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Feilding FL, Crosby L, Earle E, Beesley R, Leslie K, MacDonald E, Wright C, Wilson D, Sherriffs A, Duerr T, Ramanan AV. How can trial designs better serve the needs of children and young people with juvenile idiopathic arthritis? THE LANCET. RHEUMATOLOGY 2024; 6:e648-e652. [PMID: 38552652 DOI: 10.1016/s2665-9913(24)00026-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 08/23/2024]
Abstract
In juvenile idiopathic arthritis we have seen remarkable progress in the number of available licensed biological and small molecule treatments in the past two decades, leading to improved outcomes for patients. Designing clinical trials for these therapeutics is fraught with ethical, legislative, and practical challenges. However, many aspects of current clinical trial design in juvenile idiopathic arthritis do not meet the needs of patients and clinicians. Commonly used withdrawal trial designs raise substantial ethical concerns for patients and families who believe that they do not enable evidence-based and patient-centred decisions around medication choices. In this Viewpoint, we present the personal views of a patient and parent network that is of the opinion that current trial design in juvenile idiopathic arthritis is failing children and young people with juvenile idiopathic arthritis and set out the need for change informed by lived experience.
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Affiliation(s)
- Freya Luling Feilding
- Infection Immunity and Inflammation Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Laura Crosby
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
| | - Emily Earle
- CLUSTER Consortium Champions, UCL Great Ormond Street Institute of Child Health, London, UK; Children's Chronic Arthritis Association, Nuneaton, UK
| | - Richard Beesley
- CLUSTER Consortium Champions, UCL Great Ormond Street Institute of Child Health, London, UK; Juvenile Arthritis Research, Tonbridge, UK
| | - Kerry Leslie
- CLUSTER Consortium Champions, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Eilean MacDonald
- CLUSTER Consortium Champions, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Catherine Wright
- CLUSTER Consortium Champions, UCL Great Ormond Street Institute of Child Health, London, UK; Versus Arthritis, Chesterfield, UK
| | - Debbie Wilson
- CLUSTER Consortium Champions, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Anna Sherriffs
- CLUSTER Consortium Champions, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Teresa Duerr
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
| | - Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK; Translational Health Sciences, University of Bristol, Bristol, UK.
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Shenoi S, Horneff G, Aggarwal A, Ravelli A. Treatment of non-systemic juvenile idiopathic arthritis. Nat Rev Rheumatol 2024; 20:170-181. [PMID: 38321298 DOI: 10.1038/s41584-024-01079-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2024] [Indexed: 02/08/2024]
Abstract
In the past two decades, the treatment of juvenile idiopathic arthritis (JIA) has evolved markedly, owing to the availability of a growing number of novel, potent and relatively safe therapeutic agents and the shift of management strategies towards early achievement of disease remission. However, JIA encompasses a heterogeneous group of diseases that require distinct treatment approaches. Furthermore, some old drugs, such as methotrexate, sulfasalazine and intraarticular glucocorticoids, still maintain an important therapeutic role. In the past 5 years, information on the efficacy and safety of drug therapies for JIA has been further enriched through the accomplishment of several randomized controlled trials of newer biologic and synthetic targeted DMARDs. In addition, a more rational therapeutic approach has been fostered by the promulgation of therapeutic recommendations and guidelines. A multinational collaborative effort has led to the development of the recommendations for the treat-to-target strategy in JIA. There is currently increasing interest in establishing the optimal time and modality for discontinuation of treatment in children with JIA who achieve sustained clinical remission. The aim of this Review is to summarize the current evidence and discuss the therapeutic approaches to the management of non-systemic phenotypes of JIA, including oligoarthritis, polyarthritis, enthesitis-related arthritis and psoriatic arthritis.
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Affiliation(s)
- Susan Shenoi
- Seattle Children's Hospital and Research Centre, University of Washington, Seattle, WA, USA
| | - Gerd Horneff
- Department of General Paediatrics, Asklepios Clinic Sankt Augustin, Sankt Augustin, Germany
- Department of Paediatric and Adolescents Medicine, University Hospital of Cologne, Cologne, Germany
| | - Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Angelo Ravelli
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DINOGMI), Università degli Studi di Genova, Genoa, Italy.
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Mazzoni A, Annunziato F, Maggi L. T lymphocytes-related cell network in the pathogenesis of juvenile idiopathic arthritis: a key point for personalized treatment. Curr Opin Rheumatol 2024; 36:40-45. [PMID: 37905987 DOI: 10.1097/bor.0000000000000991] [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: 11/02/2023]
Abstract
PURPOSE OF REVIEW Juvenile idiopathic arthritis (JIA) is a heterogeneous group of arthritis of unknown origin occurring in children under 16 years of age and persisting for at least 6 weeks. Given that JIA is an inflammatory disorder, treatment strategies, including also biologicals, are focused on suppressing excessive inflammation. The finding that different patients display different responses to biological drugs supports the concept that different pathogenic mechanisms can exist in JIA, with specific cellular and molecular mechanisms driving inflammation in each patient. The aim of this review is to highlight the most recent advances in understanding the role of immune cells in JIA pathogenesis. RECENT FINDINGS This review encompasses the role of the different cell subsets involved in sustaining inflammation in JIA, with a particular emphasis on T cells, as they orchestrate both innate and adaptive auto-reactive immunity in affected joints. SUMMARY The characterization of the cellular and molecular pathways supporting inflammation will be crucial to design novel therapeutic approaches in the context of personalized medicine.
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Affiliation(s)
- Alessio Mazzoni
- Department of Experimental and Clinical Medicine, University of Florence
- Flow cytometry diagnostic center and immunotherapy, Careggi University Hospital, Florence, Italy
| | - Francesco Annunziato
- Department of Experimental and Clinical Medicine, University of Florence
- Flow cytometry diagnostic center and immunotherapy, Careggi University Hospital, Florence, Italy
| | - Laura Maggi
- Department of Experimental and Clinical Medicine, University of Florence
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Nijhuis L, Swart JF, Prakken BJ, van Loosdregt J, Vastert SJ. The clinical and experimental treatment of Juvenile Idiopathic Arthritis. Clin Exp Immunol 2023; 213:276-287. [PMID: 37074076 PMCID: PMC10571000 DOI: 10.1093/cei/uxad045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/02/2023] [Accepted: 04/18/2023] [Indexed: 04/20/2023] Open
Abstract
Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in children and comprises of multiple subtypes. The most relevant disease subtypes, grouped upon current insight in disease mechanisms, are nonsystemic (oligo- and polyarticular) JIA and systemic JIA (sJIA). In this review, we summarize some of the main proposed mechanisms of disease in both nonsystemic and sJIA and discuss how current therapeutic modalities target some of the pathogenic immune pathways. Chronic inflammation in nonsystemic JIA is the result of a complex interplay between effector and regulatory immune cell subsets, with adaptive immune cells, specifically T-cell subsets and antigen-presenting cells, in a central role. There is, however, also innate immune cell contribution. SJIA is nowadays recognized as an acquired chronic inflammatory disorder with striking autoinflammatory features in the first phase of the disease. Some sJIA patients develop a refractory disease course, with indications for involvement of adaptive immune pathways as well. Currently, therapeutic strategies are directed at suppressing effector mechanisms in both non-systemic and sJIA. These strategies are often not yet optimally tuned nor timed to the known active mechanisms of disease in individual patients in both non-systemic and sJIA. We discuss current treatment strategies in JIA, specifically the 'Step-up' and 'Treat to Target approach' and explore how increased insight into the biology of disease may translate into future more targeted strategies for this chronic inflammatory disease at relevant time points: preclinical disease, active disease, and clinically inactive disease.
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Affiliation(s)
- L Nijhuis
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of pediatric rheumatology & immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J F Swart
- Department of pediatric rheumatology & immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- University of Utrecht, Utrecht, The Netherlands
| | - B J Prakken
- Department of pediatric rheumatology & immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- University of Utrecht, Utrecht, The Netherlands
| | - J van Loosdregt
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- University of Utrecht, Utrecht, The Netherlands
| | - S J Vastert
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of pediatric rheumatology & immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- University of Utrecht, Utrecht, The Netherlands
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