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Polat MC, Mertek S, Özçakar ZB, Çelikel E, Aydın F, Tekin ZE, Elhan AH, Çelikel Acar B, Çakar N. Adverse events of biological agents in pediatric rheumatologic diseases. Postgrad Med 2024; 136:198-207. [PMID: 38415679 DOI: 10.1080/00325481.2024.2325333] [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: 08/02/2023] [Accepted: 02/27/2024] [Indexed: 02/29/2024]
Abstract
OBJECTIVES To evaluate adverse events (AEs) in pediatric patients with rheumatologic diseases being treated with approved or off-label biologic agents (BAs). METHODS This observational, retrospective, multicenter study was conducted from 2010 to 2022 in patients under 18 years of age with rheumatic diseases who were receiving interleukin-1 antibodies (Anti-IL1), interleukin-6 antibodies (Anti-IL6), and tumor necrosis factor alpha inhibitors (anti-TNF). Efficacy, AEs, and timing of AEs were collected from electronic medical records. RESULTS Three hundred and fifteen BAs were prescribed to 237 patients. Fifty AEs occurred in 44 patients (18.6%). Anti-TNF exposure was present in 8 (72.2%) of 11 patients with latent tuberculosis (TB) and in all 7 patients with herpes infections. Four of 6 patients (66.7%) with recurrent upper respiratory tract infections and 7 of 8 patients (87.5%) with local skin reactions were on Anti-IL1. The cutoff value for latent TB development was determined as 23.5 months by ROC analysis (AUC: 0.684 ± 0.072, p = 0.038, 95% CI: 0.54-0.82). In patients who used BA for 23.5 months or more, the risk of latent TB was 5.94-fold (p = 0.024, 95% CI: 1.26-27.97). Drug rash with eosinophilia and systemic symptoms (DRESS) occurred in 2 patients on anakinra, and anaphylaxis occurred in 1 patient on anti-IL6. There were no cases of malignancy or death in any patient. CONCLUSION The physician should be vigilant for latent TB in patients exposed to BA for more than 2 years. While local skin reactions are more prevalent in patients receiving anti-IL1, severe skin reactions such as DRESS may also occur.
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Affiliation(s)
- Merve Cansu Polat
- Department of Pediatric Rheumatology, University of Health Sciences, Ankara City Hospital, Cankaya, Turkey
| | - Saniye Mertek
- Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
| | - Zeynep Birsin Özçakar
- Department of Pediatric Rheumatology, Ankara University School of Medicine, Ankara, Turkey
| | - Elif Çelikel
- Department of Pediatric Rheumatology, University of Health Sciences, Ankara City Hospital, Cankaya, Turkey
| | - Fatma Aydın
- Department of Pediatric Rheumatology, Ankara University School of Medicine, Ankara, Turkey
| | - Zahide Ekici Tekin
- Department of Pediatric Rheumatology, University of Health Sciences, Ankara City Hospital, Cankaya, Turkey
| | - Atilla Halil Elhan
- Department of Biostatistics, Ankara University Medical School, Ankara, Turkey
| | - Banu Çelikel Acar
- Department of Pediatric Rheumatology, University of Health Sciences, Ankara City Hospital, Cankaya, Turkey
| | - Nilgün Çakar
- Department of Pediatric Rheumatology, Ankara University School of Medicine, Ankara, Turkey
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2
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Zang H, Kim HJ, Huang B, Szczesniak R. Bayesian causal inference for observational studies with missingness in covariates and outcomes. Biometrics 2023; 79:3624-3636. [PMID: 37553770 PMCID: PMC10840608 DOI: 10.1111/biom.13918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 07/13/2023] [Indexed: 08/10/2023]
Abstract
Missing data are a pervasive issue in observational studies using electronic health records or patient registries. It presents unique challenges for statistical inference, especially causal inference. Inappropriately handling missing data in causal inference could potentially bias causal estimation. Besides missing data problems, observational health data structures typically have mixed-type variables - continuous and categorical covariates - whose joint distribution is often too complex to be modeled by simple parametric models. The existence of missing values in covariates and outcomes makes the causal inference even more challenging, while most standard causal inference approaches assume fully observed data or start their works after imputing missing values in a separate preprocessing stage. To address these problems, we introduce a Bayesian nonparametric causal model to estimate causal effects with missing data. The proposed approach can simultaneously impute missing values, account for multiple outcomes, and estimate causal effects under the potential outcomes framework. We provide three simulation studies to show the performance of our proposed method under complicated data settings whose features are similar to our case studies. For example, Simulation Study 3 assumes the case where missing values exist in both outcomes and covariates. Two case studies were conducted applying our method to evaluate the comparative effectiveness of treatments for chronic disease management in juvenile idiopathic arthritis and cystic fibrosis.
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Affiliation(s)
- Huaiyu Zang
- Heart Institute, Cincinnati Children’s Hospital Medical Center, OH, U.S.A
| | - Hang J. Kim
- Division of Statistics and Data Science, University of Cincinnati, OH, U.S.A
| | - Bin Huang
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH, U.S.A
- Department of Pediatrics, University of Cincinnati, OH, U.S.A
| | - Rhonda Szczesniak
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH, U.S.A
- Department of Pediatrics, University of Cincinnati, OH, U.S.A
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3
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Shiff NJ, Shrader P, Correll CK, Dennos A, Phillips T, Beukelman T. Trajectories of disease activity in patients with JIA in the Childhood Arthritis and Rheumatology Research Alliance Registry. Rheumatology (Oxford) 2023; 62:804-814. [PMID: 35703945 DOI: 10.1093/rheumatology/keac335] [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: 09/15/2021] [Revised: 05/11/2022] [Accepted: 06/01/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To describe 2-year trajectories of the clinical Juvenile Arthritis Disease Activity Score, 10 joints (cJADAS10) and associated baseline characteristics in patients with JIA. METHODS JIA patients in the Childhood Arthritis and Rheumatology Research Alliance Registry enrolled within 3 months of diagnosis from 15 June 2015 to 6 December 2017 with at least two cJADAS10 scores and 24 months of follow-up were included. Latent growth curve models of cJADAS10 were analysed; a combination of Bayesian information criterion, posterior probabilities and clinical judgement was used to select model of best fit. RESULTS Five trajectories were identified among the 746 included patients: High, Rapidly Decreasing (HRD) (n = 199, 26.7%); High, Slowly Decreasing (HSD) (n = 154, 20.6%); High, Increasing (HI) (n = 39, 5.2%); Moderate, Persistent (MP) (n = 218, 29.2%); and Moderate, Decreasing (MD) (n = 136, 18.2%). Most patients spent a significant portion of time at moderate to high disease activity levels. At baseline, HSD patients were more likely to be older, have a lower physician global assessment, normal inflammatory markers, longer time to first biologic, and have taken systemic steroids compared with HRD. Those with a HI trajectory were more likely to be ANA negative, have a longer time to first biologic, and less likely to be taking a conventional synthetic DMARD compared with HRD. MP patients were more likely to be older with lower household income, longer time to diagnosis, and markers of higher disease activity than those with a MD trajectory. CONCLUSIONS Five trajectories of JIA disease activity, and associated baseline variables, were identified.
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Affiliation(s)
- Natalie J Shiff
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.,Janssen Scientific Affairs LLC, Horsham, PA
| | - Peter Shrader
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Anne Dennos
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Thomas Phillips
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Timothy Beukelman
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
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4
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Kip MMA, de Roock S, Currie G, Marshall DA, Grazziotin LR, Twilt M, Yeung RSM, Benseler SM, Vastert SJ, Wulffraat N, Swart JF, IJzerman MJ. Pharmacological treatment patterns in patients with juvenile idiopathic arthritis in the Netherlands: a real-world data analysis. Rheumatology (Oxford) 2022; 62:SI170-SI180. [PMID: 35583252 PMCID: PMC9949706 DOI: 10.1093/rheumatology/keac299] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 05/07/2022] [Accepted: 05/07/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate medication prescription patterns among children with JIA, including duration, sequence and reasons for medication discontinuation. METHODS This study is a single-centre, retrospective analysis of prospective data from the electronic medical records of JIA patients receiving systemic therapy aged 0-18 years between 1 April 2011 and 31 March 2019. Patient characteristics (age, gender, JIA subtype) and medication prescriptions were extracted and analysed using descriptive statistics, Sankey diagrams and Kaplan-Meier survival methods. RESULTS Over a median of 4.2 years follow-up, the 20 different medicines analysed were prescribed as monotherapy (n = 15) or combination therapy (n = 48 unique combinations) among 236 patients. In non-systemic JIA, synthetic DMARDs were prescribed to almost all patients (99.5%), and always included MTX. In contrast, 43.9% of non-systemic JIA patients received a biologic DMARD (mostly adalimumab or etanercept), ranging from 30.9% for oligoarticular persistent ANA-positive JIA, to 90.9% for polyarticular RF-positive JIA. Among systemic JIA, 91.7% received a biologic DMARD (always including anakinra). When analysing medication prescriptions according to their class, 32.6% involved combination therapy. In 56.8% of patients, subsequent treatment lines were initiated after unsuccessful first-line treatment, resulting in 68 unique sequences. Remission was the most common reason for DMARD discontinuation (44.7%), followed by adverse events (28.9%) and ineffectiveness (22.1%). CONCLUSION This paper reveals the complexity of pharmacological treatment in JIA, as indicated by: the variety of mono- and combination therapies prescribed, substantial variation in medication prescriptions between subtypes, most patients receiving two or more treatment lines, and the large number of unique treatment sequences.
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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,Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children’s Hospital, Utrecht
| | - Sytze de Roock
- Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children’s Hospital, Utrecht,Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
| | - Gillian Currie
- Department of Community Health Sciences,Department of Paediatrics, Cumming School of Medicine,Alberta Children’s Hospital Research Institute,Department of Medicine
| | - Deborah A Marshall
- Department of Community Health Sciences,Alberta Children’s Hospital Research Institute,Department of Medicine
| | | | - Marinka Twilt
- Alberta Children’s Hospital Research Institute,Division of Rheumatology, Department of Pediatrics, Alberta Children’s Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - 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
| | - Susanne M Benseler
- Alberta Children’s Hospital Research Institute,Division of Rheumatology, Department of Pediatrics, Alberta Children’s Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Sebastiaan J Vastert
- Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children’s Hospital, Utrecht,Faculty of Medicine, Utrecht University, Utrecht, The Netherlands,European Reference Network RITA (rare Immunodeficiency Autoinflammatory and Autoimmune Diseases Network)
| | - Nico Wulffraat
- Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children’s Hospital, Utrecht,Faculty of Medicine, Utrecht University, Utrecht, The Netherlands,European Reference Network RITA (rare Immunodeficiency Autoinflammatory and Autoimmune Diseases Network)
| | | | - Maarten J IJzerman
- Correspondence to: Maarten J. IJzerman, Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, PO Box 217, 7500 AE Enschede, The Netherlands. E-mail:
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5
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Grazziotin LR, Currie G, Twilt M, Ijzerman MJ, Kip MMA, Koffijberg H, Benseler SM, Swart JF, Vastert SJ, Wulffraat NM, Yeung RSM, Marshall DA. Real-world data reveals the complexity of disease modifying anti-rheumatic drug treatment patterns in juvenile idiopathic arthritis: an observational study. Pediatr Rheumatol Online J 2022; 20:25. [PMID: 35410419 PMCID: PMC8996666 DOI: 10.1186/s12969-022-00682-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 03/27/2022] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE Pharmacological treatment is a cornerstone of care for children with juvenile idiopathic arthritis (JIA). The objective of this study is to evaluate prescription patterns of conventional and biologic disease modifying anti-rheumatic drugs (c-DMARDs and b-DMARDs) for patients with JIA. METHODS We conducted a retrospective cohort study of children diagnosed with JIA at a rheumatology pediatric clinic. Eligibility criteria were defined as children and youth newly diagnosed with enthesis-related arthritis, polyarticular, or oligoarticular JIA between 2011 and 2019, with at least one year of observation. Data on c-DMARDs and b-DMARDs prescriptions were obtained from electronic medical charts. We used descriptive statistics, Kaplan-Meier survival methods, and Sankey diagrams to describe treatment prescription patterns. RESULTS A total of 325 patients with JIA were included, with a median observation time of 3.7 years. The most frequently prescribed c-DMARD and b-DMARD were methotrexate and etanercept, respectively. Within the first year of rheumatology care, 62% and 21% of patients had a c-DMARD and a b-DMARD prescribed, respectively. These proportions varied greatly by JIA subtype. Among the 147 (147/325, 45%) patients that had at least one b-DMARD prescribed, 24% were prescribed a second, and 7% a third-line of b-DMARD. A total of 112 unique treatment sequences were observed, with c-DMARD monotherapy followed by the addition of either a b-DMARD (56%) or another c-DMARD (30%) being the two most prevalent patterns in this cohort. CONCLUSION We observed a variety of treatment trajectories, with many patients experiencing multiple treatment lines, illustrating the complexity of the overall JIA treatment path.
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Affiliation(s)
- Luiza R. Grazziotin
- grid.22072.350000 0004 1936 7697Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697O’Brien Institute for Public Health, University of Calgary, Calgary, AB Canada ,grid.413571.50000 0001 0684 7358Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB Canada
| | - Gillian Currie
- grid.22072.350000 0004 1936 7697Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697O’Brien Institute for Public Health, University of Calgary, Calgary, AB Canada ,grid.413571.50000 0001 0684 7358Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB Canada
| | - Marinka Twilt
- grid.413571.50000 0001 0684 7358Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697Section of Rheumatology, Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB Canada
| | - Maarten J. Ijzerman
- grid.6214.10000 0004 0399 8953Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Michelle M. A. Kip
- grid.6214.10000 0004 0399 8953Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Hendrik Koffijberg
- grid.6214.10000 0004 0399 8953Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Susanne M. Benseler
- grid.413571.50000 0001 0684 7358Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697Section of Rheumatology, Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB Canada ,grid.413574.00000 0001 0693 8815Alberta Health Services, Calgary, AB Canada
| | - Joost F. Swart
- grid.417100.30000 0004 0620 3132Department of Pediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital / UMC Utrech, Utrecht, The Netherlands ,grid.5477.10000000120346234Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
| | - Sebastiaan J. Vastert
- grid.417100.30000 0004 0620 3132Department of Pediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital / UMC Utrech, Utrecht, The Netherlands ,grid.5477.10000000120346234Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
| | - Nico M. Wulffraat
- grid.417100.30000 0004 0620 3132Department of Pediatric Immunology and Rheumatology, Wilhelmina Children’s Hospital / UMC Utrech, Utrecht, The Netherlands ,grid.5477.10000000120346234Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
| | - Rae S. M. Yeung
- grid.17063.330000 0001 2157 2938Departments of Paediatrics, Immunology and Medical Science, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Deborah A. Marshall
- grid.22072.350000 0004 1936 7697Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697O’Brien Institute for Public Health, University of Calgary, Calgary, AB Canada ,grid.413571.50000 0001 0684 7358Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB Canada ,Present Address: Health Research Innovation Centre, Room 3C56, 3280 Hospital Drive NW, AB T2N 4Z6 Calgary, Canada
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Abstract
Health and health care disparities in pediatric rheumatology are prevalent among socially disadvantaged and marginalized populations based on race/ethnicity, socioeconomic position, and geographic region. These groups are more likely to experience greater disease severity, morbidity, mortality, decreased quality of life, and poor mental health outcomes, which are in part due to persistent structural and institutional barriers, including decreased access to quality health care. Most of the research on health and health care disparities in pediatric rheumatology focuses on juvenile idiopathic arthritis and childhood-onset systemic lupus erythematosus; there are significant gaps in the literature assessing disparities associated with other pediatric rheumatic diseases. Understanding the underlying causes of health care disparities will ultimately inform the development and implementation of innovative policies and interventions on a federal, local, and individual level.
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Affiliation(s)
- Alisha M Akinsete
- Division of Pediatric Rheumatology, Department of Pediatrics, Children's Hospital at Montefiore/Albert Einstein College of Medicine, 3415 Bainbridge Avenue, Bronx, NY 10467, USA. https://twitter.com/@akinsetemd
| | - Jennifer M P Woo
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, 111 TW Alexander Drive, Research Triangle Park, NC 27709, USA. https://twitter.com/@jmpwoo
| | - Tamar B Rubinstein
- Division of Pediatric Rheumatology, Department of Pediatrics, Children's Hospital at Montefiore/Albert Einstein College of Medicine, 3415 Bainbridge Avenue, Bronx, NY 10467, USA.
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7
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Ong MS, Ringold S, Kimura Y, Schanberg LE, Tomlinson GA, Natter MD. Improved Disease Course Associated With Early Initiation of Biologics in Polyarticular Juvenile Idiopathic Arthritis: Trajectory Analysis of a Childhood Arthritis and Rheumatology Research Alliance Consensus Treatment Plans Study. Arthritis Rheumatol 2021; 73:1910-1920. [PMID: 34105303 DOI: 10.1002/art.41892] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 06/01/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To investigate the effects of early introduction of biologic disease-modifying antirheumatic drugs (bDMARDs) on the disease course in untreated polyarticular juvenile idiopathic arthritis (JIA). METHODS We analyzed data on patients with polyarticular JIA participating in the Start Time Optimization of Biologics in Polyarticular JIA (STOP-JIA) study (n = 400) and a comparator cohort (n = 248) from the Childhood Arthritis and Rheumatology Research Alliance Registry. Latent class trajectory modeling (LCTM) was applied to identify subgroups of patients with distinct disease courses based on disease activity (clinical Juvenile Arthritis Disease Activity Score in 10 joints) over 12 months from baseline. RESULTS In the STOP-JIA study, 198 subjects (49.5%) received bDMARDs within 3 months of baseline assessment. LCTM analyses generated 3 latent classes representing 3 distinct disease trajectories, characterized by slow, moderate, or rapid disease activity improvement over time. Subjects in the rapid improvement trajectory attained inactive disease within 6 months from baseline. Odds of being in the rapid improvement trajectory versus the slow improvement trajectory were 3.6 times as high (95% confidence interval 1.32-10.0; P = 0.013) for those treated with bDMARDs ≤3 months from baseline compared with subjects who started bDMARDs >3 months after baseline, after adjusting for demographic characteristics, clinical attributes, and baseline disease activity. Shorter disease duration at first rheumatology visit approached statistical significance as a predictor of favorable trajectory without bDMARD treatment. CONCLUSION Starting bDMARDs within 3 months of baseline assessment is associated with more rapid achievement of inactive disease in subjects with untreated polyarticular JIA. These results demonstrate the utility of trajectory analysis of disease course as a method for determining treatment efficacy.
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Affiliation(s)
- Mei Sing Ong
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Yukiko Kimura
- Joseph M. Sanzari Children's Hospital and Hackensack Meridian School of Medicine, Hackensack, New Jersey
| | | | | | - Marc D Natter
- Boston Children's Hospital, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
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8
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Minden K, Klotsche J. Transition Between Treatments: What We Need to Know. J Rheumatol 2021; 48:1198-1200. [PMID: 33858980 DOI: 10.3899/jrheum.201331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Kirsten Minden
- K. Minden, MD, Epidemiology Unit, German Rheumatism Research Center Berlin, a Leibniz Institute, and Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin;
| | - Jens Klotsche
- J. Klotsche, PhD, Epidemiology Unit, German Rheumatism Research Center Berlin, a Leibniz Institute, Berlin, Germany
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9
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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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10
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Yue X, Huang B, Hincapie AL, Wigle PR, Qiu T, Li Y, Morgan EM, Guo JJ. Prescribing Patterns and Impact of Factors Associated with Time to Initial Biologic Therapy among Children with Non-systemic Juvenile Idiopathic Arthritis. Paediatr Drugs 2021; 23:171-182. [PMID: 33651370 DOI: 10.1007/s40272-021-00436-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of this study was to examine patterns of initial prescriptions, investigate time to initiation of biologic disease-modifying anti-rheumatic drugs (bDMARDs), and evaluate the impact of clinical and other baseline factors associated with the time to first bDMARD in treating children with newly diagnosed non-systemic juvenile idiopathic arthritis (JIA). METHODS Using longitudinal patient-level data extracted from electronic medical records (EMR) in a large Midwestern pediatric hospital from 2009 to 2018, the initial prescriptions and prescribing patterns of bDMARDs, conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs), non-steroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids within 3 months of JIA diagnosis were examined. Kaplan-Meier analyses were performed to assess time to initiation of bDMARDs. Cox proportional hazard models were used to identify factors associated with time to first bDMARD. RESULTS Of 821 children, the proportion of patients with initial csDMARDs increased from 45.3% in 2009 to 60.3% in 2018. Around 57.5% of polyarthritis rheumatoid factor-positive (Poly RF+) patients and 43.2% of polyarthritis rheumatoid factor-negative (Poly RF-) patients received a bDMARD therapy within 3 months of diagnosis, 14.4% as monotherapy and 28.3% in combination with a csDMARD. Among patients who received combination therapy, combination of methotrexate with adalimumab increased from 16.7% in 2009 to 40% in 2018. The proportion of patients treated with adalimumab gradually increased and passed etanercept in 2016. The predictors of earlier initiation of biologic therapy were JIA category enthesitis-related arthritis (ERA) [hazard ratio (HR) vs persistent oligoarthritis 4.82; p < 0.0001], psoriatic arthritis (PsA) (HR 2.46; p = 0.0002), or Poly RF- (HR 2.43; p = 0.0002); the number of joints with limited range of motion (HR 1.02; p = 0.0222), and erythrocyte sedimentation rate (ESR, HR 1.01; p = 0.0033). CONCLUSIONS There was a substantial increase in the proportion of patients receiving the combination of methotrexate and adalimumab among patients receiving combination therapy. Adalimumab overtook etanercept as the most frequently prescribed bDMARD. Multiple factors affect the time to biologic initiation, including the number of joints with limited range of motion, ESR, and JIA category.
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Affiliation(s)
- Xiaomeng Yue
- Division of Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati, 3225 Eden Ave., Cincinnati, OH, 45267, USA.
| | - Bin Huang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ana L Hincapie
- Division of Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati, 3225 Eden Ave., Cincinnati, OH, 45267, USA
| | - Patricia R Wigle
- Division of Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati, 3225 Eden Ave., Cincinnati, OH, 45267, USA
| | - Tingting Qiu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Yuxiang Li
- Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Esi M Morgan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jeff J Guo
- Division of Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati, 3225 Eden Ave., Cincinnati, OH, 45267, USA
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Mahar RK, McGuinness MB, Chakraborty B, Carlin JB, IJzerman MJ, Simpson JA. A scoping review of studies using observational data to optimise dynamic treatment regimens. BMC Med Res Methodol 2021; 21:39. [PMID: 33618655 PMCID: PMC7898728 DOI: 10.1186/s12874-021-01211-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 01/19/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Dynamic treatment regimens (DTRs) formalise the multi-stage and dynamic decision problems that clinicians often face when treating chronic or progressive medical conditions. Compared to randomised controlled trials, using observational data to optimise DTRs may allow a wider range of treatments to be evaluated at a lower cost. This review aimed to provide an overview of how DTRs are optimised with observational data in practice. METHODS Using the PubMed database, a scoping review of studies in which DTRs were optimised using observational data was performed in October 2020. Data extracted from eligible articles included target medical condition, source and type of data, statistical methods, and translational relevance of the included studies. RESULTS From 209 PubMed abstracts, 37 full-text articles were identified, and a further 26 were screened from the reference lists, totalling 63 articles for inclusion in a narrative data synthesis. Observational DTR models are a recent development and their application has been concentrated in a few medical areas, primarily HIV/AIDS (27, 43%), followed by cancer (8, 13%), and diabetes (6, 10%). There was substantial variation in the scope, intent, complexity, and quality between the included studies. Statistical methods that were used included inverse-probability weighting (26, 41%), the parametric G-formula (16, 25%), Q-learning (10, 16%), G-estimation (4, 6%), targeted maximum likelihood/minimum loss-based estimation (4, 6%), regret regression (3, 5%), and other less common approaches (10, 16%). Notably, studies that were primarily intended to address real-world clinical questions (18, 29%) tended to use inverse-probability weighting and the parametric G-formula, relatively well-established methods, along with a large amount of data. Studies focused on methodological developments (45, 71%) tended to be more complicated and included a demonstrative real-world application only. CONCLUSIONS As chronic and progressive conditions become more common, the need will grow for personalised treatments and methods to estimate the effects of DTRs. Observational DTR studies will be necessary, but so far their use to inform clinical practice has been limited. Focusing on simple DTRs, collecting large and rich clinical datasets, and fostering tight partnerships between content experts and data analysts may result in more clinically relevant observational DTR studies.
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Affiliation(s)
- Robert K Mahar
- Biostatistics Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia.
- Cancer Health Services Research Unit, University of Melbourne Centre for Cancer Research and Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia.
- Victorian Comprehensive Cancer Centre, Parkville, Victoria, Australia.
| | - Myra B McGuinness
- Biostatistics Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia
| | - Bibhas Chakraborty
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
- Department of Statistics and Applied Probability, Faculty of Science, National University of Singapore, Singapore, Singapore
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - John B Carlin
- Biostatistics Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Maarten J IJzerman
- Cancer Health Services Research Unit, University of Melbourne Centre for Cancer Research and Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
- Victorian Comprehensive Cancer Centre, Parkville, Victoria, Australia
- Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
| | - Julie A Simpson
- Biostatistics Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
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13
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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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