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Hinze CH, Foell D, Kessel C. Treatment of systemic juvenile idiopathic arthritis. Nat Rev Rheumatol 2023; 19:778-789. [PMID: 37923864 DOI: 10.1038/s41584-023-01042-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2023] [Indexed: 11/06/2023]
Abstract
Systemic juvenile idiopathic arthritis (sJIA) is an inflammatory disease with hallmarks of severe systemic inflammation, which can be accompanied by arthritis. Contemporary scientific insights set this paediatric disorder on a continuum with its counterpart, adult-onset Still disease (AOSD). Patients with sJIA are prone to complications, including life-threatening hyperinflammation (macrophage activation syndrome (sJIA-MAS)) and sJIA-associated lung disease (sJIA-LD). Meanwhile, the treatment arsenal in sJIA has expanded markedly. State-of-the-art therapeutic approaches include biologic agents that target the IL-1 and IL-6 pathways. Beyond these, a range of novel agents are on the horizon, some of them already being used on a compassionate use basis, including JAK inhibitors and biologic agents that target IL-18, IFNγ, or IL-1β and IL-18 simultaneously. However, sJIA, sJIA-MAS and sJIA-LD still pose challenging conundrums to rheumatologists treating paediatric and adult patients worldwide. Although national and international consensus treatment plans exist for the treatment of 'classic' sJIA, the treatment approaches for early sJIA without arthritis, and for refractory or complicated sJIA, are not well defined. Therefore, in this Review we outline current approaches for the treatment of sJIA and provide an outlook on knowledge gaps.
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Affiliation(s)
- Claas H Hinze
- Department of Paediatric Rheumatology and Immunology, Münster University Hospital, Münster, Germany
| | - Dirk Foell
- Department of Paediatric Rheumatology and Immunology, Münster University Hospital, Münster, Germany.
| | - Christoph Kessel
- Department of Paediatric Rheumatology and Immunology, Münster University Hospital, Münster, Germany
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Ambler WG, Nanda K, Onel KB, Shenoi S. Refractory systemic onset juvenile idiopathic arthritis: current challenges and future perspectives. Ann Med 2022; 54:1839-1850. [PMID: 35786149 PMCID: PMC9258439 DOI: 10.1080/07853890.2022.2095431] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Systemic juvenile idiopathic arthritis (SJIA) is a rare disease with distinct features not seen in other categories of juvenile idiopathic arthritis. In recent years, advances in the understanding of disease immunopathogenesis have led to improved targeted therapies with significant improvement in patient outcomes. Despite these advances, there remain subsets of SJIA with refractory disease and severe disease-associated complications. This review highlights existing options for treatment of refractory SJIA and explores potential future therapeutics for refractory disease.Key Points:Despite targeted Interleukin IL-1 and IL-6 inhibitors a subset of SJIA remains refractory to therapy. About 1 in 7 SJIA patients will be refractory to targeted IL-1 or IL-6 therapy.There is no current agreed upon definition for refractory SJIA and we propose in this review that refractory SJIA is presence of active systemic or arthritic features despite treatment with anti-IL-1 or anti-IL-6 therapy or disease requiring glucocorticoids for control beyond 6 months.SJIA disease associated complications include presence of associated macrophage activation syndrome (MAS), interstitial lung disease (ILD) or amyloidosis and management of each differs.Refractory SJIA treatment options currently include additional conventional synthetic disease modifying anti-rheumatic drugs (csDMARDS), biologic (bDMARDS), combination biologic therapy, targeted synthetic (tsDMARDS) or other immunomodulatory therapies.
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Affiliation(s)
- William G Ambler
- Division of Pediatric Rheumatology, Hospital for Special Surgery, New York, NY, USA.,Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Kabita Nanda
- Department of Pediatrics, Division of Rheumatology, University of Washington School of Medicine & Seattle Children's Hospital, Seattle, WA, USA
| | - Karen Brandt Onel
- Division of Pediatric Rheumatology, Hospital for Special Surgery, New York, NY, USA.,Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Susan Shenoi
- Department of Pediatrics, Division of Rheumatology, University of Washington School of Medicine & Seattle Children's Hospital, Seattle, WA, USA
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Di Cola I, Cipriani P, Ruscitti P. Perspectives on the use of non-biological pharmacotherapy for adult-onset Still's disease. Expert Opin Pharmacother 2022; 23:1577-1587. [PMID: 36124816 DOI: 10.1080/14656566.2022.2126764] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The treatment of the patients with adult-onset Still's disease (AOSD) remains largely empirical and it is based on the administration of immunosuppressive drugs. In this work, we described the use of non-biological pharmacotherapies for AOSD. AREA COVERED Although nonsteroidal anti-inflammatory drugs (NSAIDs) are employed during the diagnostic phase, glucocorticoids (GCs) are the first-line therapy, administered at the beginning of the disease. As second-line therapy, conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs) are used when GCs do not fully control the disease and/or to reduce the dosage of concomitant GCs. Methotrexate (MTX) is the most commonly administered csDMARDs whereas calcineurin inhibitors (CNIs) are used in severe patients. The lack of achievement of clinical response may lead to the administration of biologic DMARDs, with or without csDMARDs. EXPERT OPINION The management of AOSD may benefit from the administration of non-biological pharmacotherapies, including GCs, MTX, and CNIs. These therapies showed efficacy in inducing a clinical response, in managing life-threatening complications, and may be well tolerated in combination with biologic DMARDs. However, further specific studies are needed to fully clarify the specific role of such drugs in clinical practice to improve the management of AOSD and to provide a more tailored treatment.
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Affiliation(s)
- Ilenia Di Cola
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Paola Cipriani
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Piero Ruscitti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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Pallesen KAU, Herlin T, Holm M, Høst C, Christiansen M, Ramsing M, Rasmussen MK, Sommerlund M. Idiopathic hypereosinophilic syndrome: A rare diagnosis in children. Clin Case Rep 2020; 8:2013-2016. [PMID: 33088541 PMCID: PMC7563636 DOI: 10.1002/ccr3.3165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/24/2020] [Accepted: 05/28/2020] [Indexed: 11/10/2022] Open
Abstract
Idiopathic hypereosinophilic syndrome (IHES) is one of numerous hypereosinophilic syndromes. The incidence of IHES among children is unknown, but it is considered a rare disease. We report a pediatric case of IHES and the challenges to finding an effective treatment. The patient described here was responsive to prednisolone and thalidomide.
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Affiliation(s)
| | - Troels Herlin
- Department of Paediatrics Aarhus University Hospital Aarhus N Denmark
| | - Mette Holm
- Department of Paediatrics Aarhus University Hospital Aarhus N Denmark
| | - Christian Høst
- Department of Paediatrics Aarhus University Hospital Aarhus N Denmark
| | - Mette Christiansen
- Department of Molecular Medicine Aarhus University Hospital Aarhus N Denmark
| | - Mette Ramsing
- Department of Pathology Regionshospitalet Randers Randers Denmark
| | | | - Mette Sommerlund
- Department of Dermatology Aarhus University Hospital Aarhus N Denmark
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5
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Shenoi S, Wallace CA. Diagnosis and Treatment of Systemic Juvenile Idiopathic Arthritis. J Pediatr 2016; 177:19-26. [PMID: 27499217 DOI: 10.1016/j.jpeds.2016.06.056] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 06/03/2016] [Accepted: 06/16/2016] [Indexed: 12/23/2022]
Affiliation(s)
- Susan Shenoi
- Department of Pediatrics, Division of Rheumatology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Carol A Wallace
- Department of Pediatrics, Division of Rheumatology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
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Sathe K, Khubchandani RP. Thalidomide for systemic onset juvenile idiopathic arthritis. Indian Pediatr 2013; 50:237-9. [DOI: 10.1007/s13312-013-0041-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Chan AY, Milojevic D. Treatment of juvenile idiopathic arthritis. Pediatr Ann 2012; 41. [PMID: 23814934 DOI: 10.3928/00904481-20121022-12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Alice Y Chan
- Pediatric Rheumatology, University of California San Francisco, 533 Parnassus Avenue, Box 0107, San Francisco, CA 94113, USA
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8
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Gurion R, Lehman TJA, Moorthy LN. Systemic arthritis in children: a review of clinical presentation and treatment. Int J Inflam 2011; 2012:271569. [PMID: 22235382 PMCID: PMC3253447 DOI: 10.1155/2012/271569] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2011] [Accepted: 09/06/2011] [Indexed: 12/14/2022] Open
Abstract
Systemic juvenile idiopathic arthritis (sJIA) constitutes a small part of juvenile idiopathic arthritis (JIA), yet has a disproportionally higher rate of mortality. Despite being grouped under JIA, it is considered to be a multifactorial autoinflammatory disease. The objective of this paper is to review the epidemiology, pathogenesis, genetics, clinical manifestations, complications, therapy, prognosis, and outcome of sJIA. The presentation and clinical manifestations of sJIA have not changed much in the past several decades, but the collective understanding of the pathogenesis and the development of new targeted therapies (particularly the biologic agents) have transformed and improved the disease outcome for children with sJIA.
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Affiliation(s)
- R. Gurion
- Division of Pediatric Rheumatology, Rainbow Babies & Children's Hospital, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - T. J. A. Lehman
- Division of Pediatric Rheumatology, Hospital for Special Surgery and Clinical Pediatrics Weill Medical Center, Cornell University, 535 E 70 St, New York, NY 10021, USA
| | - L. N. Moorthy
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Medicine and Dentistry of NJ-Robert Wood Johnson Medical School, 89 French Street, New Brunswick, NJ 08901, USA
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Kim KN. Treatment of juvenile rheumatoid arthritis. KOREAN JOURNAL OF PEDIATRICS 2010; 53:936-41. [PMID: 21218015 PMCID: PMC3012273 DOI: 10.3345/kjp.2010.53.11.936] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2010] [Accepted: 10/19/2010] [Indexed: 11/27/2022]
Abstract
The systematic approach to pharmacologic treatment is typically to begin with the safest, simplest, and most conservative measures. It has been realized that the more rapidly inflammation is under control, the less likely it is that there will be permanent sequelae. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of initial treatment for inflammation. In addition, the slow-acting antirheumatic drugs (SAARDs) and disease-modifying antirheumatic drugs (DMARDs) have efficacy of anti-inflammatory action in children with chronic arthritis. New therapeutic modalities for inflammation, such as etanercept and infliximab, promise even further improvements in the risk/benefit ratio of treatment. It is not typically possible at the onset of the disease to predict which children will recover and which will go on to have unremitting disease with lingering disability or enter adulthood with serious functional impairment. Therefore, the initial therapeutic approach must be vigorous in all children.
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Affiliation(s)
- Kwang Nam Kim
- Department of Pediatrics, Hangang Sacred Heart Hospital, School of Medicine Hallym University, Seoul, Korea
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Yasui K, Yashiro M, Nagaoka Y, Manki A, Wada T, Tsuge M, Kondo Y, Morishima T. Thalidomide prevents formation of multinucleated giant cells (Langhans-type cells) from cultured monocytes: possible pharmaceutical applications for granulomatous disorders. Int J Immunopathol Pharmacol 2009; 22:707-14. [PMID: 19822087 DOI: 10.1177/039463200902200316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Thalidomide is an effective drug for chronic inflammatory diseases, but the mechanism underlying its immunomodulatory action remains uncertain. Thalidomide has been reported to clinically improve chronic inflammatory granulomatous disorders. In such disorders, the granulomas consist of epithelioid cells, scattered lymphocytes and multinucleated giant cells (MNGC; Langhans-type cells). The present experimental approach permitted the reproduction of MNGC formation from peripheral blood monocytes and examination of thalidomides effect on it. MNGC can be effectively generated from monocytes cultured in the presence of interleukin-4 (IL-4) and macrophage colony-stimulating factor(M-CSF) for 14 days. Thalidomide can inhibit the formation of MNGC in a dose-dependent manner. MNGC formation was partly inhibited by the presence of neutralizing TNF-alpha antibody in the responses induced by IL-4 and M-CSF. Autocrinal TNF-alpha production and modulation of cadhelin expression to regulate cell adhesion might be involved in this inhibitory action of thalidomide. Our results support thalidomides clinical efficacy in the treatment of chronic granulomatous disorders (granulomatosis).
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Affiliation(s)
- K Yasui
- Department of Pediatrics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
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Yasui K, Uchida N, Akazawa Y, Nakamura S, Minami I, Amano Y, Yamazaki T. Thalidomide for treatment of intestinal involvement of juvenile-onset Behçet disease. Inflamm Bowel Dis 2008; 14:396-400. [PMID: 17973303 DOI: 10.1002/ibd.20317] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Thalidomide has been identified and its anti-inflammatory and immunomodulatory properties clarified. This report expands our report of 2 entero-Behçet disease children who developed significant steroid toxicity and improved dramatically with thalidomide. METHODS We studied the effects of thalidomide in 7 juvenile-onset patients with severe, recurrent intestinal involvement of Behçet disease. Thalidomide was given at an initial dose of 2 mg/kg per day, and the dose was increased to 3 mg/kg per day if necessary (3 of 7 patients) or decreased to 1-0.5 mg/kg per day according to the responses to the drug. RESULTS All 7 patients showed dramatic improvement in clinical symptoms with thalidomide therapy, and they successfully discontinued steroid therapy. Patients receiving thalidomide were monitored for prolonged neurotoxicity, and the treatment and a few side effects were well tolerated by all patients. CONCLUSIONS Our results indicate that thalidomide can be an efficacious medication in appropriately selected patients with some inflammatory bowel diseases with many chances of success.
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Affiliation(s)
- Kozo Yasui
- Department of Pediatrics, Nagano Red Cross Hospital, Nagano, Japan.
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Priolo T, Lamba LD, Giribaldi G, De Negri E, Grosso P, De Grandis E, Veneselli E, Buoncompagni A, Viola S, Alpigiani MG, Gandullia P, Calevo MG. Childhood thalidomide neuropathy: a clinical and neurophysiologic study. Pediatr Neurol 2008; 38:196-9. [PMID: 18279755 DOI: 10.1016/j.pediatrneurol.2007.11.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2007] [Revised: 07/25/2007] [Accepted: 11/12/2007] [Indexed: 10/22/2022]
Abstract
Thalidomide was recently reintroduced to treat several immune-mediated pathologies. Peripheral neuropathy is a significant side effect limiting its clinical use. Our aims include: (1) describing and identifying the incidence of clinical or electrophysiologic peripheral neuropathy in children, (2) determining whether peripheral neuropathy correlates with cumulative dose of thalidomide and with age, and (3) defining its reversibility rate. We studied 13 children manifesting immune-mediated pathologies treated with thalidomide at doses ranging from 25-100 mg/day. Clinical and neurophysiologic evaluation was performed before and after starting treatment. Seven children (53.8%) showed neurophysiologic signs of sensory peripheral axonal polyneuropathy. Five presented associated clinical symptoms, while the other two only presented subclinical, neurophysiologic signs of peripheral neuropathy. We found a significant correlation between the incidence of peripheral neuropathy and thalidomide cumulative dose (P = 0.02). We observed a lower incidence of peripheral neuropathy at a cumulative dose <20 gm, and a correlation with age (P < 0.01). The clinical and electrophysiologic recovery rate was 40%, and clinical improvement alone was observed in another 40%. Thalidomide induces dose-dependent and age-dependent peripheral neuropathy at a significant frequency in childhood (53.8%). In our experience a cumulative dosage at >20 gm and long-term administration for >10 months seem to increase the risk of peripheral neuropathy. We propose clinical and neurophysiologic follow-up every 3 months to identify and monitor possible side effects.
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Affiliation(s)
- Tiziana Priolo
- Children's Neuropsychiatry Operative Unit, Department of Neurosciences, Ophthalmology, and Genetics, IRCCS G. Gaslini Institute, University of Genoa, Largo Gaslini 5, Genoa, Italy
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Lehman TJA. Thalidomide for rheumatic disease: the best of both worlds? ACTA ACUST UNITED AC 2007; 3:308-9. [PMID: 17538563 DOI: 10.1038/ncprheum0504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2007] [Accepted: 03/20/2007] [Indexed: 11/08/2022]
Affiliation(s)
- Thomas J A Lehman
- Division of Pediatric Rheumatology, Hospital for Special Surgery, and Weill Medical College of Cornell University, New York, NY 10021, USA.
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García-Carrasco M, Fuentes-Alexandro S, Escárcega RO, Rojas-Rodriguez J, Escobar LE. Efficacy of thalidomide in systemic onset juvenile rheumatoid arthritis. Joint Bone Spine 2007; 74:500-3. [PMID: 17706449 DOI: 10.1016/j.jbspin.2006.12.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2006] [Accepted: 12/21/2006] [Indexed: 12/01/2022]
Abstract
UNLABELLED Thalidomide is an immunomodulating agent which reverses many of the cytokine disturbances seen in systemic onset juvenile idiopathic arthritis (SoJIA) with inadequate response to other treatments. We report 3 cases of recalcitrant SoJIA which improved dramatically after treatment with thalidomide. PATIENTS Three children aged 9, 8, and 6 years diagnosed with SoJIA treated with conventional therapy including NSAIDs, corticosteroids, methotrexate and etanercept failed to respond fully and their condition worsened. Thalidomide was begun based on two previous reports showing its efficacy in recalcitrant SoJIA. RESULTS Thalidomide produced successful remission of the disease in all 3 patients according to the preliminary criteria for inactive disease and clinical remission of JIA. CONCLUSION Thalidomide may be a viable, alternative corticoid-sparing therapy in patients with recalcitrant, multidrug-resistant SoJIA.
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Affiliation(s)
- Mario García-Carrasco
- Systemic Autoimmune Diseases Research Unit, HGZ #36, CMN Manuel Avila Camacho, Instituto Mexicano del Seguro Social, Puebla, Mexico.
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Goli V. Does thalidomide have an analgesic effect? Current status and future directions. Curr Pain Headache Rep 2007; 11:109-14. [PMID: 17367589 DOI: 10.1007/s11916-007-0007-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Dramatic relief of pain and life-altering changes in quality of life in some patients treated with immunomodulators such as thalidomide compel us to look more closely at unconventional mechanisms that may be involved in propagation of persistent pain. Tumor necrosis factor (TNF)-alpha, interleukin (IL)-1beta, IL-6, and IL-10 are the cytokines with the most evidence in pain modulation. TNF-alpha and IL-1beta seem to initiate neuropathic pain, IL-6 maintains such pain, and IL-10 inhibits this persistent pain. Thalidomide was found to be effective in animal models by inhibiting TNF-alpha production. Several case reports and case series in humans have demonstrated mixed results, with some patients having dramatic responses, especially in chronic intractable conditions such as complex regional pain syndrome. Thalidomide may be an alternative for some patients with intractable pain. However, use of thalidomide is limited by its neurotoxic and teratogenic effects. Newer analogues may significantly improve the risk/benefit of using such immunomodulators.
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Affiliation(s)
- Veeraindar Goli
- Duke University Medical Center, 932 Morreene Road, Durham, NC 27705, USA.
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Mirkinson LJ, Katona IM. Systemic onset juvenile idiopathic arthritis: update on pathogenesis and treatment. Expert Rev Clin Immunol 2007; 3:313-21. [DOI: 10.1586/1744666x.3.3.313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kimura Y, Walco GA, Sugarman E, Conte PM, Schanberg LE. Treatment of pain in juvenile idiopathic arthritis: A survey of pediatric rheumatologists. ACTA ACUST UNITED AC 2006; 55:81-5. [PMID: 16463417 DOI: 10.1002/art.21689] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To assess the opinions and current practice of pediatric rheumatologists regarding treatment of chronic pain in children with juvenile idiopathic arthritis (JIA). METHODS Standardized questionnaires were distributed to pediatric rheumatologists who are members of the Children's Arthritis and Rheumatology Research Alliance. Demographic data, opinions, and attitudes were solicited about pain assessment, current treatment of JIA with residual pain, and actual use of opioids to treat pain in children with JIA. RESULTS Of 99 rheumatologists who were contacted, 53 responses were received (53.5%). No significant demographic differences were found in attitudes about pain management and use of opioids. A total of 77.3% of respondents agreed that there are patients who continue to have significant pain despite adequate treatment. However, 59.6% disagreed with the use of opioid analgesics for treatment of those patients. Cross tabulations showed significant relationships between attitudes about opioid use and concerns for side effects, including drowsiness, fatigue, and constipation (chi(2) = 1.16, P > 0.05), as well as addiction (chi(2) = 5.51, P = 0.019). Thirty percent of those who strongly disagreed with opioid use and 52.4% of those who disagreed had in fact prescribed opioids in the past year. The most commonly prescribed opioids were codeine and oxycodone. Practitioners' perceived knowledge of the drugs significantly affected their likelihood to prescribe them. CONCLUSION Pediatric rheumatologists are divided in their attitudes regarding treatment of residual pain in children with JIA. Concern for side effects appears to be a major factor in the decision to prescribe these analgesics. More data are needed to facilitate clearer cost-benefit analyses in the decision to prescribe opioids to this clinical population.
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Affiliation(s)
- Yukiko Kimura
- Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, 30 Prospect Avenue, Hackensack, NJ 07601, USA.
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Pascual V, Allantaz F, Arce E, Punaro M, Banchereau J. Role of interleukin-1 (IL-1) in the pathogenesis of systemic onset juvenile idiopathic arthritis and clinical response to IL-1 blockade. ACTA ACUST UNITED AC 2005; 201:1479-86. [PMID: 15851489 PMCID: PMC2213182 DOI: 10.1084/jem.20050473] [Citation(s) in RCA: 653] [Impact Index Per Article: 34.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Systemic onset juvenile idiopathic arthritis (SoJIA) encompasses ∼10% of cases of arthritis that begin in childhood. The disease is unique in terms of clinical manifestations, severity of joint involvement, and lack of response to tumor necrosis factor blockade. Here, we show that serum from SoJIA patients induces the transcription of innate immunity genes, including interleukin (IL)-1 in healthy peripheral blood mononuclear cells (PBMCs). Upon activation, SoJIA PBMCs release large amounts of IL-1β. We administered recombinant IL-1 receptor antagonist to nine SoJIA patients who were refractory to other therapies. Complete remission was obtained in seven out of nine patients and a partial response was obtained in the other two patients. We conclude that IL-1 is a major mediator of the inflammatory cascade that underlies SoJIA and that this cytokine represents a target for therapy in this disease.
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Affiliation(s)
- Virginia Pascual
- Baylor Institute for Immunology Research, Dallas, TX 75204, USA.
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Abstract
Treatment of children with rheumatic diseases has advanced with novel therapeutics and the use of early aggressive treatment to achieve better long-term functional outcome. Many of the current treatments in pediatric rheumatology are based on studies in adults on medications without U.S. Food and Drug Administration labeling for pediatric use. This is not ideal because the pharmacokinetics (absorption, distribution, metabolism, and elimination) of many medications when used in children vary according to age, somatic growth, sexual maturity, and ontogeny of drug-metabolizing enzymes. Special dosing, administration considerations, and toxicity screening are reviewed for the more commonly used medications. Vaccinations for children on antirheumatic drugs are also discussed. Continued study of the long-term impact of medications and biologic treatments on children is necessary, but given the paucity of children with rheumatic diseases, this will require multicentered trials and collaborations. Lastly, this article reviews recent regulatory and legislative action on pediatric drug testing. Passage of the Pediatric Research Equity Act of 2003, which requires testing of pharmaceuticals in children, will facilitate more rational use of drugs in pediatric rheumatic diseases in the future.
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Affiliation(s)
- Esi M DeWitt
- Children's Hospital of Philadelphia, and the University of Pennsylvania School of Medicine, 3615 Civic Center Boulevard, Philadelphia, PA 19104-4318, USA
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Lehman TJA, Schechter SJ, Sundel RP, Oliveira SK, Huttenlocher A, Onel KB. Thalidomide for severe systemic onset juvenile rheumatoid arthritis: A multicenter study. J Pediatr 2004; 145:856-7. [PMID: 15580219 DOI: 10.1016/j.jpeds.2004.08.020] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Thirteen children with difficult systemic onset juvenile rheumatoid arthritis were treated with thalidomide. At 6 months, 11 of the 13 were able to reduce their use of prednisone ( P < .002), with a concurrent improvement in erythrocyte sedimentation rate ( P < .0001) and an increase in hemoglobin level ( P < 0.005). Juvenile rheumatoid arthritis improvement scores >/=50% were obtained by 10 of the 13 children.
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Affiliation(s)
- Thomas J A Lehman
- Division of Pediatric Rheumatology, Hospital for Special Surgery, and the Department of Pediatrics, Sanford Weill Medical College of Cornell University, New York, New York, USA
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Fleming FJ, Vytopil M, Chaitow J, Jones HR, Darras BT, Ryan MM. Thalidomide neuropathy in childhood. Neuromuscul Disord 2004; 15:172-6. [PMID: 15694139 DOI: 10.1016/j.nmd.2004.10.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2004] [Revised: 10/11/2004] [Accepted: 10/15/2004] [Indexed: 11/15/2022]
Abstract
Thalidomide was withdrawn from world markets in 1961 following recognition of its teratogenic effects. More recently, however, thalidomide treatment has been reintroduced to adult and paediatric practice for a variety of dermatologic, immunologic, rheumatologic and neoplastic disorders. Neuropathy is a significant side effect of thalidomide therapy, which may limit its clinical use. We report four cases of sensorimotor axonal neuropathy in children aged 10-15 years, treated with thalidomide for myxopapillary ependymoma, Crohn's disease and recurrent giant aphthous ulceration. Thalidomide neuropathy is often associated with proximal weakness and may progress even after discontinuation of treatment, in the phenomenon of 'coasting'. Children treated with thalidomide should undergo regular neurophysiologic studies in order to detect presymptomatic or progressive peripheral neuropathy.
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Affiliation(s)
- Fiona J Fleming
- Institute for Neuromuscular Research, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, Sydney 2145, NSW, Australia
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Abstract
PURPOSE OF REVIEW Children with rheumatic diseases frequently require therapy with disease-modifying antirheumatic drugs and/or biologic agents. Therapies that have been prospectively tested in adults are often used in children before full evaluation of their safety and efficacy. Published experience that may report "off-label" usage can be helpful in decision making, although such reports do not reduce the need for prospective clinical trials in children. The purpose of this review is to summarize the recent published evidence regarding efficacy (and safety, when available) of standard and novel agents used in pediatric rheumatic disease. RECENT FINDINGS Etanercept, one of three currently available tumor necrosis factor-alpha inhibitors has a juvenile idiopathic arthritis indication. Novel "off-label" uses in children for interleukin-1 receptor agonist (Anakinra), antiinterleukin-6 receptor antibody (MRA), and rituximab (anti-CD20 monoclonal antibody) are discussed. SUMMARY This review summarizes the published evidence that supports the use of selected disease-modifying antirheumatic drugs and novel biologic agents in children with rheumatic diseases.
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Affiliation(s)
- Nora G Singer
- Department of Pediatrics and Internal Medicine, CASE School of Medicine and Rainbow Babies and Children's Hospital/University Hospitals, Cleveland, Ohio 44106, USA.
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Abstract
PURPOSE OF REVIEW Better understanding of the etiology of autoimmune diseases and their progression has brought about numerous novel therapies used in the treatment of pediatric rheumatic diseases. The introduction of biologic agents such as tumor necrosis factor inhibitors has changed how we approach and manage autoimmune diseases. This has led to a proliferation of other therapies targeting specific inflammatory processes evident in many rheumatic illnesses, with hopes of improving efficacy and decreasing adverse effects from treatment. RECENT FINDINGS Clinical studies demonstrate safety and efficacy of these newer medications in both adults and children. Although most of the novel therapies have been studied primarily in the adult rheumatic population, many are being evaluated in children in randomized controlled and open label trials as well. Long-term results are being collected regarding these newer regimens in both adults and children. SUMMARY This review looks at the risks and benefits of the variety of novel therapies including the new biologics, immunosuppressives, and stem cell transplantation currently being used in rheumatic conditions. Using these new therapies along with traditional antirheumatic medications, pediatric rheumatologists intervene to control disease early and more effectively to prevent long-term damage and complications.
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Affiliation(s)
- Peter Chira
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California 94305-5208, USA
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Nasca MR, Micali G, Cheigh NH, West LE, West DP. Dermatologic and nondermatologic uses of thalidomide. Ann Pharmacother 2003; 37:1307-20. [PMID: 12921515 DOI: 10.1345/aph.19255] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To review published data on thalidomide, with emphasis on current knowledge about mechanism of action, new and/or potential dermatologic and nondermatologic therapeutic applications, well-known and emerging adverse effects, and current indications for its safe use. DATA SOURCES Review articles, in vitro research studies, references from retrieved articles, case reports, and clinical trials were identified from a computerized literature search using MEDLINE and OVID (1966-January 2003) and on the Cochrane Clinical Trials Register (January 2003). Information available from meetings' abstract books, Internet, or pharmaceutical companies was also considered. STUDY SELECTION AND DATA EXTRACTION All articles identified as relevant, including those from non-English literature, were considered in an attempt to provide to the reader both the theoretical basis and practical guidelines for thalidomide pharmacotherapy. DATA SYNTHESIS Thalidomide has hypnosedative, antiangiogenic, antiinflammatory, and immunomodulatory properties. Moreover, it has been shown to selectively inhibit the production of tumor necrosis factor-alpha and reduce the expression of various integrin receptors on the membrane of leukocytes and other cell types in a dose-dependent fashion. Controlled trials demonstrated the efficacy of thalidomide in a number of diseases, including erythema nodosum leprosum, lupus erythematosus, aphthosis, graft-versus-host disease, prurigo nodularis, and actinic prurigo. Single case reports or studies in small series have also suggested a possible role for thalidomide in numerous other dermatologic and nondermatologic disorders. Possibly severe and sometimes irreversible risks related to the clinical use of thalidomide include teratogenicity and neurotoxicity. CONCLUSIONS Although teratogenicity and neurotoxicity are significant adverse effects requiring cautious use, thalidomide is an effective therapeutic modality in a variety of difficult-to-treat disorders and, providing careful selection of patients, should offer an acceptable risk-to-benefit ratio.
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Affiliation(s)
- Maria R Nasca
- Department of Dermatology, University of Catania, Catania, Italy
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Davis JC, Huang F, Maksymowych W. New therapies for ankylosing spondylitis: etanercept, thalidomide, and pamidronate. Rheum Dis Clin North Am 2003; 29:481-94, viii. [PMID: 12951863 DOI: 10.1016/s0889-857x(03)00028-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Ankylosing spondylitis (AS) is the most common of a group of diseases called seronegative spondyloarthropathies. This group of diseases shares common demographic, clinical, and genetic features. This article reviews the rationale, clinical efficacy, and safety reports of etanercept, thalidomide, and pamidronate in the treatment of patients who have AS.
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Affiliation(s)
- John C Davis
- Division of Rheumatology, Department of Medicine, University of California-San Francisco, 533 Parnassus Avenue, Box 0633, San Francisco, CA 94143, USA.
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26
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Abstract
BACKGROUND Thalidomide is best known as a major teratogen that caused birth defects in up to 12,000 children in the 1960s. More recently, this agent has been approved by the US Food and Drug Administration for the treatment of erythema nodosum leprosum (ENL) through a restricted-use program. Its immunomodulatory, anti-inflammatory, and antiangiogenic properties are currently under study in a number of clinical conditions. OBJECTIVE This article reviews the pharmacology of thalidomide; its approved and off-label uses in dermatologic, oncologic, and gastrointestinal conditions; and adverse events associated with its use. METHODS Relevant articles were identified through searches of MEDLINE (1966-June 2002), International Pharmaceutical Abstracts (1970-June 2002), and EMBASE (1990-June 2002). Search terms included but were not limited to thalidomide, pharmacokinetics, pharmacology, therapeutic use, and teratogenicity, as well as terms for specific disease states and adverse events. Further publications were identified from the reference lists of the reviewed articles. Abstracts of recent symposia were obtained from the American Society of Clinical Oncology Web site. RESULTS Thalidomide is thought to exert its therapeutic effect through the modulation of cytokines, particularly tumor necrosis factor-alpha. In addition to its approved indication for ENL, thalidomide has been studied in various other conditions, including graft-versus-host disease, discoid lupus erythematosus, sarcoidosis, relapsed/refractory multiple myeloma, Waldenstrom's macroglobulinemia, myelodysplastic syndromes, acute myeloid leukemia, myelofibrosis with myeloid metaplasia, renal cell carcinoma, malignant gliomas, prostate cancer, Kaposi's sarcoma, colorectal carcinoma, oral aphthous ulcers, Behçet's disease, Crohn's disease, and HIV/AIDS-associated wasting. Adverse events most frequently associated with its use include somnolence, constipation, rash, peripheral neuropathy, and thromboembolism. CONCLUSIONS Use of thalidomide is limited by toxicity, limited efficacy data, and restricted access. Evidence of its efficacy in conditions other than ENL awaits the results of controlled clinical trials.
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Affiliation(s)
- S James Matthews
- Department of Pharmacy Practice, School of Pharmacy, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts 02115, USA.
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Agle LMA, Rosenkranz M, Lehman TJA. Novel therapies for the treatment of juvenile rheumatoid arthritis (juvenile idiopathic arthritis). Expert Opin Investig Drugs 2003; 12:19-28. [PMID: 12517251 DOI: 10.1517/13543784.12.1.19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The majority of children with juvenile idiopathic arthritis respond well to conventional treatment. However, some children will have a more aggressive disease course and will be resistant to standard management. Over the past 20 years, growth in our understanding of the immunopathogenesis of juvenile idiopathic arthritis and related diseases has facilitated significant therapeutic advances. In this report, recently released antirheumatic drugs, as well as some treatments currently in development, will be discussed. Biological agents, such as antiTNF and other cytokines inhibitors, and unique drugs, such as thalidomide, provide new opportunities to suppress the inflammation found in severe cases of systemic onset juvenile idiopathic arthritis and can obtain a satisfactory outcome.
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Affiliation(s)
- Lucila M A Agle
- Division of Pediatric Rheumatology, Hospital for Special Surgery, Sanford Weill Medical Center of Cornell University, 535 East 70th Street, New York, NY 10021, USA
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Abstract
Treatment of chronic arthritis in childhood is progressing quickly. Nonsteroidal antiinflammatory drugs still remain mainstays of treatment, but weekly methotrexate and intra-articular corticosteroid injections have made the biggest impact on disease control. Recently, tumor necrosis factor inhibitors have become available for the treatment of chronic childhood arthritis and have already had a substantial influence on disease activity. Very aggressive measures are still reserved for the sickest children who do not respond to conventional therapy, but the future for children with chronic arthritis looks bright with newer, highly targeted biologic therapies in the pipeline.
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Affiliation(s)
- Randy Q Cron
- The Children's Hospital of Philadelphia. University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104-4318, USA.
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