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Guo Y, Fang Y, Zhang T, Pan Y, Wang P, Fan Z, Yu H. Axial involvement in enthesitis-related arthritis: results from a single-center cohort. Pediatr Rheumatol Online J 2023; 21:13. [PMID: 36747282 PMCID: PMC9903626 DOI: 10.1186/s12969-023-00792-0] [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: 09/19/2022] [Accepted: 01/15/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Axial involvement in children with enthesitis-related arthritis (ERA) has characteristics that differ from those of peripheral involvement. This study characterized their clinical characteristics and treatment. METHODS Patients with ERA at the Children's Hospital of Nanjing Medical University between January 2018 and December 2020 were included. The ERA cohort was divided into two based on the presence or absence of axial joint involvement. Demographic characteristics, clinical features, and treatments were described and compared. RESULTS In total, 105 children with ERA were enrolled (axial ERA, n = 57; peripheral ERA, n = 48). The age at disease onset of the axial group tended to be higher (11.93 ± 1.72 vs. 11.09 ± 1.91 years) and the diagnosis delay was bigger in patients with axial ERA (10.26 ± 11.66 months vs. 5.13 ± 7.92 months). The inflammatory marker levels were significantly higher in patients with axial. There were no differences in HLA-B27 positivity between the groups (34 [59.65%] vs. 28 [58.33%], P > 0.05). Hip involvement was more frequent in the axial group (52.63% vs 27.08%; X2 = 7.033). A total of 38 (66.67%) and 10 (20.83%) patients with axial and peripheral ERA, respectively, were treated with biological disease-modifying anti-rheumatic drugs (DMARDs) at diagnosis. The administration of biologics increased gradually in the axial ERA group, peaking at 18 months and decreasing thereafter, whereas that in the peripheral ERA group peaked at 6 months and began to decline thereafter. CONCLUSIONS Axial ERA is a persistent active disease and requires a more aggressive treatment. Classification and early recognition of axial involvement may help with timely diagnosis and appropriate management.
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Affiliation(s)
- Yanli Guo
- grid.452511.6Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Yuying Fang
- grid.452511.6Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Tonghao Zhang
- grid.452511.6Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Yuting Pan
- grid.452511.6Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Panpan Wang
- grid.452511.6Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Zhidan Fan
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China.
| | - Haiguo Yu
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China.
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2
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Vilaiyuk S, Lerkvaleekul B, Jino J, Charuvanij S, Book YX, Arkachaisri T. Comparison of the outcomes between early and late anti-tumor necrosis factor therapy in patients with enthesitis-related subcategory of juvenile idiopathic arthritis: a multi-center study in Southeast Asia. Expert Opin Biol Ther 2022; 22:1323-1332. [PMID: 35876095 DOI: 10.1080/14712598.2022.2105140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Little is known about the impact of delayed initiation of anti-tumor necrosis factor (TNF) therapy in patients with enthesitis-related arthritis (ERA). Here, we compared the impact of delayed treatment on disease outcomes of ERA patients in Southeast Asia. RESEARCH DESIGN AND METHODS This retrospective study enrolled 149 ERA patients from Thailand and Singapore. Early (e-aTNF) and late (l-aTNF) treatment groups received anti-TNF therapy starting at ≤6 months and >6 months, respectively, after diagnosis. Outcomes included mean differences in disease activity parameters, Juvenile Spondyloarthritis Disease Activity (JSpADA) score, Juvenile Arthritis Diseases Activity (JADAS)-10 score, and American College of Rheumatology Pediatric (ACR Pedi) criteria, and the frequency of clinically inactive disease and first flare event. RESULTS The mean changes in JSpADA (p = 0.002) and JADAS-10 (p < 0.001) scores over time were significantly higher in the e-aTNF group than in the l-aTNF group. A significantly higher proportion of patients in the e-aTNF group than l-aTNF group satisfied ACR Pedi 100 criteria at 2 years (p = 0.042). All other long-term outcomes were not significantly different between the groups. CONCLUSIONS Although early anti-TNF treatment improved disease activity parameters somewhat better than delayed anti-TNF therapy, there was no significant difference in long-term outcomes.
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Affiliation(s)
- Soamarat Vilaiyuk
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Butsabong Lerkvaleekul
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Janejira Jino
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sirirat Charuvanij
- Division of Rheumatology, Department of Paediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yun Xin Book
- Rheumatology and Immunology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, SingHealth, Duke-NUS medical school, Singapore, Singapore Singapore
| | - Thaschawee Arkachaisri
- Rheumatology and Immunology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, SingHealth, Duke-NUS medical school, Singapore, Singapore Singapore
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3
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Smith JA, Burgos-Vargas R. Outcomes in Juvenile-Onset Spondyloarthritis. Front Med (Lausanne) 2021; 8:680916. [PMID: 34124112 PMCID: PMC8192716 DOI: 10.3389/fmed.2021.680916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/30/2021] [Indexed: 01/31/2023] Open
Abstract
Some studies have suggested children with juvenile onset spondyloarthritis (JoSpA) have a relatively poor outcome compared to other juvenile idiopathic arthritis (JIA) categories, in regards to functional status and failure to attain remission. Thus, in the interest of earlier recognition and risk stratification, awareness of the unique characteristics of this group is critical. Herein, we review the clinical burden of disease, prognostic indicators and outcomes in JoSpA. Of note, although children exhibit less axial disease at onset compared to adults with spondyloarthritis (SpA), 34–62% have magnetic resonance imaging (MRI) evidence for active inflammation in the absence of reported back pain. Furthermore, some studies have reported that more than half of children with “enthesitis related arthritis” (ERA) develop axial disease within 5 years of diagnosis. Axial disease, and more specifically sacroiliitis, portends continued active disease. The advent of TNF inhibitors has promised to be a “game changer,” given their relatively high efficacy for enthesitis and axial disease. However, the real world experience in various cohorts since the introduction of more widespread TNF inhibitor usage, in which greater than a third still have persistently active disease, suggests there is still work to be done in developing new therapies and improving the outlook for JoSpA.
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Affiliation(s)
- Judith A Smith
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Ruben Burgos-Vargas
- Departamento de Reumatologia, Hospital General de Mexico, Mexico City, Mexico
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4
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Tay SH, Yeo JG, Leong JY, Albani S, Arkachaisri T. Juvenile Spondyloarthritis: What More Do We Know About HLA-B27, Enthesitis, and New Bone Formation? Front Med (Lausanne) 2021; 8:666772. [PMID: 34095174 PMCID: PMC8174582 DOI: 10.3389/fmed.2021.666772] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 04/20/2021] [Indexed: 12/13/2022] Open
Abstract
Juvenile spondyloarthritis (JSpA) refers to a diverse spectrum of immune-mediated inflammatory arthritides whose onset occurs in late childhood and adolescence. Like its adult counterpart, JSpA is typified by a strong association with human leukocyte antigen-B27 (HLA-B27) and potential axial involvement, while lacking rheumatoid factor (RF) and distinguishing autoantibodies. A characteristic manifestation of JSpA is enthesitis (inflammation of insertion sites of tendons, ligaments, joint capsules or fascia to bone), which is commonly accompanied by bone resorption and new bone formation at affected sites. In this Review, advances in the role of HLA-B27, enthesitis and its associated osteoproliferation in JSpA pathophysiology and treatment options will be discussed. A deeper appreciation of how these elements contribute to the JSpA disease mechanism will better inform diagnosis, prognosis and therapy, which in turn translates to an improved quality of life for patients.
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Affiliation(s)
- Shi Huan Tay
- SingHealth Duke-National University of Singapore Academic Medical Centre, Translational Immunology Institute, Singapore, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Joo Guan Yeo
- SingHealth Duke-National University of Singapore Academic Medical Centre, Translational Immunology Institute, Singapore, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore.,Rheumatology and Immunology Service, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jing Yao Leong
- SingHealth Duke-National University of Singapore Academic Medical Centre, Translational Immunology Institute, Singapore, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Salvatore Albani
- SingHealth Duke-National University of Singapore Academic Medical Centre, Translational Immunology Institute, Singapore, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore.,Rheumatology and Immunology Service, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Thaschawee Arkachaisri
- Duke-National University of Singapore Medical School, Singapore, Singapore.,Rheumatology and Immunology Service, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
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5
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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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6
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Kearsley-Fleet L, Beresford MW, Davies R, De Cock D, Baildam E, Foster HE, Southwood TR, Thomson W, Hyrich KL. Short-term outcomes in patients with systemic juvenile idiopathic arthritis treated with either tocilizumab or anakinra. Rheumatology (Oxford) 2019; 58:94-102. [PMID: 30137641 PMCID: PMC6293481 DOI: 10.1093/rheumatology/key262] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Indexed: 12/22/2022] Open
Abstract
Objectives To investigate real-world short-term outcomes among patients with systemic JIA starting tocilizumab or anakinra. Methods This analysis included all systemic JIA patients within the UK Biologics for Children with Rheumatic Diseases study starting tocilizumab or anakinra between 2010 and 2016. Disease activity was assessed at baseline and one year. At one year the following outcomes were assessed: minimal disease activity, clinically inactive disease, 90% ACR Paediatric response (ACRPedi90). Univariable logistic regression was used to identify baseline characteristics associated with these outcomes. Multiple imputation was used to account for missing data. Results Seventy-six systemic JIA patients were included (54 tocilizumab; 22 anakinra). More patients starting anakinra as their first biologic compared with tocilizumab (86% vs 63%; P = 0.04), with shorter disease duration (1 vs 2 years; P = 0.003) and higher frequency of prior macrophage activation syndrome (37% vs 8%; P = 0.004). Overall, at one year, 42% achieved ACRPedi90, 51% minimal disease activity, and 39% clinically inactive disease, with similar responses seen between the two drugs. Response was not associated with baseline disease characteristics. Fifteen (20%) patients stopped biologic treatment by one year. Treatment survival was better with tocilizumab (89% at one year vs 59% anakinra; P = 0.002), with three stopping for anakinra injection-related problems. Conclusion In this real-world cohort of patients with systemic JIA receiving tocilizumab or anakinra, approximately half achieved a minimal disease state by one year. Treatment responses appeared similar between the two therapies albeit with better persistence observed with tocilizumab.
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Affiliation(s)
- Lianne Kearsley-Fleet
- Arthritis Research UK Centre for Epidemiology, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Michael W Beresford
- Institute of Translational Medicine (Child Health), University of Liverpool, UK.,Clinical Academic Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Rebecca Davies
- Arthritis Research UK Centre for Epidemiology, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Diederik De Cock
- 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
| | - Helen E Foster
- 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, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.,National Institute of Health Research Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Kimme L Hyrich
- Arthritis Research UK Centre for Epidemiology, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.,National Institute of Health Research Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK
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7
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Nørgaard M, Herlin T. Specific Sports Habits, Leisure-Time Physical Activity, and School-Educational Physical Activity in Children With Juvenile Idiopathic Arthritis: Patterns and Barriers. Arthritis Care Res (Hoboken) 2019; 71:271-280. [PMID: 30354015 DOI: 10.1002/acr.23795] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 10/16/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Juvenile idiopathic arthritis (JIA) may cause functional impairment and reduced time engaged in physical activity. The aim of this study was to investigate the habits of patients with JIA regarding participation in club sports, leisure-time physical activity, and school-educational physical activity and relate this to objectively measured physical activity using accelerometry and to compare the findings with those in healthy controls. METHODS Consecutive patients from the Aarhus University Hospital outpatient clinic were included. Clinical characteristics, functional ability, and exploration of specific habits in club sports, leisure-time physical activity, and school-educational physical activity (based on a standardized questionnaire) in patients were recorded and compared with those in healthy controls. The intensity and frequency of physical activity were measured by accelerometer monitoring, using ActiGraph GT1M. RESULTS Sixty-eight patients with JIA and 118 healthy control subjects were included. Despite having low disease activity, children with JIA had significantly lower accelerometry-monitored physical activity levels compared with healthy controls. The distribution of specific club sport activities was the same among patients and controls. However, the proportion of patients spending >3 hours/week participating in club sports was significantly lower than the proportion of controls, whereas no difference in time spent engaging in physical activity during leisure-time was observed. Participation in compulsory school-educational physical activity was equally high in patients and controls, although participation by patients was significantly less consistent than that by controls. Patient reports of time spent with club sport and leisure-time physical activity was significantly related to accelerometry measures, whereas this was not observed for school-educational physical activity. CONCLUSION The results of this study indicate the need for structured guidance for all patients with JIA (including those with minimal disease activity) in both understanding and coping with the consequences of a low level of physical activity.
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8
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Ringold S, Angeles-Han ST, Beukelman T, Lovell D, Cuello CA, Becker ML, Colbert RA, Feldman BM, Ferguson PJ, Gewanter H, Guzman J, Horonjeff J, Nigrovic PA, Ombrello MJ, Passo MH, Stoll ML, Rabinovich CE, Schneider R, Halyabar O, Hays K, Shah AA, Sullivan N, Szymanski AM, Turgunbaev M, Turner A, Reston J. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Non-Systemic Polyarthritis, Sacroiliitis, and Enthesitis. Arthritis Rheumatol 2019; 71:846-863. [PMID: 31021537 DOI: 10.1002/art.40884] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 02/27/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To develop treatment recommendations for children with juvenile idiopathic arthritis manifesting as non-systemic polyarthritis, sacroiliitis, or enthesitis. METHODS The Patient/Population, Intervention, Comparison, and Outcomes (PICO) questions were developed and refined by members of the guideline development teams. A systematic review was conducted to compile evidence for the benefits and harms associated with treatments for these conditions. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of evidence. A group consensus process was conducted among the Voting Panel to generate the final recommendations and grade their strength. A Parent and Patient Panel used a similar consensus approach to provide patient/caregiver preferences for key questions. RESULTS Thirty-nine recommendations were developed (8 strong and 31 conditional). The quality of supporting evidence was very low or low for 90% of the recommendations. Recommendations are provided for the use of nonsteroidal antiinflammatory drugs, disease-modifying antirheumatic drugs, biologics, and intraarticular and oral glucocorticoids. Recommendations for the use of physical and occupational therapy are also provided. Specific recommendations for polyarthritis address general medication use, initial and subsequent treatment, and adjunctive therapies. Good disease control, with therapeutic escalation to achieve low disease activity, was recommended. The sacroiliitis and enthesitis recommendations primarily address initial therapy and adjunctive therapies. CONCLUSION This guideline provides direction for clinicians, caregivers, and patients making treatment decisions. Clinicians, caregivers, and patients should use a shared decision-making process that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.
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Affiliation(s)
| | - Sheila T Angeles-Han
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Daniel Lovell
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | | | | | - Brian M Feldman
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | | | - Harry Gewanter
- Children's Hospital of Richmond, Virginia Commonwealth University, Richmond
| | - Jaime Guzman
- BC Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Peter A Nigrovic
- Brigham & Women's Hospital and Boston Children's Hospital, Boston, Massachusetts
| | | | | | | | | | - Rayfel Schneider
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
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9
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Ringold S, Angeles-Han ST, Beukelman T, Lovell D, Cuello CA, Becker ML, Colbert RA, Feldman BM, Ferguson PJ, Gewanter H, Guzman J, Horonjeff J, Nigrovic PA, Ombrello MJ, Passo MH, Stoll ML, Rabinovich CE, Schneider R, Halyabar O, Hays K, Shah AA, Sullivan N, Szymanski AM, Turgunbaev M, Turner A, Reston J. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Non-Systemic Polyarthritis, Sacroiliitis, and Enthesitis. Arthritis Care Res (Hoboken) 2019; 71:717-734. [PMID: 31021516 DOI: 10.1002/acr.23870] [Citation(s) in RCA: 162] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 02/27/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To develop treatment recommendations for children with juvenile idiopathic arthritis manifesting as non-systemic polyarthritis, sacroiliitis, or enthesitis. METHODS The Patient/Population, Intervention, Comparison, and Outcomes (PICO) questions were developed and refined by members of the guideline development teams. A systematic review was conducted to compile evidence for the benefits and harms associated with treatments for these conditions. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of evidence. A group consensus process was conducted among the Voting Panel to generate the final recommendations and grade their strength. A Parent and Patient Panel used a similar consensus approach to provide patient/caregiver preferences for key questions. RESULTS Thirty-nine recommendations were developed (8 strong and 31 conditional). The quality of supporting evidence was very low or low for 90% of the recommendations. Recommendations are provided for the use of nonsteroidal antiinflammatory drugs, disease-modifying antirheumatic drugs, biologics, and intraarticular and oral glucocorticoids. Recommendations for the use of physical and occupational therapy are also provided. Specific recommendations for polyarthritis address general medication use, initial and subsequent treatment, and adjunctive therapies. Good disease control, with therapeutic escalation to achieve low disease activity, was recommended. The sacroiliitis and enthesitis recommendations primarily address initial therapy and adjunctive therapies. CONCLUSION This guideline provides direction for clinicians, caregivers, and patients making treatment decisions. Clinicians, caregivers, and patients should use a shared decision-making process that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.
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Affiliation(s)
| | - Sheila T Angeles-Han
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Daniel Lovell
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | | | | | - Brian M Feldman
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | | | - Harry Gewanter
- Children's Hospital of Richmond, Virginia Commonwealth University, Richmond
| | - Jaime Guzman
- BC Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Peter A Nigrovic
- Brigham & Women's Hospital and Boston Children's Hospital, Boston, Massachusetts
| | | | | | | | | | - Rayfel Schneider
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
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10
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Bethencourt Baute JJ, Sanchez-Piedra C, Ruiz-Montesinos D, Medrano San Ildefonso M, Rodriguez-Lozano C, Perez-Pampin E, Ortiz A, Manrique S, Roselló R, Hernandez V, Campos C, Sellas A, Sifuentes-Giraldo WA, García-González J, Sanchez-Alonso F, Díaz-González F, Gómez-Reino JJ, Bustabad Reyes S. Persistence and adverse events of biological treatment in adult patients with juvenile idiopathic arthritis: results from BIOBADASER. Arthritis Res Ther 2018; 20:227. [PMID: 30305158 PMCID: PMC6235210 DOI: 10.1186/s13075-018-1728-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 09/19/2018] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Biologic therapy has changed the prognosis of patients with juvenile idiopathic arthritis (JIA). The aim of this study was to examine the pattern of use, drug survival, and adverse events of biologics in patients with JIA during the period from diagnosis to adulthood. METHODS All patients included in BIOBADASER (Spanish Registry for Adverse Events of Biological Therapy in Rheumatic Diseases), a multicenter prospective registry, diagnosed with JIA between 2000 and 2015 were analyzed. Proportions, means, and SDs were used to describe the population. Incidence rates and 95% CIs were calculated to assess adverse events. Kaplan-Meier analysis was used to compare the drug survival rates. RESULTS A total of 469 patients (46.1% women) were included. Their mean age at diagnosis was 9.4 ± 5.3 years. Their mean age at biologic treatment initiation was 23.9 ± 13.9 years. The pattern of use of biologics during their pediatric years showed a linear increase from 24% in 2000 to 65% in 2014. Biologic withdrawal for disease remission was higher in patients who initiated use biologics prior to 16 years of age than in those who were older (25.7% vs 7.9%, p < 0.0001). Serious adverse events had a total incidence rate of 41.4 (35.2-48.7) of 1000 patient-years. Patients younger than 16 years old showed significantly increased infections (p < 0.001). CONCLUSIONS Survival and suspension by remission of biologics were higher when these compounds were initiated in patients with JIA who had not yet reached 16 years of age. The incidence rate of serious adverse events in pediatric vs adult patients with JIA treated with biologics was similar; however, a significant increase of infection was observed in patients under 16 years old.
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Affiliation(s)
| | | | | | | | - Carlos Rodriguez-Lozano
- Servicio de Reumatología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain
| | - Eva Perez-Pampin
- Servicio de Reumatología, Hospital Clínico Universitario de Santiago, A Coruña, Spain
| | - Ana Ortiz
- Servicio de Reumatología, Hospital de La Princesa, Madrid, Spain
| | - Sara Manrique
- UGC de Reumatología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga, Universidad de Málaga, Málaga, Spain
| | - Rosa Roselló
- Servicio de Reumatología, Hospital San Jorge, Huesca, Spain
| | - Victoria Hernandez
- Servicio de Reumatología, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Cristina Campos
- Servicio de Reumatología, Hospital General Universitario Valencia, Valencia, Spain
| | - Agustí Sellas
- Servicio de Reumatología, Hospital Vall d’Hebron, Barcelona, Spain
| | | | | | | | - Federico Díaz-González
- Servicio de Reumatología, Hospital Universitario de Canarias, c/Ofra s/n 38320, La Laguna, Santa Cruz de Tenerife, Spain
| | | | - Sagrario Bustabad Reyes
- Servicio de Reumatología, Hospital Universitario de Canarias, c/Ofra s/n 38320, La Laguna, Santa Cruz de Tenerife, Spain
| | - on behalf of the BIOBADASER study group
- Servicio de Reumatología, Hospital Universitario de Canarias, Tenerife, Spain
- Research Unit, Sociedad Española de Reumatología, Madrid, Spain
- Servicio de Reumatología, Hospital Universitario del Virgen Macarena, Sevilla, Spain
- Servicio de Reumatología Hospital Universitario Miguel Servet, Zaragoza, Spain
- Servicio de Reumatología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain
- Servicio de Reumatología, Hospital Clínico Universitario de Santiago, A Coruña, Spain
- Servicio de Reumatología, Hospital de La Princesa, Madrid, Spain
- UGC de Reumatología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga, Universidad de Málaga, Málaga, Spain
- Servicio de Reumatología, Hospital San Jorge, Huesca, Spain
- Servicio de Reumatología, Hospital Clinic de Barcelona, Barcelona, Spain
- Servicio de Reumatología, Hospital General Universitario Valencia, Valencia, Spain
- Servicio de Reumatología, Hospital Vall d’Hebron, Barcelona, Spain
- Servicio Reumatología, Hospital Ramón y Cajal, Madrid, Spain
- Servicio de Reumatología, Hospital 12 de Octubre, Madrid, Spain
- Servicio de Reumatología, Hospital Universitario de Canarias, c/Ofra s/n 38320, La Laguna, Santa Cruz de Tenerife, Spain
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Mehta J, Beukelman T. Biologic Agents in the Treatment of Childhood-Onset Rheumatic Disease. J Pediatr 2017; 189:31-39. [PMID: 28711176 DOI: 10.1016/j.jpeds.2017.06.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 06/05/2017] [Accepted: 06/15/2017] [Indexed: 12/22/2022]
Affiliation(s)
- Jay Mehta
- Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Timothy Beukelman
- Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, Birmingham, AL.
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Cimaz R, Marino A, Martini A. How I treat juvenile idiopathic arthritis: A state of the art review. Autoimmun Rev 2017; 16:1008-1015. [DOI: 10.1016/j.autrev.2017.07.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 06/19/2017] [Indexed: 12/22/2022]
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Alexeeva EI, Namazova-Baranova LS, Bzarova TM, Valieva SI, Denisova RV, Sleptsova TV, Isaeva KB, Chomahidze AM, Taibulatov NI, Fetisova AN, Karaseva AV, Baranov AA. Predictors of the response to etanercept in patients with juvenile idiopathic arthritis without systemic manifestations within 12 months: results of an open-label, prospective study conducted at the National Scientific and Practical Center of Children's Health, Russia. Pediatr Rheumatol Online J 2017; 15:51. [PMID: 28615036 PMCID: PMC5471744 DOI: 10.1186/s12969-017-0178-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 06/02/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the efficacy of etanercept treatment and to identify predictors of response to therapy within 12 months in patients with juvenile idiopathic arthritis (JIA) without systemic manifestations. METHODS A total of 197 juvenile patients were enrolled in this study. Response to therapy was assessed using the ACRPedi 30/50/70/90 criteria, the Wallace criteria, and the Juvenile Arthritis Disease Activity Score 71 (JADAS-71). Univariate and multivariate logistic regression analyses were performed to identify potential baseline factors associated with treatment response in different JIA categories. RESULTS One year after treatment initiation, 179 (90.9%) patients achieved ACRPedi30; 177 (89.8%) patients achieved ACRPedi50; 168 (85.3%) patients achieved ACRPedi70; and 135 (68.5%) patients achieved ACRPedi90 response. A total of 132 (67.0%) and 92 (46.7%) patients achieved inactive disease according to the Wallace criteria and the JADAS-71 cut-off point, respectively. Excellent response (achieving ACRPedi90 and clinically inactive disease according both to the Wallace criteria and the JADAS71 cut-off point) was associated with persistent oligoarticular JIA category, shorter disease duration before the start of etanercept, a lower number of DMARDs used before the introduction of etanercept, a lower number of joints with limited motion, and lower C-reactive protein at baseline. Poor response (failure to achieve ACR 70 or active disease according to both the Wallace criteria and JADAS71 even when ACR 70 was achieved) was associated with the polyarticular or enthesitis-related JIA categories, higher disease duration before the start of etanercept, and older age at disease onset. CONCLUSION Almost half (45.7%) of the patients who initiated etanercept treatment achieved an excellent response (inactive disease and ACRPedi90) after 1 year. What may be novel is our finding that the response to etanercept therapy was strongly associated with the JIA category. The response to etanercept therapy was also associated with the disease duration before the start of etanercept treatment.
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Affiliation(s)
- Ekaterina I. Alexeeva
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia ,0000 0000 9216 2496grid.415738.cFederal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia ,0000 0000 9216 2496grid.415738.cRheumatology Department, Federal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Leyla S. Namazova-Baranova
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Tatyana M. Bzarova
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia ,0000 0000 9216 2496grid.415738.cFederal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Saniya I. Valieva
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Rina V. Denisova
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Tatyana V. Sleptsova
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Kseniya B. Isaeva
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Alexandra M. Chomahidze
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Nikolay I. Taibulatov
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Anna N. Fetisova
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Anna V. Karaseva
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Alexandr A. Baranov
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
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Davies R, Gaynor D, Hyrich KL, Pain CE. Efficacy of biologic therapy across individual juvenile idiopathic arthritis subtypes: A systematic review. Semin Arthritis Rheum 2017; 46:584-593. [DOI: 10.1016/j.semarthrit.2016.10.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 10/21/2016] [Accepted: 10/28/2016] [Indexed: 01/26/2023]
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Verazza S, Davì S, Consolaro A, Bovis F, Insalaco A, Magni-Manzoni S, Nicolai R, Marafon DP, De Benedetti F, Gerloni V, Pontikaki I, Rovelli F, Cimaz R, Marino A, Zulian F, Martini G, Pastore S, Sandrin C, Corona F, Torcoletti M, Conti G, Fede C, Barone P, Cattalini M, Cortis E, Breda L, Olivieri AN, Civino A, Podda R, Rigante D, La Torre F, D’Angelo G, Jorini M, Gallizzi R, Maggio MC, Consolini R, De Fanti A, Muratore V, Alpigiani MG, Ruperto N, Martini A, Ravelli A. Disease status, reasons for discontinuation and adverse events in 1038 Italian children with juvenile idiopathic arthritis treated with etanercept. Pediatr Rheumatol Online J 2016; 14:68. [PMID: 27993144 PMCID: PMC5170898 DOI: 10.1186/s12969-016-0126-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 11/24/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Data from routine clinical practice are needed to further define the efficacy and safety of biologic medications in children with juvenile idiopathic arthritis (JIA). The aim of this analysis was to investigate the disease status, reasons for discontinuation and adverse events in Italian JIA patients treated with etanercept (ETN). METHODS In 2013, all centers of the Italian Pediatric Rheumatology Study Group were asked to make a census of patients given ETN after January 2000. Patients were classified in three groups: group 1 = patients still taking ETN; group 2 = patients discontinued from ETN for any reasons; group 3 = patients lost to follow-up while receiving ETN. All three groups received a retrospective assessment; patients in group 1 also underwent a cross-sectional assessment. RESULTS 1038 patients were enrolled by 23 centers: 422 (40.7%) were in group 1, 462 (44.5%) in group 2, and 154 (14.8%) in group 3. Median duration of ETN therapy was 2.5 years. At cross-sectional assessment, 41.8% to 48.6% of patients in group 1 met formal criteria for inactive disease, whereas 52.4% of patients in group 2 and 55.8% of patients in group 3 were judged in clinical remission by their caring physician at last visit. A relatively greater proportion of patients with systemic arthritis were discontinued or lost to follow-up. Parent evaluations at cross-sectional visit in group 1 showed that 52.4% of patients had normal physical function, very few had impairment in quality of life, 51.2% had no pain, 76% had no morning stiffness, and 82.7% of parents were satisfied with their child's illness outcome. Clinically significant adverse events were reported for 27.8% of patients and ETN was discontinued for side effects in 9.5%. The most common adverse events were new onset or recurrent uveitis (10.2%), infections (6.6%), injection site reactions (4.4%), and neuropsychiatric (3.1%), gastrointestinal (2.4%), and hematological disorders (2.1%). Ten patients developed an inflammatory bowel disease and 2 had a malignancy. One patient died of a fulminant streptococcal sepsis. CONCLUSIONS Around half of the patients achieved complete disease quiescence under treatment with ETN. The medication was overall well tolerated, as only one quarter of patients experienced clinically significant adverse events and less than 10% had treatment discontinued for toxicity.
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Affiliation(s)
| | | | - Alessandro Consolaro
- Università degli Studi di Genova, Genova, Italy ,Istituto Giannina Gaslini, Genova, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Fabrizia Corona
- Fondazione IRCCS Cà Granda – Ospedale Maggiore Policlinico, Milano, Italy
| | - Marta Torcoletti
- Fondazione IRCCS Cà Granda – Ospedale Maggiore Policlinico, Milano, Italy
| | - Giovanni Conti
- Azienda Ospedaliera Universitaria Policlinico G. Martino, Messina, Italy
| | - Claudia Fede
- Azienda Ospedaliera Universitaria Policlinico G. Martino, Messina, Italy
| | - Patrizia Barone
- Azienda Ospedaliero-Universitaria Policlinico Vittorio Emanuele, Catania, Italy
| | | | | | | | | | - Adele Civino
- Azienda Ospedaliera Card. G. Panico, Tricase, Italy
| | - Rosanna Podda
- Ospedale Regionale per le Microcitemie, Cagliari, Italy
| | | | | | | | | | | | | | | | | | | | | | | | - Alberto Martini
- Università degli Studi di Genova, Genova, Italy ,Istituto Giannina Gaslini, Genova, Italy
| | - Angelo Ravelli
- Università degli Studi di Genova, Genova, Italy. .,Istituto Giannina Gaslini, Genova, Italy. .,Pediatria II-Reumatologia, Istituto G. Gaslini, Largo G. Gaslini 5, 16147, Genova, Italy.
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16
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Blazina Š, Markelj G, Avramovič MZ, Toplak N, Avčin T. Management of Juvenile Idiopathic Arthritis: A Clinical Guide. Paediatr Drugs 2016; 18:397-412. [PMID: 27484749 DOI: 10.1007/s40272-016-0186-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease of childhood. The outcome in patients with JIA has markedly improved with the advent of biologic drugs. Although early aggressive therapy with biologics seems to be very effective, this approach leads to overtreatment in patients who would respond to classic disease-modifying anti-rheumatic drugs. Therefore, methotrexate remains first-line long-term therapy for most children with polyarticular JIA. Tumor necrosis factor-α inhibitors have shown tremendous benefit in children with refractory non-systemic JIA. Similar effects have been observed with interleukin-1 and interleukin-6 blockade in patients with systemic JIA. Correct choice and timely use of available medications to achieve early and sustained remission with as few side effects as possible remain challenges for the treating physician. In this review, a practical, clinically oriented guide to the management of JIA is provided, focusing on pharmacological treatment with non-steroidal anti-inflammatory drugs, intra-articular and systemic corticosteroids, disease-modifying anti-rheumatic drugs, and biologic agents. In addition, issues regarding treatment failure, early aggressive treatment, and drug tapering are discussed, with alternative treatment options being suggested.
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Affiliation(s)
- Štefan Blazina
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Center Ljubljana, Bohoričeva 20, 1525, Ljubljana, Slovenia
| | - Gašper Markelj
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Center Ljubljana, Bohoričeva 20, 1525, Ljubljana, Slovenia
| | - Mojca Zajc Avramovič
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Center Ljubljana, Bohoričeva 20, 1525, Ljubljana, Slovenia
| | - Nataša Toplak
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Center Ljubljana, Bohoričeva 20, 1525, Ljubljana, Slovenia.,Department of Pediatrics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tadej Avčin
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Center Ljubljana, Bohoričeva 20, 1525, Ljubljana, Slovenia. .,Department of Pediatrics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
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17
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Luca NJ, Burnett HF, Ungar WJ, Moretti ME, Beukelman T, Feldman BM, Schwartz G, Bayoumi AM. Cost-Effectiveness Analysis of First-Line Treatment With Biologic Agents in Polyarticular Juvenile Idiopathic Arthritis. Arthritis Care Res (Hoboken) 2016; 68:1803-1811. [DOI: 10.1002/acr.22903] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 02/25/2016] [Accepted: 03/29/2016] [Indexed: 12/19/2022]
Affiliation(s)
- Nadia J. Luca
- Alberta Children's Hospital and University of Calgary; Calgary Alberta Canada
| | - Heather F. Burnett
- The Hospital for Sick Children and University of Toronto; Toronto Ontario Canada
| | - Wendy J. Ungar
- The Hospital for Sick Children and University of Toronto; Toronto Ontario Canada
| | - Myla E. Moretti
- The Hospital for Sick Children and University of Toronto; Toronto Ontario Canada
| | | | - Brian M. Feldman
- The Hospital for Sick Children and University of Toronto; Toronto Ontario Canada
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18
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Davies R, Carrasco R, Foster HE, Baildam EM, Chieng SEA, Davidson JE, Ioannou Y, Wedderburn LR, Thomson W, Hyrich KL. Treatment prescribing patterns in patients with juvenile idiopathic arthritis (JIA): Analysis from the UK Childhood Arthritis Prospective Study (CAPS). Semin Arthritis Rheum 2016; 46:190-195. [PMID: 27422803 PMCID: PMC5052142 DOI: 10.1016/j.semarthrit.2016.06.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 05/05/2016] [Accepted: 06/06/2016] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Initial treatment of juvenile idiopathic arthritis (JIA) is largely based on the extent of joint involvement, disease severity and ILAR category. The licensing of biologic therapies for JIA has expanded treatment options. The aims of the study are (1) to describe treatment prescribing patterns in JIA over the first 3 years following first presentation to paediatric rheumatology and (2) to determine whether patterns of treatment have changed as biologics have become more widely available. METHODS Children with at least 3 years of follow-up within the Childhood Arthritis Prospective Study (CAPS) were included. For analysis, children were placed into one of five groups according to their initial presentation to paediatric rheumatology: oligoarthritis (oJIA), polyarthritis (pJIA), systemic (sJIA), enthesitis-related arthritis (ERA) and psoriatic arthritis (PsA). Treatment patterns over 3 years were described. RESULTS Of 1051 children, 58% received synthetic disease-modifying anti-rheumatic drugs (sDMARD) and 20% received biologics over the 3 years. Use of sDMARDs and biologics was higher in more severe disease presentations (sJIA and pJIA); however, 35% and 10% who presented with oJIA were also treated with sDMARDs and biologics, respectively. The number of children receiving sDMARD after 2006 was higher (p = 0.02); however, there was no difference in biologic prescribing before and after 2006 (p = 0.4). CONCLUSIONS A high proportion of children presenting with JIA received sDMARDs plus/minus biologics during 3 years of follow-up. This was most common for patients with severe JIA but was also prescribed for patients with oligoarticular disease, despite the lack of evidence for effectiveness in this category.
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Affiliation(s)
- Rebecca Davies
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Roberto Carrasco
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Helen E Foster
- Musculoskeletal Research Group, Institute Cellular Medicine, Newcastle University and Paediatric Rheumatology, Great North Children׳s Hospital, Newcastle upon Tyne, UK
| | - Eileen M Baildam
- Department of Paediatric Rheumatology, Alder Hey Children׳s Hospital NHS Foundation Trust, Liverpool, UK
| | - S E Alice Chieng
- Department of Rheumatology, Royal Manchester Children׳s Hospital, Manchester, UK
| | - Joyce E Davidson
- Department of Paediatric Rheumatology, Royal Hospital for Children, Glasgow, UK
| | - Yiannis Ioannou
- Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, UK
| | - Lucy R Wedderburn
- Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, UK; Infection, Inflammation, and Rheumatology Section, Institute of Child Health, UCL and Great Ormond Street Hospital NHS Trust, UCL Institute of Child Health, London, UK
| | - Wendy Thomson
- Arthritis Research UK Centre for Genetics and Genomics, Centre for Musculoskeletal Research, 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
| | - Kimme L Hyrich
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, 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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19
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Aktuelle Therapie der polyartikulären Verlaufsform der juvenilen idiopathischen Arthritis. Z Rheumatol 2016; 75:284-91. [DOI: 10.1007/s00393-016-0063-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Burgos-Vargas R, Tse SML, Horneff G, Pangan AL, Kalabic J, Goss S, Unnebrink K, Anderson JK. A Randomized, Double-Blind, Placebo-Controlled Multicenter Study of Adalimumab in Pediatric Patients With Enthesitis-Related Arthritis. Arthritis Care Res (Hoboken) 2016. [PMID: 26223543 PMCID: PMC5057351 DOI: 10.1002/acr.22657] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Objective Enthesitis‐related arthritis (ERA) is a juvenile idiopathic arthritis (JIA) category, primarily affecting entheses and peripheral joints. This study evaluated efficacy, safety, and pharmacokinetics of adalimumab versus placebo in patients with ERA. Methods This is a phase III, multicenter, randomized double‐blind study in patients ages ≥6 to <18 years with ERA treated with adalimumab (24 mg/m2, maximum dose 40 mg every other week) or placebo for 12 weeks, followed by up to 192 weeks of open‐label adalimumab. The primary end point was percent change from baseline in number of active joints with arthritis (AJC) at week 12. Samples were collected to determine adalimumab serum concentrations. Adverse events (AEs) were assessed throughout the study. Results Forty‐six patients were randomized (31 adalimumab/15 placebo). At baseline, mean age was 12.9 years, mean duration of ERA symptoms was 2.6 years, mean AJC was 7.8, and mean enthesitis count was 8.1. Mean percent change from baseline in AJC at week 12 was greater in the adalimumab group versus placebo (−62.6% versus −11.6%; P = 0.039). Most secondary variables favored adalimumab versus placebo at week 12. Treatment response further increased with continued adalimumab therapy through week 52. Mean steady‐state adalimumab serum concentrations were 7.5–11.8 μg/ml, similar to patients age ≥2 years with polyarticular JIA. AE rates were similar between placebo and adalimumab: any AE (53.3% versus 67.7%), serious AEs (0% versus 3.2%), and infectious AEs (20.0% versus 29.0%). Conclusion Adalimumab reduced signs and symptoms of ERA at week 12, with improvement sustained through week 52. The safety profile was consistent with previous adalimumab studies.
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Affiliation(s)
- Rubén Burgos-Vargas
- Hospital General de Mexico, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Shirley M L Tse
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Gerd Horneff
- Asklepios Klinik Sankt Augustin, Sankt Augustin, Germany
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22
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Kearsley-Fleet L, Davies R, Lunt M, Southwood TR, Hyrich KL. Factors associated with improvement in disease activity following initiation of etanercept in children and young people with Juvenile Idiopathic Arthritis: results from the British Society for Paediatric and Adolescent Rheumatology Etanercept Cohort Study. Rheumatology (Oxford) 2015; 55:840-7. [PMID: 26721878 PMCID: PMC4830911 DOI: 10.1093/rheumatology/kev434] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Indexed: 11/24/2022] Open
Abstract
Objectives. The objectives of this study were to investigate change in disease activity, and explore factors associated with response, in children with JIA over the initial year of etanercept treatment. Methods. This analysis included children with JIA starting etanercept in the British Society for Paediatric and Adolescent Rheumatology Etanercept Cohort Study. Response was assessed using change in juvenile arthritis disease activity score-71 (JADAS-71), an excellent response (ACR Pedi 90), and achieving minimal disease activity (MDA) at 1 year. Change in JADAS-71 was evaluated over time. Multivariable backward stepwise logistic regression was performed to identify factors associated with ACR Pedi 90 and MDA. Results. A total of 496 children were included. Over the first year, 17 stopped due to inefficacy, 9 due to adverse events and 7 for other reasons. One child stopped for remission. At 1 year, 74, 69 and 38% reached ACR Pedi 30, 50 and 90, respectively, and 48% had achieved MDA. Independent predictors of achieving ACR Pedi 90 at 1 year included shorter disease duration [odds ratio (OR) 0.91; 95% CI: 0.85, 0.97)], no concurrent oral corticosteroid use (OR 0.48; 95% CI: 0.29, 0.80) and history of uveitis (OR 2.26; 95% CI: 1.08, 4.71). Independent predictors of achieving MDA at 1 year included younger patients (OR 0.60; 95% CI: 0.38, 0.95), and disease not treated with concurrent oral corticosteroids (OR 0.57; 95% CI: 0.35, 0.93). Conclusion. Among this real-world cohort of children with severe JIA, a significant proportion of children achieved an excellent ACR Pedi response and MDA within 1 year of starting etanercept, although few clinical factors could predict this outcome.
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Affiliation(s)
- Lianne Kearsley-Fleet
- Arthritis Research UK Centre for Epidemiology, Manchester Academic Health Science Centre, The University of Manchester, Manchester
| | - Rebecca Davies
- Arthritis Research UK Centre for Epidemiology, Manchester Academic Health Science Centre, The University of Manchester, Manchester
| | - Mark Lunt
- Arthritis Research UK Centre for Epidemiology, Manchester Academic Health Science Centre, The University of Manchester, Manchester
| | - Taunton R Southwood
- Department of Paediatric Rheumatology, Institute of Child Health, Birmingham Children's Hospital - NHS Trust and University of Birmingham, Birmingham and
| | - Kimme L Hyrich
- Arthritis Research UK Centre for Epidemiology, Manchester Academic Health Science Centre, The University of Manchester, Manchester, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester Partnership, Manchester, UK
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Horneff G, Foeldvari I, Minden K, Trauzeddel R, Kümmerle-Deschner JB, Tenbrock K, Ganser G, Huppertz HI. Efficacy and safety of etanercept in patients with the enthesitis-related arthritis category of juvenile idiopathic arthritis: results from a phase III randomized, double-blind study. Arthritis Rheumatol 2015; 67:2240-9. [PMID: 25891010 DOI: 10.1002/art.39145] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Accepted: 03/31/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of etanercept in patients with enthesitis-related arthritis (ERA) in juvenile idiopathic arthritis (JIA). METHODS This was a 2-phase study in JIA patients with active, refractory ERA. Phase I was an open-label, uncontrolled 24-week study period in which all patients were administered etanercept. Patients considered to be treatment responders at week 24 according to the American College of Rheumatology (ACR) Pediatric 30 (Pedi 30) criteria for improvement in juvenile arthritis entered the second phase, a 24-week randomized, double-blind, placebo-controlled withdrawal study, for an additional 24 weeks, for evaluation of the primary end point, occurrence of a disease flare from week 24 to week 48, based on the ACR preliminary definition of disease flare in juvenile arthritis. RESULTS Forty-one patients were enrolled. At week 24, treatment with etanercept resulted in response rates of 93%, 93%, 80%, 56%, and 54% based on the ACR Pedi 30, Pedi 50, Pedi 70, Pedi 90, and Pedi 100 criteria, respectively. In addition, a marked decrease in all disease activity measures was observed. The mean number of tender joints, swollen joints, and joints with active arthritis decreased by 91%, 97%, and 94%, respectively. Physician's global assessment of disease activity, parent's assessment of patient's overall well-being, and the Childhood Health Assessment Questionnaire disability index improved by 91%, 80%, and 86%, respectively. The number of tender enthesis sites and total scores for back pain, nocturnal pain, Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Functional Index, and Juvenile Arthritis Disease Activity Score based on 10-joint counts (JADAS10) decreased by 75%, 72%, 81%, 72%, 85%, and 87%, respectively. In phase II, 38 patients were randomly assigned to receive placebo (n = 18) or to continue receiving etanercept (n = 20). Up to week 48, 12 disease flares occurred, in 9 patients receiving placebo and 3 patients receiving etanercept (odds ratio 6.0, P = 0.02). There were no serious infections, malignancies, or deaths. CONCLUSION In this study of patients with the ERA category of JIA, etanercept proved effective, as indicated by high ACR Pedi response rates and JADAS10 response rates at week 24. Patients who continued treatment with etanercept had significantly fewer flares than those who received placebo, although 50% of patients in the placebo group did not experience a flare. Treatment suspension may be a consideration for patients with the ERA category of JIA who achieve remission.
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Affiliation(s)
- Gerd Horneff
- Asklepios Clinic Sankt Augustin, Sankt Augustin, Germany
| | - Ivan Foeldvari
- Hamburg Center for Pediatric Rheumatology, Hamburg, Germany
| | | | | | | | | | - Gerd Ganser
- St. Josef-Stift Sendenhorst Hospital, Sendenhorst, Germany
| | - Hans-Iko Huppertz
- Prof.-Hess Children's Hospital and Gesundheit Nord Klinikverbund Bremen, Bremen, Germany
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24
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Nørgaard M, Twilt M, Andersen LB, Herlin T. Accelerometry-based monitoring of daily physical activity in children with juvenile idiopathic arthritis. Scand J Rheumatol 2015; 45:179-87. [DOI: 10.3109/03009742.2015.1057862] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- M Nørgaard
- Department of Physiotherapy, Aarhus University Hospital, Aarhus, Denmark
| | - M Twilt
- Paediatric Rheumatology Clinic, Aarhus University Hospital, Aarhus, Denmark
| | - LB Andersen
- Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - T Herlin
- Paediatric Rheumatology Clinic, Aarhus University Hospital, Aarhus, Denmark
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25
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Chang CY, Meyer RML, Reiff AO. Impact of medication withdrawal method on flare-free survival in patients with juvenile idiopathic arthritis on combination therapy. Arthritis Care Res (Hoboken) 2015; 67:658-66. [PMID: 25220674 DOI: 10.1002/acr.22477] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 08/05/2014] [Accepted: 09/09/2014] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine whether order of medication withdrawal in children with juvenile idiopathic arthritis (JIA) taking methotrexate (MTX) and tumor necrosis factor inhibitor (TNFi) combination therapy (CBT) affects flare-free survival (FFS). METHODS This retrospective observational study of 335 patients with polyarticular JIA or enthesitis-related arthritis analyzed FFS off medications in 4 withdrawal arms: 1) TNFi plus MTX, off MTX first, 2) TNFi plus MTX, off TNFi first, 3) MTX monotherapy, or 4) TNFi monotherapy. Outcomes were evaluated based on order of medication withdrawal, clinical presentation, serologic parameters, and duration of clinically inactive disease (CID) while taking medications. RESULTS Sixty-four percent of all patients achieved CID. However, 89% of patients on CBT who withdrew TNFi first flared within 12 months despite continuing MTX, compared to 12% of those who withdrew MTX and continued TNFi (P < 0.0005). Twenty-seven percent of patients discontinued all medications, but 63% flared within 12 months, and only 49% of these regained CID within 12 months of restarting therapy. Patients on MTX monotherapy had the best FFS after medication withdrawal. FFS was independent of disease subtype, rheumatoid factor status, initial erythrocyte sedimentation rate, initial joint count, corticosteroid exposure, time in CID, and method of medication discontinuation. CONCLUSION This study confirms that flare rates in JIA are high, and discontinuing medications is challenging. Withdrawal of TNFi from CBT first carries a significantly higher risk of disease flare than withdrawing MTX first. The high relapse rate after discontinuation of TNFi suggests that these medications may not modify the underlying disease process.
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26
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Anink J, Prince FHM, Dijkstra M, Otten MH, Twilt M, ten Cate R, Gorter SL, Koopman-Keemink Y, van Rossum MAJ, Hoppenreijs EPA, van Suijlekom-Smit LWA. Long-term quality of life and functional outcome of patients with juvenile idiopathic arthritis in the biologic era: a longitudinal follow-up study in the Dutch Arthritis and Biologicals in Children Register. Rheumatology (Oxford) 2015; 54:1964-9. [PMID: 26078219 DOI: 10.1093/rheumatology/kev195] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To carry out a longitudinal investigation of functional outcome, health-related quality of life (HRQoL) and treatment strategies in JIA patients who started etanercept >5 years ago. METHODS We approached patients whose HRQoL changes were described previously in a subanalysis of the Dutch Arthritis and Biologicals in Children register. Recent disease status, co-morbidities and structural damage were retrieved. Disability and HRQoL were assessed by (Childhood) HAQ [(C)HAQ], Child Health Questionnaire, Short Form 36 and Health Utilities Index Mark 3. Changes over time were analysed with linear mixed models. RESULTS Forty-three patients (81% response) started etanercept a median 8.5 years ago. At the time of this long-term analysis, median age was 22 years (interquartile range: 18-24 years). HRQoL outcome was similar to HRQoL 15-27 months after the initiation of etanercept; 42% had a (C)HAQ of 0.00 and 67% had achieved inactive disease. Patients reported increasing levels of bodily pain compared with earlier measurements. Unemployment (12%) was comparable to the general population; educational level was higher. Use of biologic agents was as follows: 40% etanercept; 40% other biologic agents; and 20% none. Joint surgery occurred in 14% of patients. CONCLUSION At a median 8.5 years after the commencement of etanercept treatment, JIA patients maintain most of the acquired improvement in HRQoL. Although disability and disease activity are low, chronic pain remains an issue. Persistence and possible deterioration of radiological damage emphasize the importance of early treatment. The fact that 20% of patients do not use any anti-rheumatic medication shows that clinical remission of medication might be an achievable goal.
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Affiliation(s)
- Janneke Anink
- Department of Paediatrics/Paediatric Rheumatology, Erasmus MC Sophia Children's Hospital, Rotterdam,
| | - Femke H M Prince
- Department of Paediatrics/Paediatric Rheumatology, Erasmus MC Sophia Children's Hospital, Rotterdam
| | - Maryanne Dijkstra
- Department of Paediatrics/Paediatric Rheumatology, Erasmus MC Sophia Children's Hospital, Rotterdam
| | - Marieke H Otten
- Department of Paediatrics/Paediatric Rheumatology, Erasmus MC Sophia Children's Hospital, Rotterdam
| | - Marinka Twilt
- Department of Paediatrics/Paediatric Rheumatology, Erasmus MC Sophia Children's Hospital, Rotterdam
| | - Rebecca ten Cate
- Department of Paediatrics/Paediatric Rheumatology, Leiden University Medical Centre, Leiden
| | - Simone L Gorter
- Department of Internal Medicine, Subdivision of Rheumatology, Maastricht University Medical Centre, Maastricht
| | | | - Marion A J van Rossum
- Department of Paediatrics/Paediatric Rheumatology, Emma Children's Hospital/Academic Medical Centre and Reade location Jan van Breemen, Amsterdam and
| | - Esther P A Hoppenreijs
- Department of Paediatrics/Paediatric Rheumatology, St Maartenskliniek and Radboud University Medical Centre, Nijmegen, The Netherlands
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Abstract
With its approval more than 15 years ago, subcutaneous etanercept (Enbrel(®)) was the first biological disease-modifying antirheumatic drug (bDMARD) and the first tumour necrosis factor inhibitor to be approved for use in rheumatic diseases. Etanercept remains an important cost-effective treatment option in adult patients with rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis or plaque psoriasis, and in paediatric patients with juvenile idiopathic arthritis or plaque psoriasis. In all of these populations, etanercept (with or without methotrexate) effectively reduced signs and symptoms, disease activity and disability, and improved health-related quality of life, with these benefits sustained during long-term treatment. The safety profile of etanercept during short- and long-term treatment was consistent with the approved product labelling, with adverse events being of a predictable and manageable nature. The introduction of etanercept and other bDMARDs as therapeutic options for patients with autoimmune rheumatic diseases and spondyloarthropathies revolutionized disease management and these agents continue to have a central role in treatment strategies. This article reviews the extensive clinical experience with etanercept in these patient populations.
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Affiliation(s)
- Lesley J Scott
- Springer, Private Bag 65901, Mairangi Bay, 0754, Auckland, New Zealand,
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28
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Smith EMD, Foster HE, Beresford MW. The development and assessment of biological treatments for children. Br J Clin Pharmacol 2015; 79:379-94. [PMID: 24750505 PMCID: PMC4345949 DOI: 10.1111/bcp.12406] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 04/11/2014] [Indexed: 12/14/2022] Open
Abstract
The development of biological agents with specific immunological targets has revolutionized the treatment of a wide variety of paediatric diseases where traditional immunosuppressive agents have been partly ineffective or intolerable. The increasing requirement for pharmaceutical companies to undertake paediatric studies has provided impetus for studies of biologics in children. The assessment of biological agents in children to date has largely relied upon randomized controlled trials using a withdrawal design, rather than a parallel study design. This approach has been largely used due to ethical concerns, including use of placebo treatments in children with active chronic disease, and justified on the basis that treatments have usually already undergone robust assessment in related adult conditions. However, this study design limits the reliability of the data and can confuse the interpretation of safety results. Careful ongoing monitoring of safety and efficacy in real-world practice through national and international biologics registries and robust reporting systems is crucial. The most commonly used biological agents in children target tumour necrosis factor-α, interleukin-1, interleukin-6 and cytotoxic lymphocyte-associated antigen-4. These agents are most frequently used in paediatric rheumatic diseases. This review discusses the development and assessment of biologics within paediatric rheumatology with reference to the lessons learned from use in other subspecialties.
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Affiliation(s)
- Eve M D Smith
- Institute of Translational Medicine, University of LiverpoolLiverpool, UK
| | - Helen E Foster
- Paediatric Rheumatology, Institute of Cellular Medicine, Newcastle UniversityNewcastle upon Tyne, UK
- Great North Children's Hospital, Newcastle Hospitals NHS Foundation TrustNewcastle upon Tyne, UK
| | - Michael W Beresford
- Institute of Translational Medicine, University of LiverpoolLiverpool, UK
- Alder Hey Children's NHS Foundation TrustLiverpool, UK
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29
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Abstract
The search for biomarkers in paediatric rheumatic diseases, particularly juvenile idiopathic arthritis (JIA), childhood lupus nephritis (LN), and juvenile idiopathic inflammatory myopathies (JIIMs) is attracting increased interest. In JIA, a number of biomarkers have shown potential for predicting clinical phenotype, disease activity and severity, clinical remission and relapse, response to treatment, and disease course over time. In systemic JIA, measurement of biomarkers that reflect the degree of activation and expansion of T cells and macrophages might be helpful for detecting subclinical macrophage activation syndrome. Urine biomarkers for childhood LN hold promise for facilitating early diagnosis and improving disease monitoring and assessment of response to therapy. Myositis-specific autoantibodies define distinct serological subgroups of JIIMs, albeit with similar clinical features, responses to therapy, and prognoses. Use of biomarkers may potentially help to avoid invasive procedures, such as renal biopsy in systemic lupus erythematosus and muscle biopsy in juvenile dermatomyositis. Incorporation of effective and reliable biomarkers into routine practice might facilitate adoption of a stratified approach to investigation and management, foster the implementation of research into the design of personalized and targeted therapies, and ultimately lead to more rational and effective clinical care.
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30
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Schmeling H, Minden K, Foeldvari I, Ganser G, Hospach T, Horneff G. Efficacy and safety of adalimumab as the first and second biologic agent in juvenile idiopathic arthritis: the German Biologics JIA Registry. Arthritis Rheumatol 2014; 66:2580-9. [PMID: 24942886 DOI: 10.1002/art.38741] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Accepted: 06/03/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of adalimumab in patients with juvenile idiopathic arthritis (JIA). METHODS Baseline demographic and clinical characteristics and disease activity parameters were prospectively documented in the German Biologics JIA Registry. Efficacy was determined using the American College of Rheumatology (ACR) Pediatric (Pedi) response criteria and the Juvenile Arthritis Disease Activity Score based on a 10-joint count (JADAS-10). Safety assessments were based on adverse event reports from the responsible physician. RESULTS Two hundred eighty-nine patients with a total of 1,046 visits were identified (435.7 patient-years). A high proportion of patients demonstrated a significant response to treatment, with a marked decrease in the JADAS-10 score in both the biologics-naive group (which consisted of patients who had not received therapy with a biologic agent prior to initiation of adalimumab) and the biologic-switcher group (which consisted of patients who had been treated with a different biologic agent prior to initiation of adalimumab). The median JADAS-10 score at treatment start was significantly higher in the biologics-naive group than in the biologic-switcher group (12.9 versus 8.5; P = 0.00044), although the score in the biologics-naive group was lower over the course of adalimumab treatment. ACR Pedi 30, 50, 70, and 90 scores were achieved in 63.4%, 61.0%, 48.8%, and 34.2% of biologics-naive patients, respectively, at 6 months of treatment, while ACR Pedi 30, 50, 70, and 90 scores were achieved in 47.6%, 38.1%, 21.9%, and 15.2% of biologic-switcher patients, respectively. Forty-eight patients experienced 222 adverse events (50.9 per 100 patient-years). Eleven were reported as serious (2.5 per 100 patient-years). No malignancies were observed during adalimumab exposure. There were 16 uveitis flares in 11 patients. Treatment was discontinued in 58 patients for the following reasons: inefficacy 11.1%, adverse events 5.2%, remission 4.5%, patient request 11.8%, and other reasons 7.9%. CONCLUSION Adalimumab appears to be highly effective in children and adolescents with JIA who have been previously treated with biologic agents and in children and adolescents who switched biologic agents. The treatment is safe and its efficacy is similar to that of other biologic agents used to treat JIA. Few patients discontinued therapy due to intolerance or inefficacy.
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Affiliation(s)
- Heinrike Schmeling
- Alberta Children's Hospital and University of Calgary, Calgary, Alberta, Canada
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31
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Windschall D, Müller T, Becker I, Horneff G. Safety and efficacy of etanercept in children with juvenile idiopathic arthritis below the age of 2 years. Rheumatol Int 2014; 35:613-8. [PMID: 25208527 DOI: 10.1007/s00296-014-3125-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 08/29/2014] [Indexed: 12/19/2022]
Abstract
Etanercept is approved for the treatment of patients with juvenile idiopathic arthritis (JIA) above the age of 2 years. Experience with younger children is limited. The aim of the present study was to evaluate the efficacy and safety of treatment with etanercept in children with JIA younger than 2 years. The prospective long-term observational BIKER registry documents baseline demographics, clinical characteristics, disease activity parameters and safety issues. Efficacy was determined using the PedACR response criteria, the JADAS-10 and the proposed criteria for inactive disease and remission after 3, 6, 12, 18 and 24 months. Safety assessments were based on adverse events (AE) and serious adverse events (SAEs) reports. Between January 2001 and June 2013, a total of 13 patients including four patients with systemic JIA (sJIA), four patients with extended oligoarthritis, one patient with persistent oligoarthritis and four patients with RF negative polyarthritis were treated with etanercept. Eleven patients with follow-up assessments were analysed in our study. Prior to etanercept, all patients have been exposed to methotrexate. At last observation, 6/11 patients reached a PedACR 70 response. Two patients with sJIA and 1 with nonsystemic JIA achieved inactive disease. Tolerability was good in most of the patients. Eight AE and one SAE occurred. One patient with sJIA was affected by Hodgkin's disease 18 months after discontinuation of etanercept. New onset uveitis occurred in two patients. Reasons for discontinuation were inefficacy in three (2 sJIA), intolerance in two, remission in three (2 sJIA) and the parents' request in one patient. Etanercept seems to improve JIA patients younger than 2 years including some of the patients with sJIA. Attention should be paid to the development of malignancies and autoimmune disorders.
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Affiliation(s)
- D Windschall
- Department of Pediatrics, Asklepios Hospital Weissenfels, Naumburgerstrasse 76, 06667, Weissenfels, Germany,
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32
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Horneff G. Moderne Behandlung der juvenilen idiopathischen Arthritis. Monatsschr Kinderheilkd 2014. [DOI: 10.1007/s00112-014-3101-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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33
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Guzman J, Oen K, Tucker LB, Huber AM, Shiff N, Boire G, Scuccimarri R, Berard R, Tse SML, Morishita K, Stringer E, Johnson N, Levy DM, Duffy KW, Cabral DA, Rosenberg AM, Larché M, Dancey P, Petty RE, Laxer RM, Silverman E, Miettunen P, Chetaille AL, Haddad E, Houghton K, Spiegel L, Turvey SE, Schmeling H, Lang B, Ellsworth J, Ramsey S, Bruns A, Campillo S, Benseler S, Chédeville G, Schneider R, Yeung R, Duffy CM. The outcomes of juvenile idiopathic arthritis in children managed with contemporary treatments: results from the ReACCh-Out cohort. Ann Rheum Dis 2014; 74:1854-60. [PMID: 24842571 DOI: 10.1136/annrheumdis-2014-205372] [Citation(s) in RCA: 156] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 05/03/2014] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To describe clinical outcomes of juvenile idiopathic arthritis (JIA) in a prospective inception cohort of children managed with contemporary treatments. METHODS Children newly diagnosed with JIA at 16 Canadian paediatric rheumatology centres from 2005 to 2010 were included. Kaplan-Meier survival curves for each JIA category were used to estimate probability of ever attaining an active joint count of 0, inactive disease (no active joints, no extraarticular manifestations and a physician global assessment of disease activity <10 mm), disease remission (inactive disease >12 months after discontinuing treatment) and of receiving specific treatments. RESULTS In a cohort of 1104 children, the probabilities of attaining an active joint count of 0 exceeded 78% within 2 years in all JIA categories. The probability of attaining inactive disease exceeded 70% within 2 years in all categories, except for RF-positive polyarthritis (48%). The probability of discontinuing treatment at least once was 67% within 5 years. The probability of attaining remission within 5 years was 46-57% across JIA categories except for polyarthritis (0% RF-positive, 14% RF-negative). Initial treatment included joint injections and non-steroidal anti-inflammatory drugs for oligoarthritis, disease-modifying antirheumatic drugs (DMARDs) for polyarthritis and systemic corticosteroids for systemic JIA. CONCLUSIONS Most children with JIA managed with contemporary treatments attain inactive disease within 2 years of diagnosis and many are able to discontinue treatment. The probability of attaining remission within 5 years of diagnosis is about 50%, except for children with polyarthritis.
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Affiliation(s)
- Jaime Guzman
- British Columbia Children's Hospital and the University of British Columbia, Vancouver, Canada
| | - Kiem Oen
- Winnipeg Children's Hospital and University of Manitoba, Winnipeg, Canada
| | - Lori B Tucker
- British Columbia Children's Hospital and the University of British Columbia, Vancouver, Canada
| | - Adam M Huber
- IWK Health Centre and Dalhousie University, Halifax, Canada
| | - Natalie Shiff
- Royal University Hospital and University of Saskatchewan, Saskatoon, Canada
| | - Gilles Boire
- Centre Hospitalier Universitaire de Sherbrooke and Université de Sherbrooke, Sherbrooke, Canada
| | - Rosie Scuccimarri
- McGill University Health Centre and McGill University, Montreal, Canada
| | - Roberta Berard
- London Health Sciences Centre and Western University, London, Canada
| | - Shirley M L Tse
- Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Kimberly Morishita
- British Columbia Children's Hospital and the University of British Columbia, Vancouver, Canada
| | | | - Nicole Johnson
- The Alberta Children's Hospital and University of Calgary, Calgary, Canada
| | - Deborah M Levy
- Hospital for Sick Children and University of Toronto, Toronto, Canada
| | | | - David A Cabral
- British Columbia Children's Hospital and the University of British Columbia, Vancouver, Canada
| | - Alan M Rosenberg
- Royal University Hospital and University of Saskatchewan, Saskatoon, Canada
| | | | - Paul Dancey
- Janeway Children's Health and Rehabilitation Centre and Memorial University, Saint John's, Canada
| | - Ross E Petty
- British Columbia Children's Hospital and the University of British Columbia, Vancouver, Canada
| | - Ronald M Laxer
- Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Earl Silverman
- Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Paivi Miettunen
- The Alberta Children's Hospital and University of Calgary, Calgary, Canada
| | | | - Elie Haddad
- CHU Ste. Justine and Université de Montréal, Montréal, Canada
| | - Kristin Houghton
- British Columbia Children's Hospital and the University of British Columbia, Vancouver, Canada
| | - Lynn Spiegel
- Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Stuart E Turvey
- British Columbia Children's Hospital and the University of British Columbia, Vancouver, Canada
| | - Heinrike Schmeling
- The Alberta Children's Hospital and University of Calgary, Calgary, Canada
| | - Bianca Lang
- IWK Health Centre and Dalhousie University, Halifax, Canada
| | - Janet Ellsworth
- The Stollery Children's Hospital and University of Alberta, Edmonton, Canada
| | - Suzanne Ramsey
- IWK Health Centre and Dalhousie University, Halifax, Canada
| | - Alessandra Bruns
- Centre Hospitalier Universitaire de Sherbrooke and Université de Sherbrooke, Sherbrooke, Canada
| | - Sarah Campillo
- McGill University Health Centre and McGill University, Montreal, Canada
| | - Susanne Benseler
- The Alberta Children's Hospital and University of Calgary, Calgary, Canada
| | - Gaëlle Chédeville
- McGill University Health Centre and McGill University, Montreal, Canada
| | - Rayfel Schneider
- Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Rae Yeung
- Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Ciarán M Duffy
- Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, Canada
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Southwood TR. Paediatric rheumatic disease: Treatment of JIA in the biologic era: what are we waiting for? Nat Rev Rheumatol 2014; 10:132-4. [PMID: 24514914 DOI: 10.1038/nrrheum.2014.14] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Taunton R Southwood
- Department of Paediatric Rheumatology, Institute of Child Health, 4th Floor Laboratories Block, Birmingham Children's Hospital-NHS Trust and University of Birmingham, Whittall Street, Birmingham B4 6NH, UK
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35
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Ringold S, Weiss PF, Beukelman T, DeWitt EM, Ilowite NT, Kimura Y, Laxer RM, Lovell DJ, Nigrovic PA, Robinson AB, Vehe RK. 2013 update of the 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: recommendations for the medical therapy of children with systemic juvenile idiopathic arthritis and tuberculosis screening among children receiving biologic medications. ARTHRITIS AND RHEUMATISM 2013; 65:2499-512. [PMID: 24092554 PMCID: PMC5408575 DOI: 10.1002/art.38092] [Citation(s) in RCA: 168] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 07/02/2013] [Indexed: 12/12/2022]
Abstract
Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are intended to provide guidance for particular patterns of practice and not to dictate the care of a particular patient. The ACR considers adherence to these guidelines and recommendations to be voluntary, with the ultimate determination regarding their application to be made by the physician in light of each patient's individual circumstances. Guidelines and recommendations are intended to promote beneficial or desirable outcomes but cannot guarantee any specific outcome. Guidelines and recommendations developed or endorsed by the ACR are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice. The American College of Rheumatology is an independent, professional, medical and scientific society which does not guarantee, warrant, or endorse any commercial product or service.
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Affiliation(s)
| | - Pamela F. Weiss
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | - Norman T. Ilowite
- Albert Einstein College of Medicine and Children's Hospital at Montefiore, Bronx, New York
| | - Yukiko Kimura
- Hackensack University Medical Center, Hackensack, New Jersey
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36
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Ringold S, Weiss PF, Beukelman T, DeWitt EM, Ilowite NT, Kimura Y, Laxer RM, Lovell DJ, Nigrovic PA, Robinson AB, Vehe RK. 2013 update of the 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: recommendations for the medical therapy of children with systemic juvenile idiopathic arthritis and tuberculosis screening among children receiving biologic medications. Arthritis Care Res (Hoboken) 2013; 65:1551-63. [PMID: 24078300 PMCID: PMC5408573 DOI: 10.1002/acr.22087] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 07/02/2013] [Indexed: 12/25/2022]
Abstract
Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are intended to provide guidance for particular patterns of practice and not to dictate the care of a particular patient. The ACR considers adherence to these guidelines and recommendations to be voluntary, with the ultimate determination regarding their application to be made by the physician in light of each patient's individual circumstances. Guidelines and recommendations are intended to promote beneficial or desirable outcomes but cannot guarantee any specific outcome. Guidelines and recommendations developed or endorsed by the ACR are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice. The American College of Rheumatology is an independent, professional, medical and scientific society which does not guarantee, warrant, or endorse any commercial product or service.
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Affiliation(s)
| | - Pamela F. Weiss
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | - Norman T. Ilowite
- Albert Einstein College of Medicine and Children's Hospital at Montefiore, Bronx, New York
| | - Yukiko Kimura
- Hackensack University Medical Center, Hackensack, New Jersey
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Papadopoulou C, Kostik M, Gonzalez-Fernandez MI, Bohm M, Nieto-Gonzalez JC, Pistorio A, Lanni S, Consolaro A, Martini A, Ravelli A. Delineating the role of multiple intraarticular corticosteroid injections in the management of juvenile idiopathic arthritis in the biologic era. Arthritis Care Res (Hoboken) 2013; 65:1112-20. [PMID: 23335483 DOI: 10.1002/acr.21947] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 12/21/2012] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To investigate the outcome and predicting factors of multiple intraarticular corticosteroid (IAC) injections in children with juvenile idiopathic arthritis (JIA). METHODS The clinical charts of patients who received their first IAC injection in ≥3 joints between January 2002 and December 2011 were reviewed. The corticosteroid used was triamcinolone hexacetonide for large joints and methylprednisolone acetate for small or difficult to access joints. In each patient, the followup period after IAC injection was censored in case of synovitis flare or at the last visit with continued remission. Predictors included sex, age at disease onset, JIA category, antinuclear antibody (ANA) status, age and disease duration, disease course, general anesthesia, number and type of injected joints, acute-phase reactants, and concomitant systemic medications. RESULTS A total of 220 patients who had 1,096 joints injected were included. Following IAC therapy, 66.4% of patients had synovitis flare after a median of 0.5 years, whereas 33.6% of patients had sustained remission after a median of 0.9 years. The cumulative probability of survival without synovitis flare was 50.0%, 31.5%, and 19.5% at 1, 2, and 3 years, respectively. On Cox regression analysis, positive C-reactive protein value, negative ANA, lack of concomitant methotrexate administration, and a polyarticular (versus an oligoarticular) disease course were the strongest predictors for synovitis flare. CONCLUSION Multiple IAC injection therapy induced sustained remission of joint synovitis in a substantial proportion of patients. A controlled trial comparing multiple IAC injection therapy and methotrexate versus methotrexate and a tumor necrosis factor antagonist is worthy of consideration.
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Horneff G, Burgos-Vargas R, Constantin T, Foeldvari I, Vojinovic J, Chasnyk VG, Dehoorne J, Panaviene V, Susic G, Stanevica V, Kobusinska K, Zuber Z, Mouy R, Rumba-Rozenfelde I, Breda L, Dolezalova P, Job-Deslandre C, Wulffraat N, Alvarez D, Zang C, Wajdula J, Woodworth D, Vlahos B, Martini A, Ruperto N. Efficacy and safety of open-label etanercept on extended oligoarticular juvenile idiopathic arthritis, enthesitis-related arthritis and psoriatic arthritis: part 1 (week 12) of the CLIPPER study. Ann Rheum Dis 2013; 73:1114-22. [PMID: 23696632 PMCID: PMC4033142 DOI: 10.1136/annrheumdis-2012-203046] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate the efficacy and safety of etanercept (ETN) in paediatric subjects with extended oligoarticular juvenile idiopathic arthritis (eoJIA), enthesitis-related arthritis (ERA), or psoriatic arthritis (PsA). METHODS CLIPPER is an ongoing, Phase 3b, open-label, multicentre study; the 12-week (Part 1) data are reported here. Subjects with eoJIA (2-17 years), ERA (12-17 years), or PsA (12-17 years) received ETN 0.8 mg/kg once weekly (maximum 50 mg). Primary endpoint was the percentage of subjects achieving JIA American College of Rheumatology (ACR) 30 criteria at week 12; secondary outcomes included JIA ACR 50/70/90 and inactive disease. RESULTS 122/127 (96.1%) subjects completed the study (mean age 11.7 years). JIA ACR 30 (95% CI) was achieved by 88.6% (81.6% to 93.6%) of subjects overall; 89.7% (78.8% to 96.1%) with eoJIA, 83.3% (67.2% to 93.6%) with ERA and 93.1% (77.2% to 99.2%) with PsA. For eoJIA, ERA, or PsA categories, the ORs of ETN vs the historical placebo data were 26.2, 15.1 and 40.7, respectively. Overall JIA ACR 50, 70, 90 and inactive disease were achieved by 81.1, 61.5, 29.8 and 12.1%, respectively. Treatment-emergent adverse events (AEs), infections, and serious AEs, were reported in 45 (35.4%), 58 (45.7%), and 4 (3.1%), subjects, respectively. Serious AEs were one case each of abdominal pain, bronchopneumonia, gastroenteritis and pyelocystitis. One subject reported herpes zoster and another varicella. No differences in safety were observed across the JIA categories. CONCLUSIONS ETN treatment for 12 weeks was effective and well tolerated in paediatric subjects with eoJIA, ERA and PsA, with no unexpected safety findings.
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Affiliation(s)
- Gerd Horneff
- Department of Pediatrics, Asklepios Clinic, , Sankt Augustin, Germany
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Huppertz HL. Remission in der Kinderrheumatologie. Z Rheumatol 2013; 72:354-60. [DOI: 10.1007/s00393-012-1062-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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40
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Trachana M, Pratsidou-Gertsi P, Badouraki M, Haidich AB, Pardalos G. Achievement of clinical remission in patients with juvenile idiopathic arthritis under a 2-10-year Etanercept exposure. Clin Rheumatol 2013; 32:1191-7. [PMID: 23604548 DOI: 10.1007/s10067-013-2261-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 03/15/2013] [Accepted: 04/06/2013] [Indexed: 10/26/2022]
Abstract
The objective of this retrospective study was to record the achievement of clinical remission (CR) in juvenile idiopathic arthritis patients under a 2-10 years' administration of Etanercept (ETN) and to detect any variables associated with CR. Patients previously resistant to conventional regimens were enrolled. The annual impact of ETN was assessed by: (a) the American College of Rheumatology pediatric criteria (ACRpedi), (b) the pre- and posttreatment disease activity score (juvenile arthritis disease activity score [JADAS71]), and (c) Wallace's criteria for CR. A total of 41 patients (F: 31) were registered. The median age and disease duration at baseline were 10.6 and 4.17 years, respectively, and their disease course was mainly polyarthritis (32/41). In respect to baseline, there was an impressive JADAS71 reduction posttreatment, most prominent after the first year. From year 1 to 5, more than 50 % of the patients achieved and retained CR and 66 % reached an ACRpedi 70, whereas after the 5th year, no patient was withdrawn due to an ACRpedi <30. JADAS71 at baseline was not associated with the subsequent CR achievement. However, JADAS71 1-year posttreatment had a significant association with the CR of the second posttreatment year, (p = 0.028, OR 0.79; 95 % CI 0.63-0.98) and a similar trend was observed for the following years. These findings emphasize the sustained impact of ETN in the achievement of CR. A low JADAS71 score 1-year posttreatment, may be associated with the maintenance of CR over the next treatment year.
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Affiliation(s)
- Maria Trachana
- Pediatric Immunology and Rheumatology Referral Center, 1st Department of Pediatrics, Aristotle University, Ippokration Hospital, Thessaloniki, Greece.
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Nørgaard M, Thastum M, Herlin T. The relevance of using the Childhood Health Assessment Questionnaire (CHAQ) in revised versions for the assessment of juvenile idiopathic arthritis. Scand J Rheumatol 2013; 42:457-64. [DOI: 10.3109/03009742.2013.768701] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Cai Y, Liu X, Zhang W, Xu J, Cao L. Clinical trial of etanercept tapering in juvenile idiopathic arthritis during remission. Rheumatol Int 2013; 33:2277-82. [PMID: 23468176 DOI: 10.1007/s00296-012-2642-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Accepted: 12/15/2012] [Indexed: 11/28/2022]
Abstract
To explore the possibility of step-down method and low dose of etanercept for long-term stable remission of patients with juvenile idiopathic arthritis (JIA). Patients with JIA were enrolled into this study between February 2008 and March 2010 and then followed up for 2 years. The inclusion criteria were clinical remission and use of etanercept for therapy. On the first year of the study, the dose of etanercept was kept at 0.4 mg/kg per week, the half dose of what those patients had been used. On the second year, the dose of etanercept was further lowered to 0.4 mg/kg per month. DMARDs were allowed in this study. MR images were performed to observe joint changes. The primary end point was disease flare defined according to clinical and/or radiological data. The flare rate curve was analyzed by Kaplan-Meier, and logistic regression model was used to find factors associating with disease flare. MRI was performed to prove no active changes or progressions of bone erosions on joints. Thirty-one patients were enrolled in this study. There were 4 patients experiencing disease flare during the first 12th month. During the second year, disease flare was not occurred. Thus, the cumulative flare rate was 12.9 % on 12th month and then unchanged on the second year. Logistic regression model indicates there are no differences in sex, age of disease initiation, disease duration, subtypes, DMARDs, HLA-B27, months of etanercept duration and scores on MRI between patients with remission and those experiencing flares. At the end of the study, MRI found no progressions of joints to the patients keeping stable remission. Step-down method can be used for etanercept tapering. Long-term remission and low flare rate can be got by this method.
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Affiliation(s)
- Yubo Cai
- Department of Pediatrics, Renji Hospital, Medicine College of Jiaotong University, 145 Middle Shandong Road, Shanghai 200001, China
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Ungar WJ, Costa V, Burnett HF, Feldman BM, Laxer RM. The use of biologic response modifiers in polyarticular-course juvenile idiopathic arthritis: a systematic review. Semin Arthritis Rheum 2013; 42:597-618. [PMID: 23337074 DOI: 10.1016/j.semarthrit.2012.10.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 10/12/2012] [Accepted: 10/30/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To systematically review the clinical efficacy and safety evidence of biologic drugs used to treat the polyarticular category of juvenile idiopathic arthritis (JIA). METHODS The literature was searched between 2000 and September 2012 for randomized controlled trials (RCTs), non-randomized comparative studies, and non-comparative observational cohort studies. The drugs evaluated included etanercept, infliximab, adalimumab, abatacept, anakinra, and ritixumab. Eligible studies included 20 or more patients with JIA, the majority of whom had polyarticular course disease. Outcomes of interest were disease improvement defined by the American College of Rheumatology criteria for Pediatrics, disease flares, rates of inactive disease, remissions, discontinuations, and adverse events (severe and non-severe). RESULTS Thirty-seven studies were included, the majority focused on etanercept. Seven RCTs were identified, including one each for etanercept, infliximab, adalimumab, abatacept, and anakinra, and one each looking at etanercept or infliximab as first-line therapies. There was strong evidence to support the efficacy and safety of biologics over the short-term, but a lack of long-term data for treatments other than etanercept. Several high-quality patient registries confirmed the efficacy and safety of etanercept over the long-term. CONCLUSIONS Current evidence shows that a short-term improvement in treatment response is achieved when patients with polyarticular JIA with an inadequate response to conventional treatment are treated with biologics. Long-term effectiveness data, however, are sparse leaving many questions regarding switches between biologics, handling patients that achieve disease remission, and long-term safety. Study designs other than RCTs may be important in understanding the role of biologics in JIA over the long-term.
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Affiliation(s)
- Wendy J Ungar
- Program of Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada.
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Horneff G. Update on biologicals for treatment of juvenile idiopathic arthritis. Expert Opin Biol Ther 2013; 13:361-76. [DOI: 10.1517/14712598.2013.735657] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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45
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Anink J, Otten MH, Prince FHM, Hoppenreijs EPAH, Wulffraat NM, Swart JF, ten Cate R, van Rossum MAJ, van den Berg JM, Dolman KM, Koopman-Keemink Y, Armbrust W, Kamphuis S, van Pelt PA, Gorter SL, van Suijlekom-Smit LWA. Tumour necrosis factor-blocking agents in persistent oligoarticular juvenile idiopathic arthritis: results from the Dutch Arthritis and Biologicals in Children Register. Rheumatology (Oxford) 2012; 52:712-7. [PMID: 23267169 DOI: 10.1093/rheumatology/kes373] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Because TNF inhibitors are not approved for persistent oligoarticular JIA (oJIA), although they are used off-label, we evaluated their effectiveness in patients in this category. METHODS Persistent oJIA patients were selected from the Dutch Arthritis and Biologicals in Children (ABC) register, an ongoing multicentre prospective study that aims to include all Dutch children with JIA using biologic agents. Response was assessed by the JIA core-set disease activity variables and modified Wallace criteria for inactive disease. RESULTS Until February 2011, 16 persistent oJIA patients (68.8% females) had been included in the register. Median age of onset was 8.4 years [interquartile range (IQR) 2.1-13.5 years]; history of uveitis in 18.8%; ANA-positive 56.3%. All had previously used MTX, and 81.3% had used IA CSs. Median follow-up after the introduction of biologic treatment was 13.7 months (IQR 8.3-16.7 months). Fourteen patients started etanercept and two patients who had active arthritis as well as uveitis started adalimumab. Although patients with persistent oJIA had few affected joints [median of two active joints at the start of biologic (IQR 1-3)], the patient/parent assessments of pain [median visual analogue score (VAS) 51 (IQR 1-64)] and well-being [median VAS 44 (IQR 6-66)] were high. Additionally, their physician evaluated the disease activity as moderately high [median VAS 36 (IQR 4-65)]. After 3 months this decreased to 0 (IQR 0-30) and 63% achieved inactive disease. After 15 months the disease was inactive in 9/10 observed patients. TNF inhibitors were tolerated well. CONCLUSION TNF blocking agents seem an effective and justifiable option in persistent oJIA when treatment with IA CS injections and MTX has failed.
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Affiliation(s)
- Janneke Anink
- Department of Paediatrics/Paediatric Rheumatology, Erasmus MC Sophia Children’s Hospital, Rotterdam, The Netherlands.
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SOLARI NICOLETTA, PALMISANI ELENA, CONSOLARO ALESSANDRO, PISTORIO ANGELA, VIOLA STEFANIA, BUONCOMPAGNI ANTONELLA, GATTORNO MARCO, PICCO PAOLO, RUPERTO NICOLINO, MALATTIA CLARA, MARTINI ALBERTO, RAVELLI ANGELO. Factors Associated with Achievement of Inactive Disease in Children with Juvenile Idiopathic Arthritis Treated with Etanercept. J Rheumatol 2012. [DOI: 10.3899/jrheum.120842] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.To evaluate the rate of inactive disease in children with juvenile idiopathic arthritis (JIA) treated with etanercept, and to identify clinical characteristics associated with attainment of inactive disease.Methods.Clinical charts of patients who were given etanercept between January 2002 and January 2011 were evaluated retrospectively. For each patient, all visits from initiation of etanercept to the last followup evaluation in which the patient was still receiving etanercept were examined to establish whether the patient had reached the state of inactive disease and to identify the first visit in which inactive disease was documented. Clinical characteristics associated with achievement of inactive disease were determined through univariate analyses and Cox regression procedures.Results.A total of 173 patients who received etanercept for a median of 2.2 years (range 0.5–10.5 yrs) were studied. Eighty-seven patients (50.3%) achieved inactive disease after a median of 0.6 years (range 0.1–2.5 yrs) of therapy. At last followup evaluation, 85 patients (49.1%) still had inactive disease and 70 (40.5%) were in clinical remission on medication. The probability of achievement of inactive disease after 6, 12, and 24 months of therapy was 24%, 46% and 57%, respectively. On Cox regression analysis, the attainment of inactive disease was associated with lack of wrist involvement and an age at disease onset < 3.6 years.Conclusion.Around half of our patients with JIA treated with etanercept achieved a state of inactive disease. Children who lacked wrist involvement and were younger at disease onset had a greater likelihood of achieving inactive disease.
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Otten MH, Anink J, Spronk S, van Suijlekom-Smit LWA. Efficacy of biological agents in juvenile idiopathic arthritis: a systematic review using indirect comparisons. Ann Rheum Dis 2012; 72:1806-12. [PMID: 23172748 DOI: 10.1136/annrheumdis-2012-201991] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Marieke H Otten
- Department of Pediatrics/Pediatric Rheumatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
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Nordstrom BL, Mines D, Gu Y, Mercaldi C, Aquino P, Harrison MJ. Risk of malignancy in children with juvenile idiopathic arthritis not treated with biologic agents. Arthritis Care Res (Hoboken) 2012; 64:1357-64. [PMID: 22511558 DOI: 10.1002/acr.21709] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To estimate the relative risk of incident cancer diagnosis among patients with juvenile idiopathic arthritis (JIA) compared to patients without JIA. METHODS A cohort of biologics-naive patients diagnosed with JIA between 1998 and 2007 and a matched cohort of comparators without JIA were assembled from the PharMetrics Patient-Centric Database. The primary outcome was any incident malignancy, excluding nonmelanoma skin cancer and carcinoma in situ. Claims profiles of patients with any cancer-related diagnosis codes were reviewed to determine outcomes. Incidence rates and 95% confidence intervals (95% CIs) of cancer were calculated and compared between cohorts using Cox proportional hazards regression. Standardized incidence ratios (SIRs) for each cohort compared to the general population were calculated using reference rates from the US Surveillance, Epidemiology, and End-Results (SEER) program. RESULTS The JIA and non-JIA cohorts included 3,605 and 37,689 patients, respectively, with a mean age of 11 years. The incidence rates of cancer were 67.0 (95% CI 1.3-132.5) cases/100,000 person-years (PY) for JIA and 23.2 (95% CI 12.2-34.2) cases/100,000 PY for non-JIA. The risk of cancer associated with biologics-naive JIA was elevated (hazard ratio 2.8, 95% CI 0.9-8.3). The JIA cohort had a significantly elevated SIR of 4.0 (95% CI 2.6-6.0); the non-JIA cohort SIR was not significantly above SEER rates (SIR 1.4, 95% CI 0.6-2.6). CONCLUSION We found a nearly 3-fold increased risk of cancer in biologics-naive JIA patients, which approached significance despite the small number of outcomes. This finding suggests an elevated underlying risk of cancer in this disease population.
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Weiss PF, Beukelman T, Schanberg LE, Kimura Y, Colbert RA. Enthesitis-related arthritis is associated with higher pain intensity and poorer health status in comparison with other categories of juvenile idiopathic arthritis: the Childhood Arthritis and Rheumatology Research Alliance Registry. J Rheumatol 2012; 39:2341-51. [PMID: 23070991 DOI: 10.3899/jrheum.120642] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the relative effect of clinical factors and medications on pain intensity, physical function, and health status in juvenile idiopathic arthritis (JIA). METHODS We conducted a retrospective cross-sectional study of data from children with JIA enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry. We tested whether clinical characteristics of JIA were associated with pain intensity, physical function, and health status using multivariable linear and ordinal logistic regression. RESULTS During the study period, 2571 subjects with JIA enrolled in the CARRA Registry. Ratings of pain intensity, physical function, and health status differed significantly between JIA categories. In comparison to other categories of JIA, subjects with enthesitis-related arthritis (ERA) reported worse pain and function. In multivariable analyses, higher active joint count and current use of nonsteroidal antiinflammatory drugs (NSAID), biologics, or corticosteroids were associated with worse scores on all patient-reported measures. ERA and older age were significantly associated with higher pain intensity and poorer health status. Systemic JIA and uveitis were significantly associated with worse health status. Enthesitis, sacroiliac tenderness, and NSAID use were independently associated with increased pain intensity in ERA. The correlation was low between physician global assessment of disease activity and patient-reported pain intensity, physical function, and health status. CONCLUSION Significant differences in pain intensity, physical function, and health status exist among JIA categories. These results suggest that current treatments may not be equally effective for particular disease characteristics more common in specific JIA categories, such as enthesitis or sacroiliac tenderness in ERA.
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Affiliation(s)
- Pamela F Weiss
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA.
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Minden K, Niewerth M, Zink A, Seipelt E, Foeldvari I, Girschick H, Ganser G, Horneff G. Long-term outcome of patients with JIA treated with etanercept, results of the biologic register JuMBO. Rheumatology (Oxford) 2012; 51:1407-15. [DOI: 10.1093/rheumatology/kes019] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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