1
|
Petrongari D, Di Filippo P, Misticoni F, Basile G, Di Pillo S, Chiarelli F, Attanasi M. Lung Involvement in Systemic Juvenile Idiopathic Arthritis: A Narrative Review. Diagnostics (Basel) 2022; 12:diagnostics12123095. [PMID: 36553101 PMCID: PMC9777523 DOI: 10.3390/diagnostics12123095] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/02/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
Systemic juvenile idiopathic arthritis associated with lung disorders (sJIA-LD) is a subtype of sJIA characterized by the presence of chronic life-threatening pulmonary disorders, such as pulmonary hypertension, interstitial lung disease, pulmonary alveolar proteinosis and/or endogenous lipoid pneumonia, which were exceptionally rare before 2013. Clinically, these children show a striking dissociation between the relatively mild clinical manifestations (tachypnoea, clubbing and chronic cough) and the severity of the pulmonary inflammatory process. Our review describes sJIA-LD as having a reported prevalence of approximately 6.8%, with a mortality rate of between 37% and 68%. It is often associated with an early onset (<2 years of age), macrophage activation syndrome and high interleukin (IL)-18 circulating levels. Other risk factors may be trisomy 21 and a predisposition to adverse reactions to biological drugs. The most popular hypothesis is that the increase in the number of sJIA-LD cases can be attributed to the increased use of IL-1 and IL-6 blockers. Two possible explanations have been proposed, named the “DRESS hypothesis” and the “cytokine plasticity hypothesis”. Lung ultrasounds and the intercellular-adhesion-molecule-5 assay seem to be promising tools for the early diagnosis of sJIA-LD, although high resolution computed tomography remains the gold standard. In this review, we also summarize the treatment options for sJIA-LD, focusing on JAK inhibitors.
Collapse
|
2
|
Hur P, Yi E, Ionescu-Ittu R, Manceur AM, Lomax KG, Cammarota J, Xie J, Gautam R, Nakasato P, Sanghera N, Kim N, Grom AA. Reasons for Initiating Canakinumab among Patients with Systemic Juvenile Idiopathic Arthritis and Adult-Onset Still's Disease in the U.S. Real-World Settings. Rheumatol Ther 2021; 9:265-283. [PMID: 34874547 PMCID: PMC8814295 DOI: 10.1007/s40744-021-00402-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/15/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction The aim of this study was to understand the reasons for canakinumab initiation among patients with Still’s disease, including systemic juvenile idiopathic arthritis (SJIA) and adult-onset Still’s disease (AOSD), in US clinical practice. Methods Physicians retrospectively reviewed the medical charts of patients with Still’s disease (regardless of age at symptom onset) who were prescribed canakinumab from 2016 to 2018. Patients aged < 16 years at symptom onset were classified as having SJIA and those aged ≥ 16 years at symptom onset (calculated from case-record forms) were classified as having AOSD. Patient treatment history and physician reasons for canakinumab initiation were analyzed. Overall results were presented as SJIA/AOSD. Sensitivity analyses were performed for the robustness of the results. Results Forty-three physicians in the USA (rheumatologists/dermatologists/immunologists/allergists: 51.2/27.9/11.6/9.3%; subspecialty in adults/pediatrics: 67.4/32.6%) abstracted information for 72 patients with SJIA/AOSD (SJIA/AOSD/age unknown at symptom onset: 75.0/18.1/6.9%; mean age 19.4 years; children 61.1%; females 56.9%). Most patients (90.3%) received treatment directly preceding canakinumab initiation (etanercept 27.7%; anakinra 18.5%; adalimumab 16.9%); the respective treatment was discontinued due to lack of efficacy/effectiveness (43.1%) and availability of a new treatment (27.8%). Most common reasons for canakinumab initiation were physician perceived/experienced efficacy/effectiveness of canakinumab (77.8%; children/adults: 81.8/71.4%), lack-of-response to previous treatment (45.8%; children/adults: 36.4/60.7%), convenient administration/dosing (26.4%; children/adults: 29.5/21.4%) and ability to discontinue/spare steroids (25.0%; children/adults: 20.5/32.1%). The sensitivity analysis provided similar results. Conclusions In US clinical practice, physician perceived/experienced efficacy/effectiveness of canakinumab and lack-of-response to previous treatment were the primary reasons for canakinumab initiation among patients with SJIA/AOSD. Physician perceived/experienced efficacy/effectiveness and convenient administration/dosing of canakinumab were the most common reasons for canakinumab initiation among children, whereas lack-of-response to previous treatment and ability to discontinue/spare steroids being the most frequent reasons among adults. Supplementary Information The online version contains supplementary material available at 10.1007/s40744-021-00402-z.
Collapse
Affiliation(s)
- Peter Hur
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Esther Yi
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | | | | | | | - Jipan Xie
- Analysis Group, Inc, Los Angeles, CA, USA
| | - Raju Gautam
- Novartis Healthcare Pvt. Ltd, Hyderabad, India
| | | | | | - Nina Kim
- Baylor Scott and White Medical Center-Temple, Temple, TX, USA.,The University of Texas at Austin, Austin, TX, USA
| | - Alexei A Grom
- Division of Pediatric Rheumatology, Children's Hospital Medical Center, MLC 4010, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
| |
Collapse
|
3
|
Paç Kısaarslan A, Özdemir Çiçek S, Şahin N, Başol M, Doğantan Ş, Taşkın SN, Poyrazoğlu MH. Factors and glucocorticoid usage affecting the prognosis of systemic juvenile idiopathic arthritis. Pediatr Int 2021; 63:1424-1432. [PMID: 33760311 DOI: 10.1111/ped.14706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/25/2021] [Accepted: 03/10/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The rate of glucocorticoid (GC) use is significantly higher in systemic juvenile idiopathic arthritis (SJIA) than other juvenile idiopathic arthritis subtypes. There is no consensus on the duration and dosage of GC treatment. We aimed to investigate the risk factors for a polyphasic / persistent disease course and the effect of dose and duration of GC treatment on SJIA prognosis. METHODS Forty-two patients who were diagnosed with SJIA, and for whom the duration of disease was longer than 2 years, were included. Patients were divided into monophasic and others (polyphasic / persistent disease course). Risk factors for polyphasic / persistent disease course, which were clinical and laboratory findings regarding the patients, treatment options, dose, and duration of GCs, were evaluated for the first active disease periods and for all flares in the entire disease course. RESULTS Of the 42 SJIA patients, 21 had monophasic, and 21 had polyphasic / persistent disease. Cumulative dosages and durations of glucocorticoid treatment were similar in the two groups at the first flare (odds ratio (OR): 1.032 P: 0.671; OR:1,113 P: 0.115). Durations of the first active disease period were longer in the polyphasic / persistent group (OR:1.275, P: 0.01). Active disease duration cut-off values of 1.5 months with sensitivity 85.7%, specificity 52.4% were observed on receiver operating characteristic curve analysis. The presence of hepatosplenomegaly at first flare was detected as an independent risk factor of polyphasic/persistent disease by multivariate analysis included both dosage and duration of a steroid (hazard ratio (HR): 4.129, P: 0.034), (HR: 3.992, P: 0.038). Multivariate recurrent events survival analysis determined ALT levels as a risk factor affecting polyphasic / persistent disease (HR: 0.986, P: 0.037). CONCLUSIONS Glucocorticoid dose and duration did not affect the active disease periods and disease course in SJIA. An active disease period longer than 1.5 months, presentation of hepatosplenomegaly at the initial disease course, and high ALT levels at the recurrences should warn physicians of polyphasic / persistent disease.
Collapse
Affiliation(s)
- Ayşenur Paç Kısaarslan
- Division of Pediatric Rheumatology, Department of Pediatrics, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Sümeyra Özdemir Çiçek
- Division of Pediatric Rheumatology, Department of Pediatrics, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Nihal Şahin
- Division of Pediatric Rheumatology, Department of Pediatrics, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Merve Başol
- Department of Biostatistics, Abant İzzet Baysal University, Faculty of Medicine, Bolu, Turkey
| | - Şeyda Doğantan
- Division of Pediatric Rheumatology, Department of Pediatrics, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Sema Nur Taşkın
- Division of Pediatric Rheumatology, Department of Pediatrics, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Muammer Hakan Poyrazoğlu
- Division of Pediatric Rheumatology, Department of Pediatrics, Erciyes University Faculty of Medicine, Kayseri, Turkey
| |
Collapse
|
4
|
Erkens R, Esteban Y, Towe C, Schulert G, Vastert S. Pathogenesis and Treatment of Refractory Disease Courses in Systemic Juvenile Idiopathic Arthritis: Refractory Arthritis, Recurrent Macrophage Activation Syndrome and Chronic Lung Disease. Rheum Dis Clin North Am 2021; 47:585-606. [PMID: 34635293 DOI: 10.1016/j.rdc.2021.06.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Systemic juvenile idiopathic arthritis is a distinct and heterogeneous disease presently classified under the umbrella of juvenile idiopathic arthritis, with some patients following a monophasic remitting course, whereas others have persistent disease with chronic organ- and life-threatening complications. Although biologic therapies have revolutionized treatment, recent follow-up studies report significant numbers of children with persistently active disease on long term follow-up. This review focuses on refractory disease courses, specifically refractory arthritis, systemic juvenile idiopathic arthritis with recurrent, or longstanding signs of macrophage activation syndrome, and systemic juvenile idiopathic arthritis associated with suspected, probable, or definite lung disease.
Collapse
Affiliation(s)
- Remco Erkens
- Division of Pediatric Rheumatology & Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; Center for Translational Immunology, University Medical Center Utrecht, University of Utrecht, the Netherlands
| | - Ysabella Esteban
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Christopher Towe
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Grant Schulert
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sebastiaan Vastert
- Division of Pediatric Rheumatology & Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; Center for Translational Immunology, University Medical Center Utrecht, University of Utrecht, the Netherlands.
| |
Collapse
|
5
|
Maller J, Fox E, Park KT, Paul SS, Baszis K, Borocco C, Prahalad S, Quartier P, Reinhardt A, Schonenberg-Meinema D, Shipman-Duensing L, Terreri MT, Simard J, Lavi I, Chalom E, Hsu J, Zisman D, Mellins ED. Inflammatory Bowel Disease in Children With Systemic Juvenile Idiopathic Arthritis. J Rheumatol 2020; 48:567-574. [PMID: 32541073 DOI: 10.3899/jrheum.200230] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The incidence of inflammatory bowel disease (IBD) in juvenile idiopathic arthritis (JIA) is higher than in the general pediatric population. However, reports of IBD in the systemic JIA (sJIA) subtype are limited. We sought to characterize sJIA patients diagnosed with IBD and to identify potential contributing risk factors. METHODS Using an internationally distributed survey, we identified 16 patients with sJIA who were subsequently diagnosed with IBD (sJIA-IBD cohort). Five hundred twenty-two sJIA patients without IBD were identified from the CARRA Legacy Registry and served as the sJIA-only cohort for comparison. Differences in demographic, clinical characteristics, and therapy were assessed using chi-square test, Fisher exact test, t-test, and univariate and multivariate logistic regression, as appropriate. RESULTS Of the patients with sJIA-IBD, 75% had a persistent sJIA course and 25% had a history of macrophage activation syndrome. sJIA-IBD subjects were older at sJIA diagnosis, more often non-White, had a higher rate of IBD family history, and were more frequently treated with etanercept or canakinumab compared to sJIA-only subjects. Sixty-nine percent of sJIA-IBD patients successfully discontinued sJIA medications following IBD diagnosis, and sJIA symptoms resolved in 9 of 12 patients treated with tumor necrosis factor-α (TNF-α) inhibitors. CONCLUSION IBD in the setting of sJIA is a rare occurrence. The favorable response of sJIA symptoms to therapeutic TNF-α inhibition suggests that the sJIA-IBD cohort may represent a mechanistically distinct sJIA subgroup. Our study highlights the importance of maintaining a high level of suspicion for IBD when gastrointestinal involvement occurs in patients with sJIA and the likely broad benefit of TNF-α inhibition in those cases.
Collapse
Affiliation(s)
- Justine Maller
- J. Maller, MD, PhD, Department of Pediatrics, Division of Rheumatology, Stanford University School of Medicine, Stanford, California, USA
| | - Emily Fox
- E. Fox, MD, Department of Pediatrics, Division of Rheumatology, Stanford University School of Medicine, Stanford, California, and Department of Pediatrics, Division of Rheumatology, Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - K T Park
- K.T. Park, MD, Department of Pediatrics, Division of Gastroenterology, Stanford University School of Medicine, Stanford, California, USA
| | - Sarah Sertial Paul
- S. Sertial Paul, DO, Department of Pediatrics, Goryeb Children's Hospital, Morristown, New Jersey, USA
| | - Kevin Baszis
- K. Baszis, MD, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Charlotte Borocco
- C. Borocco, MD, Paris University, Imagine Institute and Pediatric Hematology-Immunology and Rheumatology Unit, Necker Hospital, AP-HP, Paris, France
| | - Sampath Prahalad
- S. Prahalad, MD, Department of Pediatrics and Department of Genetics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Pierre Quartier
- P. Quartier, MD, Paris University, Imagine Institute, RAISE Reference Centre and Pediatric Hematology-Immunology and Rheumatology Unit, Necker Hospital, AP-HP, Paris, France
| | - Adam Reinhardt
- A. Reinhardt, MD, Department of Pediatrics, Boys Town National Research Hospital, Omaha, Nebraska, USA
| | - Dieneke Schonenberg-Meinema
- D. Schonenberg-Meinema, MD, Department of Pediatric Immunology, Rheumatology and Infectious Diseases, Amsterdam Universitair Medische Centra, Amsterdam, the Netherlands
| | - Lauren Shipman-Duensing
- L. Shipman-Duensing, MD, Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Maria Teresa Terreri
- M.T. Terreri, MD, Department of Pediatrics, Pediatric Rheumatology Unit, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Julia Simard
- J. Simard, ScD, Department of Health Research & Policy, Division of Epidemiology, and Department of Medicine, Division of Immunology & Rheumatology, Stanford University, Stanford, California, USA
| | - Idit Lavi
- I. Lavi, MA, Department of Community Medicine and Epidemiology, Carmel Medical Center, Haifa, Israel
| | - Elizabeth Chalom
- E. Chalom, MD, Department of Pediatrics, Saint Barnabas Medical Center, Livingston, New Jersey, USA
| | - Joyce Hsu
- J. Hsu, MD, Department of Pediatrics, Division of Allergy, Immunology and Rheumatology, Stanford University School of Medicine, Stanford, California, USA
| | - Devy Zisman
- D. Zisman, MD, Carmel Medical Center, Rheumatology Unit, The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Elizabeth D Mellins
- E.D. Mellins, MD, Department of Pediatrics, Division of Human Gene Therapy, Program in Immunology, Stanford University School of Medicine, Stanford, California, USA.
| | | |
Collapse
|
6
|
Takei S, Iwata N, Kobayashi I, Igarashi T, Yoshinaga Y, Matsubara N, Sunaga N, Ito A, Yokota S. Safety and effectiveness of adalimumab in Japanese patients with juvenile idiopathic arthritis: Results from a real-world postmarketing study. Mod Rheumatol 2020; 31:421-430. [PMID: 32340508 DOI: 10.1080/14397595.2020.1761075] [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 study was conducted to assess the real-world safety and effectiveness of adalimumab in patients with juvenile idiopathic arthritis (JIA). METHODS In this all-case, postmarketing surveillance study (NCT01412021) conducted in Japan, patients receiving adalimumab for JIA affecting multiple joints were observed for 24 weeks. The safety (adverse drug reactions [ADRs]/serious ADRs) and effectiveness (4-variable Disease Activity Score in 28 joints using erythrocyte sedimentation rate [DAS28-4/ESR] remission rate) were assessed. RESULTS In the safety population (n = 356), 90.3% (65/72; weight, ≥15-<30 kg) of patients received adalimumab 20 mg every 2 weeks (q2w) and 98.3% (236/240; weight ≥30 kg) received 40 mg q2w. Incidence of ADRs and serious ADRs was 29.8% (106/356) and 3.4% (12/356), respectively. Incidence of ADRs was significantly higher in patients aged <15 years vs. ≥15 years (34.6% vs. 21.1%, p = .0072), those with comorbidities vs. without (38.3% vs. 25.7%, p = .0155), and those receiving dose <40 mg q2w vs. ≥40 mg q2w (38.8% vs. 26.9%, p = .0418). DAS28-4/ESR remission rate improved from 21.7% (36/166) at baseline to 74.7% (112/150) at week 24. CONCLUSIONS Adalimumab was well tolerated and had acceptable safety and effectiveness in patients with JIA in the real-world setting.
Collapse
Affiliation(s)
- Syuji Takei
- Department of Pediatrics, Kagoshima University, Kagoshima, Japan
| | - Naomi Iwata
- Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | | | - Toru Igarashi
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | | | | | | | | | - Shumpei Yokota
- Fuji Toranomon Orthopedic Hospital, Gotemba, Shizuoka, Japan
| |
Collapse
|
7
|
Abstract
Systemic juvenile idiopathic arthritis (sJIA) is characterized by fever, arthritis, and other signs of systemic inflammation. Historically, sJIA was named Still's disease after George Frederic Still, who first reported patients. Individuals who manifest after the 16th birthday are diagnosed with adult onset Still's disease (AOSD). The pathophysiology of sJIA and AOSD are incompletely understood. Increased activation of inflammasomes and the expression of proinflammatory cytokines play a central role. S100 proteins, which can activate Toll-like receptors, thus, maintaining positive feedback loops, have also been detected at increased levels in sera from sJIA patients. Reduced expression of the immune-modulatory cytokine IL-10 may further contribute to immune cell activation and the production of proinflammatory molecules. Here, we discuss the clinical picture, differential diagnoses, the current pathophysiological understanding, and treatment options in sJIA and AOSD.
Collapse
Affiliation(s)
- C M Hedrich
- Arbeitsbereich Pädiatrische Rheumatologie und Immunologie, Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - C Günther
- Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Deutschland
| | - M Aringer
- Bereich Rheumatologie, Medizinische Klinik und Poliklinik III, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Deutschland
| |
Collapse
|
8
|
Sota J, Insalaco A, Cimaz R, Alessio M, Cattalini M, Gallizzi R, Maggio MC, Lopalco G, La Torre F, Fabiani C, Pardeo M, Olivieri AN, Sfriso P, Salvarani C, Gaggiano C, Grosso S, Bracaglia C, De Benedetti F, Rigante D, Cantarini L. Drug Retention Rate and Predictive Factors of Drug Survival for Interleukin-1 Inhibitors in Systemic Juvenile Idiopathic Arthritis. Front Pharmacol 2019; 9:1526. [PMID: 30670972 PMCID: PMC6331484 DOI: 10.3389/fphar.2018.01526] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 12/12/2018] [Indexed: 12/24/2022] Open
Abstract
Background and Objectives: Few studies have reported the drug retention rate (DRR) of biologic drugs in juvenile idiopathic arthritis (JIA), and none of them has specifically investigated the DRR of interleukin (IL)-1 inhibitors on systemic JIA (sJIA). This study aims to describe IL-1 inhibitors DRR and evaluate predictive factors of drug survival based on data from a real-world setting concerning sJIA. Methods: Medical records from sJIA patients treated with anakinra (ANA) and canakinumab (CAN) were retrospectively analyzed from 15 Italian tertiary referral centers. Results: Seventy seven patients were enrolled for a total of 86 treatment courses. The cumulative retention rate of the IL-1 inhibitors at 12-, 24-, 48-, and 60-months of follow-up was 79.9, 59.5, 53.5, and 53.5%, respectively, without any statistically significant differences between ANA and CAN (p = 0.056), and between patients treated in monotherapy compared to the subgroup co-administered with conventional immunosuppressors (p = 0.058). On the contrary, significant differences were found between biologic-naive patients and those previously treated with biologic drugs (p = 0.038) and when distinguishing according to adverse events (AEs) occurrence (p = 0.04). In regression analysis, patients pre-treated with other biologics (HR = 3.357 [CI: 1.341-8.406], p = 0.01) and those experiencing AEs (HR = 2.970 [CI: 1.186-7.435], p = 0.020) were associated with a higher hazard ratio of IL-1 inhibitors withdrawal. The mean treatment delay was significantly higher among patients discontinuing IL-1 inhibitors (p = 0.0002). Conclusions: Our findings suggest an excellent overall DRR for both ANA and CAN that might be further augmented by paying attention to AEs and employing these agents as first-line biologics in an early disease phase.
Collapse
Affiliation(s)
- Jurgen Sota
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Antonella Insalaco
- Division of Rheumatology, Department of Pediatric Medicine, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rolando Cimaz
- Rheumatology Unit, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Maria Alessio
- Department of Pediatrics, University of Naples Federico II, Naples, Italy
| | | | - Romina Gallizzi
- Department of Pediatrics, Azienda Ospedaliera Universitaria Policlinico "G. Martino" - Messina, University of Messina, Messina, Italy
| | | | - Giuseppe Lopalco
- Rheumatology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Francesco La Torre
- Pediatric Rheumatology Section, Pediatric Oncoematology Unit, Vito Fazzi Hospital, Lecce, Italy
| | - Claudia Fabiani
- Ophthalmology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Manuela Pardeo
- Division of Rheumatology, Department of Pediatric Medicine, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alma Nunzia Olivieri
- Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Università degli Studi di Napoli, Naples, Italy
| | - Paolo Sfriso
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Carlo Salvarani
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | - Carla Gaggiano
- Clinical Pediatrics, Department of Molecular Medicine and Development, University of Siena, Siena, Italy
| | - Salvatore Grosso
- Clinical Pediatrics, Department of Molecular Medicine and Development, University of Siena, Siena, Italy
| | - Claudia Bracaglia
- Division of Rheumatology, Department of Pediatric Medicine, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Fabrizio De Benedetti
- Division of Rheumatology, Department of Pediatric Medicine, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Donato Rigante
- Institute of Pediatrics, Periodic Fever Research Center, Università Cattolica Sacro Cuore, Fondazione Policlinico A. Gemelli, IRCCS, Rome, Italy
| | - Luca Cantarini
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| |
Collapse
|
9
|
Feng M, Kang M, He F, Xiao Z, Liu Z, Yao H, Wu J. Plasma interleukin-37 is increased and inhibits the production of inflammatory cytokines in peripheral blood mononuclear cells in systemic juvenile idiopathic arthritis patients. J Transl Med 2018; 16:277. [PMID: 30305171 PMCID: PMC6180625 DOI: 10.1186/s12967-018-1655-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 10/04/2018] [Indexed: 12/22/2022] Open
Abstract
Background Interleukin (IL)-37 has emerged as a novel anti-inflammatory cytokine that play an immunosuppressive role in regulating inflammatory response. This study aimed to measure IL-37 levels in the plasma and peripheral blood mononuclear cells (PBMCs) of patients with systemic juvenile idiopathic arthritis (sJIA), and to establish the correlation between IL-37 levels and disease activity, laboratory parameters and inflammatory cytokines. Methods The mRNA levels of IL-37 in PBMCs and plasma IL-37 concentrations in 46 sJIA patients and 30 age- and sex-matched healthy controls were measured by real-time polymerase chain reaction (RT-PCR) and enzyme-linked immunosorbent assay (ELISA), respectively. The correlations between plasma IL-37 levels and disease activity, laboratory parameters and inflammatory cytokines in sJIA were analyzed by Spearman correlation test. PBMCs from the sJIA patients were stimulated with recombinant human IL-37 (rhIL-37) protein, expressions of IL-1β, IL-6, TNF-α and IL-17 were detected by RT-PCR and ELISA. Results Plasma levels of IL-37 and relative IL-37 mRNA expression were significantly elevated in sJIA patients, especially in active sJIA patients, when compared with the healthy controls (P < 0.001). Furthermore, patients with active disease showed higher IL-37 mRNAs and plasma protein levels than those with inactive disease as well as healthy controls. Plasma IL-37 levels were correlated with disease activity and inflammatory cytokines (IL-6, TNF-α, IL-17 and GM-CSF) in sJIA patients. The productions of inflammatory cytokines such as IL-6, TNF-α, IL-17 in PBMCs from sJIA patients were obviously decreased after recombinant IL-37 stimulation, whereas the production of IL-1β was not changed. Conclusions Our results demonstrate that levels of IL-37 were higher in sJIA patients, which were correlated with disease activity and sJIA related inflammatory cytokines. In addition, rhIL-37 down-regulates the expressions of inflammatory cytokines form PBMCs in sJIA patients, suggesting that IL-37 may have the potential role as a natural inhibitor for the pathogenesis and therapy of sJIA. Electronic supplementary material The online version of this article (10.1186/s12967-018-1655-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Miao Feng
- Department of Biochemistry and Immunology, Capital Institute of Pediatrics, No. 2 Yabao Road, Chao Yang District, Beijing, 100020, China
| | - Min Kang
- Department of Immunology and Rheumatology, Capital Institute of Pediatrics, No. 2 Yabao Road, Chao Yang District, Beijing, 100020, China
| | - Feng He
- Department of Biochemistry and Immunology, Capital Institute of Pediatrics, No. 2 Yabao Road, Chao Yang District, Beijing, 100020, China
| | - Zonghui Xiao
- Department of Biochemistry and Immunology, Capital Institute of Pediatrics, No. 2 Yabao Road, Chao Yang District, Beijing, 100020, China
| | - Zhewei Liu
- Department of Biochemistry and Immunology, Capital Institute of Pediatrics, No. 2 Yabao Road, Chao Yang District, Beijing, 100020, China
| | - Hailan Yao
- Department of Biochemistry and Immunology, Capital Institute of Pediatrics, No. 2 Yabao Road, Chao Yang District, Beijing, 100020, China.
| | - Jianxin Wu
- Department of Biochemistry and Immunology, Capital Institute of Pediatrics, No. 2 Yabao Road, Chao Yang District, Beijing, 100020, China.
| |
Collapse
|
10
|
Toplak N, Blazina Š, Avčin T. The role of IL-1 inhibition in systemic juvenile idiopathic arthritis: current status and future perspectives. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 12:1633-1643. [PMID: 29922038 PMCID: PMC5996857 DOI: 10.2147/dddt.s114532] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The pathogenesis, clinical course, and response to treatment in systemic juvenile idiopathic arthritis (SJIA) differ from other types of juvenile idiopathic arthritis and are similar to other interleukin-1 (IL-1)-mediated diseases. The main cytokine involved in the pathogenesis of SJIA is IL-1β, which can be neutralized by targeted anti-IL-1 therapy. In SJIA, no antibodies have been found and there is growing evidence that it is mainly an autoinflammatory and not an autoimmune disease. Before the era of biologic therapy, treatment of SJIA was primarily based on long-term treatment with high doses of glucocorticosteroids (GCS). The side effects of GCS could have a significant impact on the outcome of the disease and could cause long-term damage. Treatment with anti-IL-1 agents early in the disease course has revolutionized the management principles of SJIA. However, not all SJIA patients respond equally well to anti-IL-1 therapy, and it has been shown that age at the onset of disease, duration of the disease, number of affected joints, neutrophil count, and ferritin level can predict the response to anti-IL-1 therapy. In particular, an elevated ferritin level should prompt testing for macrophage activation syndrome (MAS), the most severe complication of SJIA. Anti-IL-1 therapy has been shown to be effective also in patients with MAS. Although anti-IL-1 agents are currently not recommended as first-line treatment, there is growing evidence that anti-IL-1 agents introduced at the beginning of SJIA could enable lower doses and a shorter duration of GCS therapy, change the long-term disease outcome, and even influence molecular disease patterns. There are currently three anti-IL-1 agents available: anakinra, canakinumab, and rilonacept. In this review, we present the current knowledge on the pathogenesis of SJIA, the rational for anti-IL-1 treatment, and future perspectives on the treatment of SJIA.
Collapse
Affiliation(s)
- Nataša Toplak
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Štefan Blazina
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Tadej Avčin
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| |
Collapse
|
11
|
Mimura T, Kondo Y, Ohta A, Iwamoto M, Ota A, Okamoto N, Kawaguchi Y, Kono H, Takasaki Y, Takei S, Nishimoto N, Fujimoto M, Asanuma YF, Mimori A, Okiyama N, Kaneko S, Takahashi H, Yokosawa M, Sumida T. Evidence-based clinical practice guideline for adult Still’s disease. Mod Rheumatol 2018; 28:736-757. [DOI: 10.1080/14397595.2018.1465633] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Toshihide Mimura
- Department of Rheumatology and Applied Immunology, Saitama Medical University, Saitama, Japan
- Center for Intractable Diseases, Saitama Medical University, Saitama, Japan
| | - Yuya Kondo
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Akihide Ohta
- Faculty of Medicine, Saga University, Saga, Japan
| | - Masahiro Iwamoto
- Department of Internal Medicine, Division of Rheumatology/Clinical Immunology, Jichi Medical University, Tochigi, Japan
| | - Akiko Ota
- Department of Social Medicine, Faculty of Medicine, Division of Public Health, Saitama Medical University, Saitama, Japan
| | - Nami Okamoto
- Department of Pediatrics, Osaka Medical College, Osaka, Japan
| | - Yasushi Kawaguchi
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hajime Kono
- Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yoshinari Takasaki
- Department of Rheumatology, Juntendo University Koshigaya Hospital, Saitama, Japan
| | - Shuji Takei
- Faculty of Medicine, School of Health Sciences, Kagoshima University, Kagoshima, Japan
| | - Norihiro Nishimoto
- Department of Molecular Regulation for Intractable Diseases, Institute of Medical Science, Tokyo Medical University, Tokyo, Japan
| | - Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yu Funakubo Asanuma
- Department of Rheumatology and Applied Immunology, Saitama Medical University, Saitama, Japan
| | - Akio Mimori
- Department of Rheumatology, Iwate Prefectural Central Hospital, Iwate, Japan
| | - Naoko Okiyama
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Shunta Kaneko
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Hiroyuki Takahashi
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Masahiro Yokosawa
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Takayuki Sumida
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| |
Collapse
|
12
|
Becker ML, Funk RS. Reverse Translation in Advancing Pharmacotherapy in Pediatric Rheumatology: A Logical Approach in Rare Diseases with Limited Resources. Clin Transl Sci 2017; 11:106-108. [PMID: 29193724 PMCID: PMC5866971 DOI: 10.1111/cts.12513] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 09/17/2017] [Indexed: 11/29/2022] Open
Affiliation(s)
- Mara L Becker
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Division of Rheumatology, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Ryan S Funk
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Department of Pharmacy Practice, University of Kansas Medical Center, Kansas City, Kansas, USA
| |
Collapse
|
13
|
Grevich S, Shenoi S. Update on the management of systemic juvenile idiopathic arthritis and role of IL-1 and IL-6 inhibition. ADOLESCENT HEALTH MEDICINE AND THERAPEUTICS 2017; 8:125-135. [PMID: 29184458 PMCID: PMC5687245 DOI: 10.2147/ahmt.s109495] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Systemic juvenile idiopathic arthritis (SJIA) is a disease marked with arthritis and several features of systemic inflammation including fevers, rashes, hepatosplenomegaly, lymphadenopathy, and serositis. The presentation can be variable and arthritis can be a later feature. Macrophage activation syndrome can be a life-threatening complication of this illness and requires early recognition and prompt therapy. Advancements in understanding the biology of SJIA have led to the development of cytokine-targeted therapies, mainly interleukin-1 (IL-1) and IL-6 inhibitors that have significantly improved outcomes. In this review, we provide an update on the advances in the understanding of SJIA biology and also the therapeutic options.
Collapse
Affiliation(s)
- Sriharsha Grevich
- Department of Rheumatology, Seattle Children's Hospital, Seattle, WA, USA
| | - Susan Shenoi
- Department of Rheumatology, Seattle Children's Hospital, Seattle, WA, USA
| |
Collapse
|
14
|
Klotsche J, Raab A, Niewerth M, Sengler C, Ganser G, Kallinich T, Niehues T, Hufnagel M, Thon A, Hospach T, Horneff G, Minden K. Outcome and Trends in Treatment of Systemic Juvenile Idiopathic Arthritis in the German National Pediatric Rheumatologic Database, 2000-2013. Arthritis Rheumatol 2017; 68:3023-3034. [PMID: 27332999 DOI: 10.1002/art.39796] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 06/16/2016] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To investigate the clinical presentation and medical treatment of patients with systemic juvenile idiopathic arthritis (JIA) during the first year of illness. Our study focused on 3-year outcomes in a subsample of patients who were followed up longitudinally. METHODS From 2000 to 2013, 597 patients with systemic JIA and a disease duration of ≤12 months were recorded in the National Pediatric Rheumatologic Database. Among those patients, 3-year outcome data were available for 133. These data included the clinical Juvenile Arthritis Disease Activity Score in 10 joints (JADAS-10) and the physician's global assessment score (on a numerical rating scale), as well as assessment of joint involvement, growth retardation, and patient-reported outcomes. RESULTS The median clinical JADAS-10 declined significantly, from 7 in 2000 to 2 in 2013, while the proportion of patients with inactive disease increased from 19% in 2000 to 41% in 2013. The rate of treatment with systemic glucocorticoids and disease-modifying antirheumatic drugs (DMARDs) remained stable from 2000 to 2013. By 2013, the proportion of patients with systemic JIA who were treated with biologic DMARDs had increased to 20%. At 3-year follow-up, 72% of patients with systemic JIA had inactive disease, and 77% had no functional limitations. Growth retardation was associated with persistently high disease activity and continuing treatment with systemic glucocorticoids. At the 3-year follow-up, one-third of patients were still being treated with systemic glucocorticoids. CONCLUSION The proportion of patients with inactive disease has increased over the past decade. Possible explanations may include improved access to specialized care, additional treatment options, and earlier or faster step-up treatment. However, challenges in the management of systemic JIA remain, as ∼30% of patients continue to present with ongoing active disease.
Collapse
Affiliation(s)
- Jens Klotsche
- German Rheumatism Research Centre Berlin and Charité University Hospital Berlin, Berlin, Germany
| | - Anna Raab
- German Rheumatism Research Centre Berlin and Charité University Hospital Berlin, Berlin, Germany
| | | | | | - Gerd Ganser
- St. Josef-Stift Sendenhorst Hospital, Sendenhorst, Germany
| | | | | | | | | | - Toni Hospach
- Olgahospital, Clinical Center Stuttgart, Stuttgart, Germany
| | - Gerd Horneff
- Asklepios Clinic Sankt Augustin, St. Augustin, Germany
| | - Kirsten Minden
- German Rheumatism Research Centre Berlin and Charité University Hospital Berlin, Berlin, Germany
| |
Collapse
|
15
|
Chantarogh S, Vilaiyuk S, Tim-Aroon T, Worawichawong S. Clinical improvement of renal amyloidosis in a patient with systemic-onset juvenile idiopathic arthritis who received tocilizumab treatment: a case report and literature review. BMC Nephrol 2017; 18:159. [PMID: 28499374 PMCID: PMC5429510 DOI: 10.1186/s12882-017-0573-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 05/05/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Juvenile idiopathic arthritis (JIA) is a common rheumatic disease in children and adolescents. Although JIA may cause secondary amyloidosis, this is a rare complication in patients with JIA and other rheumatic diseases. Many previous studies have revealed that common heterozygous or homozygous mutations in the MEFV gene are associated with systemic-onset JIA (SJIA). CASE PRESENTATION We herein report a case involving a 19-year-old female patient with difficult-to-control SJIA. She developed progressive proteinuria without clinical signs or symptoms of edema. Renal amyloidosis was diagnosed by renal pathologic examination, which demonstrated deposition of eosinophilic amorphous material in the interlobular arteries, arterioles, and interstitium. Electron microscopy showed fibrillary material deposits with a diameter of 8 to 10 nm. A heterozygous E148Q mutation in the MEFV gene was identified. Conventional disease-modifying anti-rheumatic drugs and etanercept had been used to treat the SJIA, but the disease could not be controlled. Therefore, we decided to start tocilizumab to control the disease activity. However, the patient was unable to receive a standard dose of tocilizumab in the early period of treatment because of socioeconomic limitations. Her disease course was still active, and proteinuria was found. Therefore, tocilizumab was increased to a dose of 8 mg/kg every 2 weeks (standard dose of SJIA), and the patient exhibited a clinical response within 3 months. CONCLUSION Refractory SJIA associated with renal amyloidosis is an uncommon cause of proteinuria in adolescents. Tocilizumab may be a beneficial treatment for renal amyloidosis in patients with SJIA.
Collapse
Affiliation(s)
- Songkiat Chantarogh
- Division of Nephrology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Postal address: 270, Rama 6 Road, Phayathai, Ratchathewi, Bangkok, 10400, Thailand.
| | - Soamarat Vilaiyuk
- Division of Rheumatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Postal address: 270, Rama 6 Road, Phayathai, Ratchathewi, Bangkok, 10400, Thailand
| | - Thipwimol Tim-Aroon
- Division of Medical Genetics, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Postal address: 270, Rama 6 Road, Phayathai, Ratchathewi, Bangkok, 10400, Thailand
| | - Suchin Worawichawong
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Postal address: 270, Rama 6 Road, Phayathai, Ratchathewi, Bangkok, 10400, Thailand
| |
Collapse
|
16
|
Abstract
Systemic juvenile idiopathic arthritis (sJIA) is characterized by fever, arthritis, and other signs of systemic inflammation. Historically, sJIA was named Still's disease after George Frederic Still, who first reported patients. Individuals who manifest after the 16th birthday are diagnosed with adult onset Still's disease (AOSD). The pathophysiology of sJIA and AOSD are incompletely understood. Increased activation of inflammasomes and the expression of proinflammatory cytokines play a central role. S100 proteins, which can activate Toll-like receptors, thus, maintaining positive feedback loops, have also been detected at increased levels in sera from sJIA patients. Reduced expression of the immune-modulatory cytokine IL-10 may further contribute to immune cell activation and the production of proinflammatory molecules. Here, we discuss the clinical picture, differential diagnoses, the current pathophysiological understanding, and treatment options in sJIA and AOSD.
Collapse
Affiliation(s)
- C M Hedrich
- Arbeitsbereich Pädiatrische Rheumatologie und Immunologie, Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - C Günther
- Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Deutschland
| | - M Aringer
- Bereich Rheumatologie, Medizinische Klinik und Poliklinik III, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Deutschland
| |
Collapse
|
17
|
Davies R, Gaynor D, Hyrich KL, Pain CE. Efficacy of biologic therapy across individual juvenile idiopathic arthritis subtypes: A systematic review. Semin Arthritis Rheum 2017; 46:584-593. [DOI: 10.1016/j.semarthrit.2016.10.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 10/21/2016] [Accepted: 10/28/2016] [Indexed: 01/26/2023]
|
18
|
Blazina Š, Markelj G, Avramovič MZ, Toplak N, Avčin T. Management of Juvenile Idiopathic Arthritis: A Clinical Guide. Paediatr Drugs 2016; 18:397-412. [PMID: 27484749 DOI: 10.1007/s40272-016-0186-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease of childhood. The outcome in patients with JIA has markedly improved with the advent of biologic drugs. Although early aggressive therapy with biologics seems to be very effective, this approach leads to overtreatment in patients who would respond to classic disease-modifying anti-rheumatic drugs. Therefore, methotrexate remains first-line long-term therapy for most children with polyarticular JIA. Tumor necrosis factor-α inhibitors have shown tremendous benefit in children with refractory non-systemic JIA. Similar effects have been observed with interleukin-1 and interleukin-6 blockade in patients with systemic JIA. Correct choice and timely use of available medications to achieve early and sustained remission with as few side effects as possible remain challenges for the treating physician. In this review, a practical, clinically oriented guide to the management of JIA is provided, focusing on pharmacological treatment with non-steroidal anti-inflammatory drugs, intra-articular and systemic corticosteroids, disease-modifying anti-rheumatic drugs, and biologic agents. In addition, issues regarding treatment failure, early aggressive treatment, and drug tapering are discussed, with alternative treatment options being suggested.
Collapse
Affiliation(s)
- Štefan Blazina
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Center Ljubljana, Bohoričeva 20, 1525, Ljubljana, Slovenia
| | - Gašper Markelj
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Center Ljubljana, Bohoričeva 20, 1525, Ljubljana, Slovenia
| | - Mojca Zajc Avramovič
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Center Ljubljana, Bohoričeva 20, 1525, Ljubljana, Slovenia
| | - Nataša Toplak
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Center Ljubljana, Bohoričeva 20, 1525, Ljubljana, Slovenia.,Department of Pediatrics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tadej Avčin
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Center Ljubljana, Bohoričeva 20, 1525, Ljubljana, Slovenia. .,Department of Pediatrics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
| |
Collapse
|
19
|
Shenoi S, Wallace CA. Diagnosis and Treatment of Systemic Juvenile Idiopathic Arthritis. J Pediatr 2016; 177:19-26. [PMID: 27499217 DOI: 10.1016/j.jpeds.2016.06.056] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 06/03/2016] [Accepted: 06/16/2016] [Indexed: 12/23/2022]
Affiliation(s)
- Susan Shenoi
- Department of Pediatrics, Division of Rheumatology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Carol A Wallace
- Department of Pediatrics, Division of Rheumatology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| |
Collapse
|
20
|
Orrock JE, Ilowite NT. Canakinumab for the treatment of active systemic juvenile idiopathic arthritis. Expert Rev Clin Pharmacol 2016; 9:1015-24. [DOI: 10.1080/17512433.2016.1204910] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
21
|
Janow G, Schanberg LE, Setoguchi S, Hasselblad V, Mellins ED, Schneider R, Kimura Y. The Systemic Juvenile Idiopathic Arthritis Cohort of the Childhood Arthritis and Rheumatology Research Alliance Registry: 2010–2013. J Rheumatol 2016; 43:1755-62. [DOI: 10.3899/jrheum.150997] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2016] [Indexed: 12/20/2022]
Abstract
Objective.We aimed to identify the (1) demographic/clinical characteristics, (2) medication usage trends, (3) variables associated with worse disease activity, and (4) characteristics of patients with persistent chronic arthritis in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Legacy Registry’s systemic juvenile idiopathic arthritis (sJIA) cohort.Methods.Demographics, disease activity measures, and medications at enrollment of patients with sJIA in the CARRA Registry were analyzed using descriptive statistics. Multivariate analyses were conducted to identify associations with increased disease activity. Medication usage frequencies were calculated by year.Results.There were 528 patients with sJIA enrolled in the registry (2010–2013). There were 435 patients who had a complete dataset; of these, 372 met the International League of Associations for Rheumatology criteria and were included in the analysis. At enrollment, median disease duration and joint count were 3.7 years and 0, respectively; 16.4% had a rash and 6.7% had a fever. Twenty-six percent were taking interleukin 1 (IL-1) inhibitors and 29% glucocorticoids. Disease-modifying antirheumatic drugs and tumor necrosis factor inhibitors use decreased, while IL-6 inhibitor use increased between 2010 and 2013. African American patients had worse joint counts (p = 0.003), functional status (p = 0.01), and physician’s global assessment (p = 0.008). Of the 255 subjects with > 2 years of disease duration, 56% had no arthritis or systemic symptoms, while 32% had persistent arthritis only.Conclusion.Most patients in the largest sJIA cohort reported to date had low disease activity. Practice patterns for choice of biologic agents appeared to change over the study period. Nearly one-third had persistent arthritis without systemic symptoms > 2 years after onset. African Americans were associated with worse disease activity. Strategies are needed to improve outcomes in subgroups with poor prognosis.
Collapse
|
22
|
Batu ED. Biologic therapies in systemic juvenile idiopathic arthritis. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1177511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Ezgi Deniz Batu
- Department of Pediatrics, Division of Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| |
Collapse
|
23
|
Kumar S. Systemic Juvenile Idiopathic Arthritis: Diagnosis and Management. Indian J Pediatr 2016; 83:322-7. [PMID: 26916892 DOI: 10.1007/s12098-016-2060-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 02/02/2016] [Indexed: 01/24/2023]
Abstract
Systemic juvenile idiopathic arthritis (sJIA) is an inflammatory condition characterized by fever, lymphadenopathy, arthritis, rash and serositis. In sJIA, systemic inflammation has been associated with dysregulation of the innate immune system, suggesting that it is an autoinflammatory disorder. IL-1 and IL-6 play a major role in the pathogenesis of sJIA and treatment with IL-1 and IL-6 inhibitors has shown to be highly effective. Recent data suggests that early cytokine blockage might abrogate chronic, destructive, therapy resistant arthritis phase, reflecting a potential "window of opportunity" in the care of children with sJIA.
Collapse
Affiliation(s)
- Sathish Kumar
- Department of Pediatrics, Christian Medical College, Vellore, Tamil Nadu, 632004, India.
| |
Collapse
|
24
|
Current understanding of the pathophysiology of systemic juvenile idiopathic arthritis (sJIA) and target-directed therapeutic approaches. Clin Immunol 2015; 159:72-83. [DOI: 10.1016/j.clim.2015.04.018] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 04/16/2015] [Accepted: 04/19/2015] [Indexed: 01/21/2023]
|
25
|
Woerner A, von Scheven-Gête A, Cimaz R, Hofer M. Complications of systemic juvenile idiopathic arthritis: risk factors and management recommendations. Expert Rev Clin Immunol 2015; 11:575-88. [PMID: 25843554 DOI: 10.1586/1744666x.2015.1032257] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Systemic juvenile idiopathic arthritis (SJIA) is an inflammatory condition characterized by fever, lymphadenopathy, arthritis, rash and serositis. Systemic inflammation has been associated with dysregulation of the innate immune system, suggesting that SJIA is an autoinflammatory disorder. IL-1 and IL-6 play a major role in the pathogenesis of SJIA, and treatment with IL-1 and IL-6 inhibitors has shown to be highly effective. However, complications of SJIA, including macrophage activation syndrome, limitations in functional outcome by arthritis and long-term damage from chronic inflammation, continue to be a major issue in SJIA patients' care. Translational research leading to a profound understanding of the cytokine crosstalk in SJIA and the identification of risk factors for SJIA complications will help to improve long-term outcome.
Collapse
Affiliation(s)
- Andreas Woerner
- Pediatric Rheumatology, University of Basel, University Children's Hospital, Basel, Switzerland
| | | | | | | |
Collapse
|
26
|
Windschall D, Müller T, Becker I, Horneff G. Safety and efficacy of etanercept in children with juvenile idiopathic arthritis below the age of 2 years. Rheumatol Int 2014; 35:613-8. [PMID: 25208527 DOI: 10.1007/s00296-014-3125-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 08/29/2014] [Indexed: 12/19/2022]
Abstract
Etanercept is approved for the treatment of patients with juvenile idiopathic arthritis (JIA) above the age of 2 years. Experience with younger children is limited. The aim of the present study was to evaluate the efficacy and safety of treatment with etanercept in children with JIA younger than 2 years. The prospective long-term observational BIKER registry documents baseline demographics, clinical characteristics, disease activity parameters and safety issues. Efficacy was determined using the PedACR response criteria, the JADAS-10 and the proposed criteria for inactive disease and remission after 3, 6, 12, 18 and 24 months. Safety assessments were based on adverse events (AE) and serious adverse events (SAEs) reports. Between January 2001 and June 2013, a total of 13 patients including four patients with systemic JIA (sJIA), four patients with extended oligoarthritis, one patient with persistent oligoarthritis and four patients with RF negative polyarthritis were treated with etanercept. Eleven patients with follow-up assessments were analysed in our study. Prior to etanercept, all patients have been exposed to methotrexate. At last observation, 6/11 patients reached a PedACR 70 response. Two patients with sJIA and 1 with nonsystemic JIA achieved inactive disease. Tolerability was good in most of the patients. Eight AE and one SAE occurred. One patient with sJIA was affected by Hodgkin's disease 18 months after discontinuation of etanercept. New onset uveitis occurred in two patients. Reasons for discontinuation were inefficacy in three (2 sJIA), intolerance in two, remission in three (2 sJIA) and the parents' request in one patient. Etanercept seems to improve JIA patients younger than 2 years including some of the patients with sJIA. Attention should be paid to the development of malignancies and autoimmune disorders.
Collapse
Affiliation(s)
- D Windschall
- Department of Pediatrics, Asklepios Hospital Weissenfels, Naumburgerstrasse 76, 06667, Weissenfels, Germany,
| | | | | | | |
Collapse
|
27
|
Beukelman T. Treatment advances in systemic juvenile idiopathic arthritis. F1000PRIME REPORTS 2014; 6:21. [PMID: 24765526 PMCID: PMC3974570 DOI: 10.12703/p6-21] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Systemic juvenile idiopathic arthritis (JIA) is an autoinflammatory condition that is distinct from other forms of childhood arthritis. Recently, biologic agents that specifically inhibit the cytokines interleukin (IL)-1 and IL-6 have demonstrated remarkable clinical effectiveness and confirmed the importance of these cytokines in the disease process. Future studies are likely to optimize the care of children with systemic arthritis and further elucidate the disease pathogenesis.
Collapse
Affiliation(s)
- Timothy Beukelman
- The University of Alabama at Birmingham, Division of Pediatric Rheumatology 1600 7th Avenue South, CPP 210, Birmingham, AL, 35233-1711 USA
| |
Collapse
|
28
|
Guillaume-Czitrom S, Bachelez H, Berthelot JM, Bouhnik Y, Bruckert E, Claudepierre P, Constantin A, de Bandt M, Fautrel B, Gaudin P, Goëb V, Gossec L, Gottenberg JE, Goupille P, Hachulla E, Huet I, Jullien D, Launay O, Lemannf M, Lequerré T, Maillefert JF, Mariette X, Marolleau JP, Martinez V, Masson C, Morel J, Mouthon L, Pham T, Pol S, Puéchal X, Richette P, Saraux A, Schaeverbeke T, Sellam J, Blacher J, Soubrier M, Sudre A, Viguier M, Vittecoq O, Wendling D, Sibilia J. Biologic targeted therapies in pediatric rheumatology. Joint Bone Spine 2014; 81 Suppl 1:2-48. [DOI: 10.1016/s1297-319x(14)70020-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
29
|
Advances in the pathogenesis and treatment of systemic juvenile idiopathic arthritis. Pediatr Res 2014; 75:176-83. [PMID: 24213625 DOI: 10.1038/pr.2013.187] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 07/11/2013] [Indexed: 11/08/2022]
Abstract
Systemic juvenile idiopathic arthritis (s-JIA) is clinically distinct from other types of JIA. It is typified by extraarticular features such as quotidian fevers, rash, splenomegaly, lymphadenopathy, laboratory abnormalities (including leukocytosis, thrombocytosis, anemia, hyperferritinemia, and elevated inflammatory markers), and a close association with the macrophage activation syndrome. Recent investigations have highlighted dysregulation of the innate immune system as the critical pathogenic driver of s-JIA. Key innate immune mediators of s-JIA are the macrophage-derived cytokines interleukin-1 (IL-1) and IL-6. Increased understanding of the roles of IL-1 and IL-6 in the pathogenesis of s-JIA has led to major changes in therapeutic options. Until recently, the most commonly used medications included corticosteroids, methotrexate, and tumor necrosis factor (TNF) inhibitors, which are incompletely effective in most cases. Newer biologic agents targeting IL-1 and IL-6 have proven very effective in treating s-JIA and in minimizing corticosteroid exposure. Here we review recent advances in the understanding of the pathogenesis of s-JIA and the recent clinical trials that have revolutionized the care of children with s-JIA.
Collapse
|
30
|
Ringold S, Weiss PF, Beukelman T, DeWitt EM, Ilowite NT, Kimura Y, Laxer RM, Lovell DJ, Nigrovic PA, Robinson AB, Vehe RK. 2013 update of the 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: recommendations for the medical therapy of children with systemic juvenile idiopathic arthritis and tuberculosis screening among children receiving biologic medications. ARTHRITIS AND RHEUMATISM 2013; 65:2499-512. [PMID: 24092554 PMCID: PMC5408575 DOI: 10.1002/art.38092] [Citation(s) in RCA: 168] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 07/02/2013] [Indexed: 12/12/2022]
Abstract
Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are intended to provide guidance for particular patterns of practice and not to dictate the care of a particular patient. The ACR considers adherence to these guidelines and recommendations to be voluntary, with the ultimate determination regarding their application to be made by the physician in light of each patient's individual circumstances. Guidelines and recommendations are intended to promote beneficial or desirable outcomes but cannot guarantee any specific outcome. Guidelines and recommendations developed or endorsed by the ACR are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice. The American College of Rheumatology is an independent, professional, medical and scientific society which does not guarantee, warrant, or endorse any commercial product or service.
Collapse
Affiliation(s)
| | - Pamela F. Weiss
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | - Norman T. Ilowite
- Albert Einstein College of Medicine and Children's Hospital at Montefiore, Bronx, New York
| | - Yukiko Kimura
- Hackensack University Medical Center, Hackensack, New Jersey
| | | | | | | | | | | |
Collapse
|
31
|
Ringold S, Weiss PF, Beukelman T, DeWitt EM, Ilowite NT, Kimura Y, Laxer RM, Lovell DJ, Nigrovic PA, Robinson AB, Vehe RK. 2013 update of the 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: recommendations for the medical therapy of children with systemic juvenile idiopathic arthritis and tuberculosis screening among children receiving biologic medications. Arthritis Care Res (Hoboken) 2013; 65:1551-63. [PMID: 24078300 PMCID: PMC5408573 DOI: 10.1002/acr.22087] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 07/02/2013] [Indexed: 12/25/2022]
Abstract
Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are intended to provide guidance for particular patterns of practice and not to dictate the care of a particular patient. The ACR considers adherence to these guidelines and recommendations to be voluntary, with the ultimate determination regarding their application to be made by the physician in light of each patient's individual circumstances. Guidelines and recommendations are intended to promote beneficial or desirable outcomes but cannot guarantee any specific outcome. Guidelines and recommendations developed or endorsed by the ACR are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice. The American College of Rheumatology is an independent, professional, medical and scientific society which does not guarantee, warrant, or endorse any commercial product or service.
Collapse
Affiliation(s)
| | - Pamela F. Weiss
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | - Norman T. Ilowite
- Albert Einstein College of Medicine and Children's Hospital at Montefiore, Bronx, New York
| | - Yukiko Kimura
- Hackensack University Medical Center, Hackensack, New Jersey
| | | | | | | | | | | |
Collapse
|
32
|
Huppertz HL. Remission in der Kinderrheumatologie. Z Rheumatol 2013; 72:354-60. [DOI: 10.1007/s00393-012-1062-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
33
|
Trachana M, Pratsidou-Gertsi P, Badouraki M, Haidich AB, Pardalos G. Achievement of clinical remission in patients with juvenile idiopathic arthritis under a 2-10-year Etanercept exposure. Clin Rheumatol 2013; 32:1191-7. [PMID: 23604548 DOI: 10.1007/s10067-013-2261-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 03/15/2013] [Accepted: 04/06/2013] [Indexed: 10/26/2022]
Abstract
The objective of this retrospective study was to record the achievement of clinical remission (CR) in juvenile idiopathic arthritis patients under a 2-10 years' administration of Etanercept (ETN) and to detect any variables associated with CR. Patients previously resistant to conventional regimens were enrolled. The annual impact of ETN was assessed by: (a) the American College of Rheumatology pediatric criteria (ACRpedi), (b) the pre- and posttreatment disease activity score (juvenile arthritis disease activity score [JADAS71]), and (c) Wallace's criteria for CR. A total of 41 patients (F: 31) were registered. The median age and disease duration at baseline were 10.6 and 4.17 years, respectively, and their disease course was mainly polyarthritis (32/41). In respect to baseline, there was an impressive JADAS71 reduction posttreatment, most prominent after the first year. From year 1 to 5, more than 50 % of the patients achieved and retained CR and 66 % reached an ACRpedi 70, whereas after the 5th year, no patient was withdrawn due to an ACRpedi <30. JADAS71 at baseline was not associated with the subsequent CR achievement. However, JADAS71 1-year posttreatment had a significant association with the CR of the second posttreatment year, (p = 0.028, OR 0.79; 95 % CI 0.63-0.98) and a similar trend was observed for the following years. These findings emphasize the sustained impact of ETN in the achievement of CR. A low JADAS71 score 1-year posttreatment, may be associated with the maintenance of CR over the next treatment year.
Collapse
Affiliation(s)
- Maria Trachana
- Pediatric Immunology and Rheumatology Referral Center, 1st Department of Pediatrics, Aristotle University, Ippokration Hospital, Thessaloniki, Greece.
| | | | | | | | | |
Collapse
|
34
|
Russo RAG, Katsicas MM. Patients with very early-onset systemic juvenile idiopathic arthritis exhibit more inflammatory features and a worse outcome. J Rheumatol 2013; 40:329-34. [PMID: 23322471 DOI: 10.3899/jrheum.120386] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Systemic juvenile idiopathic arthritis (SJIA) frequently leads to disability and damage. Predictive factors for a poor outcome include persistent systemic features and younger age at onset. We describe and analyze disease features in patients with early-onset (EO) SJIA (disease onset before age 18 mo) and compare them to patients with later-onset (LO) disease. METHODS Clinical features at onset, activity measures (occurrence of macrophage activation syndrome, remission), and outcome measures for disability [Childhood Health Assessment Questionnaire (CHAQ) ≥ 0.5] and damage [radiographic joint destruction, Juvenile Arthritis Damage Index (JADI) score, growth retardation] observed during followup were analyzed retrospectively in patients with SJIA followed for ≥ 3 years since disease onset. RESULTS In total 132 patients were included. SJIA started at age ≤ 18 months in 19 (14%) patients and at a later age in 113 (86%) children. At onset, serositis (p < 0.01) and hepatomegaly (p < 0.05) were more frequent in EO patients, who also exhibited lower hemoglobin levels (p < 0.03) and higher platelet counts (p < 0.03) than patients with LO. Macrophage activation syndrome occurred in 20 patients (11 EO and 9 LO; p < 0.0001). Remission was achieved by 49 patients (37%; 4 EO and 45 LO). At last visit, destructive hip disease (p < 0.04), growth retardation (p < 0.01), radiographic damage (p < 0.02), and disability (p < 0.04) were more frequent in patients with EO disease, who had higher JADI scores (p < 0.003). CONCLUSION Patients with EO exhibited a more aggressive and destructive disease course than patients with LO SJIA.
Collapse
Affiliation(s)
- Ricardo A G Russo
- Service of Immunology and Rheumatology, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina.
| | | |
Collapse
|
35
|
Correlation analyses of clinical and molecular findings identify candidate biological pathways in systemic juvenile idiopathic arthritis. BMC Med 2012; 10:125. [PMID: 23092393 PMCID: PMC3523070 DOI: 10.1186/1741-7015-10-125] [Citation(s) in RCA: 9] [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: 05/02/2012] [Accepted: 10/23/2012] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Clinicians have long appreciated the distinct phenotype of systemic juvenile idiopathic arthritis (SJIA) compared to polyarticular juvenile idiopathic arthritis (POLY). We hypothesized that gene expression profiles of peripheral blood mononuclear cells (PBMC) from children with each disease would reveal distinct biological pathways when analyzed for significant associations with elevations in two markers of JIA activity, erythrocyte sedimentation rate (ESR) and number of affected joints (joint count, JC). METHODS PBMC RNA from SJIA and POLY patients was profiled by kinetic PCR to analyze expression of 181 genes, selected for relevance to immune response pathways. Pearson correlation and Student's t-test analyses were performed to identify transcripts significantly associated with clinical parameters (ESR and JC) in SJIA or POLY samples. These transcripts were used to find related biological pathways. RESULTS Combining Pearson and t-test analyses, we found 91 ESR-related and 92 JC-related genes in SJIA. For POLY, 20 ESR-related and 0 JC-related genes were found. Using Ingenuity Systems Pathways Analysis, we identified SJIA ESR-related and JC-related pathways. The two sets of pathways are strongly correlated. In contrast, there is a weaker correlation between SJIA and POLY ESR-related pathways. Notably, distinct biological processes were found to correlate with JC in samples from the earlier systemic plus arthritic phase (SAF) of SJIA compared to samples from the later arthritis-predominant phase (AF). Within the SJIA SAF group, IL-10 expression was related to JC, whereas lack of IL-4 appeared to characterize the chronic arthritis (AF) subgroup. CONCLUSIONS The strong correlation between pathways implicated in elevations of both ESR and JC in SJIA argues that the systemic and arthritic components of the disease are related mechanistically. Inflammatory pathways in SJIA are distinct from those in POLY course JIA, consistent with differences in clinically appreciated target organs. The limited number of ESR-related SJIA genes that also are associated with elevations of ESR in POLY implies that the SJIA associations are specific for SJIA, at least to some degree. The distinct pathways associated with arthritis in early and late SJIA raise the possibility that different immunobiology underlies arthritis over the course of SJIA.
Collapse
|
36
|
Abstract
Early juvenile idiopathic arthritis (JIA) is important to recognize as timely diagnosis and treatment improves prognosis. It is a misconception that complications of JIA arise only from long-standing disease and that children will outgrow it. Early aggressive treatment is the paradigm as early disease activity has long-term consequences. There are predictors of persistent disease and joint erosions that may identify patients at higher risk. Control of disease activity within the first 6 months of onset confers improved clinical course and outcomes. The treatment perspective is thus one of early aggressive treatment for induction of disease control and ultimately remission.
Collapse
|
37
|
Bracaglia C, Buonuomo PS, Tozzi AE, Pardeo M, Nicolai R, Campana A, Insalaco A, Cortis E, DE Benedetti F. Safety and efficacy of etanercept in a cohort of patients with juvenile idiopathic arthritis under 4 years of age. J Rheumatol 2012; 39:1287-1290. [PMID: 22589254 DOI: 10.3899/jrheum.111555] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To evaluate safety, tolerability, and efficacy of etanercept in a cohort of patients with juvenile idiopathic arthritis (JIA) under 4 years of age. METHODS Data were collected at every visit during treatment with etanercept in 25 children who began treatment at a mean age of 3 years (range 18-48 months). Safety endpoints included the incidence of any adverse events. Efficacy endpoints included the American College of Rheumatology (ACR) Pediatric 30, 50, and 70 criteria for improvement. RESULTS Data from 25 patients with JIA treated with etanercept for a mean period of 23 months were analyzed. All patients received concomitant medications: 24 methotrexate, 3 cyclosporin A, and 10 corticosteroids. After the first 6 months of treatment, 15 (71.4%) patients achieved an ACR Pedi30 response and at the last observation 20 (80%) achieved ACR Pedi30. ACR Pedi50 and 70 responses were, respectively, 62% and 43% at 6 months and 72% and 64% at the last followup. Five patients (20%) discontinued etanercept for lack of efficacy. Two (8%) developed adverse events, both primary varicella zoster virus (VZV) infections (both not vaccinated). One was hospitalized because of a necrotizing fasciitis secondary to VZV infection. No cases of tuberculosis, opportunistic infections, or malignancies were reported. CONCLUSION In our cohort of patients etanercept proved to be safe and efficacious in the majority of children. The response in toddlers was similar to that in older children. We observed only 1 case of severe infection that required hospitalization and stopped treatment temporarily.
Collapse
Affiliation(s)
- Claudia Bracaglia
- Division of Rheumatology, Department of Pediatric Medicine, Ospedale Pediatrico Bambino GesùIRCCS, Rome, Italy.
| | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Gurion R, Lehman TJA, Moorthy LN. Systemic arthritis in children: a review of clinical presentation and treatment. Int J Inflam 2011; 2012:271569. [PMID: 22235382 PMCID: PMC3253447 DOI: 10.1155/2012/271569] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2011] [Accepted: 09/06/2011] [Indexed: 12/14/2022] Open
Abstract
Systemic juvenile idiopathic arthritis (sJIA) constitutes a small part of juvenile idiopathic arthritis (JIA), yet has a disproportionally higher rate of mortality. Despite being grouped under JIA, it is considered to be a multifactorial autoinflammatory disease. The objective of this paper is to review the epidemiology, pathogenesis, genetics, clinical manifestations, complications, therapy, prognosis, and outcome of sJIA. The presentation and clinical manifestations of sJIA have not changed much in the past several decades, but the collective understanding of the pathogenesis and the development of new targeted therapies (particularly the biologic agents) have transformed and improved the disease outcome for children with sJIA.
Collapse
Affiliation(s)
- R. Gurion
- Division of Pediatric Rheumatology, Rainbow Babies & Children's Hospital, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - T. J. A. Lehman
- Division of Pediatric Rheumatology, Hospital for Special Surgery and Clinical Pediatrics Weill Medical Center, Cornell University, 535 E 70 St, New York, NY 10021, USA
| | - L. N. Moorthy
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Medicine and Dentistry of NJ-Robert Wood Johnson Medical School, 89 French Street, New Brunswick, NJ 08901, USA
| |
Collapse
|
39
|
Pham T, Bachelez H, Berthelot JM, Blacher J, Bouhnik Y, Claudepierre P, Constantin A, Fautrel B, Gaudin P, Goëb V, Gossec L, Goupille P, Guillaume-Czitrom S, Hachulla E, Huet I, Jullien D, Launay O, Lemann M, Maillefert JF, Marolleau JP, Martinez V, Masson C, Morel J, Mouthon L, Pol S, Puéchal X, Richette P, Saraux A, Schaeverbeke T, Soubrier M, Sudre A, Tran TA, Viguier M, Vittecoq O, Wendling D, Mariette X, Sibilia J. TNF alpha antagonist therapy and safety monitoring. Joint Bone Spine 2011; 78 Suppl 1:15-185. [PMID: 21703545 DOI: 10.1016/s1297-319x(11)70001-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To develop and/or update fact sheets about TNFα antagonists treatments, in order to assist physicians in the management of patients with inflammatory joint disease. METHODS 1. selection by a committee of rheumatology experts of the main topics of interest for which fact sheets were desirable; 2. identification and review of publications relevant to each topic; 3. development and/or update of fact sheets based on three levels of evidence: evidence-based medicine, official recommendations, and expert opinion. The experts were rheumatologists and invited specialists in other fields, and they had extensive experience with the management of chronic inflammatory diseases, such as rheumatoid. They were members of the CRI (Club Rhumatismes et Inflammation), a section of the Société Francaise de Rhumatologie. Each fact sheet was revised by several experts and the overall process was coordinated by three experts. RESULTS Several topics of major interest were selected: contraindications of TNFα antagonists treatments, the management of adverse effects and concomitant diseases that may develop during these therapies, and the management of everyday situations such as pregnancy, surgery, and immunizations. After a review of the literature and discussions among experts, a consensus was developed about the content of the fact sheets presented here. These fact sheets focus on several points: 1. in RA and SpA, initiation and monitoring of TNFα antagonists treatments, management of patients with specific past histories, and specific clinical situations such as pregnancy; 2. diseases other than RA, such as juvenile idiopathic arthritis; 3. models of letters for informing the rheumatologist and general practitioner; 4. and patient information. CONCLUSION These TNFα antagonists treatments fact sheets built on evidence-based medicine and expert opinion will serve as a practical tool for assisting physicians who manage patients on these therapies. They will be available continuously at www.cri-net.com and updated at appropriate intervals.
Collapse
Affiliation(s)
- Thao Pham
- Rheumatology Department, CHU Sainte-Marguerite, Marseille, France.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Baszis K, Garbutt J, Toib D, Mao J, King A, White A, French A. Clinical outcomes after withdrawal of anti-tumor necrosis factor α therapy in patients with juvenile idiopathic arthritis: A twelve-year experience. ACTA ACUST UNITED AC 2011; 63:3163-8. [DOI: 10.1002/art.30502] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
41
|
Is anti-TNF switching in refractory Still’s disease safe and effective? Clin Rheumatol 2011; 30:1129-34. [DOI: 10.1007/s10067-011-1735-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 01/07/2011] [Accepted: 03/07/2011] [Indexed: 10/18/2022]
|
42
|
Beukelman T, Patkar NM, Saag KG, Tolleson-Rinehart S, Cron RQ, DeWitt EM, Ilowite NT, Kimura Y, Laxer RM, Lovell DJ, Martini A, Rabinovich CE, Ruperto N. 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: initiation and safety monitoring of therapeutic agents for the treatment of arthritis and systemic features. Arthritis Care Res (Hoboken) 2011; 63:465-82. [PMID: 21452260 PMCID: PMC3222233 DOI: 10.1002/acr.20460] [Citation(s) in RCA: 525] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are intended to provide guidance for particular patterns of practice and not to dictate the care of a particular patient. The ACR considers adherence to these guidelines and recommendations to be voluntary, with the ultimate determination regarding their application to be made by the physician in light of each patient’s individual circumstances. Guidelines and recommendations are intended to promote beneficial or desirable outcomes but cannot guarantee any specific outcome. Guidelines and recommendations developed or endorsed by the ACR are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice.
Collapse
Affiliation(s)
- Timothy Beukelman
- University of Alabama at Birmingham, Birmingham, AL 35233-1711, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Nigrovic PA, Mannion M, Prince FHM, Zeft A, Rabinovich CE, van Rossum MAJ, Cortis E, Pardeo M, Miettunen PM, Janow G, Birmingham J, Eggebeen A, Janssen E, Shulman AI, Son MB, Hong S, Jones K, Ilowite NT, Cron RQ, Higgins GC. Anakinra as first-line disease-modifying therapy in systemic juvenile idiopathic arthritis: report of forty-six patients from an international multicenter series. ACTA ACUST UNITED AC 2011; 63:545-55. [PMID: 21280009 DOI: 10.1002/art.30128] [Citation(s) in RCA: 323] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To examine the safety and efficacy of the interleukin-1 (IL-1) receptor antagonist anakinra as first-line therapy for systemic juvenile idiopathic arthritis (JIA). METHODS Patients with systemic JIA receiving anakinra as part of initial disease-modifying antirheumatic drug (DMARD) therapy were identified from 11 centers in 4 countries. Medical records were abstracted using a standardized instrument, and resulting data were analyzed to characterize concomitant therapies, clinical course, adverse events, and predictors of outcome. RESULTS Among 46 patients meeting inclusion criteria, anakinra monotherapy was used in 10 patients (22%), while 67% received corticosteroids and 33% received additional DMARDs. Outcomes were evaluated at a median followup interval of 14.5 months. Fever and rash resolved within 1 month in >95% of patients, while C-reactive protein and ferritin normalized within this interval in >80% of patients. Active arthritis persisted at 1 month in 39% of patients, at 3 months in 27%, and at >6 months of followup in 11%. Approximately 60% of patients, including 8 of 10 receiving anakinra monotherapy, attained a complete response without escalation of therapy. Disease characteristics and treatment were similar in partial and complete responders, except that partial responders were markedly younger at onset (median age 5.2 years versus 10.2 years; P = 0.004). Associated adverse events included documented bacterial infection in 2 patients and hepatitis in 1 patient. Tachyphylaxis was not observed. CONCLUSION Anakinra as first-line therapy for systemic JIA was associated with rapid resolution of systemic symptoms and prevention of refractory arthritis in almost 90% of patients during the interval examined. These results justify further study of IL-1 inhibition as first-line, rather than rescue, therapy in systemic JIA.
Collapse
Affiliation(s)
- Peter A Nigrovic
- Children's Hospital Boston and Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Papsdorf V, Horneff G. Complete control of disease activity and remission induced by treatment with etanercept in juvenile idiopathic arthritis. Rheumatology (Oxford) 2010; 50:214-21. [DOI: 10.1093/rheumatology/keq292] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
45
|
Trachana M, Pratsidou-Gertsi P, Pardalos G, Kozeis N, Badouraki M, Kanakoudi-Tsakalidou F. Safety and efficacy of adalimumab treatment in Greek children with juvenile idiopathic arthritis. Scand J Rheumatol 2010; 40:101-7. [PMID: 21108543 DOI: 10.3109/03009742.2010.517546] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To evaluate the safety and efficacy of adalimumab (AD) administration in patients with juvenile idiopathic arthritis (JIA). METHODS Twenty-six patients were enrolled from January 2004 to January 2008 in this prospective observational study. Inclusion criteria were either unresponsiveness to disease-modifying anti-rheumatic drugs (DMARDs; n = 17) or to other anti-tumour necrosis factor (anti-TNF) agents (n = 9) or development of uveitis under other anti-TNFs (n = 2 of the 9). Efficacy was estimated using the American College of Rheumatology Pediatric (ACR Pedi) criteria. RESULTS After 1-5 years of AD exposure, nine different adverse events (AEs) were recorded (12.6 AEs/100 patient-years), mainly mild respiratory tract infections and injection site-related reactions. Serious AEs (SAEs, 2.8/100 patient-years) were the development of abscess at the site of injection (n = 1) and lethal sepsis (n = 1). The ACR Pedi ≥ 30 responses for the first to the fifth year of treatment were 88.5, 57.7, 50.0, 34.6, and 11.5%, respectively. In total, 17 of the 26 (65.4%) patients responded to AD. Five of the 11 patients under steroids discontinued them 6 months post-treatment. Seven patients required weekly AD treatment to maintain remission and four of them benefited from this policy. Recurrent uveitis was hindered in three of the six patients, no new cases were recorded, and radiological regression was observed in two of the four patients with lesions. CONCLUSIONS AD was safe and efficacious during the study period in the majority of patients. However, vigilance is required for the early detection of severe and potentially fatal infections. AD may control recurrent uveitis and radiological progression.
Collapse
Affiliation(s)
- M Trachana
- 1st Department of Pediatrics, Pediatric Immunology and Rheumatology Referral Center, Thessaloniki, Greece.
| | | | | | | | | | | |
Collapse
|
46
|
Swart JF, Barug D, Möhlmann M, Wulffraat NM. The efficacy and safety of interleukin-1-receptor antagonist anakinra in the treatment of systemic juvenile idiopathic arthritis. Expert Opin Biol Ther 2010; 10:1743-52. [PMID: 20979564 DOI: 10.1517/14712598.2010.532785] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD Systemic juvenile idiopathic arthritis (sJIA) is a debilitating childhood disease presenting with fever, rash and arthritis. Current therapy consisting mainly of corticosteroids, NSAIDs and methotrexate, can be inefficient and is often accompanied by many serious adverse events. Although an IL-1 receptor antagonist (anakinra) seems to be very efficient in case series, it is not registered for use in sJIA. Pediatric rheumatologists all over the world are having a hard time to convince insurance companies to approve off-label use of this drug for their sJIA patients. AREAS COVERED IN THIS REVIEW Using the MeSH terms 'Arthritis Juvenile Rheumatoid' and 'Interleukin 1 Receptor Antagonist Protein', we searched MEDLINE, EMBASE and reference lists of selected articles. This review is largely based on manuscripts from 2005 to 2010 and abstracts presented at the major (pediatric) rheumatology congresses. WHAT THE READER WILL GAIN This review summarizes the data of 140 children with sJIA treated with anakinra and enables an understanding in the benefit-risk profile of anakinra in sJIA patients. TAKE HOME MESSAGE Anakinra has shown to be a very efficient and quick acting medicine in reducing symptoms even in therapy-resistant sJIA patients with typically poor outcomes.
Collapse
Affiliation(s)
- Joost Frans Swart
- VU University Medical Center, Department of Pediatric Infectious diseases, Immunology and Rheumatology, Amsterdam, The Netherlands.
| | | | | | | |
Collapse
|
47
|
Sawhney S, Agarwal M. Outcome measures in pediatric rheumatology. Indian J Pediatr 2010; 77:1183-9. [PMID: 20938818 DOI: 10.1007/s12098-010-0208-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Accepted: 07/14/2010] [Indexed: 11/30/2022]
Abstract
Children with rheumatologic disorders need periodic systematic evaluation of their disease status so that all aspects of the child's life that are affected can be adequately assessed. The commonest rheumatologic disease that afflicts children is Juvenile Idiopathic Arthritis (JIA). The child with JIA should have several domains assessed at regular intervals. These outcome measures include the physical, functional and the quality of life assessment measures. No single measure can capture the full impact of the disease on the child's life. This article highlights the key outcome measures in a child with JIA and introduces the readers to several disease measurement tools that have been developed for assessment of outcome for the child with JIA.
Collapse
Affiliation(s)
- Sujata Sawhney
- Pediatric Rheumatology Unit, Centre for Child Health, Sir Ganga Ram Hospital, New Delhi, India.
| | | |
Collapse
|
48
|
Bazsó A, Sevcic K, Orbán I, Poór G, Balogh Z, Kiss E. Overlapping juvenile idiopathic arthritis and systemic lupus erythematosus: a case report. Rheumatol Int 2010; 31:695-8. [PMID: 20676642 DOI: 10.1007/s00296-010-1594-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2010] [Accepted: 07/14/2010] [Indexed: 11/26/2022]
Abstract
Hereby, we report the case of a 12-year-old girl developing oligoarthritis and progressing into a polyarticular form. Rheumatoid factor was positive, and juvenile idiopathic arthritis (JIA) was diagnosed. After a poor response to DMARDs, an anti-TNF agent (infliximab) was initiated, but to be discontinued due to an allergic reaction. The same complication was observed with the fully human derivative, adalimumab. At the age of 22, the patient presented septicemia with severe anemia and subsequent development of leukopenia, myocarditis with heart failure, and ANA, aSm, aSS-A, aCL positives, and nephrotic syndrome. These new clinical manifestations fulfilled the classification criteria for the diagnosis of systemic lupus erythematosus. Due to the poor therapeutic responses for both diseases, alternative medical options have to be considered, such as targeted therapy with anti-CD20 or interleukin-6 receptor antagonist monoclonal antibodies. This patient may also be a candidate for autologous hemopoietic stem cell transplantation.
Collapse
Affiliation(s)
- Anna Bazsó
- National Institute of Rheumatology and Physiotherapy, Budapest, Hungary.
| | | | | | | | | | | |
Collapse
|
49
|
Abstract
Juvenile idiopathic arthritis (JIA) is the most common chronic inflammatory arthritic disease affecting children. Despite the availability of potent disease-modifying antirheumatic medications, most children still experience a chronic course with long periods of active disease. Goals of treatment should include achievement of disease remission with optimal physical functioning that allows children to lead normal lives with no structural joint damage. The term remission implies a complete lack of disease activity. This article focuses on recently developed preliminary criteria for inactive disease and remission in JIA. Recent studies using these new definitions demonstrate only modest rates of achievement of remission favoring children with persistent oligoarticular JIA. Children with rheumatoid factor-positive polyarticular JIA are least likely to achieve remission. Therapeutic strategies to achieve remission are also discussed.
Collapse
Affiliation(s)
- Susan Shenoi
- Division of Pediatric Rheumatology, University of Washington School of Medicine and Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | | |
Collapse
|
50
|
Current World Literature. Curr Opin Rheumatol 2010; 22:229-34. [DOI: 10.1097/bor.0b013e32833755c4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|