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van Baalen A. Febrile infection-related epilepsy syndrome in childhood: A clinical review and practical approach. Seizure 2023; 111:215-222. [PMID: 37703593 DOI: 10.1016/j.seizure.2023.09.008] [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: 05/24/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 09/15/2023] Open
Abstract
Febrile infection-related epilepsy syndrome (FIRES) of unknown aetiology is an extremely rare but severe epilepsy syndrome. It is characterized by a nonspecific febrile infection a few days before the onset of super-refractory status epilepticus, followed by refractory epilepsy and high morbidity in previously healthy children and young adults. To date, FIRES is incurable and irreversible. The clinical course may depend more on time than on therapy, while the outcome may depend more on the clinical spectrum than on therapy. Based on a literature search, retrospective data analysis, and personal observations, this review aimed to explore the clinical spectrum and therapeutic options for FIRES to improve outcomes by optimized and more standardized diagnosis and therapy, including adapted immunotherapy and a less aggressive approach to manage seizures, as seizure-freeness is difficult to achieve and, therefore, not the primary goal for cryptogenic FIRES.
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Affiliation(s)
- Andreas van Baalen
- Department of Neuropediatrics, University Medical Center Schleswig-Holstein, Kiel University (CAU), Arnold-Heller-Street 3, House C, Kiel 24105, Germany.
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2
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Reiff DD, Cron RQ. Cytokine Storm Syndrome Triggered by Extracorporeal Membrane Oxygenation in Pediatric Patients. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1052. [PMID: 37371283 DOI: 10.3390/children10061052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/05/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023]
Abstract
Cytokine storm syndrome (CSS) is a serious and potentially life-threatening condition caused by severe systemic inflammation, immune activation, and a positive feedback loop of cytokine release. Typically triggered by systemic infection, malignancy, monogenic or rheumatic disease, similar patterns of hyper-inflammation have been seen in patients undergoing cardiopulmonary bypass (CPB) and in patients treated with extracorporeal membrane oxygenation (ECMO). Typical treatments used for the prevention and treatment of CPB/ECMO-induced hyper-inflammation have not been shown to be substantially effective. Two patients suffering from ECMO-related CSS were identified by their severe hyper-inflammatory profile and life-threatening sequelae of vasodilatory shock and respiratory failure. Anakinra, an interleukin-1 receptor antagonist, was employed as specific cytokine-directed therapy for the treatment of CSS in these two patients to good effect, with significant improvement in hyper-inflammation and cardiorespiratory status. The use of cytokine-directed therapies in CPB/ECMO-related CSS has great potential to improve the treatment and outcomes of this serious condition.
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Affiliation(s)
- Daniel D Reiff
- Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Randy Q Cron
- Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, USA
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3
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Saunders BN, Kuijpers MV, Sloan JJ, Gertner E. Continuous IV infusion of anakinra. Front Pharmacol 2023; 14:1162742. [PMID: 37229265 PMCID: PMC10203171 DOI: 10.3389/fphar.2023.1162742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/26/2023] [Indexed: 05/27/2023] Open
Abstract
Objective: A review of the use of continuous IV infusion of anakinra; a description of the protocol for continuous IV infusion of anakinra in the treatment of cytokine storm developed over the past 4 years at a tertiary level academic medical center in the United States. Methods: We reviewed published reports of continuous IV infusion of anakinra in cytokine storm and summarize this method of treatment in other diseases. As well, over the past 4 years, continuous IV infusions of anakinra were administered at our tertiary level academic medical center in the United States (Regions Hospital, St. Paul, Minnesota) for approximately 400 patient days of treatment primarily for the cytokine storm associated with macrophage activation syndrome (MAS) in adults. This updated protocol is presented. While this a single center protocol, it may serve as an initial guide for further refinement of protocols in MAS and other conditions. Conclusion:Continuous IV infusion of anakinra has advantages over subcutaneous infusions and may be important in controlling severe life-threatening cytokine storm as seen in macrophage activation syndrome. This has the potential to be an important therapy for other syndromes including Cytokine Release Syndrome related to CAR T-cell therapy. Close collaboration between Rheumatology, Pharmacy and Nursing allows this treatment to be delivered rapidly and efficiently.
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4
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Recent advances in the treatment of hemophagocytic lymphohistiocytosis and macrophage activation syndrome. Curr Opin Allergy Clin Immunol 2022; 22:364-370. [PMID: 36206094 DOI: 10.1097/aci.0000000000000865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
PURPOSE OF REVIEW The approach to treating patients with hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) has shifted in recent years with the aim to limit exposure to genotoxic agents, such as etoposide, yet dampen hyperinflammation by targeting the activity of specific HLH/MAS-associated cytokines. In this review, we discuss recent efforts to reduce the dose of etoposide and/or incorporate cytokine-targeted therapies for the treatment of HLH/MAS. RECENT FINDINGS There is emerging evidence that reduced-dose etoposide and/or cytokine-targeted therapies, including agents that neutralize or inhibit signaling induced by interferon gamma, interleukin (IL)-1, IL-18, and IL-6, can effectively ameliorate the clinical and laboratory manifestations of HLH/MAS and improve overall outcomes. SUMMARY The application of novel regimens containing lower doses of etoposide and/or cytokine-directed agents to treat HLH/MAS holds potential to dampen inflammation while minimizing therapy-associated toxicities. Nevertheless, further research is needed to better understand, which patients represent the most appropriate candidates to receive cytokine-targeted therapies, elucidate the optimal timing and dose of these therapies, and decipher whether they should be administered alone or in combination with conventional HLH-directed therapies, such as dexamethasone and standard-dose or reduced-dose etoposide.
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5
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Naymagon L. Anakinra for the treatment of adult secondary HLH: a retrospective experience. Int J Hematol 2022; 116:947-955. [PMID: 35948764 PMCID: PMC9365216 DOI: 10.1007/s12185-022-03430-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 11/30/2022]
Abstract
Anti-cytokine therapies have been gaining attention as a means of improving outcomes in adult secondary HLH (asHLH), which currently has poor outcomes when treated with standard etoposide-based therapies. Anakinra is an interleukin-1 antagonist that is increasingly being used in the management of asHLH. Here is described a multi-hospital series of 16 adult patients with secondary HLH treated with anakinra. Provoking factors of secondary HLH included hematologic malignancy (n = 7, 44%), bacterial infection (n = 7, 44%), viral infection (n = 5, 31%), rheumatologic disorder (n = 4, 25%), and unknown (n = 1, 6%). Five patients remained alive at time of last follow-up (OS = 31%). Median OS was 1.7 months from initiation of anakinra (range 0.2–59). OS among patients with rheumatologic causes of secondary HLH was 75%, whereas only 17% of patients with other provoking factors survived (p = 0.0293). Anakinra was well tolerated, with only 1 patient experiencing associated toxicity (grade 3 liver injury). Anakinra may be useful in the management of asHLH provoked by rheumatologic conditions, although its benefit in asHLH provoked by other factors may be limited.
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Affiliation(s)
- Leonard Naymagon
- Mount Sinai School of Medicine, Tisch Cancer Institute, New York, NY, USA.
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Ohashi A, Uemura Y, Yoshimori M, Wada N, Imadome KI, Yudo K, Koyama T, Shimizu N, Nishio M, Arai A. The Plasma Level of Interleukin-1β Can Be a Biomarker of Angiopathy in Systemic Chronic Active Epstein-Barr Virus Infection. Front Microbiol 2022; 13:874998. [PMID: 35464987 PMCID: PMC9019545 DOI: 10.3389/fmicb.2022.874998] [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] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 03/16/2022] [Indexed: 01/12/2023] Open
Abstract
Systemic chronic active Epstein-Barr virus infection (sCAEBV) is an EBV-positive T- or NK-cell neoplasm revealing persistent systemic inflammation. Twenty-five percent of sCAEBV patients accompany angiopathy. It is crucial to clarify the mechanisms of angiopathy development in sCAEBV because angiopathy is one of the main causes of death. Interleukin-1β (IL-1β) is reported to be involved in angiopathy onset. We investigated if IL-1β plays a role as the inducer of angiopathy of sCAEBV. We detected elevated IL-1β levels in four out of 17 sCAEBV patient's plasma. Interestingly, three out of the four had clinically associated angiopathy. None of the other patients with undetectable level of IL-1β had angiopathy. In all patients with high plasma levels of IL-1β and vascular lesions, EBV-infected cells were CD4-positive T cells. In one patient with high plasma IL-1β, the level of IL-1β mRNA of the monocytes was 17.2 times higher than the level of the same patient's EBV-infected cells in peripheral blood. In Ea.hy926 cells, which are the models of vascular endothelial cells, IL-1β inhibited the proliferation and induced the surface coagulation activity. IL-1β is a potent biomarker and a potent therapeutic target to treat sCAEBV accompanying angiopathy.
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Affiliation(s)
- Ayaka Ohashi
- Department of Frontier Medicine, Institute of Medical Science, St. Marianna University School of Medicine, Kanagawa, Japan.,Department of Laboratory Molecular Genetics of Hematology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan.,Division of Hematology and Oncology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Yu Uemura
- Division of Hematology and Oncology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Mayumi Yoshimori
- Department of Hematological Therapeutics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Naomi Wada
- Department of Advanced Medicine for Viral Infections, National Center for Child Health and Development, Tokyo, Japan
| | - Ken-Ichi Imadome
- Department of Advanced Medicine for Viral Infections, National Center for Child Health and Development, Tokyo, Japan
| | - Kazuo Yudo
- Department of Frontier Medicine, Institute of Medical Science, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Takatoshi Koyama
- Department of Laboratory Molecular Genetics of Hematology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan.,Department of Hematology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Norio Shimizu
- Center of Stem Cell and Regenerative Medicine, Advanced Multidisciplinary Research Cluster, Institute of Research, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Miwako Nishio
- Department of Laboratory Molecular Genetics of Hematology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Ayako Arai
- Division of Hematology and Oncology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan.,Department of Hematological Therapeutics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
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7
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Çaǧlayan Ş, Sönmez HE, Otar Yener G, Baǧlan E, Öztürk K, Ulu K, Guliyeva V, Demirkol D, Çakan M, Özdel S, Bukulmez H, Aktay Ayaz N, Sözeri B. Anakinra treatment in multisystemic inflammatory syndrome in children (MIS-C) associated with COVID-19. Front Pediatr 2022; 10:942455. [PMID: 36061383 PMCID: PMC9433644 DOI: 10.3389/fped.2022.942455] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/25/2022] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE The study aimed to report the efficacy and safety of anakinra treatment in patients with the refractory multisystemic inflammatory syndrome in children (MIS-C). METHODS This is a cross-sectional retrospective study consisting of pediatric patients diagnosed with MIS-C who were treated with anakinra. RESULTS Among the 378 patients diagnosed with MIS-C, 82 patients (21.6%) who were treated with anakinra were included in the study. The median age of patients was 115 (6-214) months. The median duration of hospitalization was 15 (6-42) days. Sixty patients (73.1%) were admitted to the pediatric intensive care unit. Patients were treated with a median dose of 2.7 mg/kg/day anakinra concomitant with IVIG and steroids. Intravenous anakinra was applied to 12 patients while 70 patients received it subcutaneously. Twenty-eight patients required high dose (4-10 mg/kg/day) anakinra. The median day of anakinra initiation was 2 (1-14) days and the median duration of anakinra use was 7 (1-41) days. No injection site reactions were observed while elevated transaminase levels were detected in 13 patients. Seventy-three patients (89.1%) were discharged without any sequela or morbidity. Seven patients (1.8%) died. Abnormal echocardiographic findings continued in two patients (2.4%) (coronary artery dilatation in one, low ejection fraction in one) at discharge and became normal on the 2nd month. CONCLUSION Based on the results of the study, anakinra was associated with clinical improvements and was safe for most patients with refractory MIS-C.
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Affiliation(s)
- Şengül Çaǧlayan
- Department of Pediatric Rheumatology, Umraniye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | | | - Gülçin Otar Yener
- Department of Pediatric Rheumatology, Şanlıurfa Research and Training Hospital, Şanlıurfa, Turkey
| | - Esra Baǧlan
- Department of Pediatric Rheumatology, Sami Ulus Research and Training Hospital, Ankara, Turkey
| | - Kübra Öztürk
- Department of Pediatric Rheumatology, Göztepe Research and Training Hospital, Istanbul Medeniyet University, Istanbul, Turkey
| | - Kadir Ulu
- Department of Pediatric Rheumatology, Umraniye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Vafa Guliyeva
- Department of Pediatric Rheumatology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Demet Demirkol
- Department of Pediatric Intensive Care Unit, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mustafa Çakan
- Department of Pediatric Rheumatology, Umraniye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Semanur Özdel
- Department of Pediatric Rheumatology, Sami Ulus Research and Training Hospital, Ankara, Turkey
| | - Hulya Bukulmez
- Division of Pediatric Rheumatology, Department of Pediatrics, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Nuray Aktay Ayaz
- Department of Pediatric Rheumatology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Betül Sözeri
- Department of Pediatric Rheumatology, Umraniye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
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8
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Fingerhutová Š, Jančová E, Doležalová P. Anakinra in Paediatric Rheumatology and Periodic Fever Clinics: Is the Higher Dose Safe? Front Pediatr 2022; 10:823847. [PMID: 35321008 PMCID: PMC8936593 DOI: 10.3389/fped.2022.823847] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 01/14/2022] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE Anakinra has been increasingly used in off-label indications as well as dosing and mode of administration in a variety of inflammatory conditions. We aimed to review our clinical practice and compare treatment outcomes with published data. METHODS Clinical data from electronic records were retrospectively reviewed for patients treated with anakinra over the past 6 years for autoinflammatory diseases (AID). RESULTS From 47 eligible patients (27 female patients), 32 were children. Macrophage activation syndrome (MAS) was the indication for anakinra therapy in 42.6% of patients. Systemic juvenile idiopathic arthritis (SJIA) was the most common underlying diagnosis (19/47) followed by the spectrum of AID. Off-label use was noted in 38.3% patients. Recommended dose was exceeded in 21 children (mean induction dose 5.1, highest dose 29.4 mg/kg/day) and two adults; five patients were treated intravenously. The mean treatment duration for SJIA was 1.4 years, that for AID was 2.2 years, and that for patients with higher anakinra dose was 9.7 (19.3) months. The mean follow-up duration was 2.7 (1.7) years. Treatment was effective in the majority of SJIA and cryopyrinopathy patients as well as those with MAS. Anakinra was well-tolerated without any major adverse effects even in patients with long-term administration of higher than recommended doses including two infants treated with a dose of over 20 mg/kg/day. CONCLUSION Our results support early use of anakinra in the individually tailored dosing. In patients with hyperinflammation, anakinra may be lifesaving and may even allow for corticosteroid avoidance. Further studies are needed in order to set up generally accepted response parameters and define condition-specific optimal dosing regimen.
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Affiliation(s)
- Šárka Fingerhutová
- Centre for Paediatric Rheumatology and Autoinflammatory Diseases, Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Eva Jančová
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Pavla Doležalová
- Centre for Paediatric Rheumatology and Autoinflammatory Diseases, Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
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Charlesworth JEG, Wilson S, Qureshi A, Blanco E, Mitchell A, Segal S, Kelly D, Weitz J, O'Shea D, Bailey K, Kavirayani A. Continuous intravenous anakinra for treating severe secondary haemophagocytic lymphohistiocytosis/macrophage activation syndrome in critically ill children. Pediatr Blood Cancer 2021; 68:e29102. [PMID: 34114322 DOI: 10.1002/pbc.29102] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/20/2021] [Accepted: 04/20/2021] [Indexed: 11/08/2022]
Abstract
The cytokine storm of secondary haemophagocytic lymphohistiocytosis (sHLH)/macrophage activation syndrome (MAS) can cause life-threatening multiorgan failure. Interleukin-1 (IL-1) receptor blockade with anakinra can be effective in the management of sHLH/MAS. Subcutaneous (SC) dosing regimens are widely described; however, intravenous (IV) dosing is advantageous where time-critical intervention is vital and where SC oedema and/or hypoperfusion limits absorption. We review three critically ill children (aged 9, 11 and 17) with sHLH and rapidly progressive multiorgan dysfunction, successfully treated with continuous IV anakinra infusion. This case series significantly enhances the incipient knowledge regarding the safety and efficacy of IV anakinra for life-threatening sHLH.
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Affiliation(s)
- James E G Charlesworth
- Oxford University Clinical Academic Graduate School, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Shaun Wilson
- Paediatric Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Amrana Qureshi
- Paediatric Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Esther Blanco
- Paediatric Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Amy Mitchell
- Paediatric Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Shelley Segal
- Paediatric Infectious Diseases, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Dominic Kelly
- Oxford University Clinical Academic Graduate School, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Paediatric Infectious Diseases, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - James Weitz
- Paediatric Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Deirdre O'Shea
- Paediatric Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kathryn Bailey
- Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Akhila Kavirayani
- Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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10
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Phadke O, Rouster-Stevens K, Giannopoulos H, Chandrakasan S, Prahalad S. Intravenous administration of anakinra in children with macrophage activation syndrome. Pediatr Rheumatol Online J 2021; 19:98. [PMID: 34187503 PMCID: PMC8240425 DOI: 10.1186/s12969-021-00585-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/05/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Subcutaneous anakinra is an interleukin-1 inhibitor used to treat juvenile idiopathic arthritis. Recent reports suggest anakinra can be a valuable addition to the treatment of COVID-19 associated cytokine storm syndrome and the related multisystem inflammatory syndrome (MIS-C) in children. Herein, we describe our experience with intravenously administered anakinra. FINDINGS 19 Patients (9 male) received intravenous (IV) anakinra for treatment of macrophage activation syndrome (MAS) secondary to systemic lupus erythematosus (SLE), systemic JIA (SJIA) or secondary hemophagocytic lymphohistiocytosis (sHLH). In most cases the general trend of the fibrinogen, ferritin, AST, and platelet count (Ravelli criteria) improved after initiation of IV anakinra. There were no reports of anaphylaxis or reactions associated with administration of IV anakinra. CONCLUSION Intravenous administration of anakinra is an important therapeutic option for critically ill patients with MAS/HLH. It is also beneficial for those with thrombocytopenia, subcutaneous edema, neurological dysfunction, or very young, hospitalized patients who need multiple painful subcutaneous injections.
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Affiliation(s)
- Omkar Phadke
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA. .,Children's Healthcare of Atlanta, Atlanta, GA, USA.
| | - Kelly Rouster-Stevens
- grid.189967.80000 0001 0941 6502Department of Pediatrics, Emory University School of Medicine, Atlanta, GA USA ,grid.428158.20000 0004 0371 6071Children’s Healthcare of Atlanta, Atlanta, GA USA
| | - Helen Giannopoulos
- grid.428158.20000 0004 0371 6071Children’s Healthcare of Atlanta, Atlanta, GA USA
| | - Shanmuganathan Chandrakasan
- grid.189967.80000 0001 0941 6502Department of Pediatrics, Emory University School of Medicine, Atlanta, GA USA ,grid.428158.20000 0004 0371 6071Children’s Healthcare of Atlanta, Atlanta, GA USA
| | - Sampath Prahalad
- grid.189967.80000 0001 0941 6502Department of Pediatrics, Emory University School of Medicine, Atlanta, GA USA ,grid.428158.20000 0004 0371 6071Children’s Healthcare of Atlanta, Atlanta, GA USA
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