Remittive agents in pediatric rheumatology

Prescribing for Children With Rheumatic Disease: Perceived Treatment Approaches Between Pediatric and Adult Rheumatologists

OBJECTIVE

To compare practice patterns and prescribing differences for juvenile idiopathic arthritis (JIA) between adult rheumatologists (ARs) and pediatric rheumatologists (PRs), the perceived educational needs, and factors that enhance or impede co-management.

METHODS

Two parallel, cross-sectional surveys focusing on JIA were administered in 2009 to a random sample of 193 PRs and 500 ARs using the American College of Rheumatology membership file. Bivariate analysis was conducted for common items.

RESULTS

The response rate was 62.1% for ARs (n = 306) and 72.3% for PRs (n = 138). Only 23% of responding ARs (n = 69) reported caring for children with JIA. Of these, 94% strongly agreed/agreed feeling comfortable diagnosing JIA; however, only 76% felt comfortable treating JIA. Clinical vignettes highlighted several prescribing differences. Forty-eight percent of ARs and 31% of PRs felt medications to treat JIA did not have clear dosing guidelines. Though PRs initiated disease-modifying antirheumatic drugs and biologic agents earlier, treatments were similar after 3 months. To enhance co-management, 74% of pediatric respondents endorsed shared medical records.

CONCLUSION

Nearly one-quarter of surveyed ARs care for children with JIA, with most limiting their practice to older children. There was more discomfort in treating JIA than diagnosing it, and there were significant prescribing differences. Both provider types identified the need for better dosing and treatment resources. Updated management guidelines along with exposure to pediatric rheumatology in fellowship could reduce treatment differences and enhance the care of children with JIA. Shared medical records and improvement in reimbursement may optimize co-management.

The indications, efficacy and adverse events of rituximab in a large cohort of patients with juvenile-onset SLE

Background

B cells drive antibody formation and T cell activation. This study aimed to describe the clinical indications, efficacy and adverse events (AEs) for the B-cell depleting agent, rituximab, in a large cohort of children with lupus.

Methods

Prescribing records and the UK JSLE Cohort Study database identified rituximab use.

Results

Sixty-three patients received 104 courses of intravenous rituximab over a 10-year period. Patients were aged 12.2 (IQR 9.0–13.9) years at diagnosis and 50 (79%) were female. They had disease for 1.4 (0.2–3.0) years at the time of rituximab. Lupus nephritis was the most common indication (36% of first courses). Clinical biomarkers, 2.5 (1.6–4.3) months after treatment, demonstrated a statistically significant improvement in ESR, C3, C4, creatinine, albumin, haemoglobin, anti-dsDNA titres and urine albumin:creatinine ratio. IgG, IgA and IgM levels decreased ( p < 0.01). Oral corticosteroid dose significantly reduced after rituximab (dose before 0.26 (0.09–0.44) mg/kg, after 0.17 (0.09–0.30) mg/kg; p = 0.01)). AEs occurred in 19 (18%) of all courses including; delayed second dose (8%), Ig replacement (2%) and infusion reactions (6%; anaphylaxis 2%). The global BILAG score showed a trend toward improvement (before 4.5 (2.0–9.0), after 3.0 (2.0–5.0); p = 0.16).

Conclusion

Rituximab improves disease activity in children with lupus and serious AEs are infrequent. Controlled studies are required.

A severe case of chronic infantile neurologic, cutaneous, articular syndrome treated with biologic agents

In this report we describe a case of severe chronic infantile neurologic, cutaneous, articular (CINCA) syndrome with a novel G307V cryopyrin mutation and all of the characteristic clinical and laboratory features of this autoinflammatory disease. There was no clear response to standard therapies, including human interleukin-1 (IL-1) receptor antagonist (anakinra) and soluble tumor necrosis factor receptor (etanercept). The patient finally had a partial clinical response (reduction in fever and irritability) and complete laboratory response (improved C-reactive protein and serum amyloid A levels) to humanized anti-IL-6 receptor antibody (MRA), but died from congestive heart failure and interstitial pneumonia 2 months after initiation of therapy. We serially measured the serum cytokine levels and expression of NF-kappaB activation in the patient's peripheral blood mononuclear cells before and during consecutive therapies. Pathologic examination of autopsy specimens was also performed. This case illustrates the continued difficulty in management of patients with CINCA syndrome and the complexity of the inflammatory pathways in this disorder.

Juvenile idiopathic arthritis: why do I have to hurt so much?

In the current world of high-tech medicine, some individuals nevertheless experience immeasurable chronic pain daily. Among these are 60,000 to 70,000 children in the United States who have juvenile idiopathic arthritis. The children affected by this disease experience a decreased quality of life and sometimes blindness. Outcome severity in these cases is related directly to the amount of injury to bones, joints, soft tissue, and eyes at the time of diagnosis. There are not enough specialists to ensure timely diagnosis and medications, and although the symptoms of juvenile idiopathic arthritis are treatable, there is no cure. Until timely diagnosis and treatment can be ensured, pain and blindness will continue to be the daily experience of these children.

Recent developments in immunomodulatory peptides in juvenile rheumatic diseases: from trigger to dimmer?

PURPOSE OF REVIEW

Current therapy for juvenile rheumatic diseases is based on general immune suppression or blocking inflammatory pathways. These treatments do not induce long-term disease remission and have a risk of side effects; this is especially unfavorable in children. It is better to focus on induction of tolerance mechanisms than on suppression of inflammation. This promotes epitope specific immunotherapy as a possible safe treatment option.

RECENT FINDINGS

In the search for specific peptides for immunotherapy in autoimmunity, the focus is shifting from purported triggers of disease to peptides that regulate the ongoing inflammation. These so-called 'immunomodulatory peptides' are important in every healthy immune system. Several juvenile rheumatic diseases have been linked to certain immunomodulatory peptides. In juvenile dermatomyositis, peptides from human skeletal myosin play a role in the perpetuation of the disease. In systemic lupus erythematosus, the focus is mostly on DNA-derived peptides and peptides from anti-DNA antibodies. In juvenile idiopathic arthritis, heat shock proteins have been shown to contain important immunomodulatory epitopes.

SUMMARY

Immunomodulatory peptides play an important role in juvenile rheumatic diseases. Promising candidates for immunotherapy have been identified. This opens the possibility of clinical testing in rheumatic diseases of childhood.