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Sunar Yayla EN, Yıldız Ç, Esmeray Şenol P, Karaçayır N, Gezgin Yıldırım D, Bakkaloğlu SA. How Safe Are Biological Agents in Pediatric Rheumatology? Turk Arch Pediatr 2024; 59:185-192. [PMID: 38454228 PMCID: PMC11059757 DOI: 10.5152/turkarchpediatr.2024.23221] [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: 09/14/2023] [Accepted: 02/06/2024] [Indexed: 03/09/2024]
Abstract
OBJECTIVE Biologic therapy has changed the prognosis of patients with rheumatologic disease. Despite all benefits of the biological agents, adverse events may occur due to their long-term use. The aim of this study is to analyze the adverse events observed in pediatric patients who received biological treatment. MATERIALS AND METHODS This retrospective observational cohort study was conducted between January 2010 and January 2022. File records of 139 patients used biological agents for rheumatologic diseases in a pediatric rheumatology clinic were evaluated. Diagnosis, received treatment, the rationale for stopping treatment, requirement of tuberculosis prophylaxis, presence of an adverse event, and results were recorded. RESULTS The most used biological therapy was etanercept (41.7%). Anakinra, adalimumab, canakinumab were used in 30.9%, 27.3%, 23.7% of patients, and the others in less than 10%. Totally 491 adverse events (97.9/100 patient-years) were encountered during the duration of biological treatment. The most often adverse event was recurrent upper respiratory tract infection in the patients (31.9/100 patient-years). Elevated aminotransferase levels (10.4/100 patient-years), abdominal pain (7/100 patient-years), and headache (5.2/100 patient-years) were among the other common side effects. Isoniazid (INH) prophylaxis was needed before biological treatment in 20.9% of the patients. Tuberculosis developed in none of the patients followed-up for latent tuberculosis, however, it developed in a patient while receiving etanercept due to noncompliance with his scheduled outpatient visits during etanercept treatment. CONCLUSION The most commonly used biological treatments were TNFi and IL-antagonists, and the majority of side effects were infections and laboratory abnormalities. Although the rate of serious adverse events is quite low, close follow-up of patients receiving biological therapy is very important.
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Affiliation(s)
- Emine Nur Sunar Yayla
- Division of Pediatric Rheumatology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
- Clinic of Pediatric Rheumatology, Ankara Etlik City Hospital, Ankara, Turkey
| | - Çisem Yıldız
- Division of Pediatric Rheumatology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Pelin Esmeray Şenol
- Division of Pediatric Rheumatology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Nihal Karaçayır
- Division of Pediatric Rheumatology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Deniz Gezgin Yıldırım
- Division of Pediatric Rheumatology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Sevcan A. Bakkaloğlu
- Division of Pediatric Rheumatology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
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Selection of Comparator Group in Observational Drug Safety Studies – Alternatives to the Active Comparator New User Design. Epidemiology 2022; 33:707-714. [DOI: 10.1097/ede.0000000000001521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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3
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Research progress in drug therapy of juvenile idiopathic arthritis. World J Pediatr 2022; 18:383-397. [PMID: 35364799 DOI: 10.1007/s12519-022-00530-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/17/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in children. With the gradual expansion of the incidence of JIA in the population, the pathogenesis and treatment of JIA were further explored and analyzed, and JIA has achieved some success in drug therapy. DATA SOURCES A systemic literature search was conducted on PubMed, Cochrane Library, EMBASE, ISI Web of Science, the US National Institutes of Health Ongoing Trials Register, and the EU Clinical Trials Register. Through the searching of clinical trials of JIA in recent years, we summarized the progress of the clinical treatment of JIA. RESULTS The main treatment drugs for JIA include non-steroidal anti-inflammatory drugs, glucocorticoids, disease-modifying antirheumatic drugs and biological agents. So far, a variety of biological agents targeting the cytokines and receptors involved in its pathogenesis have been gradually approved for JIA in many countries. The application of biological agents in JIA showed good efficacy and safety, bringing unprecedented experience to children and adolescents with JIA. CONCLUSIONS The potential and advantages of biologic agents in the treatment of JIA are significant, and the application of biologic agents in the treatment of JIA will be more and more common.
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Implications of Evolving Disease Classification for Drug Approval in Juvenile Idiopathic Arthritis. Paediatr Drugs 2022; 24:185-191. [PMID: 35364780 PMCID: PMC10389810 DOI: 10.1007/s40272-022-00496-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2022] [Indexed: 10/18/2022]
Abstract
The classification of inflammatory arthritis incorporates a sharp divide between diseases of childhood onset, grouped together as juvenile idiopathic arthritis, and diseases such as rheumatoid arthritis that begin by definition in adulthood. An important consequence of this divide is that regulatory authorities and many rheumatologists regard pediatric and adult arthritides as truly different, with the implication that drugs should be evaluated separately for each category. However, it is now clear that most forms of arthritis transcend the pediatric/adult boundary and that agents generally exhibit comparable success irrespective of age of onset, offering new opportunities in drug development and regulation focused on pharmacology and safety rather than efficacy. This paradigm shift will enable advances in arthritis treatment, originating either with adults or children, to translate more rapidly across the age spectrum.
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Waldron JL, Schworer SA, Kwan M. Hypersensitivity and Immune-related Adverse Events in Biologic Therapy. Clin Rev Allergy Immunol 2021; 62:413-431. [PMID: 34319562 DOI: 10.1007/s12016-021-08879-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 12/13/2022]
Abstract
Biologic medications are an expanding field of therapeutics for various medical conditions including cancer and inflammatory diseases. Due to their targeted approach to therapy, biologics can be less toxic than traditional systemic medications. However, as use becomes more widespread, adverse effects from biologic administration have also become apparent. Immune-related adverse events are a common mechanism by which biologics can cause on-target immune-related toxicities and both immediate and delayed-type hypersensitivity reactions. Immediate hypersensitivity reactions can be mediated by cytokine release or antibody mediated reactions, while delayed-type hypersensitivity is most often caused by serum sickness-like reactions. Additionally, biologics used for treatment of cancer using checkpoint blockade and rheumatologic disease using cytokine blockade can result in autoimmunity. Finally, when inflammatory cytokines are targeted for treatment of autoimmune or autoinflammatory disease, the host immune defense can be compromised predisposing to secondary immunodeficiency. This review will discuss the mechanisms of these reactions and discuss examples of biologics implicated in each of these adverse events.
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Affiliation(s)
- Jamie L Waldron
- Department of Medicine, Division of Rheumatology, Allergy, and Immunology, UNC School of Medicine, Chapel Hill, NC, USA
| | - Stephen A Schworer
- Department of Pediatrics, Division of Allergy & Immunology, UNC School of Medicine, Chapel Hill, NC, USA
| | - Mildred Kwan
- Department of Medicine, Division of Rheumatology, Allergy, and Immunology, UNC School of Medicine, Chapel Hill, NC, USA.
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Gupta M, Wani A, Ahsan AU, Ali M, Chibber P, Singh S, Digra SK, Datt M, Bharate SB, Vishwakarma RA, Singh G, Kumar A. Safranal inhibits NLRP3 inflammasome activation by preventing ASC oligomerization. Toxicol Appl Pharmacol 2021; 423:115582. [PMID: 34019860 DOI: 10.1016/j.taap.2021.115582] [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: 09/30/2020] [Revised: 05/14/2021] [Accepted: 05/16/2021] [Indexed: 01/01/2023]
Abstract
NLRP3 inflammasome is involved in several chronic inflammatory diseases. The inflammatory effect of the NLRP3 inflammasome is executed through IL-1β and IL-18. Therefore, IL-1β is one of the primary targets in chronic inflammatory conditions. However, current treatment regimens are dependent on anti- IL-1β biologicals. The therapies targeting IL-1β through inhibition of NLRP3 inflammasome are thus being actively explored. We identified safranal, a small molecule responsible for the essence of saffron as a potential inhibitor of the NLRP3 inflammasome. Safranal significantly suppressed the release of IL-1β from ATP stimulated J774A.1 and bone marrow-derived macrophages (BMDMs) by regulating CASP1 and CASP8 dependent cleavage of pro-IL-1β. Safranal markedly suppressed the expression of NLRP3 and its ATPase activity. Safranal treatment enhanced the expression of NRF2, whereas, si-RNA mediated silencing of Nrf2 abrogated the anti-NLRP3 effect of safranal. Furthermore, safranal inhibited ASC oligomerization and formation of ASC specks. Safranal also displayed anti-NLRP3 activity in multiple mice models. Treatment of animals with safranal reduced the production of IL-1β in ATP elicited peritoneal inflammation, MSU induced air pouch inflammation, and MSU injected foot paw edema in mice. Thus, our data projects safranal as a potential preclinical drug candidate against NLRP3 inflammasome triggered chronic inflammation.
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Affiliation(s)
- Mehak Gupta
- PK-PD-Toxicology and Formulation Division, CSIR-Indian Institute of Integrative Medicine, Canal Road, Jammu 180001, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Abubakar Wani
- PK-PD-Toxicology and Formulation Division, CSIR-Indian Institute of Integrative Medicine, Canal Road, Jammu 180001, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Aitizaz Ul Ahsan
- Cytogenetics Laboratory, Department of Zoology, Panjab University, Chandigarh, India
| | - Mehboob Ali
- PK-PD-Toxicology and Formulation Division, CSIR-Indian Institute of Integrative Medicine, Canal Road, Jammu 180001, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Pankaj Chibber
- PK-PD-Toxicology and Formulation Division, CSIR-Indian Institute of Integrative Medicine, Canal Road, Jammu 180001, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Surjeet Singh
- PK-PD-Toxicology and Formulation Division, CSIR-Indian Institute of Integrative Medicine, Canal Road, Jammu 180001, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Sanjeev K Digra
- Department of Paediatrics, Government Medical College, Jammu, India
| | - Manish Datt
- Biological and Life Sciences Division, School of Arts and Sciences, Ahmedabad University, Ahmedabad, Gujarat 380009, India
| | - Sandip B Bharate
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India; Medicinal Chemistry Division, Indian Institute of Integrative Medicine, CSIR, Jammu, India
| | - Ram A Vishwakarma
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India; Medicinal Chemistry Division, Indian Institute of Integrative Medicine, CSIR, Jammu, India
| | - Gurdarshan Singh
- PK-PD-Toxicology and Formulation Division, CSIR-Indian Institute of Integrative Medicine, Canal Road, Jammu 180001, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India.
| | - Ajay Kumar
- PK-PD-Toxicology and Formulation Division, CSIR-Indian Institute of Integrative Medicine, Canal Road, Jammu 180001, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India.
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Horton DB, Salas J, Wec A, Kohlheim M, Kapadia P, Beukelman T, Boneparth A, Haverkamp K, Mannion ML, Moorthy LN, Ringold S, Rosenthal M. Making Decisions About Stopping Medicines for Well-Controlled Juvenile Idiopathic Arthritis: A Mixed-Methods Study of Patients and Caregivers. Arthritis Care Res (Hoboken) 2021; 73:374-385. [PMID: 31880862 PMCID: PMC7319899 DOI: 10.1002/acr.24129] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 12/17/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Improved treatments for juvenile idiopathic arthritis (JIA) have increased remission rates. We conducted this study to investigate how patients and caregivers make decisions about stopping medications when JIA is inactive. METHODS We performed a mixed-methods study of caregivers and patients affected by JIA, recruited through social media and flyers, and selected by purposive sampling. Participants discussed their experiences with JIA, medications, and decision-making through recorded telephone interviews. Of 44 interviewees, 20 were patients (50% ages <18 years), and 24 were caregivers (50% caring for children ages ≤10 years). We evaluated characteristics associated with high levels of reported concerns about JIA or medicines using Fisher's exact testing. RESULTS Decisions about stopping medicines were informed by competing risks between disease activity and treatment. Participants who expressed more concerns about JIA were more likely to report disease-related complications (P = 0.002) and more motivated to continue treatment. However, participants expressing more concern about medicines were more likely to report treatment-related complications (P = 0.04) and felt more compelled to stop treatment. Additionally, participants considered how JIA or treatments facilitated or interfered with their sense of normalcy and safety, expressed feelings of guilt and regret about previous or potential adverse events, and reflected on uncertainty and unpredictability of future harms. Decision-making was also informed by trust in rheumatologists and other information sources (e.g., family and online support groups). CONCLUSION When deciding whether to stop medicines whenever JIA is inactive, patients and caregivers weigh competing risks between disease activity and treatment. Based on our results, we suggest specific approaches for clinicians to perform shared decision-making regarding stopping medicines for JIA.
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Affiliation(s)
- Daniel B. Horton
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Jomaira Salas
- Department of Sociology, Rutgers University, New Brunswick, NJ, USA
| | | | - Melanie Kohlheim
- Pediatric Rheumatology Care and Outcomes Improvement Network, Cincinnati, OH, USA
| | - Pooja Kapadia
- Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | | | | | - Ky Haverkamp
- University of Washington School of Medicine, Seattle, WA, USA
| | | | - L. Nandini Moorthy
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | | | - Marsha Rosenthal
- Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ, USA
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Adiguzel Dundar H, Acari C, Turkucar S, Unsal E. Treatment of systemic JIA: When do we need a biologic? Real world data of a single center. Mod Rheumatol 2021; 31:684-690. [PMID: 32343644 DOI: 10.1080/14397595.2020.1761079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES This paper aimed to present real-world data of treatment results of a single center in patients with systemic Juvenile Idiopathic arthritis (SJIA), in which methotrexate (MTX) along with glucocorticoids was preferred as the first-line treatment option. METHODS The medical records of 50 patients (58 episodes) with SJIA were evaluated. All patients with SJIA were hospitalized and were given high dose glucocorticoid treatment along with subcutaneous MTX. A biological agent was added in which disease activity control was not available with MTX. RESULTS Forty-one (70.6%) of 58 episodes were controlled by MTX, following discontinuation of steroids, while a biologic drug was needed in the remaining 17 (29.4%) episodes. The patients receiving MTX were divided into two groups: Group I (n = 36) (41 episodes) consisted of patients receiving MTX alone, and Group II (n = 14) (17 episodes) consisted of patients receiving MTX plus a biologic agent. Group I was dominated by the monocyclic course (56.1%), whereas group II was dominated by persistent course (70.6%). The initial erythrocyte sedimentation rate (82 vs 67 mm/h) and neutrophil/lymphocyte ratio (8.6 vs 4.1) were significantly elevated in the Group II (p = .003 and p = .007, respectively). NLR of 5.23 predicted the requirement for biological agents with a sensitivity of 66.7%, specificity 71.4%. Odds ratio for NLR ≥ 5.23 was 5.1 in Group II. CONCLUSION This study suggested that MTX was highly successful in cases with any SJIA episode, regardless of whether arthritis was present or not, even in cases presenting with MAS. A biologic drug is needed, if NLR is greater than 5.23.Key messagesHigh dose glucocorticoids with high dose SC methotrexate are the initial treatment option in systemic JIA.In glucocorticoid dependent patients, where methotrexate is ineffective, biologic therapy is mandatory.A neutrophil/lymphocyte ratio greater than 5.23 predicts the need for early biologic treatment.High dose S.C. MTX could be an option as an initial treatment in SJIA, especially biologics are not available.
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Affiliation(s)
- Hatice Adiguzel Dundar
- Division of Pediatric Rheumatolgy, Department of Pediatrics, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Ceyhun Acari
- Division of Pediatric Rheumatolgy, Department of Pediatrics, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Serkan Turkucar
- Division of Pediatric Rheumatolgy, Department of Pediatrics, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Erbil Unsal
- Division of Pediatric Rheumatolgy, Department of Pediatrics, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
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Klein A, Klotsche J, Hügle B, Minden K, Hospach A, Weller-Heinemann F, Schwarz T, Dressler F, Trauzeddel R, Hufnagel M, Foeldvari I, Borte M, Kuemmerle-Deschner J, Brunner J, Oommen PT, Föll D, Tenbrock K, Urban A, Horneff G. Long-term surveillance of biologic therapies in systemic-onset juvenile idiopathic arthritis: data from the German BIKER registry. Rheumatology (Oxford) 2021; 59:2287-2298. [PMID: 31846042 DOI: 10.1093/rheumatology/kez577] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/22/2019] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Using data from the German Biologics JIA Registry (BIKER), long-term safety of biologics for systemic-onset JIA with regard to adverse events of special interest was assessed. METHODS Safety assessments were based on adverse event reports after first dose through 90 days after last dose. Rates of adverse event, serious adverse event and 25 predefined adverse events of special interest were analysed. Incidence rates were compared for each biologic against all other biologics combined applying a mixed-effect Poisson model. RESULTS Of 260 systemic-onset JIA patients in this analysis, 151 patients received etanercept, 109 tocilizumab, 71 anakinra and 51 canakinumab. Patients with etanercept had higher clinical Juvenile Arthritis Disease Activity Score 10 scores, active joint counts and steroid use at therapy start. Serious adverse events were reported with higher frequency in patients receiving canakinumab [20/100 patient years (PY)] and tocilizumab (21/100 PY). Cytopenia and hepatic events occurred with a higher frequency with tocilizumab and canakinumab. Medically important infections were seen more often in patients with IL-6 or IL-1 inhibition. Macrophage activation syndrome occurred in all cohorts with a higher frequency in patients with canakinumab (3.2/100 PY) and tocilizumab (2.5/100 PY) vs anakinra (0.83/100 PY) and etanercept (0.5/100 PY). After adjustment only an elevated risk for infections in anakinra-treated patients remained significant. Three definite malignancies were reported in patients ever exposed to biologics. Two deaths occurred in patients treated with etanercept. CONCLUSION Surveillance of pharmacotherapy as provided by BIKER is an import approach especially for patients on long-term treatment. Overall, tolerance was acceptable. Differences between several biologics were noted and should be considered in daily patient care.
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Affiliation(s)
- Ariane Klein
- Centre for Paediatric Rheumatology, Department of Paediatrics, Asklepios Clinic Sankt Augustin, Sankt Augustin.,Department of Pediatrics, Medical Faculty, University of Cologne, Cologne
| | - Jens Klotsche
- German Rheumatism Research Centre Berlin, and Charité, University Medicine, Berlin
| | - Boris Hügle
- German Centre Pediatric and Adolescent Rheumatology, Garmisch-Partenkirchen
| | - Kirsten Minden
- German Rheumatism Research Centre Berlin, and Charité, University Medicine, Berlin
| | | | | | - Tobias Schwarz
- Department of Pediatric Rheumatology, St Josef Hospital, Sendenhorst
| | - Frank Dressler
- Pediatric Pneumology, Allergology, Neonatology, Immunology, Medizinische Hochschule Hannover, Hannover
| | | | - Markus Hufnagel
- Department of Pediatrics and Adolescent Medicine, University Medical Center, Freiburg
| | - Ivan Foeldvari
- Hamburg Centre for Pediatric and Adolescent Rheumatology, Hamburg
| | - Michael Borte
- Pediatric Immunology, Children's Hospital Sankt Georg, Leipzig
| | | | - Jürgen Brunner
- Department of Pediatrics I, Medical University, Innsbruck, Austria
| | - Prasad Thomas Oommen
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, University Children's Hospital, Heinrich-Heine-University, Düsseldorf
| | - Dirk Föll
- Department of Pediatrics, Rheumatology and Immunology, University Hospital, Münster
| | - Klaus Tenbrock
- Department of Pediatric and Adolescent Medicine, RWTH Aachen University, Aachen
| | - Andreas Urban
- Klinikum St Marien Klinik für Kinder und Jugendliche - Rheumatology/Pneumology, Amberg, Germany
| | - Gerd Horneff
- Centre for Paediatric Rheumatology, Department of Paediatrics, Asklepios Clinic Sankt Augustin, Sankt Augustin.,Department of Pediatrics, Medical Faculty, University of Cologne, Cologne
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Atemnkeng Ntam V, Klein A, Horneff G. Safety and efficacy of anakinra as first-line or second-line therapy for systemic onset juvenile idiopathic arthritis - data from the German BIKER registry. Expert Opin Drug Saf 2020; 20:93-100. [PMID: 33148061 DOI: 10.1080/14740338.2021.1843631] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Background: The IL-1 receptor-antagonist anakinra is recommended for the treatment of systemic juvenile idiopathic arthritis (sJIA) and was recently approved for first-line treatment. Long-term data from clinical practise are scarce. Methods: SJIA patients from the German biologics in pediatric rheumatology (BIKER) registry starting anakinra were grouped into two cohorts: Patients in the first-line cohort received no prior sJIA treatment except NSAID and a maximum of 3 days of steroids. Second-line cohort patients were pre-treated with steroids; DMARDs or biologics. Patient characteristics, disease-activity parameters, efficacy, and safety-parameters were compared. Results: Until December 2018, 51 anakinra patients were documented, representing 117.96 patient-years. Mean disease duration was 3.5 (± 3.8) years. At baseline, all anakinra first-line users had active systemic disease compared to 82% in the second-line users. Significant JADAS-10 improvement at last follow-up was observed in both cohorts (p = 0.02, p = 0.0014). Substantial numbers of patients in both groups reached JADAS-MDA/JADAS-remission/inactive disease (66.7%50%50% in first-liners and 60%45%70% in second-liners). Rates of serious adverse events were comparable and consistent with the overall AE profile of anakinra in patients. Conclusion: This analysis adds to the established safety profile of anakinra and demonstrates that anakinra is effective as first-line or second-line treatment.
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Affiliation(s)
- V Atemnkeng Ntam
- Asklepios Clinic Sankt Augustin, Centre of Pediatric Rheumatology , Sankt Augustin, Germany
| | - A Klein
- Asklepios Clinic Sankt Augustin, Centre of Pediatric Rheumatology , Sankt Augustin, Germany.,Department of Pediatrics, University Clinic, University of Cologne , Germany
| | - G Horneff
- Asklepios Clinic Sankt Augustin, Centre of Pediatric Rheumatology , Sankt Augustin, Germany.,Department of Pediatrics, University Clinic, University of Cologne , Germany
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Armaroli G, Klein A, Ganser G, Ruehlmann MJ, Dressler F, Hospach A, Minden K, Trauzeddel R, Foeldvari I, Kuemmerle-Deschner J, Weller-Heinemann F, Urban A, Horneff G. Long-term safety and effectiveness of etanercept in JIA: an 18-year experience from the BiKeR registry. Arthritis Res Ther 2020; 22:258. [PMID: 33121528 PMCID: PMC7597050 DOI: 10.1186/s13075-020-02326-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 09/22/2020] [Indexed: 01/22/2023] Open
Abstract
Background At present, etanercept represents the most commonly prescribed biologic agent for juvenile idiopathic arthritis (JIA) treatment. Children and adolescents with JIA are often treated with etanercept over long periods, sometimes even into adulthood. The objectives of this analysis were to determine the long-term safety of etanercept compared to a biologic-naïve cohort and to assess the long-term treatment response upon continuous etanercept exposure using data from the German biologics registry (BiKeR). Methods JIA patients newly exposed to etanercept were documented in the BiKeR registry from January 2001 to March 2019, and baseline characteristics, effectiveness, and safety parameters were analysed. Response to treatment was assessed according to 10-joint Juvenile Arthritis Disease Activity Score (JADAS10), JADAS-defined minimal disease activity and remission, JIA-American College of Rheumatology (ACR) improvement criteria, and ACR-inactive disease definition. Safety assessments were based on adverse event (AE) reports. Results A total of 2725 new etanercept users with a diagnosis of JIA were registered. Of these, etanercept was received as a first-line biologic by 95.8% and as monotherapy without concomitant methotrexate by 31.5%. After nine years on continuous treatment, 68.1% of patients presented minimal disease activity, 43.1% JADAS-defined remission on drug, and 36.6% ACR-inactive disease. JIA-ACR30/50/70/90 response rates were still 82/79/71/54% after nine years of treatment. Overall, 2053 AEs (34.3/100PY), including 226 serious AEs (SAE, 3.8/100PY), were observed upon etanercept, compared to 1345 AEs [35.6/100PY; p = 0.3] and 52 SAEs (1.4/100PY; p = 0.0001) in the biologic-naïve cohort. Respective exposure-adjusted rates for etanercept and biologic-naïve patients were 0.9/100PY and 0.2/100PY (p = 0.0001) for serious infections, 0.4/100PY and 0.1/100PY (p = 0.01) for zoster reactivation, 0.3/100PY and 0.03/100PY (p = 0.015) for inflammatory bowel disease, and 1.9/100PY and 1.4/100PY (p = 0.09) for uveitis. Three and two malignancies were documented in the etanercept and biologic-naïve groups, as well as three and one deaths, respectively. Conclusions No new safety signal was observed, especially no increased risk for malignancies or autoimmune disorders other than inflammatory bowel disease. However, SAEs and serious infections, though infrequent, were more often reported on etanercept than in biologic-naïve patients. In addition, etanercept demonstrated a long-term maintenance of clinical benefits up to nine years of continuous treatment.
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Affiliation(s)
- Giulia Armaroli
- Division of Paediatric Rheumatology, Sankt Augustin Asklepios Children's Hospital, 53757 Sankt Augustin, Germany.
| | - Ariane Klein
- Division of Paediatric Rheumatology, Sankt Augustin Asklepios Children's Hospital, 53757 Sankt Augustin, Germany.,Cologne University, Medical School, Cologne, Germany
| | - Gerd Ganser
- Division of Paediatric Rheumatology, Northwest German Rheumatology Center, St. Josef Stift, Sendenhorst, Germany
| | | | - Frank Dressler
- Division of Paediatric Pulmonology, Allergology and Immunology, Hannover Medical School, Hannover, Germany
| | - Anton Hospach
- Division of Paediatric Rheumatology, Olgahospital, Stuttgart, Germany
| | - Kirsten Minden
- German Rheumatism Research Center, Charité University Hospital, Berlin, Germany
| | - Ralf Trauzeddel
- Department of Paediatrics, Berlin-Buch Helios Hospital, Berlin, Germany
| | - Ivan Foeldvari
- Paediatric Rheumatology Medical Center, Hamburg, Germany
| | | | | | - Andreas Urban
- Department of Paediatrics, St. Marien Hospital, Amberg, Germany
| | - Gerd Horneff
- Division of Paediatric Rheumatology, Sankt Augustin Asklepios Children's Hospital, 53757 Sankt Augustin, Germany.,Cologne University, Medical School, Cologne, Germany
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12
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Licciardi F, Giani T, Baldini L, Favalli EG, Caporali R, Cimaz R. COVID-19 and what pediatric rheumatologists should know: a review from a highly affected country. Pediatr Rheumatol Online J 2020; 18:35. [PMID: 32321540 PMCID: PMC7175817 DOI: 10.1186/s12969-020-00422-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/03/2020] [Indexed: 01/08/2023] Open
Abstract
On March 11th, 2020 the World Health Organization declared COVID-19 a global pandemic. The infection, transmitted by 2019 novel coronavirus (2019-nCov), was first discovered in December 2019, in Wuhan, Hubei Province, and then rapidly spread worldwide. Italy was early and severely involved, with a critical spread of the infection and a very high number of victims. Person-to-person spread mainly occurs via respiratory droplets and contact. The median incubation period is 5 days. The spectrum of respiratory symptoms may range from mild to severe, strictly depending on the age of the patient and the underlying comorbidities.In children COVID-19 related disease is less frequent and less aggressive. In Italy 1% of positive cases are under 18 years of age, and no deaths have been recorded before 29 years of age. For patients affected by rheumatic disease, despite the concerns related to the imbalance of their immune response and the effect of immunosuppressive treatments, there are still few data to understand the real consequences of this infection. Major scientific societies have issued recommendations to help rheumatologists in caring their patients. Interestingly, some of the drugs mostly used by rheumatologists appear to be promising in critical COVID-19 infected patients, where the hyperinflammation and cytokine storm seem to drive to the multiorgan failure.Pediatric rheumatologists are expected to play a supporting role in this new front of COVID-19 pandemic, both as general pediatricians treating infected children, and as rheumatologists taking care of their rheumatic patients, as well as offering their experience in the possible alternative use of immunomodulatory drugs.
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Affiliation(s)
- Francesco Licciardi
- Division of Pediatric Immunology and Rheumatology, Department of Public Health and Pediatrics, Regina Margherita Children Hospital, University of Turin, Turin, Italy
| | - Teresa Giani
- AOU Meyer, V.le Pieraccini 24, 50139, Florence, Italy.
- Department of Medical Biotechnology, University of Siena, Siena, Italy.
| | - Letizia Baldini
- Division of Pediatric Immunology and Rheumatology, Department of Public Health and Pediatrics, Regina Margherita Children Hospital, University of Turin, Turin, Italy
| | - Ennio Giulio Favalli
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO Institute, Milan, Italy
| | - Roberto Caporali
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO Institute, Milan, Italy
- Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Università degli Studi di Milano, Milan, Italy
| | - Rolando Cimaz
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO Institute, Milan, Italy
- Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Università degli Studi di Milano, Milan, Italy
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13
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Methotrexate in juvenile idiopathic arthritis. Adverse effects and associated factors. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.anpede.2019.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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14
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Nagy A, Mosdosi B, Simon D, Dergez T, Berki T. Peripheral Blood Lymphocyte Analysis in Oligo- and Polyarticular Juvenile Idiopathic Arthritis Patients Receiving Methotrexate or Adalimumab Therapy: A Cross-Sectional Study. Front Pediatr 2020; 8:614354. [PMID: 33363071 PMCID: PMC7758242 DOI: 10.3389/fped.2020.614354] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/16/2020] [Indexed: 12/14/2022] Open
Abstract
Juvenile idiopathic arthritis (JIA) is an umbrella term for seven distinct chronic immune-mediated diseases. Disease-modifying anti-rheumatic drugs (DMARD) are used to treat the underlying joint inflammation as well as extra-articular manifestations. Immunosuppression is a considerable side effect of the drugs. The main goal of this study was to investigate the effect of different JIA therapies on leukocyte subpopulations, which play a role in immune-defense. Three study groups were established. The first group consisted of JIA patients treated with methotrexate solely, the second one received a combination of methotrexate (MTX) and adalimumab (ADA). The control group was made up of the patients' healthy siblings. A total of 63 children were recruited. Fourty-one children with JIA and 22 healthy controls were included in the study. The absolute number of CD3+ T-cells was significantly elevated in patients treated with biological therapy compared to healthy controls (p2 = 0.017). In contrast, the number of CD56+ natural killer cells was significantly lower in children receiving biological therapy in comparison with healthy donors (p2 = 0.039). A significant alteration was also demonstrated between patients treated with MTX and MTX/ADA group concerning CD 19+ B-cells (p3 = 0.042). This is the first study that demonstrates significant alterations in the number of B-cells and T-cells with a relative decrease of NK-cell ratios in JIA patients receiving different DMARD therapy. Clinical Trial Registration: NCT03833271. 21.01.2019.
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Affiliation(s)
- Arnold Nagy
- Department of Paediatrics, University of Pecs, Medical School, Pecs, Hungary
| | - Bernadett Mosdosi
- Department of Paediatrics, University of Pecs, Medical School, Pecs, Hungary
| | - Diana Simon
- Department of Immunology and Biotechnology, University of Pecs, Medical School, Pecs, Hungary
| | - Timea Dergez
- Institute of Bioanalysis, University of Pecs, Medical School, Pecs, Hungary
| | - Timea Berki
- Department of Immunology and Biotechnology, University of Pecs, Medical School, Pecs, Hungary
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15
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Salonen PH, Salonen JH, Säilä H, Helminen M, Linna M, Kauppi MJ. Decreasing trend in the incidence of serious pneumonias in Finnish children with juvenile idiopathic arthritis. Clin Rheumatol 2019; 39:853-860. [PMID: 31732822 DOI: 10.1007/s10067-019-04804-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 09/25/2019] [Accepted: 10/02/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Children with juvenile idiopathic arthritis (JIA) may be predisposed to serious pneumonia due to modern disease-modifying anti-rheumatic treatment. In this nationwide retrospective study with clinical data, we describe the pneumonia episodes among children with JIA. METHODS Patients under 18 years of age with JIA and pneumonia during 1998-2014 were identified in the National Hospital Discharge Register in Finland. Each individual patient record was reviewed, and detailed data on patients with JIA and pneumonia were retrieved, recorded, and analyzed. If the patient was hospitalized or received intravenous antibiotics, the pneumonia was considered serious. RESULTS There were 157 episodes of pneumonia among 140 children with JIA; 111 episodes (71%) were serious (80% in 1998-2006 and 66% in 2007-2014). The mean age of the patients was 9 years. Forty-eight percent had active JIA and 46% had comorbidities. Disease-modifying anti-rheumatic drugs (DMARD) were used at the time of 135 episodes (86%): methotrexate (MTX) by 62% and biologic DMARDs (bDMARD) by 30%. There was no significant difference in the use of bDMARDs, MTX and glucocorticoids between the patient groups with serious and non-serious pneumonia episodes. During six of the episodes, intensive care was needed. Two patients (1.3%) died, the remaining ones recovered fully. CONCLUSIONS Although the incidence of pneumonia and the use of immunosuppressive treatment among children with JIA increased from 1998 to 2014, the proportion of serious pneumonias in these patients decreased. There was no significant difference in the use of anti-rheumatic medication between patients with serious and non-serious pneumonia.Key Points• The incidence of serious pneumonias decreased from 1998 to 2014 among children with juvenile idiopathic arthritis (JIA).• There was no significant difference in the use of the disease-modifying anti-rheumatic medication between JIA patients with serious and non-serious pneumonias.• Active JIA, comorbidities, and combination medication were associated with nearly half of the pneumonias.
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Affiliation(s)
- Päivi H Salonen
- Faculty of Medicine and Life Science, Tampere University, Tampere, Finland. .,Päijät-Häme Joint Authority for Health and Wellbeing, Terveystie 4, 15870, Lahti, Hollola, Finland.
| | - Juha H Salonen
- Department of Infectious Diseases, Vaasa Central Hospital, Vaasa, Finland
| | - Hanna Säilä
- Orton Research Institute, Orton Foundation, Helsinki, Finland
| | - Mika Helminen
- Research, Development and Innovation Centre, Tampere University Hospital, Tampere, Finland.,Faculty of Social Sciences, Health Sciences, Tampere University, Tampere, Finland
| | | | - Markku J Kauppi
- Faculty of Medicine and Life Science, Tampere University, Tampere, Finland.,Department of Rheumatology, Päijät-Häme Central Hospital, Lahti, Finland
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16
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Barral Mena E, García Cárdaba LM, Canet Tarrés A, Enríquez Merayo E, Cruz Utrilla A, de Inocencio Arocena J. [Methotrexate in juvenile idiopathic arthritis. Adverse effects and associated factors]. An Pediatr (Barc) 2019; 92:124-131. [PMID: 31699619 DOI: 10.1016/j.anpedi.2019.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 05/02/2019] [Accepted: 05/21/2019] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Methotrexate (MTX) is the drug of choice for juvenile idiopathic arthritis. Its clinical efficacy is limited due to the development of adverse effects (AEs). PATIENTS AND METHODS A retrospective observational study was conducted on the AEs associated with MTX therapy in children diagnosed with juvenile idiopathic arthritis followed-up in a tertiary hospital between 2008 and 2016. RESULTS The study included a total of 107 patients, of whom 71 (66.3%) were girls (66.3%). The median age at diagnosis was 6.4 years (IQR 3.1-12.4), with a median follow-up of 45.7 months (IQR 28.8-92.4). There were 48 patients (44.9%) with oligoarthritis, and 26 children (24.3%) with rheumatoid-factor negative polyarthritis. Of these, 52/107 (48.6%) developed AEs, with the most frequent being gastrointestinal symptoms (35.6%) and behavioural problems (35.6%). An age older than 6 years at the beginning of therapy increased the risk of developing AEs, both in the univariate (OR=3.5; 95% CI: 1.5-7.3) and multivariate (12% increase per year) analyses. The doses used, administration route, or International League of Associations for Rheumatology (ILAR) classification, were not associated with the development of AEs. Twenty children required a dosage or route of administration modification, which resolved the AE in 11 (55%) cases. MTX was interrupted due to the development of AEs in 37/107 patients (34.6%), mainly due to increased plasma transaminases (n=14, 37.8%), gastrointestinal symptoms (n=9, 24.3%) and behavioural problems (n=6, 16.3%). CONCLUSIONS MTX is the therapy of choice for patients with juvenile idiopathic arthritis, but 50% of the children develop some form of AE. Although the AEs are not severe, they lead to interruption of therapy in 35% of the children.
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Affiliation(s)
| | | | - Anna Canet Tarrés
- Unidad de Reumatología Pediátrica, Hospital Universitario 12 de Octubre, Madrid, España
| | | | | | - Jaime de Inocencio Arocena
- Unidad de Reumatología Pediátrica, Hospital Universitario 12 de Octubre, Madrid, España; Departamento de Salud Pública y Materno-Infantil, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Madrid, España
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17
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Khraishi M, Millson B, Woolcott J, Jones H, Marshall L, Ruperto N. Reduction in the utilization of prednisone or methotrexate in Canadian claims data following initiation of etanercept in pediatric patients with juvenile idiopathic arthritis. Pediatr Rheumatol Online J 2019; 17:64. [PMID: 31500631 PMCID: PMC6734296 DOI: 10.1186/s12969-019-0358-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 08/07/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND In adult patients with arthritis, use of the tumor necrosis factor (TNF) inhibitor etanercept (ETN) is often associated with a reduction in the utilization of co-medications, particularly steroids. Comparatively little is known about the utilization of co-medications when ETN is initiated in pediatric patients with juvenile idiopathic arthritis (JIA). METHODS This study analyzed Canadian longitudinal claims level data spanning January 2007 to April 2017. Data were collated from the IQVIA Private Drug Plan, Ontario Public Drug Plan, and the Quebec Public Drug Plan (Régie de l'assurance maladie du Québec) databases. Patients < 18 years of age were indexed when filling a prescription for ETN between January 2008 and January 2016. Those who met the inclusion and exclusion criteria were assessed for methotrexate (MTX), and prednisone (PRD) use in the 6 months prior to and 12 months following initiation of ETN. RESULTS Longitudinal claims data for 330 biologic-naive pediatric patients initiating ETN therapy were included. The majority of patients were female (67%), aged 10-17 years (64%), and with a drug history consistent with JIA (96%). Most patients were from Quebec (36%) or Ontario (33%). Dosing of ETN was weight-based with a mean dosage over the first year of 31 mg per week. ETN dosing was relatively consistent over the first year. In total, 222 (67%) patients did not use MTX and 223 (68%) did not use PRD before or after starting ETN. A total of 17% (18/103) of MTX-treated and 50% (46/92) of PRD-treated patients discontinued use of those medications upon initiation of ETN treatment. In patients continuing MTX or PRD, significant reductions in the weekly dosage from 14.3 to 6.8 mg per week for MTX and from 56 to 23 mg per week for PRD were observed (P < 0.01). CONCLUSIONS This study of Canadian claims-level data is the first large prespecified analysis of co-medication utilization following the initiation of ETN therapy in pediatric patients. A decline in both MTX and PRD use and dosage was observed and may be associated with benefits related to safety, tolerability, and overall healthcare costs.
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Affiliation(s)
- Majed Khraishi
- 0000 0000 9130 6822grid.25055.37Memorial University of Newfoundland, St. Johns, NL Canada
| | | | - John Woolcott
- 0000 0000 8800 7493grid.410513.2Global Outcomes and Evidence, Pfizer, Collegeville, PA USA
| | - Heather Jones
- 0000 0000 8800 7493grid.410513.2Global Medical Affairs, Pfizer, Collegeville, PA USA
| | - Lisa Marshall
- 0000 0000 8800 7493grid.410513.2Global Medical Affairs, Pfizer, Collegeville, PA USA
| | - Nicolino Ruperto
- IRCCS, Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia - PRINTO, Genoa, Italy.
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18
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Abstract
The introduction of biologics 20 years ago has significantly changed the pharmacotherapy of juvenile idiopathic arthritis. Biologics are among the most successful innovations, not only in rheumatology. In addition to their strong efficacy the rapid onset of improvement , biologics offer an option for prevention of long-term damage and a realistic prospect of remission. This article discusses innovations in biologics and the importance of the latest group for targeted therapy with small molecules in pediatric rheumatology.
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Affiliation(s)
- Gerd Horneff
- Zentrum für Allgemein Pädiatrie und Neonatologie, Asklepios Klinik Sankt Augustin, 53757, Sankt Augustin, Deutschland.
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19
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20
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Ringold S, Angeles-Han ST, Beukelman T, Lovell D, Cuello CA, Becker ML, Colbert RA, Feldman BM, Ferguson PJ, Gewanter H, Guzman J, Horonjeff J, Nigrovic PA, Ombrello MJ, Passo MH, Stoll ML, Rabinovich CE, Schneider R, Halyabar O, Hays K, Shah AA, Sullivan N, Szymanski AM, Turgunbaev M, Turner A, Reston J. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Non-Systemic Polyarthritis, Sacroiliitis, and Enthesitis. Arthritis Rheumatol 2019; 71:846-863. [PMID: 31021537 DOI: 10.1002/art.40884] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 02/27/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To develop treatment recommendations for children with juvenile idiopathic arthritis manifesting as non-systemic polyarthritis, sacroiliitis, or enthesitis. METHODS The Patient/Population, Intervention, Comparison, and Outcomes (PICO) questions were developed and refined by members of the guideline development teams. A systematic review was conducted to compile evidence for the benefits and harms associated with treatments for these conditions. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of evidence. A group consensus process was conducted among the Voting Panel to generate the final recommendations and grade their strength. A Parent and Patient Panel used a similar consensus approach to provide patient/caregiver preferences for key questions. RESULTS Thirty-nine recommendations were developed (8 strong and 31 conditional). The quality of supporting evidence was very low or low for 90% of the recommendations. Recommendations are provided for the use of nonsteroidal antiinflammatory drugs, disease-modifying antirheumatic drugs, biologics, and intraarticular and oral glucocorticoids. Recommendations for the use of physical and occupational therapy are also provided. Specific recommendations for polyarthritis address general medication use, initial and subsequent treatment, and adjunctive therapies. Good disease control, with therapeutic escalation to achieve low disease activity, was recommended. The sacroiliitis and enthesitis recommendations primarily address initial therapy and adjunctive therapies. CONCLUSION This guideline provides direction for clinicians, caregivers, and patients making treatment decisions. Clinicians, caregivers, and patients should use a shared decision-making process that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.
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Affiliation(s)
| | - Sheila T Angeles-Han
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Daniel Lovell
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | | | | | - Brian M Feldman
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | | | - Harry Gewanter
- Children's Hospital of Richmond, Virginia Commonwealth University, Richmond
| | - Jaime Guzman
- BC Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Peter A Nigrovic
- Brigham & Women's Hospital and Boston Children's Hospital, Boston, Massachusetts
| | | | | | | | | | - Rayfel Schneider
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
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21
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Ringold S, Angeles-Han ST, Beukelman T, Lovell D, Cuello CA, Becker ML, Colbert RA, Feldman BM, Ferguson PJ, Gewanter H, Guzman J, Horonjeff J, Nigrovic PA, Ombrello MJ, Passo MH, Stoll ML, Rabinovich CE, Schneider R, Halyabar O, Hays K, Shah AA, Sullivan N, Szymanski AM, Turgunbaev M, Turner A, Reston J. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Non-Systemic Polyarthritis, Sacroiliitis, and Enthesitis. Arthritis Care Res (Hoboken) 2019; 71:717-734. [PMID: 31021516 DOI: 10.1002/acr.23870] [Citation(s) in RCA: 153] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 02/27/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To develop treatment recommendations for children with juvenile idiopathic arthritis manifesting as non-systemic polyarthritis, sacroiliitis, or enthesitis. METHODS The Patient/Population, Intervention, Comparison, and Outcomes (PICO) questions were developed and refined by members of the guideline development teams. A systematic review was conducted to compile evidence for the benefits and harms associated with treatments for these conditions. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of evidence. A group consensus process was conducted among the Voting Panel to generate the final recommendations and grade their strength. A Parent and Patient Panel used a similar consensus approach to provide patient/caregiver preferences for key questions. RESULTS Thirty-nine recommendations were developed (8 strong and 31 conditional). The quality of supporting evidence was very low or low for 90% of the recommendations. Recommendations are provided for the use of nonsteroidal antiinflammatory drugs, disease-modifying antirheumatic drugs, biologics, and intraarticular and oral glucocorticoids. Recommendations for the use of physical and occupational therapy are also provided. Specific recommendations for polyarthritis address general medication use, initial and subsequent treatment, and adjunctive therapies. Good disease control, with therapeutic escalation to achieve low disease activity, was recommended. The sacroiliitis and enthesitis recommendations primarily address initial therapy and adjunctive therapies. CONCLUSION This guideline provides direction for clinicians, caregivers, and patients making treatment decisions. Clinicians, caregivers, and patients should use a shared decision-making process that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.
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Affiliation(s)
| | - Sheila T Angeles-Han
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Daniel Lovell
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | | | | | - Brian M Feldman
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | | | - Harry Gewanter
- Children's Hospital of Richmond, Virginia Commonwealth University, Richmond
| | - Jaime Guzman
- BC Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Peter A Nigrovic
- Brigham & Women's Hospital and Boston Children's Hospital, Boston, Massachusetts
| | | | | | | | | | - Rayfel Schneider
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
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22
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Pardeo M, Wang J, Ruperto N, Alexeeva E, Chasnyk V, Schneider R, Horneff G, Huppertz HI, Minden K, Onel K, Zemel L, Martin A, Koné-Paut I, Siamopoulou-Mavridou A, Silva CA, Porter-Brown B, Bharucha KN, Brunner HI, De Benedetti F. Neutropenia During Tocilizumab Treatment Is Not Associated with Infection Risk in Systemic or Polyarticular-course Juvenile Idiopathic Arthritis. J Rheumatol 2019; 46:1117-1126. [PMID: 30824645 DOI: 10.3899/jrheum.180795] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To determine whether neutropenia is associated with increased risk for infection in patients with systemic juvenile idiopathic arthritis (sJIA) and polyarticular-course juvenile idiopathic arthritis (pcJIA) treated with tocilizumab (TCZ). METHODS Data up to Week 104 from 2 phase III trials of intravenous TCZ in sJIA (n = 112; ClinicalTrials.gov, NCT00642460) and pcJIA (n = 188; ClinicalTrials.gov, NCT00988221) were pooled. Worst common toxicity criteria grade and lowest observed absolute neutrophil count (ANC) were identified for each patient. Associations between patient characteristics and lowest observed ANC were tested using univariate regression analysis. Infection and serious infection rates per 100 patient-years (PY) in periods associated with grades 1/2 and 3/4 neutrophil counts were compared with rates associated with normal neutrophil counts. RESULTS ANC decreased to grade ≥ 3 in 25.0% and 5.9% of sJIA and pcJIA patients, respectively, and decreases were transient. Young age (p = 0.047) and methotrexate use (p = 0.012) were positively associated with neutropenia in patients with sJIA but not in patients with pcJIA. The rate of serious infections in patients with sJIA (10.9/100 PY; 95% CI 6.8-16.5) tended to be higher than in patients with pcJIA (5.2/100 PY; 95% CI 3-8.5). No increase in rates of serious or nonserious infections was observed during periods of neutropenia in either trial. CONCLUSION Patients with JIA treated with TCZ experienced transient neutropenia that was not associated with an increased number of infections.
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Affiliation(s)
- Manuela Pardeo
- IRCCS Ospedale Pediatrico Bambino Gesù, Division of Rheumatology, Rome, Italy
| | | | - Nicolino Ruperto
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO, Genoa, Italy
| | - Ekaterina Alexeeva
- Federal State Autonomous Institution National Medical Research Center of Children's Health of the Ministry of Health of the Russian Federation, Department of Rheumatology, and Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov, First Moscow State Medical University of the Ministry of Health of the Russian Federation, Department of Pediatrics and Pediatric Rheumatology, Moscow, Russia
| | - Vyacheslav Chasnyk
- Saint-Petersburg State Pediatric Medical University, Department of Hospital Pediatrics, St. Petersburg, Russia
| | - Rayfel Schneider
- Hospital for Sick Children, University of Toronto, Department of Pediatrics, Division of Rheumatology, Toronto, Ontario, Canada
| | - Gerd Horneff
- Asklepios Klinik Sankt Augustin, Centre for General Pediatrics and Neonatology, Sankt Augustin, Germany, and University Hospital of Cologne, Cologne, Germany
| | - Hans-Iko Huppertz
- Prof. Hess Children's Hospital and Pediatric Intensive Care Medicine, Bremen, Germany
| | - Kirsten Minden
- German Rheumatism Research Centre Berlin, and Charité University Medicine, Department of Rheumatology and Clinical Immunology, Berlin, Germany
| | - Karen Onel
- Hospital for Special Surgery, Division of Pediatric Rheumatology, New York, New York, USA
| | - Lawrence Zemel
- Connecticut Children's Medical Center, Pediatric Rheumatology, Hartford, Connecticut
| | - Alan Martin
- Tulsa Bone and Joint Associates, Tulsa, Oklahoma
| | - Isabelle Koné-Paut
- National Referral Centre of Auto-Inflammatory Diseases, CEREMAIA, CHU de Bicere, Department of Pediatric Rheumatology, AP-HP, University of Paris Sud, Le Kremlin Bicetre, France
| | | | - Clovis A Silva
- Children's Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Pediatric Rheumatology Unit, Sao Paulo, Brazil
| | | | - Kamal N Bharucha
- Genentech (affiliation at time of the study), South San Francisco, California
| | - Hermine I Brunner
- University of Cincinnati, Cincinnati Children's Hospital Medical Center, Division of Rheumatology, Department of Pediatrics, PRCSG Coordinating Center, Cincinnati, Ohio, USA
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23
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Aeschlimann FA, Chong SL, Lyons TW, Beinvogl BC, Góez-Mogollón LM, Tan S, Laxer RM. Risk of Serious Infections Associated with Biologic Agents in Juvenile Idiopathic Arthritis: A Systematic Review and Meta-Analyses. J Pediatr 2019; 204:162-171.e3. [PMID: 30318371 DOI: 10.1016/j.jpeds.2018.08.065] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/20/2018] [Accepted: 08/24/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess whether treatment with biologic response modifying agents during clinical trial study periods increases the risk of serious infections in children with juvenile idiopathic arthritis (JIA). STUDY DESIGN A systematic literature review using Medline, Embase, Cochrane library, and the clinical trial registry was performed up to July 2017. Random effects meta-analyses were used to compare rates of serious infections in children with JIA given biologic agents compared with controls, and the pooled relative risk calculated. Subanalyses were performed for different biologic agent classes. RESULTS In total, 19 trials accounting for 21 individual studies were included (11 for tumor necrosis factor-alpha inhibitors [n = 814 patients], 3 for interleukin-6 inhibitors [n = 318], 6 for interleukin-1 inhibitors [n = 353], and 1 for selective T-lymphocyte costimulation modulators [n = 122]). Patients (68% female) had a mean age of 10.8 years. Seventeen serious infections were reported among 810 children receiving biologic agents and 15 among 797 controls. The most frequent infections were bronchopulmonary and varicella. No statistically significant difference in risk of serious infections was found between children receiving biologic agents compared with control groups (pooled relative risk = 1.13; 95% CI [0.63, 2.03]) during the trial study periods. The risk remained nonsignificant when evaluating the different classes of biologic agents separately. However, the analyses were underpowered to detect differences in the risk of serious infections overall or differences between classes of biologic agents. CONCLUSIONS In this systematic review and meta-analyses, serious infections were uncommon and not significantly increased among patients with JIA receiving biologic agents compared with controls. However, the analyses were underpowered and study periods were relatively short. Ongoing careful monitoring for serious infections remains necessary for all patients with JIA, and particularly those receiving biologic agents.
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Affiliation(s)
- Florence A Aeschlimann
- Pediatric Immunology-Hematology and Rheumatology Unit, University Hospital Necker-Enfants Malades, Paris, France.
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital and Duke-NUS Medical School, Singapore, Singapore
| | - Todd W Lyons
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Beate C Beinvogl
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA
| | | | - Sally Tan
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Ronald M Laxer
- Division of Rheumatology, The Hospital for Sick Children, Department of Pediatrics and Medicine, University of Toronto, Toronto, Ontario, Canada
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Marino A, Giani T, Cimaz R. Risks associated with use of TNF inhibitors in children with rheumatic diseases. Expert Rev Clin Immunol 2018; 15:189-198. [PMID: 30451548 DOI: 10.1080/1744666x.2019.1550359] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction: Tumor necrosis factor alpha (TNF-α) is a pro-inflammatory cytokine involved in the pathogenesis of many inflammatory diseases. Several drugs blocking TNF-α are employed in clinical practice in pediatrics. Given their action on the immune system, TNF-α inhibitors have raised concerns on their safety profile since their introduction. A broad spectrum of side effects related to TNF inhibition has been reported: immunogenicity, infectious diseases, malignancies, and others. Areas covered: In order to assess the risk related to the use of anti-TNF-α agents in children with rheumatic diseases we analyzed data obtained from retrospective and prospective safety studies, case reports and case series, and controlled trials. Expert commentary: Anti-TNF-α agents have shown a remarkably good safety profile in the pediatric population so far. However, there are lots of questions to be answered and maintaining active surveillance on these drugs is necessary in order to not overlook any possible unexpected adverse effects.
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Affiliation(s)
- Achille Marino
- a Department of Pediatrics, Desio Hospital , ASST Monza , Desio (MB) , Italy.,b PhD student in Biomedical Sciences , University of Florence , Florence , Italy
| | - Teresa Giani
- c Department of Medical Biotechnology , University of Siena , Siena , Italy.,d Rheumatology Unit, Meyer Children's Hospital , University of Florence , Florence , Italy
| | - Rolando Cimaz
- e Department of Neurosciences, Psychology, Drug Research and Child Health, Rheumatology Unit, Meyer Children's Hospital , University of Florence , Florence , Italy
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Abstract
The EU indication for anakinra has been extended to include Still’s disease, a serious rare inflammatory disorder of unknown aetiology that comprises adult-onset Still’s disease (AOSD) and systemic juvenile idiopathic arthritis (SJIA). As activated interleukin-1 pathways are associated with the systemic manifestations of these disorders, targeted treatment with anakinra, an interleukin-1 inhibitor, has been investigated. Across clinical and real-world studies in patients with AOSD and SJIA, treatment with anakinra achieved clinical remission/response, provided rapid and sustained improvements in systemic and laboratory manifestations, and allowed the use of corticosteroid- and disease-modifying anti-rheumatic drugs (DMARD) to be reduced or discontinued. The safety profile of anakinra in the treatment of Still’s disease is consistent with that in its other approved indications.
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Cann M, Ramanan AV, Crawford A, Dick AD, Clarke SLN, Rashed F, Guly CM. Outcomes of non-infectious Paediatric uveitis in the era of biologic therapy. Pediatr Rheumatol Online J 2018; 16:51. [PMID: 30081917 PMCID: PMC6080499 DOI: 10.1186/s12969-018-0266-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 07/19/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND There is a paucity of data on the ocular outcomes in paediatric non-infectious uveitis since the introduction of the biologic agents. The purpose of this study was to outline the clinical characteristics of children with non-infectious uveitis and determine the visual outcomes and ocular complication rates in the modern era. METHODS Children with non-infectious uveitis from January 2011 to December 2015 were identified. Data was collected at baseline, 1, 3, 5, and 10 years post diagnosis. The incidence rates of visual impairment, structural ocular complications and surgical intervention were calculated. Using logistic regression the association between various baseline characteristics and later visual impairment was investigated. RESULTS Of the 166 children, 60.2% (n = 100) had a systemic disease association. 72.9% (n = 121) children received methotrexate, 58 children progressed to a biologic. The incidence rates of visual acuity loss to > 0.3 LogMAR (6/12) and to ≥1.0 LogMAR (6/60) were 0.05/Eye Year (EY) and 0.01/EY, respectively. Visual outcomes in the Juvenile Idiopathic Arthritis associated Uveitis (JIA-U) and Idiopathic Uveitis cohorts were not statistically significant. Of the 293 affected eyes, posterior synechiae was the predominant complication on presentation, while cataract had the highest incidence rate (0.05/EY). On direct comparison, children with JIA-U were statistically significantly more likely to develop glaucoma while children with Idiopathic Uveitis were statistically significantly more likely to develop macular oedema. CONCLUSION One third of children received a biological therapy, reflecting increasing utilisation and importance of biological agents in the management of inflammatory conditions. Rates of visual impairment and ocular complications are an improvement on previously published data.
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Affiliation(s)
- Megan Cann
- 0000 0004 0380 7336grid.410421.2University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Athimalaipet V. Ramanan
- 0000 0004 0380 7336grid.410421.2University Hospitals Bristol NHS Foundation Trust, Bristol, UK ,Translational Health Sciences, Bristol Medical School, Faculty of Health sciences, Bristol, UK
| | - Andrew Crawford
- 0000 0004 1936 7988grid.4305.2BHF Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, UK ,0000 0004 1936 7603grid.5337.2MRC Integrative Epidemiology Unit, Population Health Sciences, University of Bristol, Bristol, UK
| | - Andrew D. Dick
- 0000 0004 0380 7336grid.410421.2University Hospitals Bristol NHS Foundation Trust, Bristol, UK ,Translational Health Sciences, Bristol Medical School, Faculty of Health sciences, Bristol, UK ,0000 0001 2116 3923grid.451056.3National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfield Eye Hospital, London, UK ,0000000121901201grid.83440.3bUniversity College London Institute of Ophthalmology, London, UK
| | - Sarah L. N. Clarke
- 0000 0004 0380 7336grid.410421.2University Hospitals Bristol NHS Foundation Trust, Bristol, UK ,0000 0004 1936 7603grid.5337.2MRC Integrative Epidemiology Unit, Population Health Sciences, University of Bristol, Bristol, UK
| | - Fatima Rashed
- Translational Health Sciences, Bristol Medical School, Faculty of Health sciences, Bristol, UK
| | - Catherine M. Guly
- 0000 0004 0380 7336grid.410421.2University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Lee WJ, Lee TA, Suda KJ, Calip GS, Briars L, Schumock GT. Risk of serious bacterial infection associated with tumour necrosis factor-alpha inhibitors in children with juvenile idiopathic arthritis. Rheumatology (Oxford) 2018; 57:273-282. [PMID: 28431162 DOI: 10.1093/rheumatology/kex049] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Indexed: 01/29/2023] Open
Abstract
Objectives TNF-α inhibitors (TNFIs) have a black box warning for increased risk of serious infection that was based on evidence from studies of adults. Evidence of the association is lacking for children. We aimed to examine the risk of infection posed by TNFIs compared with DMARDs in children with JIA. Methods We conducted a cohort study using the 2009-13 Truven MarketScan Commercial Claims and Encounters database. Children <16 years old with JIA who initiated monotherapy with TNFIs or DMARDs were identified and followed for occurrence of serious bacterial infection requiring hospitalization. Cox proportional hazard models were used to estimate hazard ratios for infection associated with TNFIs compared with DMARDs, adjusting for potential confounders with high-dimensional propensity scores and time-varying CS use. Results We identified 2013 DMARD initiators and 482 TNFI initiators with a mean follow-up of 255 and 307 days, respectively. We identified 18 and 11 patients with a serious infection in the DMARD and TNFI groups, resulting in crude rates of 1.28 (95% CI 0.76-2.02) and 2.72 (95%CI 1.36-4.86) per 100 person-years, respectively. In adjusted models, TNFIs were associated with an increased risk of serious bacterial infection compared with DMARDs (adjusted hazard ratio 2.72, 95% CI: 1.08, 6.86). Conclusion Use of TNFIs poses a higher risk of serious infection compared with DMARDs in children with JIA. Our analysis confirms the US Food and Drug Administration warning about TNFI-associated infection in children with JIA.
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Affiliation(s)
- Wan-Ju Lee
- Department of Pharmacy Systems, Outcomes and Policy, Chicago, IL, USA
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, Chicago, IL, USA.,Center of Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Katie J Suda
- Department of Pharmacy Systems, Outcomes and Policy, Chicago, IL, USA.,Center of Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA.,Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, Chicago, IL, USA
| | - Gregory S Calip
- Department of Pharmacy Systems, Outcomes and Policy, Chicago, IL, USA.,Center of Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Leslie Briars
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Glen T Schumock
- Department of Pharmacy Systems, Outcomes and Policy, Chicago, IL, USA.,Center of Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
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Mor‐Vaknin N, Rivas M, Legendre M, Mohan S, Yuanfan Y, Mau T, Johnson A, Huang B, Zhao L, Kimura Y, Spalding SJ, Morris PW, Gottlieb BS, Onel K, Olson JC, Edelheit BS, Shishov M, Jung LK, Cassidy EA, Prahalad S, Passo MH, Beukelman T, Mehta J, Giannini EH, Adams BS, Lovell DJ, Markovitz DM. High Levels of DEK Autoantibodies in Sera of Patients With Polyarticular Juvenile Idiopathic Arthritis and With Early Disease Flares Following Cessation of Anti-Tumor Necrosis Factor Therapy. Arthritis Rheumatol 2018; 70:594-605. [PMID: 29287303 PMCID: PMC5876119 DOI: 10.1002/art.40404] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 12/18/2017] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The nuclear oncoprotein DEK is an autoantigen associated with juvenile idiopathic arthritis (JIA), especially the oligoarticular subtype. DEK is a secreted chemotactic factor. Abundant levels of DEK and DEK autoantibodies are found in inflamed synovium in JIA. We undertook this study to further characterize the nature of DEK autoantibodies in screening serum samples from 2 different cohorts that consisted mostly of patients with JIA. METHODS DEK autoantibody levels were analyzed in sera from 33 JIA patients, 13 patients with other inflammatory conditions, and 11 healthy controls, as well as in 89 serum samples from JIA patients receiving anti-tumor necrosis factor (anti-TNF) therapy. Recombinant His-tagged full-length DEK protein (1-375 amino acids [aa]) and the 187-375-aa and 1-350-aa His-tagged DEK fragments made in a baculovirus system were used for enzyme-linked immunosorbent assay (ELISA) and immunoblotting. The C-terminal 25-aa fragment of DEK was expressed in a glutathione S-transferase-tagged vector. ELISA results were calculated as area under the curve by the trapezoidal rule. RESULTS DEK autoantibody levels were significantly higher in patients with polyarticular JIA than in those with oligoarticular JIA, and were higher in patients with polyarticular JIA who had more active disease after cessation of anti-TNF therapy. Immunoblotting against the C-terminal 25-aa fragment of DEK confirmed that this section of the DEK molecule is the most immunogenic domain. CONCLUSION DEK autoantibody levels are higher in patients with polyarticular JIA than in those with oligoarticular JIA, and higher in patients who have disease flares after cessation of anti-TNF therapy. The C-terminal 25-aa fragment is the most immunogenic portion of DEK. These findings are significant with respect to the nature of DEK autoantibodies, their contribution to JIA pathogenesis, and their implications for JIA management.
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Affiliation(s)
| | | | | | | | | | | | - Anne Johnson
- Cincinnati Children's Hospital Medical CenterCincinnatiOhio
| | - Bin Huang
- Cincinnati Children's Hospital Medical Center and University of Cincinnati School of MedicineCincinnatiOhio
| | | | - Yukiko Kimura
- Joseph M. Sanzari Children's HospitalHackensack University Medical CenterHackensackNew Jersey
| | | | | | - Beth S. Gottlieb
- Cohen Children's Medical Center, Northwell HealthHofstra Norwell School of MedicineHempsteadNew York
| | - Karen Onel
- Joseph M. Sanzari Children's HospitalHackensack University Medical CenterHackensackNew Jersey
| | | | | | | | | | | | | | | | | | - Jay Mehta
- Children's Hospital at Montefiore/Albert Einstein College of MedicineBronxNew York
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Abinun M. Risks of serious infections in children treated with biologic response-modifying drugs. Rheumatology (Oxford) 2018; 57:211-212. [DOI: 10.1093/rheumatology/kex228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
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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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Brunelli JB, Schmidt AR, Sallum AME, Goldenstein-Schainberg C, Bonfá E, Silva CA, Aikawa NE. High rate of serious infection in juvenile idiopathic arthritis patients under biologic therapy in a real-life setting. Mod Rheumatol 2017; 28:264-270. [PMID: 28949278 DOI: 10.1080/14397595.2017.1349059] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES To assess the rate of serious and/or opportunistic infections in juvenile idiopathic arthritis (JIA) patients from a single tertiary center under biologic therapy and to identify possible risk factors associated to these complications. METHODS A total of 107 JIA patients followed at the biologic therapy center of our tertiary university hospital using a standardized electronic database protocol including demographic data, clinical and laboratorial findings and treatment at baseline and at the moment of infection. Opportunistic infections included tuberculosis, herpes zoster and systemic mycosis. RESULTS A total of 398 patient-yrs(py) were included. The median time of biologic exposure was 3.0 years (0.15-11.5). We observed 35 serious/opportunistic infectious events in 27 (25%) patients: 31(88.6%) were serious infections and four (11.4%) opportunistic infections. Serious/opportunistic infections rates were 10.6/100py for ETN, 10.9/100py for ADA, 2.6/100py for ABA and 14.8/100py for TCZ. Comparison of 27 patients with and 80 without infection showed a higher frequency of systemic-onset JIA, lower age at biologic therapy initiation and a history of previous serious infection (p < .05) in the former group. CONCLUSIONS This study demonstrated a high rate of serious infections in JIA patients under biologic therapy in a real-life setting. Systemic-onset JIA, lower age at biologic therapy start and history of previous serious infections were important risk factors for these complications. Also, higher rates of severe infections comparing to the former studies was possibly due to elevated MTX doses in our patients.
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Affiliation(s)
- Juliana Barbosa Brunelli
- a Pediatric Rheumatology Unit, Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , São Paulo , Brazil
| | - Ana Renata Schmidt
- a Pediatric Rheumatology Unit, Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , São Paulo , Brazil
| | - Adriana Maluf Elias Sallum
- a Pediatric Rheumatology Unit, Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , São Paulo , Brazil
| | - Claudia Goldenstein-Schainberg
- b Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , São Paulo , Brazil
| | - Eloisa Bonfá
- b Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , São Paulo , Brazil
| | - Clovis A Silva
- a Pediatric Rheumatology Unit, Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , São Paulo , Brazil
| | - Nádia Emi Aikawa
- a Pediatric Rheumatology Unit, Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , São Paulo , Brazil.,b Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de Sao Paulo , São Paulo , Brazil
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Shafrin J, Tebeka MG, Price K, Patel C, Michaud K. The Economic Burden of ACPA-Positive Status Among Patients with Rheumatoid Arthritis. J Manag Care Spec Pharm 2017; 24:4-11. [PMID: 29290168 PMCID: PMC10398189 DOI: 10.18553/jmcp.2017.17129] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Anticitrullinated protein antibodies (ACPAs) are serological biomarkers associated with early, rapidly progressing rheumatoid arthritis (RA), including more severe disease and joint damage. ACPA testing has become a routine tool for RA diagnosis and prognosis. Furthermore, treatment efficacy has been shown to vary by ACPA-positive status. However, it is not clear if the economic burden of patients with RA varies by ACPA status. OBJECTIVE To determine if the economic burden of RA varies by patient ACPA status. METHODS IMS PharMetrics Plus health insurance claims and electronic medical record (EMR) data from 2010-2015 were used to identify patients with incident RA. Patients were aged ≥ 18 years, had ≥ 1 inpatient or ≥ 2 outpatient claims reporting an RA diagnosis code (ICD-9-CM code 714.0), and had an anticyclic citrullinated peptide (anti-CCP; a surrogate of ACPA) antibody test within 6 months of diagnosis. Incident patients were defined as those who had no claims with an RA diagnosis code in the 6 months before the first observed RA diagnosis. The primary outcome of interest was RA-related medical expenditures, defined as the sum of payer- and patient-paid amounts for all claims with an RA diagnosis code. Secondary outcomes included health care utilization metrics such as treatment with a disease-modifying antirheumatic drug (DMARD) and physician visits. Generalized linear regression models were used for each outcome, controlling for ACPA-positive status (defined as anti-CCP ≥ 20 AU/mL), age, sex, and Charlson Comorbidity Index score as explanatory variables. RESULTS Of 647,171 patients diagnosed with RA, 89,296 were incident cases, and 47% (n = 42,285) had an anti-CCP test. After restricting this sample to patients with a linked EMR and reported anti-CCP test result, 859 remained, with 24.7% (n = 212) being ACPA-positive. Compared with ACPA-negative patients, adjusted results showed that ACPA-positive patients were more likely to use either conventional (71.2% vs. 49.6%; P < 0.001) or biologic (20.3% vs. 11.8%; P < 0.001) DMARDs during the first year after diagnosis and had more physician visits (5.58 vs. 3.91 times per year; P < 0.001). Annual RA-associated total expenditures were $7,941 for ACPA-positive and $5,243 for ACPA-negative patients (Δ = $2,698; P = 0.002). RA-associated medical expenditures were $4,380 for ACPA-positive and $3,427 for ACPA-negative patients (Δ = $954; P = 0.168), whereas DMARD expenditures were $3,560 and $1,817, respectively (Δ = $1,743; P = 0.001). CONCLUSIONS RA-related economic burden is higher for patients who are ACPA-positive compared with those who are ACPA-negative. Providers may wish to inform patients diagnosed with ACPA-positive RA about the likely future disease and economic burden in hopes that both stakeholders can be more proactive in addressing them. DISCLOSURES Funding for this research was contributed by Bristol-Myers Squibb. Patel and Price are employees and stockholders of Bristol-Myers Squibb. Shafrin and Tebeka are employees of Precision Health Economics, a health care consulting firm that received funding from Bristol-Myers Squibb to conduct this study. Michaud has received a grant from Pfizer and is employed by the National Data Bank for Rheumatic Diseases, which has received funds from Amgen, Bristol-Myers Squibb, Eli Lilly, Janssen, Pfizer, and Regeneron. Study concept and design were contributed by Shafrin, Price, Patel, and Michaud. Shafrin, Price, and Patel collected the data, and all authors contributed equally to data analysis. The manuscript was written by Shafrin and Tebeka and revised by Shafrin, Price, Patel, and Michaud.
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Affiliation(s)
- Jason Shafrin
- 1 Precision Health Economics, Los Angeles, California
| | | | - Kwanza Price
- 2 Bristol-Myers Squibb, Princeton Pike, New Jersey
| | - Chad Patel
- 2 Bristol-Myers Squibb, Princeton Pike, New Jersey
| | - Kaleb Michaud
- 3 University of Nebraska Medical Center, Omaha, and National Data Bank for Rheumatic Diseases, Wichita, Kansas
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