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Kostik MM, Isupova EA, Belozerov K, Likhacheva TS, Suspitsin EN, Raupov R, Masalova VV, Chikova IA, Dubko MF, Kalashnikova OV, Chasnyk VG, Cron RQ. Standard and increased canakinumab dosing to quiet macrophage activation syndrome in children with systemic juvenile idiopathic arthritis. Front Pediatr 2022; 10:894846. [PMID: 35967555 PMCID: PMC9366524 DOI: 10.3389/fped.2022.894846] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 07/11/2022] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Macrophage activation syndrome (MAS) is a life-threatening, potentially fatal condition associated with systemic juvenile idiopathic arthritis (sJIA). Interleukin-1 (IL-1) is a key cytokine in the pathogenesis of sJIA MAS. Many cases of MAS are medically refractory to traditional doses of biologic cytokine inhibitors and may require increased dosing. When MAS occurs in the setting of sJIA treated with the IL-1 receptor antagonist (IL-1Ra), anakinra, increased anakinra dosing may be beneficial. Increased dosing of another IL-1 inhibitor, canakinumab, a monoclonal antibody to IL-1β, has not been reported to treat refractory MAS in the setting of sJIA. METHODS Retrospective data collection extracted from the electronic medical record focused on canakinumab usage and dosing in 8 children with sJIA who developed MAS at a single academic center from 2011 to 2020. RESULTS Eight sJIA children (five girls) with median age 8.5 years (range, 0.9-14.2 years) were included in the present study. Five children developed MAS at disease onset and three during ongoing canakinumab therapy. MAS resolved in all eight children with canakinumab treatment. When the canakinumab dosing was insufficient or MAS developed during canakinumab therapy, the dosing was temporally up-titrated (four patients, maximum 300 mg per dose) without observed side effects. CONCLUSION This report provides evidence for the efficacy and safety of short-term increased doses (2-3-times normal) of canakinumab in treating sJIA associated MAS. Further study of the efficacy and safety of increased doses of canakinumab for treatment of MAS in children with sJIA is warranted.
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Affiliation(s)
- Mikhail M Kostik
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russia
| | - Eugenia A Isupova
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russia
| | - Konstantin Belozerov
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russia
| | - Tatyana S Likhacheva
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russia
| | - Evgeny N Suspitsin
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russia.,Medical Genetics, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russia.,Molecular Oncology, National Medical Research Center of Oncology n.a. N.N. Petrov, Saint-Petersburg, Russia
| | - Rinat Raupov
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russia
| | - Vera V Masalova
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russia
| | - Irina A Chikova
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russia
| | - Margarita F Dubko
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russia
| | - Olga V Kalashnikova
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russia
| | - Vyacheslav G Chasnyk
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russia
| | - Randy Q Cron
- Division of Rheumatology, Department of Pediatrics, University of Alabama School of Medicine, Birmingham, AL, United States
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Koç R, Sönmez HE, Çakan M, Karadağ ŞG, Tanatar A, Çakmak F, Aktay Ayaz N. Drug reactions in children with rheumatic diseases receiving parenteral therapies: 9 years’ experience of a tertiary pediatric rheumatology center. Rheumatol Int 2019; 40:771-776. [DOI: 10.1007/s00296-019-04498-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/10/2019] [Indexed: 12/19/2022]
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Mitchell C, Crayne CB, Cron RQ. Patterns of B Cell Repletion Following Rituximab Therapy in a Pediatric Rheumatology Cohort. ACR Open Rheumatol 2019; 1:527-532. [PMID: 31777835 PMCID: PMC6858005 DOI: 10.1002/acr2.11074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 07/24/2019] [Indexed: 12/19/2022] Open
Abstract
Objective To investigate the association between demographic characteristics, disease characteristics, the number of rituximab (RTX) rounds, and concurrent immunosuppression on B cell level repletion following RTX therapy. Methods A retrospective chart review of 112 children who met inclusion criteria and were treated with RTX at a single institution was performed. Demographic, clinical, and laboratory data were extracted and compared. CD19 levels were reviewed at 6 and 12 months post‐RTX with depletion defined as fewer than 10 cells/μL and complete repopulation to normal levels defined as 170 cells/μL or more. Results Among patients with CD19 levels, 48% of patients remained depleted at 6 months, 89% were repleted with 10 cells/μL or more by 12 months, and 46% remained below normal levels at 12 months following infusion. There was no significant association between the number of RTX rounds or underlying disease and persistent depletion below normal levels at 12 months following RTX infusion. Depletion at 6 months was associated with a 79% chance of persistent depletion below normal levels at 12 months. The association between concurrent cyclophosphamide (CYC) and repletion of 10 cells/μL or more at 6 (P = 0.091) and 12 months (P = 0.087) trended toward significance with no significant association between CYC and persistent depletion below normal levels. Conclusion RTX therapy for pediatric rheumatic diseases is well‐tolerated and results in variable repletion and normalization of B cell numbers at 6 and 12 months. B cell repletion in children is variable and independent of underlying disease and of the number of RTX infusions.
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Crayne CB, Eloseily E, Mannion ML, Azerf SP, Weiser P, Beukelman T, Stoll ML, Feig DI, Prescott Atkinson T, Cron RQ. Rituximab treatment for chronic steroid-dependent Henoch-Schonlein purpura: 8 cases and a review of the literature. Pediatr Rheumatol Online J 2018; 16:71. [PMID: 30428889 PMCID: PMC6236882 DOI: 10.1186/s12969-018-0285-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 10/25/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Henoch-Schonlein purpura (HSP) is a small vessel vasculitis that is characterized by non-thrombocytopenic purpura, abdominal pain, arthritis, and glomerulonephritis. Typically, HSP is self-limited requiring only supportive care, but more severe cases may require corticosteroid (CS) treatment. Rarely, a subset of these patients has persistent rash, arthritis, abdominal involvement, or renal disease despite treatment with CS, or has disease recurrence on CS tapering. Refractory HSP has been effectively treated with a variety of CS sparing therapies. For life-threatening refractory HSP, the B cell depleting agent, rituximab (RTX), has been reported as beneficial for children with substantial renal or central nervous system involvement. However, RTX use for children with less severe HSP, but chronic CS dependent disease refractory to CS sparing immunomodulatory agents, has been less well explored. Herein, we describe 8 children treated with RTX for chronic refractory HSP and report a reduction in recurrent hospitalizations and eventual CS discontinuation. METHODS This is a retrospective analysis of eight children who were treated with RTX for chronic CS dependent HSP during the years 2006-2014 at a single institution. A chart review of the electronic medical record was performed to determine the presenting symptoms, the type and duration of treatment received, and the number of hospitalizations prior to and after RTX. The number of hospitalizations and oral corticosteroid burden were analyzed using the Wilcoxon signed rank test. RESULTS Prior to receiving RTX, seven patients had at least one hospitalization for HSP (median 1.5, range 0-3). Following RTX, only two patients were hospitalized, each a single time for recurrent abdominal pain. The median oral CS burden was 0.345 mg/kg/day before RTX and 0 mg/kg/day at 6 months (p = 0.078), 1 year (p = 0.0625), and 2 years (p = 0.03) following RTX infusion. Seven out of eight children met remission criteria, defined as no active rash, arthritis, nephritis (hematuria and proteinuria), or gastrointestinal distress following RTX. No serious adverse events were noted. CONCLUSION Overall, RTX effectively reduced the number of hospital admissions and oral CS burden. RTX also helped most all children achieve clinical remission. RTX appears to be an effective and safe alternative for chronic CS dependent and immunomodulatory refractory childhood HSP.
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Affiliation(s)
- Courtney B. Crayne
- 0000000106344187grid.265892.2Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, 1600 7th Ave S, CPPN G10, Birmingham, AL 35233 USA
| | - Esraa Eloseily
- 0000000106344187grid.265892.2Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, 1600 7th Ave S, CPPN G10, Birmingham, AL 35233 USA
| | - Melissa L. Mannion
- 0000000106344187grid.265892.2Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, 1600 7th Ave S, CPPN G10, Birmingham, AL 35233 USA
| | - Saji P. Azerf
- 0000000106344187grid.265892.2School of Medicine, University of Alabama at Birmingham, 510 20th St S, #12, Birmingham, AL 35233 USA
| | - Peter Weiser
- 0000000106344187grid.265892.2Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, 1600 7th Ave S, CPPN G10, Birmingham, AL 35233 USA
| | - Timothy Beukelman
- 0000000106344187grid.265892.2Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, 1600 7th Ave S, CPPN G10, Birmingham, AL 35233 USA
| | - Matthew L. Stoll
- 0000000106344187grid.265892.2Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, 1600 7th Ave S, CPPN G10, Birmingham, AL 35233 USA
| | - Daniel I. Feig
- 0000000106344187grid.265892.2Division of Nephrology, Department of Pediatrics, University of Alabama at Birmingham, 1600 7th Ave S, ACC 516, Birmingham, AL 35233 USA
| | - T. Prescott Atkinson
- 0000000106344187grid.265892.2Division of Allergy & Immunology, Department of Pediatrics, University of Alabama at Birmingham, 1600 7th Ave S, CPPN M20, Birmingham, AL 35233 USA
| | - Randy Quentin Cron
- Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, 1600 7th Ave S, CPPN G10, Birmingham, AL, 35233, USA.
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