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Update on the treatment of nonsystemic juvenile idiopathic arthritis including treatment-to-target: is (drug-free) inactive disease already possible? Curr Opin Rheumatol 2021; 32:403-413. [PMID: 32657803 DOI: 10.1097/bor.0000000000000727] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW This review concerns the outcome for nonsystemic juvenile idiopathic arthritis (JIA) with emphasis on treatment-to-target (T2T) and treatment strategies aiming at inactive disease by giving an overview of recent articles. RECENT FINDINGS More efficacious therapies and treatment strategies/T2T with inactive disease as target, have improved the outcome for JIA significantly. Recent studies regarding treatment strategies have shown 47-68% inactive disease after 1 year. Moreover, probability of attaining inactive disease at least once in the first year seems even higher in recent cohort-studies, reaching 80%, although these studies included relatively high numbers of oligoarticular JIA patients. However, 26-76% of patients flare upon therapy withdrawal and prediction of flares is still difficult. SUMMARY Remission can be achieved and sustained in (some) JIA patients, regardless of initial treatment. Cornerstone principles in the management of nonsystemic JIA treatment are early start of DMARD therapy, striving for inactive disease and T2T by close and repeated monitoring of disease activity. T2T and tight control appear to be more important than a specific drug in JIA. Next to inactive disease, it is important that patients/parents are involved in personal targets, like reduction of pain and fatigue. Future studies should focus on predictors (based on imaging-methods or biomarkers) for sustained drug-free remission and flare.
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Jones AP, Clayton D, Nkhoma G, Sherratt FC, Peak M, Stones SR, Roper L, Young B, McErlane F, Moitt T, Ramanan AV, Foster HE, Williamson PR, Deepak S, Beresford MW, Baildam EM. Different corticosteroid induction regimens in children and young people with juvenile idiopathic arthritis: the SIRJIA mixed-methods feasibility study. Health Technol Assess 2020; 24:1-152. [PMID: 32758350 PMCID: PMC7443738 DOI: 10.3310/hta24360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In the UK, juvenile idiopathic arthritis is the most common inflammatory disorder in childhood, affecting 10 : 100,000 children and young people aged < 16 years each year, with a population prevalence of around 1 : 1000. Corticosteroids are commonly used to treat juvenile idiopathic arthritis; however, there is currently a lack of consensus as to which corticosteroid induction regimen should be used with various disease subtypes and severities of juvenile idiopathic arthritis. OBJECTIVE The main study objective was to determine the feasibility of conducting a randomised controlled trial to compare the different corticosteroid induction regimens in children and young people with juvenile idiopathic arthritis. DESIGN This was a mixed-methods study. Work packages included a literature review; qualitative interviews with children and young people with juvenile idiopathic arthritis and their families; a questionnaire survey and screening log to establish current UK practice; a consensus meeting with health-care professionals, children and young people with juvenile idiopathic arthritis, and their families to establish the primary outcome; a feasibility study to pilot data capture and to collect data for future sample size calculations; and a final consensus meeting to establish the final protocol. SETTING The setting was rheumatology clinics across the UK. PARTICIPANTS Children, young people and their families who attended clinics and health-care professionals took part in this mixed-methods study. INTERVENTIONS This study observed methods of prescribing corticosteroids across the UK. MAIN OUTCOME MEASURES The main study outcomes were the acceptability of a future trial for children, young people, their families and health-care professionals, and the feasibility of delivering such a trial. RESULTS Qualitative interviews identified differences in the views of children, young people and their families on a randomised controlled trial and potential barriers to recruitment. A total of 297 participants were screened from 13 centres in just less than 6 months. In practice, all routes of corticosteroid administration were used, and in all subtypes of juvenile idiopathic arthritis. Intra-articular corticosteroid injection was the most common treatment. The questionnaire surveys showed the varying clinical practice across the UK, but established intra-articular corticosteroids as the treatment control for a future trial. The primary outcome of choice for children, young people, their families and health-care professionals was the Juvenile Arthritis Disease Activity Score, 71-joint count. However, results from the feasibility study showed that, owing to missing blood test data, the clinical Juvenile Arthritis Disease Activity Score should be used. The Juvenile Arthritis Disease Activity Score, 71-joint count, and the clinical Juvenile Arthritis Disease Activity Score are composite disease activity scoring systems for juvenile arthritis. Two final trial protocols were established for a future randomised controlled trial. LIMITATIONS Fewer clinics were included in this feasibility study than originally planned, limiting the ability to draw strong conclusions about these units to take part in future research. CONCLUSIONS A definitive randomised controlled trial is likely to be feasible based on the findings from this study; however, important recommendations should be taken into account when planning such a trial. FUTURE WORK This mixed-methods study has laid down the foundations to develop the evidence base in this area and conducting a randomised control trial to compare different corticosteroid induction regimens in children and young people with juvenile idiopathic arthritis is likely to be feasible. STUDY REGISTRATION Current Controlled Trials ISRCTN16649996. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 36. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ashley P Jones
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
| | - Dannii Clayton
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
| | - Gloria Nkhoma
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
| | | | - Matthew Peak
- Alder Hey Children's NHS Foundation Trust, a member of the Liverpool Health Partners, Liverpool, UK
| | | | - Louise Roper
- School of Psychology, University of Liverpool, Liverpool, UK
| | - Bridget Young
- School of Psychology, University of Liverpool, Liverpool, UK
| | - Flora McErlane
- Paediatric Rheumatology, Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - Tracy Moitt
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
| | - Athimalaipet V Ramanan
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Helen E Foster
- Paediatric Rheumatology, Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - Paula R Williamson
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
| | - Samundeeswari Deepak
- Paediatric Rheumatology, Nottingham Children's Hospital, Queen's Medical Centre, Nottingham, UK
| | - Michael W Beresford
- Faculty of Health and Life Science, University of Liverpool and Alder Hey Children's NHS Foundation Trust, members of Liverpool Health Partners, Liverpool, UK
| | - Eileen M Baildam
- Alder Hey Children's NHS Foundation Trust, a member of the Liverpool Health Partners, Liverpool, UK
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Cabrera N, Avila-Pedretti G, Belot A, Larbre JP, Mainbourg S, Duquesne A, Janiaud P, Kassai B, Cucherat M, Lega JC. The benefit–risk balance for biological agents in juvenile idiopathic arthritis: a meta-analysis of randomized clinical trials. Rheumatology (Oxford) 2020; 59:2226-2236. [DOI: 10.1093/rheumatology/keaa170] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 02/05/2020] [Accepted: 02/22/2020] [Indexed: 12/28/2022] Open
Abstract
Abstract
Objective
To assess the net benefit of biological agents (BA) used in JIA.
Methods
We systematically searched databases up to March 2019 for randomized controlled trials (RCT) performed in JIA disease. Separate random-effects meta-analyses were conducted for efficacy (ACR paediatric score 30%, ACRpedi30) and serious adverse events for safety. In order to standardize the baseline risk, we performed a meta-analysis of baseline risk in the control group (for both efficacy and safety meta-analysis). The net benefit was determined as the risk difference of efficacy subtracted by the risk difference of safety.
Results
We included 19 trials: 11 parallel RCTs (754 patients) and 8 withdrawal RCTs (704 patients). The net benefit ranged from 2.4% (adalimumab) to 17.6% (etanercept), and from 2.4% (etanercept) to 36.7%, (abatacept) in parallel and withdrawal trials assessing non-systemic JIA, respectively. In the systemic JIA category, the net benefit ranged from 22.8% (rilonacept) to 70.3% (canakinumab), and from 32.3% (canakinumab) to 58.2% (tocilizumab) in parallel and withdrawal trials, respectively.
Conclusion
The results suggest that a greater number of patients experienced therapeutic success without serious adverse events in the systemic onset JIA category compared with the BAs for non-systemic JIA categories. Baseline risk, design of trial and JIA categories impact the measure of net benefit of BAs in JIA patients.
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Affiliation(s)
- Natalia Cabrera
- Laboratoire de Biométrie et Biologie Évolutive (UMR - CNRS 5558), University of Lyon, Lyon, France
| | | | - Alexandre Belot
- Department of Paediatric Rheumatology, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Lyon University Hospital, University of Lyon, Lyon
| | - Jean-Paul Larbre
- Department of Rheumatology, Hospices Civils de Lyon, Lyon University Hospital, University of Lyon, Pierre-Bénite
| | - Sabine Mainbourg
- Laboratoire de Biométrie et Biologie Évolutive (UMR - CNRS 5558), University of Lyon, Lyon, France
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hospices Civils de Lyon, University of Lyon, Pierre-Bénite
| | - Agnès Duquesne
- Department of Paediatric Rheumatology, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Lyon University Hospital, University of Lyon, Lyon
| | - Perrine Janiaud
- Laboratoire de Biométrie et Biologie Évolutive (UMR - CNRS 5558), University of Lyon, Lyon, France
| | - Behrouz Kassai
- Laboratoire de Biométrie et Biologie Évolutive (UMR - CNRS 5558), University of Lyon, Lyon, France
- Department of Pharmaco-toxicology, Clinical Investigation Centre 1407 - INSERM, Hospices Civils de Lyon, Lyon, France
| | - Michel Cucherat
- Laboratoire de Biométrie et Biologie Évolutive (UMR - CNRS 5558), University of Lyon, Lyon, France
| | - Jean-Christophe Lega
- Laboratoire de Biométrie et Biologie Évolutive (UMR - CNRS 5558), University of Lyon, Lyon, France
- Department of Internal and Vascular Medicine, National Referral Centre for Rare Juvenile Rheumatological and Autoimmune Diseases (RAISE), Hospices Civils de Lyon, University of Lyon, Pierre-Bénite
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Schanberg LE, Ramanan AV, De Benedetti F, Beukelman T, Eakin GS, Del Gaizo V, Ringold S, Vesely R, Schrandt S, Jaki T, Bili A, Chung JB, De Bono S, Douglass W, Enejosa JV, Kanik KS, Knobe K, Kunder R, Leite-Schnell JC, Suehiro RM, Wong RL, Mieszkalski KL, Marrow LC, Siebenaler K, Fraulo E, Kimura Y. Toward Accelerated Authorization and Access to New Medicines for Juvenile Idiopathic Arthritis. Arthritis Rheumatol 2019; 71:1976-1984. [PMID: 31313532 DOI: 10.1002/art.41043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 07/11/2019] [Indexed: 12/14/2022]
Abstract
A meeting was organized to bring together multiple stakeholders involved in the testing and authorization of new medications for juvenile idiopathic arthritis (JIA) to discuss current issues surrounding clinical trials and access to new medications for children and adolescents with JIA. The Childhood Arthritis and Rheumatology Research Alliance invited representatives of regulatory agencies (Food and Drug Administration and European Medicines Agency), and major pharmaceutical companies with JIA-approved products or products in development, patient and parent representatives, representatives of an advocacy organization (Arthritis Foundation), and pediatric rheumatology clinicians/investigators to a 1-day meeting in April 2018. The participants engaged in discussion regarding issues in clinical trials. As the pharmacologic options to treat inflammatory arthritis rapidly expand, registration trial designs to test medications in JIA patients must adapt. Many methodologies successfully used in the recent past are no longer feasible. The pool of patients meeting entry criteria who are willing to participate is shrinking while the number of medications to be tested is growing. Suggested solutions included proposing innovative clinical trial methods to regulatory agencies, as well as open discussions among stakeholders. Ensuring that new medications are authorized in a timely manner to meet the needs of JIA patients worldwide is critical. Approaches should include open dialog between regulatory agencies, pharmaceutical companies, and other stakeholders to develop and implement novel study designs, including patient and clinician perspectives to define meaningful trial outcomes, and changing existing study plans.
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Affiliation(s)
| | - Athimalaipet V Ramanan
- University Hospitals Bristol NHS Foundation Trust, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | | | - Vincent Del Gaizo
- Childhood Arthritis and Rheumatology Research Alliance, Milwaukee, Wisconsin
| | | | | | | | | | | | | | | | | | | | - Keith S Kanik
- Global Product Development, Pfizer Inc., New London, Connecticut
| | | | | | | | | | | | - Kelly L Mieszkalski
- Childhood Arthritis and Rheumatology Research Alliance, Milwaukee, Wisconsin
| | | | | | | | - Yukiko Kimura
- Hackensack University Medical Center, Hackensack, New Jersey
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Grönlund MM, Remes-Pakarinen T, Kröger L, Markula-Patjas K, Backström M, Putto-Laurila A, Aalto K, Vähäsalo P. Efficacy and safety of tocilizumab in a real-life observational cohort of patients with polyarticular juvenile idiopathic arthritis. Rheumatology (Oxford) 2019; 59:732-741. [DOI: 10.1093/rheumatology/kez291] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/08/2019] [Indexed: 12/14/2022] Open
Abstract
Abstract
Objectives
To evaluate the patterns of usage, efficacy and safety of tocilizumab in polyarticular JIA.
Methods
An observational study of 56 consecutive polyarticular JIA patients was conducted using patient charts and electronic JIA databases. Efficacy was assessed by tocilizumab survival, rates of low disease activity (LDA) and of inactive disease by 10-joint Juvenile Arthritis Disease Activity Score (JADAS-10), and of clinically inactive disease according to Wallace’s preliminary criteria. Efficacy and rate of adverse events (AEs) were evaluated during a 24-month period after tocilizumab commencement.
Results
Tocilizumab was started on average as third-line biological agent (median, range first- to fourth-line) at a median disease duration of 5.2 years (interquartile range 3.0–7.7). Survival rates were 82% at 12 months and 64% at 24 months. The reasons for discontinuation were inadequate treatment effect in 50%, AE plus inadequate treatment effect in 37.5% and AE alone in 12.5%. LDA (JADAS-10 ⩽3.9) was reached in 58% at 12 months and in 84% at 24 months, inactive disease (JADAS-10 ⩽0.7) in 19% and 44%, and clinically inactive disease in 28% and 46%, respectively. The rate of AEs was 200.9/100 patient years and of serious AEs 12.9/100 patient years.
Conclusion
Survival of tocilizumab was high and a large proportion of the treatment-resistant patients reached LDA at 12 months of treatment. The LDA rate continued to increase throughout 24 months. The rates of AEs and serious AEs were higher than in register studies but lower than in the originator study of tocilizumab.
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Affiliation(s)
| | | | - Liisa Kröger
- Department of Pediatrics, Kuopio University Hospital, Kuopio
| | - Kati Markula-Patjas
- Department of Paediatrics, Tampere University Hospital, Tampere
- University of Tampere, Tampere
| | | | | | - Kristiina Aalto
- Department of Children and Adolescents, Helsinki University Hospital, Helsinki
- Pediatric Research Center, University of Helsinki, Helsinki
| | - Paula Vähäsalo
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu
- Department of Children and Adolescents, Oulu University Hospital, Oulu
- PEDEGO Research Unit, University of Oulu, Oulu, Finland
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6
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Sherratt FC, Roper L, Stones SR, McErlane F, Peak M, Beresford MW, Foster H, Ramanan AV, Rooney M, Baildam E, Young B. Protective parents and permissive children: what qualitative interviews with parents and children can tell us about the feasibility of juvenile idiopathic arthritis trials. Pediatr Rheumatol Online J 2018; 16:76. [PMID: 30514320 PMCID: PMC6278083 DOI: 10.1186/s12969-018-0293-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 11/13/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Patient recruitment can be very challenging in paediatric studies, especially in relatively uncommon conditions, such as juvenile idiopathic arthritis (JIA). However, involving children and young people (CYP) in the design of such trials could promise a more rapid trajectory towards making evidence-based treatments available. Studies involving CYP are advocated in the literature but we are not aware of any early stage feasibility studies that have qualitatively accessed the perspectives of parents and CYP with a long term condition to inform design and conduct of a trial. In the context of a feasibility study to inform the design of a proposed randomised controlled trial of corticosteroid induction regimen in JIA, we explored families' perspectives on the proposed trial and on JIA trials generally. METHODS We analysed interviews with 27 participants (8 CYP aged 8-16 years and 19 parents) from four UK paediatric rheumatology centres. CYP had recently received corticosteroids to treat JIA. Audio-recorded interviews were transcribed and analysed thematically, drawing on the Framework Method. RESULTS Both parents and CYP were capable of engaging with the logic of the proposed trial but pointed to challenges with its design. Treatment preferences influenced willingness to participate in the proposed trial. The preferences of older children and their parents often differed, with CYP being more willing to participate in the proposed trial than parents. Families' current treatment preferences were largely informed by past positive and negative treatment experiences. Some participants also indicated that their treatment preferences were influenced by those of their clinicians. CONCLUSION Previous research has typically focused on deficits in patients' understandings of trials. We found that both parents and CYP understood trial concepts and were able to identify potential flaws in the proposed trial. We propose recommendations to optimise the design of a planned corticosteroid induction regimen trial in JIA. Accessing both parents' and CYP's perspectives helps to identify and address recruitment challenges, which will ultimately optimise informed consent and future recruitment.
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Affiliation(s)
- Frances C. Sherratt
- 0000 0004 1936 8470grid.10025.36Department of Psychological Sciences, University of Liverpool, Whelan Building, Brownlow Hill, Liverpool, L69 3GB UK
| | - Louise Roper
- 0000 0004 1936 8470grid.10025.36Department of Psychological Sciences, University of Liverpool, Whelan Building, Brownlow Hill, Liverpool, L69 3GB UK
| | - Simon R. Stones
- 0000 0004 1936 8403grid.9909.9School of Healthcare, University of Leeds, Leeds, UK
| | - Flora McErlane
- 0000 0004 4904 7256grid.459561.aGreat North Children’s Hospital, Newcastle upon Tyne, UK ,0000 0001 0462 7212grid.1006.7Institute Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Matthew Peak
- 0000 0004 0421 1374grid.417858.7Clinical Research Division, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Michael W. Beresford
- 0000 0004 0421 1374grid.417858.7Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK ,0000 0004 1936 8470grid.10025.36Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Helen Foster
- 0000 0004 4904 7256grid.459561.aGreat North Children’s Hospital, Newcastle upon Tyne, UK ,0000 0001 0462 7212grid.1006.7Institute Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Athimalaipet V. Ramanan
- 0000 0004 1936 7603grid.5337.2University Hospitals Bristol NHS Foundation Trust & Bristol Medical School, University of Bristol, Bristol, UK
| | - Madeleine Rooney
- 0000 0004 0374 7521grid.4777.3School of Medicine, Dentistry and Biomedical Sciences, Queens University of Belfast, Belfast, UK
| | - Eileen Baildam
- 0000 0004 0421 1374grid.417858.7Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Bridget Young
- 0000 0004 1936 8470grid.10025.36Department of Psychological Sciences, University of Liverpool, Whelan Building, Brownlow Hill, Liverpool, L69 3GB UK
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Giancane G, Alongi A, Rosina S, Tibaldi J, Consolaro A, Ravelli A. Recent therapeutic advances in juvenile idiopathic arthritis. Best Pract Res Clin Rheumatol 2017; 31:476-487. [DOI: 10.1016/j.berh.2018.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/10/2018] [Indexed: 12/31/2022]
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