate (MTX) (53%) and infrequent treatment escalation from NSAIDs to biologic DMARDs in patients with sacroiliitis (31%) or enthesitis (0%). By 12 weeks, 95% of patients with polyarthritis received synthetic DMARD, 38% of patients with systemic JIA received biologic DMARD, and 22% of patients with sacroiliitis received biologic DMARD. CONCLUSION Canadian pediatric rheumatology practices were in line with many 2019 JIA Guidelines recommendations before their publication, except for frequent use of oral methotrexate and infrequent direct escalation from NSAIDs to biologic DMARDs in sacroiliitis and enthesitis.
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Affiliation(s)
- Jonathan Park
- British Columbia Children's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada
| | - Michelle Batthish
- McMaster Children's Hospital and McMaster University, Hamilton, Ontario, Canada
| | - Roberta A Berard
- London Health Sciences Centre and Western University, London, Ontario, Canada
| | - Gaëlle Chédeville
- McGill University Health Centre and McGill University, Montreal, Québec, Canada
| | | | - Dax G Rumsey
- Stollery Children's Hospital and University of Alberta, Edmonton, Alberta, Canada
| | - Lori B Tucker
- British Columbia Children's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephanie Wong
- British Columbia Children's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada
| | - Jaime Guzman
- British Columbia Children's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada
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Grazziotin LR, Currie G, Twilt M, Ijzerman MJ, Kip MMA, Koffijberg H, Benseler SM, Swart JF, Vastert SJ, Wulffraat NM, Yeung RSM, Marshall DA. Real-world data reveals the complexity of disease modifying anti-rheumatic drug treatment patterns in juvenile idiopathic arthritis: an observational study. Pediatr Rheumatol Online J 2022; 20:25. [PMID: 35410419 PMCID: PMC8996666 DOI: 10.1186/s12969-022-00682-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 03/27/2022] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE Pharmacological treatment is a cornerstone of care for children with juvenile idiopathic arthritis (JIA). The objective of this study is to evaluate prescription patterns of conventional and biologic disease modifying anti-rheumatic drugs (c-DMARDs and b-DMARDs) for patients with JIA. METHODS We conducted a retrospective cohort study of children diagnosed with JIA at a rheumatology pediatric clinic. Eligibility criteria were defined as children and youth newly diagnosed with enthesis-related arthritis, polyarticular, or oligoarticular JIA between 2011 and 2019, with at least one year of observation. Data on c-DMARDs and b-DMARDs prescriptions were obtained from electronic medical charts. We used descriptive statistics, Kaplan-Meier survival methods, and Sankey diagrams to describe treatment prescription patterns. RESULTS A total of 325 patients with JIA were included, with a median observation time of 3.7 years. The most frequently prescribed c-DMARD and b-DMARD were methotrexate and etanercept, respectively. Within the first year of rheumatology care, 62% and 21% of patients had a c-DMARD and a b-DMARD prescribed, respectively. These proportions varied greatly by JIA subtype. Among the 147 (147/325, 45%) patients that had at least one b-DMARD prescribed, 24% were prescribed a second, and 7% a third-line of b-DMARD. A total of 112 unique treatment sequences were observed, with c-DMARD monotherapy followed by the addition of either a b-DMARD (56%) or another c-DMARD (30%) being the two most prevalent patterns in this cohort. CONCLUSION We observed a variety of treatment trajectories, with many patients experiencing multiple treatment lines, illustrating the complexity of the overall JIA treatment path.
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Affiliation(s)
- Luiza R. Grazziotin
- grid.22072.350000 0004 1936 7697Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697O’Brien Institute for Public Health, University of Calgary, Calgary, AB Canada ,grid.413571.50000 0001 0684 7358Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB Canada
| | - Gillian Currie
- grid.22072.350000 0004 1936 7697Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697O’Brien Institute for Public Health, University of Calgary, Calgary, AB Canada ,grid.413571.50000 0001 0684 7358Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB Canada
| | - Marinka Twilt
- grid.413571.50000 0001 0684 7358Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697Section of Rheumatology, Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB Canada
| | - Maarten J. Ijzerman
- grid.6214.10000 0004 0399 8953Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Michelle M. A. Kip
- grid.6214.10000 0004 0399 8953Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Hendrik Koffijberg
- grid.6214.10000 0004 0399 8953Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Susanne M. Benseler
- grid.413571.50000 0001 0684 7358Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697Section of Rheumatology, Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB Canada ,grid.413574.00000 0001 0693 8815Alberta Health Services, Calgary, AB Canada
| | - Joost F. Swart
- grid.417100.30000 0004 0620 3132Department of Pediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital / UMC Utrech, Utrecht, The Netherlands ,grid.5477.10000000120346234Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
| | - Sebastiaan J. Vastert
- grid.417100.30000 0004 0620 3132Department of Pediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital / UMC Utrech, Utrecht, The Netherlands ,grid.5477.10000000120346234Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
| | - Nico M. Wulffraat
- grid.417100.30000 0004 0620 3132Department of Pediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital / UMC Utrech, Utrecht, The Netherlands ,grid.5477.10000000120346234Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
| | - Rae S. M. Yeung
- grid.17063.330000 0001 2157 2938Departments of Paediatrics, Immunology and Medical Science, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Deborah A. Marshall
- grid.22072.350000 0004 1936 7697Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697O’Brien Institute for Public Health, University of Calgary, Calgary, AB Canada ,grid.413571.50000 0001 0684 7358Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB Canada ,Present Address: Health Research Innovation Centre, Room 3C56, 3280 Hospital Drive NW, AB T2N 4Z6 Calgary, Canada
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9
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Kocatürk B, Balık Z, Pişiren G, Kalyoncu U, Özmen F, Özen S. Spondyloarthritides: Theories and beyond. Front Pediatr 2022; 10:1074239. [PMID: 36619518 PMCID: PMC9816396 DOI: 10.3389/fped.2022.1074239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 11/24/2022] [Indexed: 12/24/2022] Open
Abstract
Spondyloarthritides (SpA) are a family of interrelated rheumatic disorders with a typical disease onset ranging from childhood to middle age. If left untreated, they lead to a severe decrease in patients' quality of life. A succesfull treatment strategy starts with an accurate diagnosis which is achieved through careful analysis of medical symptoms. Classification criterias are used to this process and are updated on a regular basis. Although there is a lack of definite knowledge on the disease etiology of SpA, several studies have paved the way for understanding plausible risk factors and developing treatment strategies. The significant increase of HLA-B27 positivity in SpA patients makes it a strong candidate as a predisposing factor and several theories have been proposed to explain HLA-B27 driven disease progression. However, the presence of HLA-B27 negative patients underlines the presence of additional risk factors. The current treatment options for SpAs are Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), TNF inhibitors (TNFis), Disease-Modifying Anti-Rheumatic Drugs (DMARDs) and physiotherapy yet there are ongoing clinical trials. Anti IL17 drugs and targeted synthetic DMARDs such as JAK inhibitors are also emerging as treatment alternatives. This review discusses the current diagnosis criteria, treatment options and gives an overview of the previous findings and theories to clarify the possible contributors to SpA pathogenesis with a focus on Ankylosing Spondylitis (AS) and enthesitis-related arthritis (ERA).
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Affiliation(s)
- Begüm Kocatürk
- Department of Basic Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Zeynep Balık
- Division of Pediatric Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Gaye Pişiren
- Department of Basic Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Umut Kalyoncu
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Füsun Özmen
- Department of Basic Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Seza Özen
- Division of Pediatric Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
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10
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Yue X, Huang B, Hincapie AL, Wigle PR, Li Y, Qiu T, Lovell DJ, Morgan EM, Guo JJ. Comparative effectiveness and persistence of TNFi and non-TNFi in juvenile idiopathic arthritis: a large paediatric rheumatology centre in the USA. Rheumatology (Oxford) 2021; 60:4063-4073. [PMID: 34469569 PMCID: PMC10452955 DOI: 10.1093/rheumatology/keaa877] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 11/25/2020] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE To evaluate the persistence and effectiveness of TNF inhibitors (TNFi) vs non-TNFi among newly diagnosed JIA patients after initiation of biologic DMARD (bDMARD). METHODS Using longitudinal patient-level data extracted from electronic medical records in a large Midwestern paediatric hospital from 2009 to 2018, we identified JIA patients initiating TNFi and non-TNFi treatment. Treatment effectiveness was assessed based on disease activity. Inverse probability of treatment weighting of propensity score was used to estimate the treatment effectiveness and Kaplan-Meier analyses were conducted to assess persistence. RESULTS Of 667 JIA patients, most (92.0%) were prescribed one of the class of TNFi as their initial biologic treatment. Etanercept was the most frequently prescribed (67.1%) treatment, followed by adalimumab (27.5%). Only around 5% of patients were prescribed off-label bDMARDs as their first-course treatment; however, >20% were prescribed off-label biologics as their second-course therapy. Some 7.2% of patients received four or more bDMARDs. The median persistence of the first-course bDMARD is 320 days, with TNFi being significantly longer than the non-TNFi (395 vs 320 days, P = 0.010). The clinical Juvenile Disease Activity Score (cJADAS) reduction of TNFi users (6.6, 95% CI 5.7, 7.5) was significant greater compared with non-TNFi users (3.0, 95% CI 1.5, 4.6, P < 0.0001) at 6-month follow-up visit. CONCLUSION Persistence was significantly longer among patients initiating TNFi as their first biologic therapy than those receiving non-TNFi. Patients receiving TNF therapy had significant greater reduction of cJADAS at the 6-month follow-up visit compared with patients in the non-TNF cohort.
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Affiliation(s)
- Xiaomeng Yue
- Division of Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center
| | - Bin Huang
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center
- Department of Pediatrics, University of Cincinnati College of Medicine
| | - Ana L Hincapie
- Division of Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center
| | - Patricia R Wigle
- Division of Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center
| | - Yuxiang Li
- Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine
| | - Tingting Qiu
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center
| | - Daniel J Lovell
- Department of Pediatrics, University of Cincinnati College of Medicine
- Division of Rheumatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Esi M Morgan
- Department of Pediatrics, University of Cincinnati College of Medicine
- Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine
- Division of Rheumatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
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Pagnini I, Scavone M, Maccora I, Mastrolia MV, Marrani E, Bertini F, Lamot L, Simonini G. The Development of Extra-Articular Manifestations in Children With Enthesitis-Related Arthritis: Natural Course or Different Disease Entity? Front Med (Lausanne) 2021; 8:667305. [PMID: 34055840 PMCID: PMC8155293 DOI: 10.3389/fmed.2021.667305] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/19/2021] [Indexed: 01/12/2023] Open
Abstract
Introduction: Enthesitis-related Arthritis (ERA) is a specific category of juvenile idiopathic arthritis (JIA) characterized by axial and/or peripheral arthritis, and enthesitis, although other different extra-articular manifestations may encompass its clinical spectrum. Materials and Methods: In order to examine if ERA-JIA with extra-articular involvement may represent a different entity from ERA without extra-articular involvement, we performed a retrospective, observational, monocentric study, in a cohort of ERA patients followed between 2001 and September 2020 at the Pediatric Rheumatology Unit of Meyer Children Hospital of Florence. We analyzed the demographic, clinical, laboratory and imaging data at the disease onset, as well as after 3, 6, and 12 months follow up. Results: We have enrolled 53 patients, 33 males. At the time of diagnosis, average age was 10.9 years, 53 patients had active arthritis and 25 active enthesitis. The middle foot involvement was present in 20 patients. Twenty-five children achieved clinical remission on medication. Extra-articular manifestations were observed in 14 patients, of whom 3 had inflammatory bowel disease, 5 uveitis, one uveitis associated with Crohn disease, 4 SAPHO syndrome, one celiac disease. The cohort was stratified according to the presence/absence of extra-articular manifestations. It was observed that middle foot involvement was more frequent in patients with no extra-articular manifestations (18/39 vs. 2/14; χ2 = 4.45, p = 0.05). Additionally, patients presenting extra-articular manifestation needed more frequently (12/14 vs. 21/39, χ2= 4.45, p = 0.05), and preciously (months: 3.7 ± 5.4 vs. 16.7 ± 26.5, p = 0.02), treatment with biologic agents. Finally, these patients achieved belatedly (months: 31.6 ± 32.3 vs. 22.9 ± 18.3, p = 0.01) and less frequently (3/14 vs. 22/39; χ2= 5.50, p = 0.03) the clinical remission on medication. Eventually, extra-articular involvement inversely correlated with the middle-foot arthritis (ρs −0.29, p = 0.03), the chance to achieve remission on medication (ρs −0.31 e p = 0.02), as well as the chance to keep overall remission, with and without medication (ρs −0.28, p = 0.04). Conclusion: In our cohort, children diagnosed with ERA-JIA at the onset of disease and then developed extra-articular manifestations show the absence of middle foot involvement and worse prognosis with an early need for the use of biologic agents, and overall low chance to achieve remission.
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Affiliation(s)
- Ilaria Pagnini
- Rheumatology Unit, Meyer Children Hospital of Florence, University of Florence, Florence, Italy
| | - Mariangela Scavone
- Rheumatology Unit, Meyer Children Hospital of Florence, University of Florence, Florence, Italy
| | - Ilaria Maccora
- Rheumatology Unit, Meyer Children Hospital of Florence, University of Florence, Florence, Italy
| | | | - Edoardo Marrani
- Rheumatology Unit, Meyer Children Hospital of Florence, University of Florence, Florence, Italy
| | - Federico Bertini
- Radiology Unit, Meyer Children Hospital of Florence, Florence, Italy
| | - Lovro Lamot
- Department of Pediatrics, School of Medicine, University of Zagreb, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Gabriele Simonini
- Rheumatology Unit, Meyer Children Hospital of Florence, University of Florence, Florence, Italy
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12
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Yue X, Huang B, Hincapie AL, Wigle PR, Qiu T, Li Y, Morgan EM, Guo JJ. Prescribing Patterns and Impact of Factors Associated with Time to Initial Biologic Therapy among Children with Non-systemic Juvenile Idiopathic Arthritis. Paediatr Drugs 2021; 23:171-182. [PMID: 33651370 DOI: 10.1007/s40272-021-00436-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of this study was to examine patterns of initial prescriptions, investigate time to initiation of biologic disease-modifying anti-rheumatic drugs (bDMARDs), and evaluate the impact of clinical and other baseline factors associated with the time to first bDMARD in treating children with newly diagnosed non-systemic juvenile idiopathic arthritis (JIA). METHODS Using longitudinal patient-level data extracted from electronic medical records (EMR) in a large Midwestern pediatric hospital from 2009 to 2018, the initial prescriptions and prescribing patterns of bDMARDs, conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs), non-steroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids within 3 months of JIA diagnosis were examined. Kaplan-Meier analyses were performed to assess time to initiation of bDMARDs. Cox proportional hazard models were used to identify factors associated with time to first bDMARD. RESULTS Of 821 children, the proportion of patients with initial csDMARDs increased from 45.3% in 2009 to 60.3% in 2018. Around 57.5% of polyarthritis rheumatoid factor-positive (Poly RF+) patients and 43.2% of polyarthritis rheumatoid factor-negative (Poly RF-) patients received a bDMARD therapy within 3 months of diagnosis, 14.4% as monotherapy and 28.3% in combination with a csDMARD. Among patients who received combination therapy, combination of methotrexate with adalimumab increased from 16.7% in 2009 to 40% in 2018. The proportion of patients treated with adalimumab gradually increased and passed etanercept in 2016. The predictors of earlier initiation of biologic therapy were JIA category enthesitis-related arthritis (ERA) [hazard ratio (HR) vs persistent oligoarthritis 4.82; p < 0.0001], psoriatic arthritis (PsA) (HR 2.46; p = 0.0002), or Poly RF- (HR 2.43; p = 0.0002); the number of joints with limited range of motion (HR 1.02; p = 0.0222), and erythrocyte sedimentation rate (ESR, HR 1.01; p = 0.0033). CONCLUSIONS There was a substantial increase in the proportion of patients receiving the combination of methotrexate and adalimumab among patients receiving combination therapy. Adalimumab overtook etanercept as the most frequently prescribed bDMARD. Multiple factors affect the time to biologic initiation, including the number of joints with limited range of motion, ESR, and JIA category.
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Affiliation(s)
- Xiaomeng Yue
- Division of Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati, 3225 Eden Ave., Cincinnati, OH, 45267, USA.
| | - Bin Huang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ana L Hincapie
- Division of Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati, 3225 Eden Ave., Cincinnati, OH, 45267, USA
| | - Patricia R Wigle
- Division of Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati, 3225 Eden Ave., Cincinnati, OH, 45267, USA
| | - Tingting Qiu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Yuxiang Li
- Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Esi M Morgan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jeff J Guo
- Division of Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati, 3225 Eden Ave., Cincinnati, OH, 45267, USA
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13
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Rebane K, Aalto K, Haanpää M, Puolakka K, Virta LJ, Kautiainen H, Pohjankoski H. Initiating disease-modifying anti-rheumatic drugs rapidly reduces purchases of analgesic drugs in juvenile idiopathic arthritis. Scand J Rheumatol 2020; 50:28-33. [PMID: 32686548 DOI: 10.1080/03009742.2020.1762923] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Objective: To describe the use of analgesics 12 months before and after initiation of the first disease-modifying anti-rheumatic drug (DMARD) in children with juvenile idiopathic arthritis (JIA). Method: A register-based study linked three nationwide registers in Finland: the Register on Reimbursement for Prescription Medicines, the Drug Purchase Register (both maintained by the Finnish Social Insurance Institution), and the Finnish Population Register. The study ran from 1 January 2010 to 31 December 2014. It included 1481 patients aged < 16 years with diagnosed JIA and 4511 matched controls. Index day was the date when reimbursement for JIA medication was approved and treatment was initiated. The study period included 12 months pre- and post-index date, and purchases of prescription drugs were assessed for 3 month periods. Results: Non-steroidal anti-inflammatory drugs (NSAIDs) were purchased for 60% of the patients. Compared to controls, NSAID purchases for JIA patients were at their highest during the last 3 months before the index day [relative rate (RR) 21.2, 95% confidence interval (CI) 17.1-26.2], and they decreased steeply over the 10-12 months post-index (RR 4.0, 95% CI 3.1-5.0). Similar trends were seen with paracetamol and opioid purchases, but only 2% of patients purchased opioids during the 12 months pre-index and 1% during the 12 months post-index. Methotrexate was the most commonly used DMARD (91.9%), biologic DMARDs were used by 2.8% and glucocorticoids by 24.8% in the 3 months after the index day. Conclusion: Initiation of DMARDs rapidly reduces the need for analgesics in patients with JIA.
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Affiliation(s)
- K Rebane
- Paediatric Research Center, Children's Hospital, University of Helsinki, Helsinki University Hospital , Helsinki, Finland
| | - K Aalto
- Paediatric Research Center, Children's Hospital, University of Helsinki, Helsinki University Hospital , Helsinki, Finland
| | - M Haanpää
- Ilmarinen Mutual Pension Insurance Company , Helsinki, Finland.,Department of Neurosurgery, Helsinki University Hospital , Helsinki, Finland
| | - K Puolakka
- Department of Medicine, South Karelia Central Hospital , Lappeenranta, Finland
| | - L J Virta
- Research Department, Social Insurance Institution of Finland , Turku, Finland
| | - H Kautiainen
- Department of General Practice and Unit of Primary Health Care, University of Helsinki and Helsinki University Hospital , Helsinki, Finland
| | - H Pohjankoski
- Department of Pediatrics, Päijät-Häme Central Hospital , Lahti, Finland
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14
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Jones AP, Clayton D, Nkhoma G, Sherratt FC, Peak M, Stones SR, Roper L, Young B, McErlane F, Moitt T, Ramanan AV, Foster HE, Williamson PR, Deepak S, Beresford MW, Baildam EM. Different corticosteroid induction regimens in children and young people with juvenile idiopathic arthritis: the SIRJIA mixed-methods feasibility study. Health Technol Assess 2020; 24:1-152. [PMID: 32758350 PMCID: PMC7443738 DOI: 10.3310/hta24360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In the UK, juvenile idiopathic arthritis is the most common inflammatory disorder in childhood, affecting 10 : 100,000 children and young people aged < 16 years each year, with a population prevalence of around 1 : 1000. Corticosteroids are commonly used to treat juvenile idiopathic arthritis; however, there is currently a lack of consensus as to which corticosteroid induction regimen should be used with various disease subtypes and severities of juvenile idiopathic arthritis. OBJECTIVE The main study objective was to determine the feasibility of conducting a randomised controlled trial to compare the different corticosteroid induction regimens in children and young people with juvenile idiopathic arthritis. DESIGN This was a mixed-methods study. Work packages included a literature review; qualitative interviews with children and young people with juvenile idiopathic arthritis and their families; a questionnaire survey and screening log to establish current UK practice; a consensus meeting with health-care professionals, children and young people with juvenile idiopathic arthritis, and their families to establish the primary outcome; a feasibility study to pilot data capture and to collect data for future sample size calculations; and a final consensus meeting to establish the final protocol. SETTING The setting was rheumatology clinics across the UK. PARTICIPANTS Children, young people and their families who attended clinics and health-care professionals took part in this mixed-methods study. INTERVENTIONS This study observed methods of prescribing corticosteroids across the UK. MAIN OUTCOME MEASURES The main study outcomes were the acceptability of a future trial for children, young people, their families and health-care professionals, and the feasibility of delivering such a trial. RESULTS Qualitative interviews identified differences in the views of children, young people and their families on a randomised controlled trial and potential barriers to recruitment. A total of 297 participants were screened from 13 centres in just less than 6 months. In practice, all routes of corticosteroid administration were used, and in all subtypes of juvenile idiopathic arthritis. Intra-articular corticosteroid injection was the most common treatment. The questionnaire surveys showed the varying clinical practice across the UK, but established intra-articular corticosteroids as the treatment control for a future trial. The primary outcome of choice for children, young people, their families and health-care professionals was the Juvenile Arthritis Disease Activity Score, 71-joint count. However, results from the feasibility study showed that, owing to missing blood test data, the clinical Juvenile Arthritis Disease Activity Score should be used. The Juvenile Arthritis Disease Activity Score, 71-joint count, and the clinical Juvenile Arthritis Disease Activity Score are composite disease activity scoring systems for juvenile arthritis. Two final trial protocols were established for a future randomised controlled trial. LIMITATIONS Fewer clinics were included in this feasibility study than originally planned, limiting the ability to draw strong conclusions about these units to take part in future research. CONCLUSIONS A definitive randomised controlled trial is likely to be feasible based on the findings from this study; however, important recommendations should be taken into account when planning such a trial. FUTURE WORK This mixed-methods study has laid down the foundations to develop the evidence base in this area and conducting a randomised control trial to compare different corticosteroid induction regimens in children and young people with juvenile idiopathic arthritis is likely to be feasible. STUDY REGISTRATION Current Controlled Trials ISRCTN16649996. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 36. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ashley P Jones
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
| | - Dannii Clayton
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
| | - Gloria Nkhoma
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
| | | | - Matthew Peak
- Alder Hey Children's NHS Foundation Trust, a member of the Liverpool Health Partners, Liverpool, UK
| | | | - Louise Roper
- School of Psychology, University of Liverpool, Liverpool, UK
| | - Bridget Young
- School of Psychology, University of Liverpool, Liverpool, UK
| | - Flora McErlane
- Paediatric Rheumatology, Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - Tracy Moitt
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
| | - Athimalaipet V Ramanan
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Helen E Foster
- Paediatric Rheumatology, Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - Paula R Williamson
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
| | - Samundeeswari Deepak
- Paediatric Rheumatology, Nottingham Children's Hospital, Queen's Medical Centre, Nottingham, UK
| | - Michael W Beresford
- Faculty of Health and Life Science, University of Liverpool and Alder Hey Children's NHS Foundation Trust, members of Liverpool Health Partners, Liverpool, UK
| | - Eileen M Baildam
- Alder Hey Children's NHS Foundation Trust, a member of the Liverpool Health Partners, Liverpool, UK
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15
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Kearsley-Fleet L, Heaf E, Davies R, Baildam E, Beresford MW, Foster HE, Southwood TR, Thomson W, Hyrich KL. Frequency of biologic switching and the outcomes of switching in children and young people with juvenile idiopathic arthritis: a national cohort study. THE LANCET. RHEUMATOLOGY 2020; 2:e217-e226. [PMID: 32280951 PMCID: PMC7134528 DOI: 10.1016/s2665-9913(20)30025-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Information is scarce about biological disease-modifying antirheumatic drug (DMARD) switching patterns in children and young people (aged ≤16 years) with juvenile idiopathic arthritis in an era of many biologic therapies. The best choice of biologic to use if the first biological DMARD is not beneficial also remains unclear. We aimed to quantify and characterise biologic switching patterns in children and young people with juvenile idiopathic arthritis, and to compare the effectiveness of using a second tumour necrosis factor inhibitor (TNFi) versus non-TNF is following failure of a first TNFi biologic in routine clinical practice. METHODS Our study population comprised patients with juvenile idiopathic arthritis who were enrolled in two parallel UK cohort studies (the British Society for Paediatric and Adolescent Rheumatology Etanercept Cohort Study [BSPAR-ETN] and the Biologics for Children with Rheumatic Diseases [BCRD] study) between Jan 1, 2004, and April 11, 2019. Data on disease characteristics and DMARD therapy were collected at the time of initiation of a first biologic, at 6 months, at 1 year, and annually thereafter. Biologic switching patterns were described in all patients who started their first biologic from Jan 1, 2010, onwards. Among patients who started treatment with their first biologic from Jan 1, 2004, onwards, had polyarticular course juvenile idiopathic arthritis (extended oligoarthritis or polyarthritis [positive or negative for rheumatoid factor]), and who had started a second biologic, we assessed changes in outcome variables at 6 months compared with baseline and compared the proportion of patients who achieved an American College of Rheumatology Pediatric (ACR Pedi) 90 response and minimal disease activity at 6 months on the basis of the class of the second biologic (a second TNFi vs non-TNFi biologic). Changes in outcome variables at 6 months were compared using linear regression or logistic regression, adjusted for propensity quintiles to account for confounding by indication. We used multiple imputation to account for missing data. FINDINGS Between Jan 1, 2004, and April 11, 2019, 2361 patients were enrolled on initiation of biologic therapy. From Jan 1, 2010, onwards, 1152 patients started their first biologic, most of whom started treatment with TNFis (1050 [91%]). The median follow-up was 2·2 years (IQR 1·1-3·8). During this time, 270 (23%) of 1152 patients started a second biologic, 61 (5%) started a third biologic, and 11 (1%) started a fourth biologic. Among 240 patients with polyarticular-course juvenile idiopathic arthritis, 194 (81%) started a second TNFi and 46 (19%) started a non-TNFi after an initial TNFi had failed. Choice of second treatment (second TNFi vs non-TNFi biologic) did not affect the proportion of patients who achieved an ACR Pedi 90 response (adjusted odds ratio [OR] 2·5, 95% CI 0·8-7·9; p=0·11) or minimal disease activity (adjusted OR 1·6, 95% CI 0·6-3·8; p=0·33). INTERPRETATION For many children and young people with juvenile idiopathic arthritis, treatment with a first or second biologic is not beneficial. We found no evidence that switching to a second non-TNFi biologic was more beneficial than a second TNFi. FUNDING Versus Arthritis and The British Society for Rheumatology.
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Affiliation(s)
- Lianne Kearsley-Fleet
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Eleanor Heaf
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Rebecca Davies
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Eileen Baildam
- Clinical Academic Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Michael W Beresford
- Clinical Academic Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK,Institute of Translational Medicine (Child Health), University of Liverpool, Liverpool, 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
- Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, The 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
- Centre for Epidemiology Versus Arthritis, The 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,Correspondence to: Prof Kimme L Hyrich, Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester M13 9PT, UK
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Minden K, Horneff G, Niewerth M, Seipelt E, Aringer M, Aries P, Foeldvari I, Haas JP, Klein A, Tatsis S, Tenbrock K, Zink A, Klotsche J. Time of Disease-Modifying Antirheumatic Drug Start in Juvenile Idiopathic Arthritis and the Likelihood of a Drug-Free Remission in Young Adulthood. Arthritis Care Res (Hoboken) 2020; 71:471-481. [PMID: 30044538 DOI: 10.1002/acr.23709] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 07/17/2018] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To study juvenile idiopathic arthritis (JIA) long-term outcomes in relation to the time of initiation of biologic disease-modifying antirheumatic drug (bDMARD). METHODS Outcomes of JIA patients prospectively followed by the Biologika in der Kinderrheumatologie (BiKeR) and Juvenile Arthritis Methotrexate/Biologics Long-Term Observation (JuMBO) registers were analyzed with regard to drug-free remission and inactive disease, functional status and quality of life, and surgery. To analyze the influence of early bDMARD therapy on outcomes, patients were assigned to 3 groups based on the time from symptom onset to bDMARD start (G1: ≤2 years, G2: >2 to ≤5 years, and G3: >5 years). Propensity score-adjusted outcome differences were analyzed by multinomial logistic regression analyses among the groups. RESULTS A total of 701 JIA patients were observed for mean ± SD 9.1 ± 3.7 years. At the last follow-up (disease duration mean ± SD 14.3 ± 6.1 years), 11.7% of patients were in drug-free remission, and 40.0% had inactive disease. More than half of the patients reported no functional limitation, while 5% had undergone arthroplasty, and 3% had eye surgery. At the 10-year time point, patients in G1 (n = 108) were significantly more likely to be in drug-free remission than those patients who began treatment later (G2, n = 199; G3, n = 259), with 18.5%, 10.1%, and 4.9%, respectively. Patients in G1 had significantly lower disease activity (clinical Juvenile Arthritis Disease Activity Score in 10 joints = 4.9), a better overall well-being (18.2% patient global assessment score = 0), and higher functional status (59.2% Health Assessment Questionnaire score = 0), compared to patients in G3 (7.1, 8.4%, and 43.7%, respectively). G1 patients required arthroplasty significantly less frequently than G3 patients and had significantly lower disease activity over time than patients in both G2 and G3. CONCLUSION Early DMARD treatment is associated with better disease control and outcomes, which supports the concept of a "window of opportunity" for JIA.
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Affiliation(s)
- Kirsten Minden
- German Rheumatism Research Center and Charité-University Medicine Berlin, Berlin, Germany
| | - Gerd Horneff
- Asklepios Clinic Sankt Augustin GmbH, Sankt Augustin, and University Hospital of Cologne, Cologne, Germany
| | | | | | - Martin Aringer
- University Medical Center Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
| | - Peer Aries
- Rheumatologie im Struensee-Haus, Hamburg, Germany
| | - Ivan Foeldvari
- Centre for Pediatric and Adolescent Rheumatology, Hamburg, Germany
| | - Johannes-Peter Haas
- German Centre for Pediatric and Adolescent Rheumatology, Garmisch-Partenkirchen, Germany
| | - Ariane Klein
- Asklepios Clinic Sankt Augustin GmbH, Sankt Augustin, Germany
| | | | - Klaus Tenbrock
- Rheinisch-Westfälische Technische Hochschule Aachen University, Aachen, Germany
| | - Angela Zink
- German Rheumatism Research Center and Charité-University Medicine Berlin, Berlin, Germany
| | - Jens Klotsche
- German Rheumatism Research Center and Charité-University Medicine Berlin, Berlin, Germany
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McErlane F, Armitt G, Cobb J, Bailey K, Cleary G, Douglas S, Lunt L, Rashid A, Sampath S, Shoop-Worrall S, Smith N, Foster H, Thomson W. CAPTURE-JIA: a consensus-derived core dataset to improve clinical care for children and young people with juvenile idiopathic arthritis. Rheumatology (Oxford) 2020; 59:137-145. [PMID: 31243450 PMCID: PMC6909903 DOI: 10.1093/rheumatology/kez214] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 03/25/2019] [Indexed: 01/11/2023] Open
Abstract
Objectives Data collected during routine clinic visits are key to driving successful quality improvement in clinical services and enabling integration of research into routine care. The purpose of this study was to develop a standardized core dataset for juvenile idiopathic arthritis (JIA) (termed CAPTURE-JIA), enabling routine clinical collection of research-quality patient data useful to all relevant stakeholder groups (clinicians, service-providers, researchers, health service planners and patients/families) and including outcomes of relevance to patients/families. Methods Collaborative consensus-based approaches (including Delphi and World Café methodologies) were employed. The study was divided into discrete phases, including collaborative working with other groups developing relevant core datasets and a two-stage Delphi process, with the aim of rationalizing the initially long data item list to a clinically feasible size. Results The initial stage of the process identified collection of 297 discrete data items by one or more of fifteen NHS paediatric rheumatology centres. Following the two-stage Delphi process, culminating in a consensus workshop (May 2015), the final approved CAPTURE-JIA dataset consists of 62 discrete and defined clinical data items including novel JIA-specific patient-reported outcome and experience measures. Conclusions CAPTURE-JIA is the first ‘JIA core dataset’ to include data items considered essential by key stakeholder groups engaged with leading and improving the clinical care of children and young people with JIA. Collecting essential patient information in a standard way is a major step towards improving the quality and consistency of clinical services, facilitating collaborative and effective working, benchmarking clinical services against quality indicators and aligning treatment strategies and clinical research opportunities.
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Affiliation(s)
- Flora McErlane
- Paediatric Rheumatology, Great North Children's Hospital, UK.,Institute of Cellular Medicine (Rheumatology), Medical School, Newcastle University, Newcastle upon Tyne, UK
| | | | - Joanna Cobb
- Arthritis Research UK Centre for Genetics and Genomics, Manchester Academic Health Science Centre, University of Manchester, UK.,National Institute of Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Kathryn Bailey
- Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Gavin Cleary
- Department of Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | | | - Laura Lunt
- Arthritis Research UK Centre for Epidemiology, UK.,National Institute of Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Amir Rashid
- Arthritis Research UK Centre for Epidemiology, UK.,Arthritis Research UK Centre for Genetics and Genomics, Manchester Academic Health Science Centre, University of Manchester, UK.,National Institute of Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Sunil Sampath
- Arthritis Research UK Centre for Epidemiology, UK.,Arthritis Research UK Centre for Genetics and Genomics, Manchester Academic Health Science Centre, University of Manchester, UK.,National Institute of Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Stephanie Shoop-Worrall
- Arthritis Research UK Centre for Epidemiology, UK.,Health eResearch Centre, The University of Manchester, Manchester, UK
| | - Nicola Smith
- Institute of Cellular Medicine (Rheumatology), Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Foster
- Paediatric Rheumatology, Great North Children's Hospital, UK.,Institute of Cellular Medicine (Rheumatology), Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Wendy Thomson
- Arthritis Research UK Centre for Genetics and Genomics, Manchester Academic Health Science Centre, University of 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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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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Abstract
Juvenile spondyloarthritis (SpA) is a distinct form of juvenile arthritis characterized by male predominance and adolescent onset. Clinical manifestations include lower extremity and sacroiliac joint arthritis, enthesitis, and subclinical gastrointestinal inflammation. Juvenile SpA is an immune-mediated inflammatory disease long recognized as associated with HLA-B27, which may be related to the microbial environment as suggested by its coexistence with reactive arthritis and psoriasis. Treatment of peripheral arthritis includes nonsteroidal anti-inflammatory drugs, joint injections, and disease-modifying agents, whereas treatment of axial disease may necessitate a tumor necrosis factor inhibitor biologic agent. Fewer than half of children achieve remission off medication 5 years after diagnosis.
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20
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Patra PK, Kumar M. Clinico-epidemiological Profile of Pediatric Rheumatology Disorders in Eastern India. J Nat Sci Biol Med 2018; 9:19-22. [PMID: 29456387 PMCID: PMC5812067 DOI: 10.4103/jnsbm.jnsbm_80_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Background Data on rheumatological disorders in children from developing countries like India are scarce. Hence, this study aimed to understand the clinical and epidemiological profile of rheumatological disorders in children as this can help organize comprehensive evidence-based health care services. Methodology A retrospective hospital-based study was designed in pediatric rheumatology clinic of the All India Institute of Medical Sciences, Patna, India, from January 2015 to December 2016. Clinical and laboratory findings and response to therapy of all children with rheumatological disorders were evaluated. Results A total of 60 children with various rheumatological disorders were included in the study. Juvenile idiopathic arthritis (JIA) was the most common pediatric rheumatology disorder observed, and polyarticular JIA was the predominate subtype observed in our patients. The mean age of disease onset was 9.1 ± 3.6 years (age range: 1-16 years). Methotrexate was the most common disease modifying antirheumatic drug used. None of the children received newer biological agents due to financial constraints. The use of alternative medicine was observed in 10% of cases. Conclusion The clinical and epidemiological profile of children with rheumatological disorders in our patient group was different from the European countries and Western world. There is a need for introspecting the lack of using biological agents and its potential impact in managing JIA in our patient group.
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Affiliation(s)
- Pratap Kumar Patra
- Department of Pediatrics, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Manish Kumar
- Department of Pediatrics, All India Institute of Medical Sciences, Patna, Bihar, India
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21
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Abstract
PURPOSE OF REVIEW This review aims to provide an update on the use of imaging in the assessment of juvenile spondyloarthritis (JSpA) disease manifestations. RECENT FINDINGS Recent studies have demonstrated superior reliability and specificity of MRI for assessment of sacroiliac joint inflammation compared with radiography. The use of gadolinium contrast may not add incremental value to the assessment of inflammatory sacroiliitis. Sacroiliitis is common at diagnosis of spondyloarthritis. Inflammatory changes of the lumbar spine are not uncommon, and changes over time in the sacroiliac and apophyseal joints may not be concordant. Ultrasonography (US) in turn has been recognized as an excellent imaging technique to visualize the peripheral manifestations of JSpA. US does not only add important information to the clinical assessment but also helps to understand the complexity of the enthesis. Recognition of specific aspects in children is important though. The standardization of image acquisition as well as the establishment of the evidence base are underway. MRI and ultrasonography are recognized as increasingly important tools in the diagnosis and management of juvenile spondyloarthritis.
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Davies R, Southwood T, Kearsley-Fleet L, Lunt M, Baildam E, Beresford MW, Foster HE, Douglas S, Thomson W, De Cock D, Hyrich KL. Mortality rates are increased in patients with systemic juvenile idiopathic arthritis. Arch Dis Child 2017; 102:206-207. [PMID: 27799155 DOI: 10.1136/archdischild-2016-311571] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/30/2016] [Indexed: 11/03/2022]
Affiliation(s)
- Rebecca Davies
- Arthritis Research UK Centre for Epidemiology, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Taunton Southwood
- Institute of Child Health, University of Birmingham and Birmingham Children's Hospital, Birmingham, UK
| | - Lianne Kearsley-Fleet
- Arthritis Research UK Centre for Epidemiology, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Mark Lunt
- Arthritis Research UK Centre for Epidemiology, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Eileen Baildam
- Clinical Academic Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Michael W Beresford
- Clinical Academic Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Institute of Translational Medicine (Child Health), University of Liverpool, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Helen E Foster
- Musculoskeletal Research Group, Institute Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Sharon Douglas
- BSPAR Parent Group, British Society for Rheumatology, London, UK.,Scottish Network for Arthritis in Children, Edinburgh, UK
| | - Wendy Thomson
- Arthritis Research UK Centre for Genetics and Genomics, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester Partnership, Manchester, UK
| | - Diederik De Cock
- Arthritis Research UK Centre for Epidemiology, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | | | | | - Kimme L Hyrich
- Arthritis Research UK Centre for Epidemiology, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester Partnership, Manchester, UK
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Horton DB, Onel KB, Beukelman T, Ringold S. Attitudes and Approaches for Withdrawing Drugs for Children with Clinically Inactive Nonsystemic JIA: A Survey of the Childhood Arthritis and Rheumatology Research Alliance. J Rheumatol 2017; 44:352-360. [PMID: 28148696 DOI: 10.3899/jrheum.161078] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess the attitudes and strategies of pediatric rheumatology clinicians toward withdrawing medications for children with clinically inactive juvenile idiopathic arthritis (JIA). METHODS Members of the Childhood Arthritis and Rheumatology Research Alliance (CARRA) completed an anonymous electronic survey on decision making and approaches for withdrawing medications for inactive nonsystemic JIA. Data were analyzed using descriptive statistics. RESULTS Of 388 clinicians in CARRA, 124 completed surveys (32%), predominantly attending pediatric rheumatologists. The most highly ranked factors in decision making for withdrawing medications were the duration of clinical inactivity, drug toxicity, duration of prior activity, patient/family preferences, joint damage, and JIA category. Diagnoses of rheumatoid factor-positive polyarthritis and persistent oligoarthritis made respondents less likely and more likely, respectively, to withdraw JIA medications. Three-quarters of respondents waited for 6-12 months of inactive disease before stopping methotrexate (MTX) or biologics, but preferences varied. There was also considerable variability in the strategies used to reduce, taper, or stop medications for clinically inactive JIA; most commonly, clinicians reported slow medication tapers lasting at least 2 months. For children receiving combination MTX-biologic therapy, 63% of respondents preferred stopping MTX first. Most clinicians reported using imaging only seldom or sometimes to guide decision making, but most were also reluctant to withdraw medications in the presence of asymptomatic imaging abnormalities suggestive of subclinical inflammation. CONCLUSION Considerable variability exists among pediatric rheumatology clinicians regarding when and how to withdraw medications for children with clinically inactive JIA. More research is needed to identify the most effective approaches to withdraw medications and predictors of outcomes.
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Affiliation(s)
- Daniel B Horton
- From the Division of Pediatric Rheumatology, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Institute for Health, Health Care Policy and Aging Research, Rutgers Biomedical and Health Sciences, New Brunswick, New Jersey; Division of Pediatric Rheumatology, Department of Pediatrics, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York; Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama; Seattle Children's Hospital and Research Institute, University of Washington School of Medicine, Seattle, Washington, USA. .,D.B. Horton, MD, MSCE, Assistant Professor of Pediatrics, Division of Pediatric Rheumatology, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Institute for Health, Health Care Policy and Aging Research, Rutgers Biomedical and Health Sciences; K.B. Onel, MD, Chief, Division of Pediatric Rheumatology, Department of Pediatrics, Hospital for Special Surgery, Weill Cornell Medical College; T. Beukelman, MD, MSCE, Associate Professor, Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham; S. Ringold, MD, MS, Assistant Professor, Seattle Children's Hospital, University of Washington School of Medicine.
| | - Karen B Onel
- From the Division of Pediatric Rheumatology, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Institute for Health, Health Care Policy and Aging Research, Rutgers Biomedical and Health Sciences, New Brunswick, New Jersey; Division of Pediatric Rheumatology, Department of Pediatrics, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York; Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama; Seattle Children's Hospital and Research Institute, University of Washington School of Medicine, Seattle, Washington, USA.,D.B. Horton, MD, MSCE, Assistant Professor of Pediatrics, Division of Pediatric Rheumatology, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Institute for Health, Health Care Policy and Aging Research, Rutgers Biomedical and Health Sciences; K.B. Onel, MD, Chief, Division of Pediatric Rheumatology, Department of Pediatrics, Hospital for Special Surgery, Weill Cornell Medical College; T. Beukelman, MD, MSCE, Associate Professor, Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham; S. Ringold, MD, MS, Assistant Professor, Seattle Children's Hospital, University of Washington School of Medicine
| | - Timothy Beukelman
- From the Division of Pediatric Rheumatology, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Institute for Health, Health Care Policy and Aging Research, Rutgers Biomedical and Health Sciences, New Brunswick, New Jersey; Division of Pediatric Rheumatology, Department of Pediatrics, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York; Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama; Seattle Children's Hospital and Research Institute, University of Washington School of Medicine, Seattle, Washington, USA.,D.B. Horton, MD, MSCE, Assistant Professor of Pediatrics, Division of Pediatric Rheumatology, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Institute for Health, Health Care Policy and Aging Research, Rutgers Biomedical and Health Sciences; K.B. Onel, MD, Chief, Division of Pediatric Rheumatology, Department of Pediatrics, Hospital for Special Surgery, Weill Cornell Medical College; T. Beukelman, MD, MSCE, Associate Professor, Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham; S. Ringold, MD, MS, Assistant Professor, Seattle Children's Hospital, University of Washington School of Medicine
| | - Sarah Ringold
- From the Division of Pediatric Rheumatology, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Institute for Health, Health Care Policy and Aging Research, Rutgers Biomedical and Health Sciences, New Brunswick, New Jersey; Division of Pediatric Rheumatology, Department of Pediatrics, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York; Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama; Seattle Children's Hospital and Research Institute, University of Washington School of Medicine, Seattle, Washington, USA.,D.B. Horton, MD, MSCE, Assistant Professor of Pediatrics, Division of Pediatric Rheumatology, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Institute for Health, Health Care Policy and Aging Research, Rutgers Biomedical and Health Sciences; K.B. Onel, MD, Chief, Division of Pediatric Rheumatology, Department of Pediatrics, Hospital for Special Surgery, Weill Cornell Medical College; T. Beukelman, MD, MSCE, Associate Professor, Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham; S. Ringold, MD, MS, Assistant Professor, Seattle Children's Hospital, University of Washington School of Medicine
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