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Elshaer R, Jaber S, Odeh N, Arbili L, Al-Mayouf SM. Safety and efficacy of biologics in childhood systemic lupus erythematosus: a critical systematic review. Clin Rheumatol 2024; 43:863-877. [PMID: 38079010 DOI: 10.1007/s10067-023-06833-z] [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: 08/18/2023] [Revised: 10/20/2023] [Accepted: 11/24/2023] [Indexed: 02/20/2024]
Abstract
Biologic agents are increasingly being used to treat adult patients with systemic lupus erythematosus (SLE). However, the available data on biologic agents' use in childhood-onset SLE (cSLE) remains limited. To collate available evidence related to the efficacy and safety of using biologic agents in cSLE. The study followed the PRISMA checklist for reporting the data and conducted a thorough search using PubMed, Cochrane Library, and Scopus from January 2005 to August 2023. Only articles meeting specific criteria were included, focusing on cSLE, the use of biologic agents, and having outcome measures at six- and 12-month follow-ups for safety and efficacy. Case reports were excluded, and four independent reviewers screened the articles for accuracy, with a fifth reviewer resolving any discrepancies that arose to achieve a consensus. The final selection included 18 studies with a total of 593 patients treated with biologic agents for severe and/ or refractory cSLE. The most common indication for using biologic agents was lupus nephritis. Rituximab was used in 12 studies, while belimumab was used in six studies. The studies evaluated the efficacy of biologic agents based on SLE disease activity scores, laboratory parameter improvements, and reduced corticosteroid dosage. Positive outcomes were reported, with improvements in renal, hematologic, and immunologic parameters along with mild adverse effects, mostly related to mild infections and infusion reactions. Belimumab and rituximab have shown promise as potential treatments for severe and refractory cSLE cases, leading to decreased disease activity and complete or partial remission in many patients with an acceptable safety profile. However, further research is needed to better understand their benefits and potential risks in these patients. Key Points • This review emphasizes the lack of sufficient randomized controlled trials exploring the use of biologics in childhood systemic lupus erythematosus (cSLE). • Treatment plans for cSLE are being derived from those used for adult systemic lupus erythematosus. • According to current evidence, belimumab and rituximab can be potential treatment options for refractory and severe cases of cSLE. • Additional studies are required to reach more definitive conclusions.
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Affiliation(s)
- Rawan Elshaer
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Samar Jaber
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Nour Odeh
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Lana Arbili
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Sulaiman M Al-Mayouf
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Alfaisal University, Po Box 3354, 11211, Riyadh, Saudi Arabia.
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2
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Keskinyan VS, Lattanza B, Reid-Adam J. Glomerulonephritis. Pediatr Rev 2023; 44:498-512. [PMID: 37653138 DOI: 10.1542/pir.2021-005259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Glomerulonephritis (GN) encompasses several disorders that cause glomerular inflammation and injury through an interplay of immune-mediated mechanisms, host characteristics, and environmental triggers, such as infections. GN can manifest solely in the kidney or in the setting of a systemic illness, and presentation can range from chronic and relatively asymptomatic hematuria to fulminant renal failure. Classic acute GN is characterized by hematuria, edema, and hypertension, the latter 2 of which are the consequence of sodium and water retention in the setting of renal impairment. Although presenting signs and symptoms and a compatible clinical history can suggest GN, serologic and urinary testing can further refine the differential diagnosis, and renal biopsy can be used for definitive diagnosis. Treatment of GN can include supportive care, renin-angiotensin-aldosterone system blockade, immunomodulatory therapy, and renal transplant. Prognosis is largely dependent on the underlying cause of GN and can vary from a self-limited course to chronic kidney disease. This review focuses on lupus nephritis, IgA nephropathy, IgA vasculitis, and postinfectious GN.
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3
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Abstract
Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease characterized by remissions and flares. Twenty percent of SLE presents in childhood where the course of SLE is often more severe with significant morbidity and mortality. Several biologic agents have been developed recently for the treatment of lupus, and although some have proven to be safe and efficacious, many have failed to demonstrate significant benefit in clinical trials. There continues to be a desperate need for safe, effective medications that target specific pathway abnormalities seen in SLE. This is an area of intense research that is changing clinical practice in the treatment of childhood SLE. In this article, we discuss the use of B-cell inhibitors, including belimumab and rituximab, as well as the anti-complement drug eculizumab. Promising treatments on the horizon include the jak-stat inhibitors as well as anifrolumab, which targets interferon. [Pediatr Ann. 2022;51(2):e63-e71.].
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Ong MS, Rothman D, Barmettler S, Son MB, Lo M, Roberts J, Natter M. New-onset Hypogammaglobulinemia and Infectious Complications Associated with Rituximab Use in Childhood-onset Rheumatic Diseases. Rheumatology (Oxford) 2021; 61:1610-1620. [PMID: 34329428 DOI: 10.1093/rheumatology/keab626] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 07/01/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To investigate the incidence and risk factors for hypogammaglobulinemia and infectious complications associated with rituximab treatment in childhood-onset rheumatic diseases. METHODS We performed a single-center retrospective study of patients (n = 85) treated at Boston Children's Hospital (BCH) from 2009 to 2019. Study subjects included patients (ages 6 to 24) who received rituximab for the treatment of a childhood-onset rheumatic disease. RESULTS New-onset hypogammaglobulinemia developed in 23 (27.1%) patients within 18 months of rituximab induction treatment. 22 patients (25.9%) developed at least one infectious complication in the 18 months following the first rituximab infusion; of these, 11 (50%) had serious infections requiring inpatient treatment. After adjusting for potential confounders, exposure to pulse corticosteroid therapy in the month prior to rituximab use was a significant predictor of both new-onset hypogammaglobulinemia (OR 3.94; 95% CI 1.07-16.0; p = 0.044) and infectious complications (OR 15.3; 95% CI 3.04-126.8; p = 0.003). Post-rituximab hypogammaglobulinemia was the strongest predictor of serious infectious complications (OR 7.89; 95% CI 1.41-65.6; p = 0.028). Younger age at rituximab use was also a significant predictor of new-onset hypogammaglobulinemia (OR 0.83; 95% CI 0.70-0.97; p = 0.021). Compared with other rheumatic diseases, patients with vasculitis had a higher likelihood of developing infectious complications, including serious infections. CONCLUSION Although rituximab was well tolerated in terms of infectious complications in the majority of patients with childhood-onset rheumatic diseases, a substantial proportion developed new-onset hypogammaglobulinemia and infectious complications following treatment. Our study highlights a role for heightened vigilance of rituximab-associated hypogammaglobulinemia and infections in pediatric patients with rheumatic conditions.
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Affiliation(s)
- Mei Sing Ong
- Department of Population Medicine, Harvard Medical School & Harvard Pilgrim Health Care Institute, Boston MA, United States
| | - Deborah Rothman
- Pediatric Rheumatology, Massachusetts General Hospital, Boston MA, United States
| | - Sara Barmettler
- Allergy and Immunology, Massachusetts General Hospital, Boston MA, United States
| | - Mary Beth Son
- Pediatric Rheumatology, Boston Children's Hospital, Boston MA, United States
| | - Mindy Lo
- Pediatric Rheumatology, Boston Children's Hospital, Boston MA, United States
| | - Jordan Roberts
- Pediatric Rheumatology, Boston Children's Hospital, Boston MA, United States
| | - Marc Natter
- Pediatric Rheumatology, Massachusetts General Hospital, Boston MA, United States.,Computational Health Informatics Program, Boston Children's Hospital, Boston MA, United States.,Department of Pediatrics, Harvard Medical School, Boston MA, United States
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5
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Barrio Nogal L, Clemente Garulo D, de Lucas Collantes C, Aparicio López C, López Robledillo JC. Systemic lupus erythematosus of atypical onset: a presentation of 3 cases. An Pediatr (Barc) 2020; 93:257-259. [DOI: 10.1016/j.anpede.2019.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 12/30/2019] [Indexed: 10/23/2022] Open
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6
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Barrio Nogal L, Clemente Garulo D, de Lucas Collantes C, Aparicio López C, López Robledillo JC. [Systemic lupus erythematosus of atypical onset: A presentation of 3 cases]. An Pediatr (Barc) 2020; 93:257-259. [PMID: 32094087 DOI: 10.1016/j.anpedi.2019.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 12/16/2019] [Accepted: 12/30/2019] [Indexed: 12/01/2022] Open
Affiliation(s)
- Laura Barrio Nogal
- Servicio de Enfermedades del Sistema Inmune y Reumatología, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España.
| | - Daniel Clemente Garulo
- Servicio de Reumatología Pediátrica, Hospital Universitario Niño Jesús. Madrid, Madrid, España
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Wenderfer SE, Chang J, Hicks MJ. Approach to Classification and Management of Childhood-Onset Lupus Nephritis. CURRENT PEDIATRICS REPORTS 2020. [DOI: 10.1007/s40124-020-00207-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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8
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Smith EMD, Lythgoe H, Midgley A, Beresford MW, Hedrich CM. Juvenile-onset systemic lupus erythematosus: Update on clinical presentation, pathophysiology and treatment options. Clin Immunol 2019; 209:108274. [PMID: 31678365 DOI: 10.1016/j.clim.2019.108274] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/12/2019] [Accepted: 10/13/2019] [Indexed: 12/25/2022]
Abstract
Juvenile-onset systemic lupus erythematosus (jSLE) accounts for up to 20% of all SLE patients. Key differences between juvenile- and adult-onset (aSLE) disease include higher disease activity, earlier development of damage, and increased use of immunosuppressive treatment in jSLE suggesting (at least partial) infectivity secondary to variable pathomechanisms. While the exact pathophysiology of jSLE remains unclear, genetic factors, immune complex deposition, complement activation, hormonal factors and immune cell dysregulation are involved to variable extents, promising future patient stratification based on immune phenotypes. Though less effective and potentially toxic, jSLE patients are treated based upon evidence from studies in aSLE cohorts. Here, age-specific clinical features of jSLE, underlying pathomechanisms, treatment options and disease outcomes will be addressed. Future directions to improve the care of jSLE patients, including implementation of the Single Hub and Access point for pediatric Rheumatology in Europe (SHARE) recommendations, biomarkers, treat to target and personalized medicine approaches are discussed.
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Affiliation(s)
- Eve Mary Dorothy Smith
- Department of Women's & Children's Health, Institution of Translational Medicine, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Eaton Rd, Liverpool L12 2AP, UK.
| | - Hanna Lythgoe
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Eaton Rd, Liverpool L12 2AP, UK
| | - Angela Midgley
- Department of Women's & Children's Health, Institution of Translational Medicine, University of Liverpool, UK
| | - Michael William Beresford
- Department of Women's & Children's Health, Institution of Translational Medicine, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Eaton Rd, Liverpool L12 2AP, UK
| | - Christian Michael Hedrich
- Department of Women's & Children's Health, Institution of Translational Medicine, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Eaton Rd, Liverpool L12 2AP, UK.
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9
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Peterknecht E, Keasey MP, Beresford MW. The effectiveness and safety of biological therapeutics in juvenile-onset systemic lupus erythematosus (JSLE): a systematic review. Lupus 2018; 27:2135-2145. [PMID: 30336753 DOI: 10.1177/0961203318804879] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To systematically review and summarize the available literature regarding the effectiveness and safety of biologics in the treatment of juvenile-onset systemic lupus erythematosus. METHODS PubMed was systematically searched for relevant literature (2012-2017 inclusive) using the following criteria: (1) patients diagnosed with juvenile-onset systemic lupus erythematosus (≤18 years at diagnosis); (2) treatment with any biological agent; and (3) outcome measures assessing effectiveness and safety. Systematic literature reviews, meta-analyses, randomized controlled trials, cohort studies, case control studies, cross sectional surveys and case-series with ≥3 patients were included. Independent extraction of articles by two authors using predefined criteria was performed. The quality of each study was assessed using CASP tools and Oxford CEBM Levels of Evidence. RESULTS Nine articles met inclusion criteria: six cohort studies, two case series and one pilot study, totalling 230 patients. All but one article reported the effects of rituximab, the other those of belimumab. Overall, patients had active disease refractory to standard of care regimens using corticosteroids and immunosuppressants. Available evidence for rituximab demonstrated improvements in disease activity, complement levels and anti-dsDNA titres accompanying a steroid-sparing effect. CONCLUSION Rituximab can be considered an effective treatment in juvenile-onset systemic lupus erythematosus patients with severe disease manifestations and/or refractory disease. Based on current evidence, use of belimumab in juvenile-onset systemic lupus erythematosus patients cannot be recommended. The long-term safety of these biological agents remains uncertain. Further prospective studies, ideally robust randomized controlled trials, are urgently needed to obtain more accurate data on the effectiveness and long-term safety of rituximab, belimumab and other biologics in juvenile-onset systemic lupus erythematosus.
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Affiliation(s)
- E Peterknecht
- 1 University of Liverpool Medical School, University of Liverpool, Liverpool, UK
| | - M P Keasey
- 2 Department of Biomedical Sciences, Quillen College of Medicine, East Tennessee State University, Johnson City, USA
| | - M W Beresford
- 3 Clinical Academic Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- 4 Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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10
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Liossis SNC, Staveri C. B Cell-Based Treatments in SLE: Past Experience and Current Directions. Curr Rheumatol Rep 2017; 19:78. [DOI: 10.1007/s11926-017-0707-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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11
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Teles KA, Medeiros‐Souza P, Lima FAC, Araújo BGD, Lima RAC. Rotina de administração de ciclofosfamida em doenças autoimunes reumáticas: uma revisão. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2016.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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12
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Abstract
The past two decades have brought immense satisfaction to pediatric rheumatologists and families of children with rheumatologic diseases. We have been able to better classify, recognize, and diagnose rheumatologic diseases, but most importantly, the discovery of biologic therapies and their efficacy and relative safety in treating multiple rheumatologic conditions, improving quality of life for the patients we care for. We will review the advances of the past two decades and discuss potential areas for new discoveries.
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Affiliation(s)
- Yonit Sterba
- Division of Pediatric Rheumatology, The Children's Hospital at Montefiore, 3415 Bainbridge Avenue, Bronx, NY, 10467, USA.
| | - Norman Ilowite
- Division of Pediatric Rheumatology, The Children's Hospital at Montefiore, 3415 Bainbridge Avenue, Bronx, NY, 10467, USA
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13
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Mehta J, Beukelman T. Biologic Agents in the Treatment of Childhood-Onset Rheumatic Disease. J Pediatr 2017; 189:31-39. [PMID: 28711176 DOI: 10.1016/j.jpeds.2017.06.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 06/05/2017] [Accepted: 06/15/2017] [Indexed: 12/22/2022]
Affiliation(s)
- Jay Mehta
- Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Timothy Beukelman
- Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, Birmingham, AL.
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14
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Pérez-De-Lis M, Retamozo S, Flores-Chávez A, Kostov B, Perez-Alvarez R, Brito-Zerón P, Ramos-Casals M. Autoimmune diseases induced by biological agents. A review of 12,731 cases (BIOGEAS Registry). Expert Opin Drug Saf 2017; 16:1255-1271. [DOI: 10.1080/14740338.2017.1372421] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Marta Pérez-De-Lis
- Servicio de Anestesiologia y Reanimación, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Soledad Retamozo
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- Hospital Privado Universitario de Córdoba, Córdoba, Argentina
- Instituto De Investigaciones En Ciencias De La Salud (INICSA), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Córdoba, Argentina
| | - Alejandra Flores-Chávez
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- Unidad de Investigación Biomédica 02, Unidad de Investigación en Epidemiología Clínica, Centro Médico Nacional de Occidente (CMNO), Instituto Mexicano del Seguro Social (IMSS), Hospital de Especialidades, Guadalajara, Mexico
- Programa de Doctorado en Ciencias Médicas, Centro Universitario de Investigaciones Biomédicas (CUIB), Universidad de Colima, Colima, Mexico
| | | | | | - Pilar Brito-Zerón
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- Autoimmune Diseases Unit, Department of Medicine, Hospital CIMA- Sanitas, Barcelona, Spain
| | - Manuel Ramos-Casals
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain
- Department of Medicine, University of Barcelona, Barcelona, Spain
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15
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Mahmoud I, Jellouli M, Boukhris I, Charfi R, Ben Tekaya A, Saidane O, Ferjani M, Hammi Y, Trabelsi S, Khalfallah N, Tekaya R, Gargah T, Abdelmoula L. Efficacy and Safety of Rituximab in the Management of Pediatric Systemic Lupus Erythematosus: A Systematic Review. J Pediatr 2017; 187:213-219.e2. [PMID: 28602379 DOI: 10.1016/j.jpeds.2017.05.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 01/31/2017] [Accepted: 05/01/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To evaluate the efficacy and safety of rituximab for treating pediatric systemic lupus erythematosus (pSLE). STUDY DESIGN We performed a systematic review to evaluate the efficacy and safety of rituximab in children with pSLE. Data from studies performed before July 2016 were collected from MEDLINE, the Cochrane Library, Scopus, and the International Rheumatic Disease Abstracts, with no language restrictions. Study eligibility criteria included clinical trials and observational studies with a minimal sample size of 5 patients, regarding treatment with rituximab in patients with refractory pSLE (aged <18 years at the time of diagnosis). Independent extraction of articles was performed by 2 investigators using predefined data fields. RESULTS Twelve case series met the criteria for data extraction for the systematic review with a good quality assessment according to an 18-criteria checklist using a modified Delphi method. Among them, 3 studies were multicenter and 3 were prospective. The total number of patients was 272. Studies collected patients with active disease refractory to steroids and immunosuppressant drugs. Refractory lupus nephritis was the most common indication (33%). Acceptable evidence suggested improvements in renal, neuropsychiatric and haematological manifestations, disease activity, complement and anti-double stranded Desoxy-Nucleo-Adenosine, with a steroid-sparing effect. However, there was poor evidence suggesting efficacy on arthralgia, photosensitivity, and mucocutaneous manifestations of SLE in children. An overall acceptable safety profile with few major adverse events was shown. CONCLUSION Rituximab exhibited a satisfactory profile regarding efficacy and safety indicating that this agent is a promising therapy for pSLE and should be further investigated.
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Affiliation(s)
- Ines Mahmoud
- Department of Rheumatology, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia.
| | - Manel Jellouli
- Department of Pediatric Nephrology, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Imen Boukhris
- Department of Internal Medicine, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Rim Charfi
- Department of Clinical Pharmacology, National Centre of Pharmacovigilance, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Aicha Ben Tekaya
- Department of Rheumatology, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Olfa Saidane
- Department of Rheumatology, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Maryem Ferjani
- Department of Pediatric Nephrology, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Yousra Hammi
- Department of Pediatric Nephrology, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Sameh Trabelsi
- Department of Clinical Pharmacology, National Centre of Pharmacovigilance, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Narjess Khalfallah
- Department of Internal Medicine, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Rawdha Tekaya
- Department of Rheumatology, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Tahar Gargah
- Department of Pediatric Nephrology, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia
| | - Leila Abdelmoula
- Department of Rheumatology, Charles Nicolle Hospital, Faculty of Medicine, Manar University, Tunis, Tunisia
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Hui-Yuen JS, Nguyen SC, Askanase AD. Targeted B cell therapies in the treatment of adult and pediatric systemic lupus erythematosus. Lupus 2017; 25:1086-96. [PMID: 27497253 DOI: 10.1177/0961203316652491] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Belimumab (Benlysta) is a fully-humanized monoclonal antibody that inhibits B-lymphocyte stimulator (also known as B cell activating factor) and was approved by the U.S. Federal Drug Administration and European Medicines Evaluation Agency for treatment in adults with autoantibody-positive systemic lupus erythematosus (SLE). Rituximab (Rituxan) is a chimeric anti-CD20 monoclonal antibody targeting B lymphocytes. This review discusses the key findings of the phase III trials in adults with SLE and of real-world use of belimumab and rituximab in the care of both adult and pediatric SLE patients. It highlights the safety profile of belimumab and rituximab and gives insight into the consideration of these therapies for specific SLE disease states. It concludes with a discussion of the current clinical trials investigating B cell therapies in specific SLE disease states and a look to the future, with ongoing clinical trials.
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Affiliation(s)
- J S Hui-Yuen
- Division of Pediatric Rheumatology, Steven and Alexandra Cohen Children Medical Center, Hofstra Northwell School of Medicine, USA
| | - S C Nguyen
- Division of Rheumatology, New York-Presbyterian Hospital/Columbia University Medical Center, USA
| | - A D Askanase
- Division of Rheumatology, New York-Presbyterian Hospital/Columbia University Medical Center, USA
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17
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Tanaka H, Joh K, Imaizumi T. Treatment of pediatric-onset lupus nephritis: a proposal of optimal therapy. Clin Exp Nephrol 2017; 21:755-763. [PMID: 28258497 DOI: 10.1007/s10157-017-1381-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 01/05/2017] [Indexed: 02/01/2023]
Abstract
Lupus nephritis (LN) is one of the major clinical manifestations of systemic lupus erythematosus (SLE) which occurs frequently in the early stages of pediatric-onset cases. Since SLE is a chronic disease associated with frequent disease flares and effective and safe maintenance therapy is required for achieving a favorable outcome, optimal treatment for LN in pubertal patients is a great challenge that remains to be overcome. Although its etiology remains unclear, it has been reported that the innate and adaptive immune systems have been reported to play an important role in the pathogenesis of SLE. However, studies of drugs that have been useful in controlling inflammatory pathways mediated by the innate and adaptive immune systems are now underway. In clinical practice, recent advances in the management of LN, together with earlier renal biopsy and selective use of aggressive immunosuppressive therapy, have contributed to a favorable outcome in children and adolescents with LN. However, the balance of the efficacy of treatment in terms of long-term prognosis and its adverse effects should be weighed in determining the treatment strategy.
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Affiliation(s)
- Hiroshi Tanaka
- Department of School Health Science, Faculty of Education, Hirosaki University, Hirosaki, 036-8650, Japan. .,Department of Pediatrics, Hirosaki University Hospital, Hirosaki, 036-8563, Japan.
| | - Kensuke Joh
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, 980-8575, Japan
| | - Tadaatsu Imaizumi
- Department of Vascular Biology, Graduate School of Medicine, Hirosaki University, Hirosaki, 036-8562, Japan
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18
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Advances in the care of children with lupus nephritis. Pediatr Res 2017; 81:406-414. [PMID: 27855151 DOI: 10.1038/pr.2016.247] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 10/07/2016] [Indexed: 12/27/2022]
Abstract
The care of children with lupus nephritis (LN) has changed dramatically over the past 50 y. The majority of patients with childhood-onset systemic lupus erythematosus (cSLE) develop LN. In the 1960's, prognosis in children was worse than in adults; therapies were limited and toxic. Nearly half of cases resulted in death within 2 y. Since this time, several diagnostic recommendations and disease-specific indices have been developed to assist physicians caring for patients with LN. Pediatric researchers are validating and adapting these indices and guidelines for the treatment of LN in cSLE. Classification systems, activity, and chronicity indices for kidney biopsy have been validated in pediatric cohorts in several countries. Implementation of contemporary immunosuppressive agents has reduced treatment toxicity and improved outcomes. Biomarkers sensitive to LN in children have been identified in the kidney, urine, and blood. Multi-institutional collaborative networks have formed to address the challenges of pediatric LN research. Considerable variation in evaluation and treatment has been addressed for proliferative forms of LN by development of consensus treatment practices. Patient survival at 5 y is now 95-97% and renal survival exceeds 90%. Moreover, international consensus exists for quality indicators for cSLE that consider the unique aspects of chronic disease in childhood.
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Teles KA, Medeiros-Souza P, Lima FAC, Araújo BGD, Lima RAC. Cyclophosphamide administration routine in autoimmune rheumatic diseases: a review. REVISTA BRASILEIRA DE REUMATOLOGIA 2016; 57:596-604. [PMID: 29173694 DOI: 10.1016/j.rbre.2016.09.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 04/07/2016] [Indexed: 12/15/2022] Open
Abstract
Cyclophosphamide is an alkylating agent widely used for the treatment of malignant neoplasia and which can be used in the treatment of multiple rheumatic diseases. Medication administration errors may lead to its reduced efficacy or increased drug toxicity. Many errors occur in the administration of injectable drugs. The present study aimed at structuring a routine for cyclophosphamide use, as well as creating a document with pharmacotherapeutic guidelines for the patient. The routine is schematized in three phases: pre-chemotherapy, administration of cyclophosphamide, and post-chemotherapy, taking into account the drugs to be administered before and after cyclophosphamide in order to prevent adverse effects, including nausea and hemorrhagic cystitis. Adverse reactions can alter laboratory tests; thus, this routine included clinical management for changes in white blood cells, platelets, neutrophils, and sodium, including cyclophosphamide dose adjustment in the case of kidney disease. Cyclophosphamide is responsible for other rare - but serious - side effects, for instance, hepatotoxicity, severe hyponatremia and heart failure. Other adverse reactions include hair loss, amenorrhea and menopause. In this routine, we also entered guidelines to post-chemotherapy patients. The compatibility of injectable drugs with the vehicle used has been described, as well as stability and infusion times. The routine aimed at the rational use of cyclophosphamide, with prevention of adverse events and relapse episodes, factors that may burden the health care system.
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Affiliation(s)
- Kaian Amorim Teles
- Universidade de Brasília (UnB), Departamento de Ciências da Saúde, Brasília, DF, Brazil.
| | - Patricia Medeiros-Souza
- Universidade de Brasília (UnB), Departamento de Ciências da Saúde, Brasília, DF, Brazil; Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brazil.
| | - Francisco Aires Correa Lima
- Universidade de Brasília (UnB), Hospital Universitário de Brasília, Serviço de Reumatologia, Ambulatório de Colagenoses, Brasília, DF, Brazil
| | | | - Rodrigo Aires Correa Lima
- Universidade de Brasília (UnB), Hospital Universitário de Brasília, Serviço de Reumatologia, Brasília, DF, Brazil; Hospital de Base do Distrito Federal, Serviço de Reumatologia, Ambulatório de Artrite Reumatoide Inicial, Brasília, DF, Brazil
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Abstract
Systemic lupus erythematosus (SLE) is a rare, severe, multisystem autoimmune disorder. Childhood-onset SLE (cSLE) follows a more aggressive course with greater associated morbidity and mortality than adult-onset SLE. Its aetiology is yet to be fully elucidated. It is recognised to be the archetypal systemic autoimmune disease, arising from a complex interaction between the innate and adaptive immune systems. Its complexity is reflected by the fact that there has been only one new drug licensed for use in SLE in the last 50 years. However, biologic agents that specifically target aspects of the immune system are emerging. Immunosuppression remains the cornerstone of medical management, with glucocorticoids still playing a leading role. Treatment choices are led by disease severity. Immunosuppressants, including azathioprine and methotrexate, are used in mild to moderate manifestations. Mycophenolate mofetil is widely used for lupus nephritis. Cyclophosphamide remains the first-line treatment for patients with severe organ disease. No biologic therapies have yet been approved for cSLE, although they are being used increasingly as part of routine care of patients with severe lupus nephritis or with neurological and/or haematological involvement. Drugs influencing B cell survival, including belimumab and rituximab, are currently undergoing clinical trials in cSLE. Hydroxychloroquine is indicated for disease manifestations of all severities and can be used as monotherapy in mild disease. However, the management of cSLE is hampered by the lack of a robust evidence base. To date, it has been principally guided by best-practice guidelines, retrospective case series and adapted adult protocols. In this pharmacological review, we provide an overview of current practice for the management of cSLE, together with recent advances in new therapies, including biologic agents.
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Huppertz HI, Lehmann HW. [Evidence of treatment of chronic inflammation in childhood and adolescence with biologics]. Z Rheumatol 2015; 73:907-16. [PMID: 25479934 DOI: 10.1007/s00393-014-1398-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Biologics, usually monoclonal antibodies or fusion proteins, are thought to specifically interfere with immunopathogenesis of chronic inflammatory diseases. In order to test these substances also in children and adolescents, financial incentives for manufacturers were created and classification of chronic inflammatory diseases and definition of disease activity, improvement, relapse and remission were established and large international research cooperation projects were founded. METHODS A selective literature search was carried out for treatment of chronic inflammatory diseases in children and adolescents with biologics including current guidelines. RESULTS Only 7 out of 18 prescribed biologics have been approved for children and mostly within narrow limits. The evidence for efficacy is based on four randomized double blind placebo-controlled studies, seven withdrawal studies and seven observational studies. In spite of the limited evidence in comparison to their use in adult patients these substances are broadly used worldwide and have enlarged and substantially improved the therapeutic choices in children when conventional treatment failed or proved to be toxic. Severe adverse events including infections occasionally occur (0.01-0.03 events per patient year) but the rate of malignancies is not obviously increased; however, only two thirds of patients respond to treatment. Improvement is often incomplete, some patients deteriorate and definite termination of drug treatment is possible in only a few patients. CONCLUSION As the prescription of biologics has become an important issue of treatment but is based on insufficient evidence data, further studies are necessary in children and adolescents with diseases, such as juvenile idiopathic arthritis, Crohn's disease, ulcerative colitis and inherited fever syndromes. As many drugs are available these studies can be conducted against verum.
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Affiliation(s)
- H-I Huppertz
- Prof.-Hess-Kinderklinik, Klinikum Bremen-Mitte, Sankt-Jürgen-Str. 1, 28177, Bremen, Deutschland,
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Abstract
Systemic lupus erythematosus (SLE) is a clinically diverse and potentially life-threatening auto-immune disease that can affect almost any organ system. Although much is still unknown regarding its pathogenesis, B cell abnormalities are thought to be central. A high relapse rate along with the toxicity associated with conventional treatments signify the need for more tailored approaches in this very heterogeneous disease. Both its mechanism targeting B cells and a relatively large number of case series and observational studies have suggested that the B cell-depleting agent rituximab could be a potent SLE drug. However, two randomized controlled trials failed to meet efficacy endpoints. Nevertheless, rituximab has continued to be used as an off-label alternative mainly in patients refractory to conventional immunosuppressive treatment. This article will review the current role of rituximab in SLE.
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Affiliation(s)
- Sara Linder Ekö
- Unit for Clinical Therapy Research, Inflammatory Diseases (ClinTRID), Karolinska Institute, 171 76, Stockholm, Sweden,
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Tambralli A, Beukelman T, Cron RQ, Stoll ML. Safety and efficacy of rituximab in childhood-onset systemic lupus erythematosus and other rheumatic diseases. J Rheumatol 2015; 42:541-6. [PMID: 25593242 DOI: 10.3899/jrheum.140863] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Rituximab (RTX) has been used to treat many pediatric autoimmune conditions. We investigated the safety and efficacy of RTX in a variety of pediatric autoimmune diseases, especially systemic lupus erythematosus (SLE). METHODS Retrospective study of children treated with RTX. Effectiveness data was recorded for patients with at least 12 months of followup; safety data was recorded for all subjects. RESULTS The study included 104 children; 50 had SLE. Improvements in corticosteroid dosage, physician's global assessment of disease activity, and SLE-associated markers of disease activity were seen. The incidence of hospitalized infections was similar to previous studies of patients with childhood-onset SLE. CONCLUSION RTX can be safely administered to children and appears to contribute to decreased disease activity and steroid burden.
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Affiliation(s)
- Ajay Tambralli
- From the University of Alabama at Birmingham, Department of Pediatrics, Division of Rheumatology, Birmingham, Alabama; University of Rochester Medical Center, Department of Medicine, Rochester, New York, USA.A. Tambralli, MD, University of Rochester Medical Center, Department of Medicine; T. Beukelman, MD, MSCE; R.Q. Cron, MD, PhD; M.L. Stoll, MD, PhD, MSCS, University of Alabama at Birmingham, Department of Pediatrics, Division of Rheumatology
| | - Timothy Beukelman
- From the University of Alabama at Birmingham, Department of Pediatrics, Division of Rheumatology, Birmingham, Alabama; University of Rochester Medical Center, Department of Medicine, Rochester, New York, USA.A. Tambralli, MD, University of Rochester Medical Center, Department of Medicine; T. Beukelman, MD, MSCE; R.Q. Cron, MD, PhD; M.L. Stoll, MD, PhD, MSCS, University of Alabama at Birmingham, Department of Pediatrics, Division of Rheumatology
| | - Randy Quentin Cron
- From the University of Alabama at Birmingham, Department of Pediatrics, Division of Rheumatology, Birmingham, Alabama; University of Rochester Medical Center, Department of Medicine, Rochester, New York, USA.A. Tambralli, MD, University of Rochester Medical Center, Department of Medicine; T. Beukelman, MD, MSCE; R.Q. Cron, MD, PhD; M.L. Stoll, MD, PhD, MSCS, University of Alabama at Birmingham, Department of Pediatrics, Division of Rheumatology
| | - Matthew Laurence Stoll
- From the University of Alabama at Birmingham, Department of Pediatrics, Division of Rheumatology, Birmingham, Alabama; University of Rochester Medical Center, Department of Medicine, Rochester, New York, USA.A. Tambralli, MD, University of Rochester Medical Center, Department of Medicine; T. Beukelman, MD, MSCE; R.Q. Cron, MD, PhD; M.L. Stoll, MD, PhD, MSCS, University of Alabama at Birmingham, Department of Pediatrics, Division of Rheumatology.
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Aringer M, Smolen JS. Safety of off-label biologicals in systemic lupus erythematosus. Expert Opin Drug Saf 2014; 14:243-51. [DOI: 10.1517/14740338.2015.986455] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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