Risks associated with use of TNF inhibitors in children with rheumatic diseases

Biologics and JAK inhibitors for the treatment of monogenic systemic autoinflammatory diseases in children

Systemic autoinflammatory diseases (SAIDs) are caused by aberrant activation of 1 or more inflammatory pathways in an antigen-independent manner. Monogenic forms of SAIDs typically manifest during childhood, and early treatment is essential to minimize morbidity and mortality. On the basis of the mechanism of disease and the dominant cytokine(s) that propagates inflammation, monogenic SAIDs can be grouped into major categories including inflammasomopathies/disorders of IL-1, interferonopathies, and disorders of nuclear factor-κB and/or aberrant TNF activity. This classification scheme has direct therapeutic relevance given the availability of biologic agents and small-molecule inhibitors that specifically target these pathways. Here, we review the experience of using biologics that target IL-1 and TNF as well as using Janus kinase inhibitors for the treatment of monogenic SAIDs in pediatric patients. We provide an evidence-based guide for the use of these medications and discuss their mechanism of action, safety profile, and strategies for therapeutic monitoring.

Pharmacosurveillance in Juvenile Idiopathic Arthritis

The advent of biologic disease-modifying antirheumatic drugs targeting specific cytokines or cell-cell interactions has dramatically changed the outlook of patients with juvenile idiopathic arthritis. However, safety concerns remain around the use of therapeutic agents for children with juvenile idiopathic arthritis. Foremost among these are the risks of serious infections and malignancy. This article provides an overview of methodologies for pharmacosurveillance in juvenile idiopathic arthritis, including spontaneous reporting systems and the use of diverse data sources, such as electronic health records, administrative claims, and clinical registries. The risks of infections and malignancies are then briefly reviewed.

Pharmacotherapy for juvenile spondyloarthritis: an overview of the available therapies

INTRODUCTION

Spondyloarthropathies (SpA) represent a heterogeneous group of inflammatory arthritides with autoimmune pathogenesis that can affect both adults and children with peculiar features such as enthesitis, sacroiliac joint, and axial involvement. Since juvenile onset of SpA (JSpA) is not well codified by the current juvenile idiopathic arthritis classification, studies in this field are restricted to single categories and therefore cannot be exhaustive. This review aims to report recent advances in the treatment of JSpA.

AREAS COVERED

In order to assess the available therapies for JSpA, the authors have analyzed data obtained from retrospective and prospective studies, case reports, and case series, as well as from controlled trials.

EXPERT OPINION

Given the challenging classification of JSpA, research in this field has been restricted to single subcategories. Little is known of which patients are more likely to develop axial involvement leading to severe spinal damage. Whether TNF inhibitors are capable to prevent or stop disease progression, once started, is yet to be ascertained with structural damage still a matter for research. Therefore, trials on the efficacy of TNF inhibitors in JSpA are strongly advocated since they may help to elucidate their place as a treatment option.

COVID-19 and what pediatric rheumatologists should know: a review from a highly affected country

On March 11th, 2020 the World Health Organization declared COVID-19 a global pandemic. The infection, transmitted by 2019 novel coronavirus (2019-nCov), was first discovered in December 2019, in Wuhan, Hubei Province, and then rapidly spread worldwide. Italy was early and severely involved, with a critical spread of the infection and a very high number of victims. Person-to-person spread mainly occurs via respiratory droplets and contact. The median incubation period is 5 days. The spectrum of respiratory symptoms may range from mild to severe, strictly depending on the age of the patient and the underlying comorbidities.In children COVID-19 related disease is less frequent and less aggressive. In Italy 1% of positive cases are under 18 years of age, and no deaths have been recorded before 29 years of age. For patients affected by rheumatic disease, despite the concerns related to the imbalance of their immune response and the effect of immunosuppressive treatments, there are still few data to understand the real consequences of this infection. Major scientific societies have issued recommendations to help rheumatologists in caring their patients. Interestingly, some of the drugs mostly used by rheumatologists appear to be promising in critical COVID-19 infected patients, where the hyperinflammation and cytokine storm seem to drive to the multiorgan failure.Pediatric rheumatologists are expected to play a supporting role in this new front of COVID-19 pandemic, both as general pediatricians treating infected children, and as rheumatologists taking care of their rheumatic patients, as well as offering their experience in the possible alternative use of immunomodulatory drugs.

Current and emerging biologics for the treatment of juvenile idiopathic arthritis

INTRODUCTION

The management of a child with juvenile idiopathic arthritis (JIA) requires a combination of pharmacological, physical, and psychosocial therapies in order to induce disease remission, by controlling articular and systemic inflammation. This review aims to provide a comprehensive discussion on the biological therapies currently in use in the treatment of JIA referring to existing recommendations and clinical evidence. We also discuss on the emerging biological drugs actually under consideration.

AREAS COVERED

Recent findings on immunological mechanisms involved in the pathogenesis of the disease allowed us to identify several specific targets for biologic therapies. A systematic literature review was conducted between January 1997 and January 2020 on PubMed including national and international guidelines and recommendations, trials and case-control studies.

EXPERT OPINION

There is now a plethora of therapies that are directed against variable targets, and the physician has to choose the most appropriate available medication in order to achieve early and sustained remission with as few side effects as possible. Research is advancing very fast in order to be more and more specific in suppressing inflammatory pathways without harming natural defenses. Finally, pharmacoeconomic considerations will also be very important to deal with, considering the high cost of most of these molecules.