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Polat MC, Çelikel E, Tekin ZE, Kurt T, Kaplan MM, Güngörer V, Tekgöz N, Sezer M, Karagöl C, Coşkun S, Öner N, Sezer S, Acar BÇ. When should the use of biological agents be considered in persistent oligoarticular juvenile idiopathic arthritis patients? Eur J Pediatr 2024:10.1007/s00431-024-05538-y. [PMID: 38554171 DOI: 10.1007/s00431-024-05538-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/19/2024] [Accepted: 03/21/2024] [Indexed: 04/01/2024]
Abstract
The purpose of this study was to compare the demographic and clinical characteristics of the groups with and without bDMARDs added to the treatment of persistent oligoarticular juvenile idiopathic arthritis (JIA) patients on methotrexate (MTX) and also to determine the predictors of adding bDMARDs to treatment. This study included 86 oligoarticular JIA patients on MTX. Patients were divided into two groups receiving MTX (n = 69) and MTX plus bDMARD (n = 17). Predictors of adding bDMARDs were investigated by comparing demographic, clinical features and laboratory findings. Gender, age at diagnosis, time elapsed from the onset of symptoms to diagnosis, and disease duration, the number and distribution of affected joint at the time of diagnosis were similar in both groups. The mean JADAS10 at the time of diagnosis were 18.8 ± 4.2 and 19.5 ± 6.4 in the MTX and MTX plus bDMARDs groups, respectively (p = 0.68). JADAS10 at 3rd and 6th month were significantly higher in patients on MTX plus bDMARDs (p = 0.001, p = 0.004, respectively). In multivariate analysis, the risk of adding bDMARD was shown to increase 1.24-fold (p = 0.004, 95% CI: 1.07-1.43) for each point increase on the JADAS 10 at 3rd months. The number (p = 0.64) or type (p = 0.18) of joint involvement at disease onset were not predictors of adding a bDMARD. CONCLUSION JADAS10 indicating ongoing severe disease activity at 3rd and 6th months rather than baseline JADAS10 is associated with the addition of bDMARDs. WHAT IS KNOWN • Oligoarticular JIA patients have the best outcomes among JIA categories and respond favorably to first-line therapies such as non-steroidal anti-inflammatory drugs and intraarticular corticosteroid injections. • Clinically inactive disease rates have increased with the widespread use of biological agents in oligoarticular JIA patients who have not responded to initial therapies. WHAT IS NEW • Approximately one-fifth of patients with persistent oligoarticular JIA on methotrexate may require the addition of a biological disease modifying anti-rheumatic drug during follow-up. • The JADAS10 calculated at 3 and 6 months is a valuable tool to identify patients who should be added biological disease modifying anti-rheumatic drugs in persistent oligoarticular JIA.
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Affiliation(s)
- Merve Cansu Polat
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey.
| | - Elif Çelikel
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
| | - Zahide Ekici Tekin
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
| | - Tuba Kurt
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
| | - Melike Mehveş Kaplan
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
| | - Vildan Güngörer
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
| | - Nilüfer Tekgöz
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
| | - Müge Sezer
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
| | - Cüneyt Karagöl
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
| | - Serkan Coşkun
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
| | - Nimet Öner
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
| | - Serdar Sezer
- Division of Rheumatology, Department of Internal Medicine, Ankara Training and Research Hospital, 06230-Altındağ, Ankara, Turkey
| | - Banu Çelikel Acar
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800-Bilkent, Ankara, Turkey
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2
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Wood S, Branch J, Vasquez P, DeGuzman MM, Brown A, Sagcal-Gironella AC, Singla S, Ramirez A, Vogel TP. Th17/1 and ex-Th17 cells are detected in patients with polyarticular juvenile arthritis and increase following treatment. Pediatr Rheumatol Online J 2024; 22:32. [PMID: 38431635 PMCID: PMC10908086 DOI: 10.1186/s12969-024-00965-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/11/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND A better understanding of the pathogenesis of polyarticular juvenile idiopathic arthritis (polyJIA) is needed to aide in the development of data-driven approaches to guide selection between therapeutic options. One inflammatory pathway of interest is JAK-STAT signaling. STAT3 is a transcription factor critical to the differentiation of inflammatory T helper 17 cells (Th17s). Previous studies have demonstrated increased STAT3 activation in adult patients with rheumatoid arthritis, but less is known about STAT3 activation in polyJIA. We hypothesized that Th17 cells and STAT3 activation would be increased in treatment-naïve polyJIA patients compared to pediatric controls. METHODS Blood from 17 patients with polyJIA was collected at initial diagnosis and again if remission was achieved (post-treatment). Pediatric healthy controls were also collected. Peripheral blood mononuclear cells were isolated and CD4 + T cell subsets and STAT activation (phosphorylation) were evaluated using flow cytometry. Data were analyzed using Mann-Whitney U and Wilcoxon matched-pairs signed rank tests. RESULTS Treatment-naïve polyJIA patients had increased Th17 cells (CD3 + CD4 + interleukin(IL)-17 +) compared to controls (0.15% v 0.44%, p < 0.05), but Tregs (CD3 + CD4 + CD25 + FOXP3 +) from patients did not differ from controls. Changes in STAT3 phosphorylation in CD4 + T cells following ex vivo stimulation were not significantly different in patients compared to controls. We identified dual IL-17 + and interferon (IFN)γ + expressing CD4 + T cells in patients, but not controls. Further, both Th17/1 s (CCR6 + CD161 + IFNγ + IL-17 +) and ex-Th17s (CCR6 + CD161 + IFNγ + IL-17neg) were increased in patients' post-treatment (Th17/1: 0.3% v 0.07%, p < 0.05 and ex-Th17s: 2.3% v 1.4%, p < 0.05). The patients with the highest IL-17 expressing cells post-treatment remained therapy-bound. CONCLUSIONS Patients with polyJIA have increased baseline Th17 cells, potentially reflecting higher tonic STAT3 activation in vivo. These quantifiable immune markers may identify patients that would benefit upfront from pathway-focused biologic therapies. Our data also suggest that inflammatory CD4 + T cell subsets not detected in controls but increased in post-treatment samples should be further evaluated as a tool to stratify patients in remission on medication. Future work will explore these proposed diagnostic and prognostic biomarkers.
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Affiliation(s)
- Stephanie Wood
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA
- Center for Human Immunobiology, Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA
| | - Justin Branch
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA
- Center for Human Immunobiology, Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA
| | - Priscilla Vasquez
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA
| | - Marietta M DeGuzman
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA
| | - Amanda Brown
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA
| | - Anna Carmela Sagcal-Gironella
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA
| | - Saimun Singla
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA
| | - Andrea Ramirez
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA
| | - Tiphanie P Vogel
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA.
- Center for Human Immunobiology, Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA.
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3
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Spekking K, Anink J, de Boer P, Bergstra SA, van den Berg JM, Schonenberg-Meinema D, van Suijlekom-Smit LWA, van Rossum MAJ, Koopman-Keemink Y, Cate RT, Allaart CF, Brinkman DMC, Muller PCEH. Significant pain decrease in children with non-systemic Juvenile Idiopathic Arthritis treated to target: results over 24 months of follow up. Pediatr Rheumatol Online J 2023; 21:90. [PMID: 37633893 PMCID: PMC10464062 DOI: 10.1186/s12969-023-00874-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/06/2023] [Indexed: 08/28/2023] Open
Abstract
BACKGROUND The aim of this study was to compare pain-scores in three targeted treatment-strategies in JIA-patients and to identify characteristics predicting persistent pain. METHODS In the BeSt-for-Kids-study 92 DMARD-naïve JIA-patients were randomized in 3 treatment-strategies: 1) initial sequential DMARD-monotherapy 2) initial methotrexate (MTX)/prednisolone-bridging or 3) initial MTX/etanercept. Potential differences in VAS pain scores (0-100 mm) over time between treatment-strategies were compared using linear mixed models with visits clustered within patients. A multivariable model was used to assess the ability of baseline characteristics to predict the chance of high pain-scores during follow-up. RESULTS Pain-scores over time reduced from mean 55.3 (SD 21.7) to 19.5 (SD 25.3) mm after 24 months. On average, pain-scores decreased significantly with β -1.37 mm (95% CI -1.726; -1.022) per month. No significant difference was found between treatment-strategies (interaction term treatment arm*time (months) β (95% CI) arm 1: 0.13 (-0.36; 0.62) and arm 2: 0.37 (-0.12; 0.86) compared to arm 3). Correction for sex and symptom duration yielded similar results. Several baseline characteristics were predictive for pain over time. Higher VAS pain [β 0.44 (95% CI 0.25; 0.65)] and higher active joint count [0.77 (0.19; 1.34)] were predictive of higher pain over time, whereas, low VAS physician [ -0.34 (-0.55; -0.06)], CHQ Physical [ -0.42 (-0.72; -0.11)] and Psychosocial summary Score [ -0.42 (-0.77; -0.06)] were predictive of lower pain. CONCLUSIONS Treatment-to-target seems effective in pain-reduction in non-systemic JIA-patients irrespective of initial treatment-strategy. Several baseline-predictors for pain over time were found, which could help to identify patients with a high risk for development of chronic pain. TRIAL REGISTRATION Dutch Trial Registry number 1574.
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Affiliation(s)
- Katinka Spekking
- Department of Pediatrics, Division of Pediatric Rheumatology, Willem-Alexander Children's Hospital, Leiden, The Netherlands.
| | - Janneke Anink
- De Kinderkliniek, Flevo Hospital, Almere, The Netherlands
| | - Piroska de Boer
- Department of Pediatrics, Division of Pediatric Rheumatology, Willem-Alexander Children's Hospital, Leiden, The Netherlands
| | - Sytske Anne Bergstra
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - J Merlijn van den Berg
- Department of Pediatric Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Dieneke Schonenberg-Meinema
- Department of Pediatric Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Lisette W A van Suijlekom-Smit
- Department of Pediatrics/Pediatric Rheumatology, Sophia Children's Hospital Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marion A J van Rossum
- Department of Pediatrics, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Department of Pediatric Rheumatology, Amsterdam Rheumatology and Immunology Center | Reade, Amsterdam, The Netherlands
| | - Yvonne Koopman-Keemink
- Department of Pediatrics, Juliana Children's Hospital, Hagaziekenhuis, the Hague, The Netherlands
| | - Rebecca Ten Cate
- Department of Pediatrics, Division of Pediatric Rheumatology, Willem-Alexander Children's Hospital, Leiden, The Netherlands
| | - Cornelia F Allaart
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Daniëlle M C Brinkman
- Department of Pediatrics, Division of Pediatric Rheumatology, Willem-Alexander Children's Hospital, Leiden, The Netherlands
| | - Petra C E Hissink Muller
- Department of Pediatrics, Division of Pediatric Rheumatology, Willem-Alexander Children's Hospital, Leiden, The Netherlands
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4
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van Til JA, Kip MMA, Schatorjé EJH, Currie G, Twilt M, Benseler SM, Swart JF, Vastert SJ, Wulffraat N, Yeung RSM, Groothuis-Oudshoorn CGMK, Warta S, Marshall DA, IJzerman MJ. Withdrawing biologics in non-systemic JIA: what matters to pediatric rheumatologists? Pediatr Rheumatol Online J 2023; 21:69. [PMID: 37434157 DOI: 10.1186/s12969-023-00845-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/15/2023] [Indexed: 07/13/2023] Open
Abstract
OBJECTIVE Approximately one third of children with JIA receive biologic therapy, but evidence on biologic therapy withdrawal is lacking. This study aims to increase our understanding of whether and when pediatric rheumatologists postpone a decision to withdraw biologic therapy in children with clinically inactive non-systemic JIA. METHODS A survey containing questions about background characteristics, treatment patterns, minimum treatment time with biologic therapy, and 16 different patient vignettes, was distributed among 83 pediatric rheumatologists in Canada and the Netherlands. For each vignette, respondents were asked whether they would withdraw biologic therapy at their minimum treatment time, and if not, how long they would continue biologic therapy. Statistical analysis included descriptive statistics, logistic and interval regression analysis. RESULTS Thirty-three pediatric rheumatologists completed the survey (40% response rate). Pediatric rheumatologists are most likely to postpone the decision to withdraw biologic therapy when the child and/or parents express a preference for continuation (OR 6.3; p < 0.001), in case of a flare in the current treatment period (OR 3.9; p = 0.001), and in case of uveitis in the current treatment period (OR 3.9; p < 0.001). On average, biologic therapy withdrawal is initiated 6.7 months later when the child or parent prefer to continue treatment. CONCLUSION Patient's and parents' preferences were the strongest driver of a decision to postpone biologic therapy withdrawal in children with clinically inactive non-systemic JIA and prolongs treatment duration. These findings highlight the potential benefit of a tool to support pediatric rheumatologists, patients and parents in decision making, and can help inform its design.
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Affiliation(s)
- Janine A van Til
- Department of Health Technology & Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, P.O. Box 217, Enschede, AE, The Netherlands
| | - Michelle M A Kip
- Department of Health Technology & Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, P.O. Box 217, Enschede, AE, The Netherlands
- Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Ellen J H Schatorjé
- Department of Paediatric Rheumatology, St. Maartenskliniek, Nijmegen, the Netherlands
- Department of Paediatric Rheumatology and Immunology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gillian Currie
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Marinka Twilt
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Division of Rheumatology, Department of Pediatrics, Cumming School of Medicine, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Susanne M Benseler
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Division of Rheumatology, Department of Pediatrics, Cumming School of Medicine, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Joost F Swart
- Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
- Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
- European Reference Network RITA (rare immunodeficiency autoinflammatory and autoimmune diseases network), Utrecht, The Netherlands
| | - Sebastiaan J Vastert
- Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
- Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
- European Reference Network RITA (rare immunodeficiency autoinflammatory and autoimmune diseases network), Utrecht, The Netherlands
| | - Nico Wulffraat
- Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
- Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
- European Reference Network RITA (rare immunodeficiency autoinflammatory and autoimmune diseases network), Utrecht, The Netherlands
| | - Rae S M Yeung
- Division of Rheumatology, The Hospital for Sick Children, Department of Paediatrics, Immunology and Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - C G M Karin Groothuis-Oudshoorn
- Department of Health Technology & Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, P.O. Box 217, Enschede, AE, The Netherlands
| | - Sanne Warta
- Department of Health Technology & Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, P.O. Box 217, Enschede, AE, The Netherlands
| | - Deborah A Marshall
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Division of Rheumatology, Department of Pediatrics, Cumming School of Medicine, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Maarten J IJzerman
- Department of Health Technology & Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, P.O. Box 217, Enschede, AE, The Netherlands.
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5
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Mannion ML, Xie F, Beukelman T. Investigation of Inactive Disease States Among Patients With Juvenile Idiopathic Arthritis in the Childhood Arthritis and Rheumatology Research Alliance Registry. ACR Open Rheumatol 2022; 4:825-831. [PMID: 35841332 PMCID: PMC9469475 DOI: 10.1002/acr2.11485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/01/2022] [Accepted: 06/15/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
| | - Fenglong Xie
- University of Alabama at Birmingham Birmingham AL USA
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6
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García-Fernández A, Briones-Figueroa A, Calvo-Sanz L, Andreu-Suárez Á, Boteanu A. Evaluation of flare rate and reduction strategies for bDMARDs in juvenile idiopathic arthritis: real world data from a single-centre cohort. Rheumatol Int 2022; 42:1133-1142. [PMID: 35304642 DOI: 10.1007/s00296-022-05108-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 03/01/2022] [Indexed: 11/26/2022]
Abstract
This study aimed to determine the flare rate (FR) in a cohort of Juvenile Idiopathic Arthritis (JIA) patients with tapered or abruptly discontinued biologic disease-modifying anti-rheumatic drugs (bDMARDs) and to identify predictors of flare. This retrospective observational study included 191 bDMARD dose-reduction events in patients with JIA followed-up at a referral hospital during the period 2000-2019. FR was analysed according to reduction strategies. To identify predictors of flare, Kaplan-Meier and Cox-regression models were plotted at 6 months (6 m), 12 months (12 m) and 24 months (24 m) following tapering (TP) or withdrawal (WD). 165 episodes of TP and 71 episodes of WD were included; 45 episodes where treatment was withdrawn after TP were included in both strategies. FR after TP was 13.4% at 6 m and increased up to 26.6% at 12 m and 51.4% at 24 m. After WD, FR was higher, 52.1% of events had a flare at 6 m and 67.6% at 12 m. Previous TP did not increase time in remission after WD of bDMARDs in the Kaplan-Meier analysis. Factors associated with flares were identified after TP at 6 m: female sex, higher number of previous bDMARDs and longer time on bDMARD treatment were positively associated with flares. Polyarticular subtype and younger age at diagnosis were associated with flares at 12 and 24 m after TP. No factors were identified in multivariable analysis after WD. TP is a successful strategy to maintain remission with lower bDMARD doses. Previous TP of bDMARDs does not seem to increase time in remission after WD.
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Affiliation(s)
- Antía García-Fernández
- Rheumatology Unit, Hospital Universitario Ramón y Cajal, Carretera de Colmenar Viejo 9, 1 km, 28034, Madrid, Spain.
| | - Andrea Briones-Figueroa
- Rheumatology Unit, Hospital Universitario Ramón y Cajal, Carretera de Colmenar Viejo 9, 1 km, 28034, Madrid, Spain
| | - Laura Calvo-Sanz
- Rheumatology Unit, Hospital Universitario Ramón y Cajal, Carretera de Colmenar Viejo 9, 1 km, 28034, Madrid, Spain
| | - África Andreu-Suárez
- Rheumatology Unit, Hospital Universitario Ramón y Cajal, Carretera de Colmenar Viejo 9, 1 km, 28034, Madrid, Spain
| | - Alina Boteanu
- Rheumatology Unit, Hospital Universitario Ramón y Cajal, Carretera de Colmenar Viejo 9, 1 km, 28034, Madrid, Spain
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7
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Gerss J, Tedy M, Klein A, Horneff G, Miranda-Garcia M, Kessel C, Holzinger D, Stanevica V, Swart JF, Cabral DA, Brunner HI, Foell D. Prevention of disease flares by risk-adapted stratification of therapy withdrawal in juvenile idiopathic arthritis: results from the PREVENT-JIA trial. Ann Rheum Dis 2022; 81:990-997. [PMID: 35260388 PMCID: PMC9209679 DOI: 10.1136/annrheumdis-2021-222029] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/24/2022] [Indexed: 12/01/2022]
Abstract
Objectives To investigate the ability of high-sensitivity C-reactive protein (hsCRP) and S100A12 to serve as predictive biomarkers of successful drug withdrawal in children with clinical remission of juvenile idiopathic arthritis (JIA). Methods This multicentre trial (PREVENT-JIA) enrolled 119 patients with JIA in clinical remission, and 100 patients reached the intervention phase in which the decision whether to continue or stop treatment was based on S100A12 and hsCRP levels. Patients were monitored for 12 months after stopping medication for flares of disease. Results were compared with withdrawal of therapy without biomarker-based stratification in patients from the German Biologika in der Kinderrheumatologie (BiKeR) pharmacovigilance registry. Results In the PREVENT-JIA group, 49 patients had a flare, and 45% of patients stopping medication showed flares within the following 12 months. All patients (n=8) continuing therapy due to permanently elevated S100A12/hsCRP at more than one visit flared during the observation phase. In the BiKeR control group, the total flare rate was 62%, with 60% flaring after stopping medication. The primary outcome, time from therapy withdrawal to first flare (cumulative flare rate after therapy withdrawal), showed a significant difference in favour of the PREVENT-JIA group (p=0.046; HR 0.62, 95% CI 0.38 to 0.99). As additional finding, patients in the PREVENT-JIA trial stopped therapy significantly earlier. Conclusion Biomarker-guided strategies of therapy withdrawal are feasible in clinical practice. This study demonstrates that using predictive markers of subclinical inflammation is a promising tool in the decision-making process of therapy withdrawal, which translates into direct benefit for patients. Trial registration number ISRCTN69963079.
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Affiliation(s)
- Joachim Gerss
- Interdisciplinary Center of Clinical Research, University of Münster, Munster, Germany.,Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Monika Tedy
- Department of Pediatric Rheumatology and Immunology, University Hospital Munster, Munster, Germany
| | - Ariane Klein
- Asklepios Children's Hospital, Sankt Augustin, Germany
| | - Gerd Horneff
- Pediatrics, Asklepios Clinic Sankt Augustin, Sankt Augustin, Germany
| | - Maria Miranda-Garcia
- Department of Pediatric Rheumatology and Immunology, University Hospital Munster, Munster, Germany
| | - Christoph Kessel
- Department of Pediatric Rheumatology and Immunology, University Hospital Munster, Munster, Germany
| | - Dirk Holzinger
- Department of Pediatric Hematology-Oncology, University of Duisburg-Essen, Essen, Germany
| | - Valda Stanevica
- Department of Pediatrics, Riga Stradins University, Riga, Latvia
| | - Joost F Swart
- Pediatric Immunology, Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - David A Cabral
- Pediatric Rheumatology, BC Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Hermine I Brunner
- Division of Rheumatology, University of Cincinnati, Cincinnati Children's Hospital Medical Center, PRCSG Coordinating Center, Cincinnati, Ohio, USA
| | - Dirk Foell
- Interdisciplinary Center of Clinical Research, University of Münster, Munster, Germany .,Department of Pediatric Rheumatology and Immunology, University Hospital Munster, Munster, Germany
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8
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Castillo-Vilella M, Giménez N, Tandaipan JL, Quintana S, Modesto C. Clinical remission and subsequent relapse in patients with juvenile idiopathic arthritis: predictive factors according to therapeutic approach. Pediatr Rheumatol Online J 2021; 19:130. [PMID: 34419078 PMCID: PMC8380331 DOI: 10.1186/s12969-021-00607-0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/31/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Juvenile idiopathic arthritis constitutes a significant cause of disability and quality of life impairment in pediatric and adult patients. The aim of this study was to ascertain clinical remission (CR) and subsequent relapse in juvenile idiopathic arthritis (JIA) patients, according to therapeutic approach and JIA subtype. Evidence in literature regarding its predictors is scarce. METHODS We conducted an observational, ambispective study. Patients diagnosed of JIA, treated with synthetic and/or biologic disease modifying antirheumatic drugs (DMARD) were included and followed-up to December 31st, 2015. Primary outcome was clinical remission defined by Wallace criteria, both on and off medication. In order to ascertain CR according to therapeutic approach, DMARD treatments were divided in four groups: 1) synthetic DMARD (sDMARD) alone, 2) sDMARD combined with another sDMARD, 3) sDMARD combined with biologic DMARD (bDMARD), and 4) bDMARD alone. RESULTS A total of 206 patients who received DMARD treatment were included. At the time the follow-up was completed, 70% of the patients in the cohort had attained CR at least once (144 out of 206), and 29% were in clinical remission off medication (59 out of 206). According to treatment group, CR was more frequently observed in patients treated with synthetic DMARD alone (53%). Within this group, CR was associated with female sex, oligoarticular persistent subtypes, ANA positivity, Methotrexate treatment and absence of HLA B27, comorbidities and DMARD toxicity. 124 DMARD treatments (62%) were withdrawn, 64% of which relapsed. Lower relapse rates were observed in those patients with persistent oligoarticular JIA (93%) when DMARD dose was tapered before withdrawal (77%). CONCLUSIONS More than two thirds of JIA patients attained CR along the 9 years of follow-up, and nearly one third achieved CR off medication. Females with early JIA onset, lower active joint count and ANA positivity were the ones achieving and sustaining remission more frequently, especially when receiving synthetic DMARD alone and in the absence of HLA B27, comorbidities or previous DMARD toxicity.
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Affiliation(s)
- Mireia Castillo-Vilella
- Department of Rheumatology, Hospital UniversitariSagrat Cor, C/ Londres, 28-38 3rd floor, 08029, Barcelona, Spain. .,Department of Rheumatology, Hospital UniversitariMútua Terrassa, Terrassa, Spain. .,Department of Rheumatology, Pediatric Rheumatology Unit, Hospital UniversitariValld'Hebrón, Barcelona, Spain. .,Departament de Farmacologia, Terapèutica i Toxicologia, UniversitatAutònoma de Barcelona, Barcelona, Spain.
| | - Nuria Giménez
- grid.5841.80000 0004 1937 0247Departament de Farmacologia, Terapèutica i Toxicologia, UniversitatAutònoma de Barcelona, Barcelona, Spain ,grid.5841.80000 0004 1937 0247Research Unit, University Hospital of Mútua Terrassa, Research Foundation Mútua Terrassa, Universitat de Barcelona, Barcelona, Spain ,grid.477342.1Hospital Sant Jaume de Calella, Laboratori de Referència de Catalunya i Corporació de Salut del Maresme i la Selva, Barcelona, Spain
| | - Jose Luis Tandaipan
- Department of Rheumatology, Hospital UniversitariMútua Terrassa, Terrassa, Spain ,grid.413396.a0000 0004 1768 8905Departament of Rheumatology and Systemic Autoimmune Diseases, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain ,grid.7080.fDepartament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Consuelo Modesto
- Department of Rheumatology, Pediatric Rheumatology Unit, Hospital UniversitariValld’Hebrón, Barcelona, Spain ,grid.411232.70000 0004 1767 5135Department of Rheumatology, Hospital Universitario de Cruces, Barakaldo, Spain
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9
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Sur LM, Gaga R, Duca E, Sur G, Lupan I, Sur D, Samasca G, Lazea C, Lazar C. Different Chronic Disorders That Fall within the Term Juvenile Idiopathic Arthritis. Life (Basel) 2021; 11:life11050398. [PMID: 33925491 PMCID: PMC8146979 DOI: 10.3390/life11050398] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 04/26/2021] [Indexed: 12/12/2022] Open
Abstract
Juvenile idiopathic arthritis (JIA) represents a significant challenge for pediatricians who intend to diagnose and treat this pathology. The classification criteria for JIA subtypes are rigid and often do not fully satisfy the possibilities of classification in the subtype. The objective of this study was to identify clearer criteria for classifying JIA subtypes. The 2019 expert committee meeting (PRINTO) shows the difficulties of this classification and proposes new research directions for the identification of disease subtypes. Four different chronic disorders are used to define JIA in a concise and easy to follow classification system. However, dates from the literature suggest that at least 10% of cases are still difficult to classify. Possibly in the future, different classifications of JIA based on pathophysiological and genetic criteria would be necessary.
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Affiliation(s)
- Lucia M. Sur
- Department Pediatrics I, University of Medicine and Pharmacology “Iuliu Hațieganu”, 3400 Cluj-Napoca, Romania; (L.M.S.); (C.L.); (C.L.)
- Pediatrics I Department, Emergency Clinical Hospital for Children, 3400 Cluj-Napoca, Romania
| | - Remus Gaga
- Pediatrics II Department, Emergency Clinical Hospital for Children, 3400 Cluj-Napoca, Romania; (R.G.); (E.D.); (G.S.)
| | - Emanuela Duca
- Pediatrics II Department, Emergency Clinical Hospital for Children, 3400 Cluj-Napoca, Romania; (R.G.); (E.D.); (G.S.)
| | - Genel Sur
- Pediatrics II Department, Emergency Clinical Hospital for Children, 3400 Cluj-Napoca, Romania; (R.G.); (E.D.); (G.S.)
| | - Iulia Lupan
- Molecular Biology Department, Babes Bolyai University, 3400 Cluj-Napoca, Romania;
| | - Daniel Sur
- The Oncology Institute “Prof. Dr. Ion Chiricuta”, 3400 Cluj-Napoca, Romania;
| | - Gabriel Samasca
- Department Pediatrics I, University of Medicine and Pharmacology “Iuliu Hațieganu”, 3400 Cluj-Napoca, Romania; (L.M.S.); (C.L.); (C.L.)
- Correspondence: ; Tel.: +40-(264)-532216
| | - Cecilia Lazea
- Department Pediatrics I, University of Medicine and Pharmacology “Iuliu Hațieganu”, 3400 Cluj-Napoca, Romania; (L.M.S.); (C.L.); (C.L.)
| | - Calin Lazar
- Department Pediatrics I, University of Medicine and Pharmacology “Iuliu Hațieganu”, 3400 Cluj-Napoca, Romania; (L.M.S.); (C.L.); (C.L.)
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10
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Kip MMA, de Roock S, Currie G, Marshall DA, Grazziotin LR, Twilt M, Yeung RSM, Benseler SM, Schreijer MA, Vastert SJ, Wulffraat N, van Royen-Kerkhof A, Swart JF, IJzerman MJ. Costs of medication use among patients with juvenile idiopathic arthritis in the Dutch healthcare system. Expert Rev Pharmacoecon Outcomes Res 2020; 21:975-984. [PMID: 33243033 DOI: 10.1080/14737167.2021.1857241] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background: This study aims to quantify medication costs in juvenile idiopathic arthritis (JIA), based on subtype.Research design and methods: This study is a single-center, retrospective analysis of prospective data from electronic medical records of JIA patients, aged 0-18 years between 1 April 2011 and 31 March 2019. Patient characteristics (age, gender, subtype) and medication use were extracted. Medication use and costs were reported as: 1) mean total annual costs; 2) between-patient heterogeneity in these costs; 3) duration of medication use; and, 4) costs over the treatment course.Results: The analysis included 691 patients. Mean total medication costs were €2,103/patient/year, including €1,930/patient/year (91.8%) spent on biologicals. Costs varied considerably between subtypes, with polyarticular rheumatoid-factor positive and systemic JIA patients having the highest mean costs (€5,020/patient/year and €4,790/patient/year, respectively). Mean annual medication costs over the patient's treatment course ranged from <€1,000/year (71.1% of patients) to >€11,000/year (2.5% of patients). Etanercept and adalimumab were the most commonly used biologicals. Cost fluctuations over the treatment course were primarily attributable to biological use.Conclusions: Polyarticular rheumatoid-factor positive and systemic JIA patients had the highest mean total annual medication costs, primarily attributable to biologicals. Costs varied considerably between subtypes, individuals, and over the treatment course.
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Affiliation(s)
- Michelle M A Kip
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands.,UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases)
| | - Sytze de Roock
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands.,Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
| | - Gillian Currie
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Deborah A Marshall
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Luiza R Grazziotin
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marinka Twilt
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Division of Rheumatology, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rae S M Yeung
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Division of Rheumatology, the Hospital for Sick Children, Department of Paediatrics, Immunology and Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Susanne M Benseler
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Division of Rheumatology, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Maud A Schreijer
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Sebastiaan J Vastert
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands.,Faculty of Medicine, Utrecht University, Utrecht, The Netherlands.,European Reference Network RITA (Rare Immunodeficiency Autoinflammatory and Autoimmune Diseases Network)
| | - Nico Wulffraat
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands.,Faculty of Medicine, Utrecht University, Utrecht, The Netherlands.,European Reference Network RITA (Rare Immunodeficiency Autoinflammatory and Autoimmune Diseases Network)
| | - Annet van Royen-Kerkhof
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands.,Faculty of Medicine, Utrecht University, Utrecht, The Netherlands.,European Reference Network RITA (Rare Immunodeficiency Autoinflammatory and Autoimmune Diseases Network)
| | - Joost F Swart
- UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands.,Faculty of Medicine, Utrecht University, Utrecht, The Netherlands.,European Reference Network RITA (Rare Immunodeficiency Autoinflammatory and Autoimmune Diseases Network)
| | - Maarten J IJzerman
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands.,UCAN CAN-DU network (Canada-Netherlands Personalized Medicine Network in Childhood Arthritis and Rheumatic Diseases).,University of Melbourne, Melbourne School of Population and Global Health, Parkville, Melbourne, Australia
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