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Sunar Yayla EN, Yıldız Ç, Esmeray Şenol P, Karaçayır N, Gezgin Yıldırım D, Bakkaloğlu SA. How Safe Are Biological Agents in Pediatric Rheumatology? Turk Arch Pediatr 2024; 59:185-192. [PMID: 38454228 PMCID: PMC11059757 DOI: 10.5152/turkarchpediatr.2024.23221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 02/06/2024] [Indexed: 03/09/2024]
Abstract
OBJECTIVE Biologic therapy has changed the prognosis of patients with rheumatologic disease. Despite all benefits of the biological agents, adverse events may occur due to their long-term use. The aim of this study is to analyze the adverse events observed in pediatric patients who received biological treatment. MATERIALS AND METHODS This retrospective observational cohort study was conducted between January 2010 and January 2022. File records of 139 patients used biological agents for rheumatologic diseases in a pediatric rheumatology clinic were evaluated. Diagnosis, received treatment, the rationale for stopping treatment, requirement of tuberculosis prophylaxis, presence of an adverse event, and results were recorded. RESULTS The most used biological therapy was etanercept (41.7%). Anakinra, adalimumab, canakinumab were used in 30.9%, 27.3%, 23.7% of patients, and the others in less than 10%. Totally 491 adverse events (97.9/100 patient-years) were encountered during the duration of biological treatment. The most often adverse event was recurrent upper respiratory tract infection in the patients (31.9/100 patient-years). Elevated aminotransferase levels (10.4/100 patient-years), abdominal pain (7/100 patient-years), and headache (5.2/100 patient-years) were among the other common side effects. Isoniazid (INH) prophylaxis was needed before biological treatment in 20.9% of the patients. Tuberculosis developed in none of the patients followed-up for latent tuberculosis, however, it developed in a patient while receiving etanercept due to noncompliance with his scheduled outpatient visits during etanercept treatment. CONCLUSION The most commonly used biological treatments were TNFi and IL-antagonists, and the majority of side effects were infections and laboratory abnormalities. Although the rate of serious adverse events is quite low, close follow-up of patients receiving biological therapy is very important.
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Affiliation(s)
- Emine Nur Sunar Yayla
- Division of Pediatric Rheumatology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
- Clinic of Pediatric Rheumatology, Ankara Etlik City Hospital, Ankara, Turkey
| | - Çisem Yıldız
- Division of Pediatric Rheumatology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Pelin Esmeray Şenol
- Division of Pediatric Rheumatology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Nihal Karaçayır
- Division of Pediatric Rheumatology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Deniz Gezgin Yıldırım
- Division of Pediatric Rheumatology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Sevcan A. Bakkaloğlu
- Division of Pediatric Rheumatology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
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Wickenheisser NE, Craig AM, Kuller JA, Dotters-Katz SK. The Risks and Benefits of Monoclonal Antibody Therapy During Pregnancy and Postpartum: Maternal, Obstetric, and Neonatal Considerations. Obstet Gynecol Surv 2023; 78:429-437. [PMID: 37480293 DOI: 10.1097/ogx.0000000000001155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
Importance Autoimmune and rheumatologic conditions can lead to multiple adverse maternal, obstetric, and neonatal outcomes, especially if they flare during pregnancy. Although many medications to control these conditions exist, concerns regarding their safety often unnecessarily limit their use. Objective We aim to review the current evidence available describing the use of monoclonal antibody (mAb) therapeutics in pregnancy and postpartum and understand the impact of their use on the developing fetus and neonate. Evidence Acquisition Original research articles, review articles, case series and case reports, and pregnancy guidelines were reviewed. Results Multiple retrospective (including 1924 patients) and prospective studies (including 899 patients) of anti-tumor necrosis factor (TNF) agent use in pregnancy found no significant increase in rates of miscarriage, preterm birth, or congenital anomalies compared with controls. Most societies, including American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine, recommend initiation or continuation of TNF-α inhibitors during pregnancy for patients with autoimmune diseases. An increased risk of mild infections in newborns has been reported, although infections requiring hospitalizations are rare. Data suggest that breastfeeding while taking anti-TNF agents is safe for neonates. Less data exist for the use of other mAbs including anticytokine, anti-integrin, and anti-B-cell agents during pregnancy and postpartum. Conclusions and Relevance Current evidence suggests that the use of mAbs, particularly anti-TNF agents, is safe in pregnancy and postpartum, without significant adverse effects on the pregnant patient or infant. The benefits of ongoing disease control in pregnant patients result in favorable maternal and neonatal outcomes.
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Affiliation(s)
| | | | | | - Sarah K Dotters-Katz
- Associate Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC
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Abstract
In inflammatory rheumatic disorders, the immune system attacks and damages the connective tissues and invariably internal organs. During the past decade, remarkable advances having been made towards our understanding on the cellular and molecular mechanisms involved in rheumatic diseases. The discovery of IL-23/IL-17 axis and the delineation of its important role in the inflammation led to the introduction of many needed new therapeutic tools. We will present an overview of the rationale for targeting therapeutically the IL-23/IL-17 axis in rheumatic diseases and the clinical benefit which has been realized so far. Finally, we will discuss the complex interrelationship between IL-23 and IL-17 and the possible uncoupling in certain disease settings.
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Kim M, Won JY, Choi SY, Ju JH, Park YH. Anti-TNFα Treatment for HLA-B27-Positive Ankylosing Spondylitis-Related Uveitis. Am J Ophthalmol 2016; 170:32-40. [PMID: 27470062 DOI: 10.1016/j.ajo.2016.07.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/09/2016] [Accepted: 07/18/2016] [Indexed: 12/17/2022]
Abstract
PURPOSE To assess the long-term efficacy of the most widely used anti-tumor necrosis factor alpha (TNFα) agents for treatment of HLA-B27-positive ankylosing spondylitis (AS)-related uveitis. DESIGN Retrospective cohort study. METHODS The medical records of 143 patients with HLA-B27-positive AS who visited Seoul St. Mary's Hospital and were taking an anti-TNFα agent for at least 1 year were studied. Subjects were divided into 3 groups according to anti-TNFα treatment: Group 1 (infliximab, 66), Group 2 (adalimumab, 45), and Group 3 (etanercept, 32). RESULTS Mean age was 41.0 ± 13.0 years, and 97 patients (67.8%) were male. Mean follow-up period was 70.6 ± 37.9 months. In cases of active ocular inflammation at the onset of anti-TNFα treatment, patients showed improved activity of uveitis after 24.0 ± 15.0 days (Group 1), 17.9 ± 6.0 days (Group 2), and 25.9 ± 18.0 days (Group 3). After the anti-TNFα treatment, 71 of 94 patients (32 [76.2%] in Group 1, 26 [78.8%] in Group 2, and 13 [68.4%] in Group 3) remained without uveitis relapse. A reduction in the number of systemic medications was achieved in 129 patients (90.2%). Twenty-eight cases of minor side effects were observed, and 4 cases were tuberculosis leading to discontinuation of anti-TNFα treatment. CONCLUSIONS Infliximab, adalimumab, and etanercept were effective for treating and reducing the number of uveitis relapses in HLA-B27-positive AS. However, the risk of serious infections was noted, so ophthalmologists should consider the possibility that prolonged use of biologic agents may result in systemic side effects.
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Affiliation(s)
- Mirinae Kim
- Department of Ophthalmology and Visual Science, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jae-Yon Won
- Department of Ophthalmology and Visual Science, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seung Yong Choi
- Department of Ophthalmology and Visual Science, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Ji Hyeon Ju
- Department of Rheumatology, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Young-Hoon Park
- Department of Ophthalmology and Visual Science, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
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Szczerba B, Rybakowska P, Dey P, Payerhin K, Peck A, Bagavant H, Deshmukh U. Type I interferon receptor deficiency prevents murine Sjogren's syndrome. J Dent Res 2013; 92:444-9. [PMID: 23533183 PMCID: PMC3627507 DOI: 10.1177/0022034513483315] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 02/09/2013] [Accepted: 02/27/2013] [Indexed: 01/05/2023] Open
Abstract
In Sjögren's Syndrome (SS), inherent glandular defects, autoimmunity, and mononuclear cell infiltration within the salivary glands cause reduced salivation leading to xerostomia. Excessive production of type I interferons (IFN), triggered by environmental and genetic factors, is considered pathogenic in this disorder. However, whether type I IFN production is causative or an outcome of the disease process is not known. To address this question, we introduced a deficiency of interferon alpha receptor 1 (Ifnar1) into B6.Aec1Aec2 mice, which are known to have the genetic loci necessary for developing a SS-like disorder. This new mouse strain, B6.Aec1Aec2Ifnar1 (-/-), lacking type I IFN-mediated signaling, was characterized for pilocarpine-induced salivation, the presence of serum autoantibodies, sialoadenitis, and dacryoadenitis. Compared with the B6.Aec1Aec2Ifnar1 (+/+) (wild-type) mice, the B6.Aec1Aec2Ifnar1 (-/-) (knockout) mice had significantly lower mononuclear cell infiltration in the salivary and lacrimal glands. The knockout mice were completely protected from salivary gland dysfunction. Surprisingly, they had a robust autoantibody response comparable with that of the wild-type mice. These findings demonstrate that, in the absence of type I IFN-mediated signaling, systemic autoantibody responses can be dissociated from glandular pathology. Our study suggests that, in genetically susceptible individuals, the type I IFN pathway can instigate certain features of SS.
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Affiliation(s)
- B.M Szczerba
- Division of Nephrology, Center for Immunity Inflammation and Regenerative Medicine
| | - P.D Rybakowska
- Division of Nephrology, Center for Immunity Inflammation and Regenerative Medicine
| | - P. Dey
- Division of Nephrology, Center for Immunity Inflammation and Regenerative Medicine
| | - K.M. Payerhin
- Division of Nephrology, Center for Immunity Inflammation and Regenerative Medicine
| | - A.B. Peck
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL
| | - H. Bagavant
- Division of Nephrology, Center for Immunity Inflammation and Regenerative Medicine
- Department of Pharmacology, University of Virginia, HSC, Box 800746, Charlottesville, VA 22908, USA
| | - U.S. Deshmukh
- Division of Nephrology, Center for Immunity Inflammation and Regenerative Medicine
- Department of Pharmacology, University of Virginia, HSC, Box 800746, Charlottesville, VA 22908, USA
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Ruth NM, Passo MH. Juvenile idiopathic arthritis: management and therapeutic options. Ther Adv Musculoskelet Dis 2012; 4:99-110. [PMID: 22870498 DOI: 10.1177/1759720x11413630] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
THE GOALS OF TREATMENT FOR JUVENILE IDIOPATHIC ARTHRITIS (JIA) INCLUDE: suppression of inflammation, achievement of remission, relief of pain, maintenance of function and doing so with minimal toxicity. Important discoveries over the past 10-15 years have led to more targeted treatments for children with JIA. The International League of Associations for Rheumatology (ILAR) classification system for childhood arthritides, better assessment tools for clinical response, improved definitions of remission, new imaging techniques and evidence in gene expression profiling have all contributed to the development of more targeted treatments. Nonsteroidal anti-inflammatory agents still have a role in mild disease and intra-articular steroid injections continue to be used most commonly in patients with oligoarticular JIA. Disease-modifying agents such as methotrexate have demonstrated efficacy and safety; however, in many patients, the disease remains active despite this treatment. These children now receive more targeted treatment including the tumor necrosis factor alpha (TNFα) inhibitors, interleukin-1 blockade, interleukin-6 blockade, selective costimulation modulators and selective B-cell blockade. The biologic targeted therapies have changed the strategy in which we treat our children with JIA; however, there remains much to be learned about the long-term effects and safety of these medicines.
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O’Neill ID, Scully C. Biologics in oral medicine: principles of use and practical considerations. Oral Dis 2012; 18:525-36. [DOI: 10.1111/j.1601-0825.2012.01919.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Zhang J, Zhou G, Du GF, Xu XY, Zhou HM. Biologics, an alternative therapeutic approach for oral lichen planus. J Oral Pathol Med 2011; 40:521-4. [DOI: 10.1111/j.1600-0714.2011.01029.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Breda L, Del Torto M, De Sanctis S, Chiarelli F. Biologics in children's autoimmune disorders: efficacy and safety. Eur J Pediatr 2011; 170:157-67. [PMID: 20556424 DOI: 10.1007/s00431-010-1238-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 06/02/2010] [Indexed: 01/19/2023]
Abstract
Advances in understanding the pathogenesis of rheumatic diseases have led to the discovery of mechanisms of inflammation and autoimmunity and have made possible the invention of new target-specific drugs. Biologic drugs, designed to inhibit specific components of the immune system, such as cytokines, cytokine gene expression, and their complex interactions, have revolutionized the treatment options in pediatric rheumatology. Only three agents are currently available for treating juvenile idiopathic arthritis (JIA): etanercept, at the dose of 0.8 mg/kg once weekly, adalimumab at the dose of 24 mg/m(2) every 2 weeks, and abatacept at the dose of 10 mg/kg at weeks 0, 2, 4, and then every 4 weeks. They are well tolerated and relatively safe in children: Side effects are generally mild and include injection site reactions and infections. Infliximab, rilonacept, and canakinumab are also approved by the Food and Drug Administration for treatment of pediatric autoimmune disorders and are currently investigated in JIA. This review summarizes the current state of biologic drugs, their clinical application, and their efficacy and safety in the pediatric age.
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Affiliation(s)
- Luciana Breda
- Department of Pediatrics, University of Chieti, Via Vestini 5, 66100 Chieti, Italy
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Bauer JW, Bilgic H, Baechler EC. Gene-expression profiling in rheumatic disease: tools and therapeutic potential. Nat Rev Rheumatol 2009; 5:257-65. [PMID: 19412192 DOI: 10.1038/nrrheum.2009.50] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Gene-expression profiling is a powerful tool for the discovery of molecular fingerprints that underlie human disease. Microarray technologies allow the analysis of messenger RNA transcript levels for every gene in the genome. However, gene-expression profiling is best viewed as part of a pipeline that extends from sample collection through clinical application. Key genes and pathways identified by microarray profiling should be validated in independent sample sets and with alternative technologies. Analysis of relevant signaling pathways at the protein level is an important step towards understanding the functional consequences of aberrant gene expression. Peripheral blood is a convenient and rich source of potential biomarkers, but surveying purified cell populations and target tissues can also enhance our understanding of disease states. In rheumatic disease, probing the transcriptome of circulating immune cells has shed light on mechanisms underlying the pathogenesis of complex diseases, such as systemic lupus erythematosus. As these discoveries advance through the pipeline, a variety of clinical applications are on the horizon, including the use of molecular fingerprints to aid in diagnosis and prognosis, improved use of existing therapies, and the development of drugs that target relevant genes and pathways.
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Affiliation(s)
- Jason W Bauer
- Division of Rheumatic and Autoimmune Diseases, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
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Current World Literature. Curr Opin Rheumatol 2009; 21:85-92. [DOI: 10.1097/bor.0b013e32832355a7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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