Update of the evidence based, interdisciplinary guideline for anti-inflammatory treatment of uveitis associated with juvenile idiopathic arthritis

BACKGROUND

Uveitis in juvenile idiopathic arthritis (JIAU) is frequently associated with the development of complications and visual loss. Topical corticosteroids are the first line therapy, and disease modifying anti-rheumatic drugs (DMARDs) are commonly used. However, treatment has not been standardized.

METHODS

Interdisciplinary guideline were developed with representatives from the German Ophthalmological Society, Society for Paediatric Rheumatology, Professional Association of Ophthalmologists, German Society for Rheumatology, parents' group, moderated by the Association of the Scientific Medical Societies in Germany. A systematic literature analysis in MEDLINE was performed, evidence and recommendations were graded, an algorithm for anti-inflammatory treatment and final statements were discussed in a consensus meeting (Nominal Group Technique), a preliminary draft was fine-tuned and discussed thereafter by all participants (Delphi procedure).

RESULTS

Consensus was reached on recommendations, including a standardized treatment strategy according to uveitis severity in the individual patient. Thus, methotrexate shall be introduced for uveitis not responding to low-dose (≤ 2 applications/day) topical corticosteroids, and a TNFalpha antibody (preferably adalimumab) used, if uveitis inactivity is not achieved. In very severe active uveitis with uveitis-related deterioration of vision, systemic corticosteroids should be considered for bridging until DMARDs take effect. If TNFalpha antibodies fail to take effect or lose effect, another biological should be selected (tocilizumab, abatacept or rituximab). De-escalation of DMARDs should be preceded by a period of  ≥ 2 years of uveitis inactivity.

CONCLUSIONS

An interdisciplinary, evidence-based treatment guideline for JIAU is presented.

Zehn Jahre Erfahrung im deutschen JIA-Etanercept-Register

Hintergrund: Seit Einführung der TNF-Inhibitoren in die Therapie der juvenilen idiopathischen Arthritis (JIA) hat sich die Prognose für viele Patienten erheblich verbessert.

Ziele und Methoden: Daten des deutschen JIA-Etanercept-Registers wurden in Jahreskohorten von 2000–2010 bzgl. Patientencharakteristika, Vorbehandlung, Begleittherapie und Krankheitsaktivität analysiert. Die Wirksamkeit der Therapie wurde anhand der PedACR30/50/70-Kriterien und Kriterien für inaktive Erkrankung und Remission analysiert. Sicherheitsbewertungen erfolgten auf der Basis von Berichten über unerwünschte Ereignisse.

Ergebnisse: Von 2000 bis 2010 wurden 1335 mit Etanercept behandelte JIA-Patienten in das Register aufgenommen. Am häufigsten erhielten Patienten mit einer seronegativen Polyarthritis Etanercept. In den frühen Jahreskohorten lag der Anteil von Patienten mit einer systemischen JIA bei 26 %, zuletzt zwischen zwei und fünf Prozent. Demgegenüber stieg der Anteil von Patienten mit einer Enthesitis-assoziierten Arthritis von zwei Prozent auf 17 % an. Die initial aufgenommenen Patienten wurden zuvor mit zahlreichen Antirheumatika (Mittel 3,4) einschließlich Zytostatika vorbehandelt. Diese Anzahl reduzierte sich über die Jahre auf 1,3/Patient. In der initialen Patientenkohorte wurden Kortikosteroide bei 83 %, Methotrexat bei 95 % und andere DMARDs bei 45 % der Patienten begleitend eingesetzt. Diese Begleitmedikation verminderte sich bei der Patientenkohorte mit Behandlungsbeginn in 2010 auf 27 %, 67 % und zehn Prozent. Die mittlere Krankheitsdauer vor Behandlungsbeginn nahm von 6,1 Jahren (Median 4,5 Jahre) auf 3,4 Jahre (Median 1,9 Jahre) ab. Der Anteil der Patienten mit einem PedACR70-Score nach Abschluss der ersten zwölf Behandlungsmonate stieg von 57 % auf 74 % an. Eine inaktive Erkrankung innerhalb eines Jahres wurde bei 24 % der initialen Patientenkohorte dokumentiert, während sich diese Rate im Beobachtungsverlauf auf 54 % erhöhte. Die Gesamtzahl unerwünschter Ereignisse im ersten Jahr der Behandlung war konstant, während die Rate schwerwiegender unerwünschter Ereignisse von 0,13/Patient auf 0,02/Patient sank.

Fazit: Bei JIA-Patienten wird eine Therapie mit Etanercept zunehmend früher begonnen. Es erfolgen weniger Vorbehandlungen und es werden weniger Medikamente begleitend eingesetzt. Dabei zeigt sich eine verbesserte Verträglichkeit mit weniger ernsthaften Nebenwirkungen und eine höhere Effektivität.

[Intra-articular injection of cortisone]

Intra-articular injections with glucocorticoids are standard procedures according to therapy guidelines in many rheumatic conditions. There is increasing evidence from clinical trials on the treatment of rheumatoid arthritis that more patients will attain the target of remission using a combination of systemic medication and intra-articular injections with glucocorticoids compared to systemic medication alone. Intra-articular injections with glucocorticoids play an important role in the therapeutic management of pediatric rheumatic diseases. In many countries competency in performing intra-articular injections is among the important skills necessary for certification as a specialist in rheumatology.

Efficacy and safety of oral and parenteral methotrexate therapy in children with juvenile idiopathic arthritis: an observational study with patients from the German Methotrexate Registry

OBJECTIVE

The German Methotrexate Registry has been collecting data concerning the efficacy and safety of methotrexate (MTX) treatment since 2005. The aim of this retrospective analysis is to compare oral and parenteral MTX treatment regarding efficacy and safety.

METHODS

Inclusion criteria were diagnosis of juvenile idiopathic arthritis, MTX treatment for at least 6 months, a consistent route of administration of MTX, and no previous or concomitant treatment with biologic agents. Efficacy was measured by the American College of Rheumatology (ACR) pediatric (Pedi) criteria. Primary outcome was efficacy defined as the number of patients reaching ACR Pedi 30 improvement criteria after 6 months of treatment. Secondary outcome criteria were the ACR Pedi 50 and Pedi 70 criteria at 6 and 12 months, respectively. Analyses were performed with the intent-to-treat population.

RESULTS

Of the 411 eligible patients, 259 (63%) received oral MTX and 152 (37%) received subcutaneous MTX. In both patient groups, a comparable weekly dose of MTX (0.4 mg/kg versus 0.42 mg/kg) was used, and a comparable number of patients received concomitant steroids. The primary outcome in both treatment groups was that a comparably high number of patients showed a clinical response according to the ACR Pedi 30 score after 6 months of treatment (73% versus 72%; P = 0.87). Twenty-two percent of patients with oral therapy and 27% with subcutaneous therapy had at least 1 documented adverse event. Discontinuation of treatment was observed in both groups with equal frequency, while significantly more patients with subcutaneous application discontinued MTX because of adverse events (11% versus 5%; P = 0.02).

CONCLUSION

In this retrospective analysis, parenteral MTX was not superior to oral administration regarding efficacy and tolerability.

IL10 promoter polymorphisms are associated with systemic onset juvenile idiopathic arthritis (SoJIA)

OBJECTIVES

Juvenile idiopathic arthritis (JIA) is a rare, but severe cause of childhood disability. Systemic onset JIA (SoJIA) accounts for approximately 5.8% of all JIA cases and is associated with cytokine dysregulation, including interleukin (IL-)1, IL-6 and tumour necrosis factor (TNF-)α. IL-10 is an immuno-regulatory cytokine, which in part regulates inflammation by controlling inflammatory cytokine expression. Dysregulation in IL-10 expression and certain single nucleotide polymorphisms (SNPs) in the IL-10 promoter were shown to be associated with autoimmune and infectious diseases.

METHODS

Genomic DNA-samples from SoJIA patients from two German Paediatric Rheumatology centres, and healthy controls were analysed for three well defined IL-10 promoter SNPs (-1082G>A, -819C>T, and -592C>A). These SNPs are in tight linkage disequilibrium, and result in three predominant (or 'classical') haplotypes: ATA, ACC, and GCC. ATA and ACC are associated with low and medium, GCC is associated with high IL-10 expression.

RESULTS

Here, we show a strong association of IL-10 promoter polymorphisms with SoJIA. We demonstrate a significantly increased frequency of low IL-10 expressing -1082A/A alleles, the medium IL-10 expressing ACC haplotype (p=0.01), and an enrichment of the rare GTC haplotype (p<0.001) in patients with SoJIA. Heterozygous -1082G/A alleles (p<0.001), and the GCC haplotype (p<0.001) on one allele protect from developing SoJIA.

CONCLUSIONS

This suggests a central role of the immuno-regulatory cytokine IL-10 in the pathogenesis of SoJIA.

The economic burden of juvenile idiopathic arthritis-results from the German paediatric rheumatologic database

OBJECTIVE

To estimate the cost of juvenile idiopathic arthritis (JIA) and to evaluate the influence of specific disease characteristics on the various costs domains.

METHODS

Data on JIA outpatients (n=369) who were enrolled in the national paediatric rheumatologic database and completed a cost questionnaire were analysed. Direct JIA-related costs, families' out-of-pocket expenses and parents' income loss were calculated per patient and year, using physicians' reports, parents' 3-month recall, and average prices as the basis.

RESULTS

The mean total cost of JIA was estimated to be 4,663 euro per patient per year. The highest costs were calculated for patients with seropositive polyarthritis and systemic arthritis (7,876 euro), and the lowest costs were seen for patients with persistent oligoarthritis (2,904 euro). Health-care costs accounted for 89% of total costs, and medication contributed to almost half of this value. A considerable amount of the cost was borne by the families, with a mean out-of-pocket cost of 223euro and a mean indirect cost due to time loss from work of 270 euros per year per family. Cost increased with disease activity and pain, disease duration, and time period from symptom onset to first paediatric rheumatologist visit; it also increased with the presence of uveitis. However, function, as measured by the Childhood Health Assessment Questionnaire, was the only factor significantly contributing to the variation in patient total costs.

CONCLUSION

JIA imposes a significant economic burden. Medication (i.e. biologic drugs) contributes substantially to the total costs. However, these must be considered in the light of the patients' long-term outcomes.

Juvenile idiopathische Arthritis und Uveitis: Epidemiologie einschließlich der Daten aus der Kerndokumentation

Uveitis is a potentially vision-threatening extra-articular manifestation of juvenile idiopathic arthritis (JIA) that manifests in approximately 13 % of all patients. According to the national ophthalmological and paediatric rheumatological database, one out of four children with JIA and uveitis develops ocular complications such as synechiae, band keratopathy, cataract, glaucoma and macula oedema. Independent risk factors of uveitis include the presence of a certain JIA subgroup, of antinuclear antibodies and age at onset. A late diagnosis, however, seems to be the relevant risk factor for uveitis complications in the course of the disease. The diagnosis of uveitis as early as possible is therefore the most important factor for a reduction of the morbidity of uveitis. Due to the usual lack of symptoms the diagnosis of uveitis requires, however, an examination by an ophthalmologist. This should be done immediately after the diagnosis of JIA and repeated in a risk-adapted manner during the follow-up.

Andere entzündlich rheumatische Erkrankungen mit Uveitis neben der juvenilen idiopathischen Arthritis

In childhood and adolescence, uveitis is part of the clinical spectrum of many inflammatory-rheumatic diseases. Besides juvenile idiopathic arthritis juvenile, ankylosing spondylitis, infection-associated arthritides, infantile sarcoidosis, systemic vasculitides, inflammatory bowel diseases, hereditary autoinflammatory syndromes and the TINU syndrome have to be excluded. These inflammatory diseases can be differentiated clinically in connection with immunogenetic and molecular genetic investigations. Early diagnosis of uveitis as well as the underlying diseases is mandatory for an early treatment and therefore for a good prognosis.

[Structural quality of rheumatology clinics for children and adolescents. Paper by a task force of the "Society of Pediatric and Adolescent Rheumatology" and of the "Association of Rheumatology Clinics in Germany"]

Rheumatic diseases in childhood and adolescence differ from those of adulthood according to type, manifestation, treatment and course. A specialized therapy, starting as early as possible, improves the prognosis, can prevent long-term damage and saves the costs of long-term care. Only a specialized pediatric care system can guarantee optimum quality of the processes involved and the results for rheumatology in childhood and adolescence within a global financial system. This requires adequate structural quality of the specialized clinics and departments for pediatric rheumatology. The management of rheumatic diseases in childhood and adolescence is comprehensive and requires a multidisciplinary, specialized and engaged team which can cover the whole spectrum of rheumatic diseases with their various age-dependent aspects. In order to guarantee an adequate, cost-efficient routine, a specialized center which concentrates on inpatient care should treat at least 300 patients with pediatric rheumatic diseases per year. The diagnoses should be divided among the various disease categories with at least 70% of them involving inflammatory rheumatic diseases. For the inpatient care of small children, an accompanying person (parent) is necessary, requiring adequate structures and services. Patient rooms as well as diagnostic (radiography, sonography, etc.) and therapeutic services (physiotherapy, occupational therapy, pool, etc.) must be adequate for small children and school children as well as adolescents. Suitable mother-child units must also be provided and a school for patients is required within the clinic. A pediatric rheumatologist must be available 24 h a day, and it must be possible to reach other specialists within a short time. For painful therapeutic procedures, age-appropriate pain management is obligatory. A continuous adjustment of these recommendations to changing conditions in health politics is intended.

Prevalence and complications of uveitis in juvenile idiopathic arthritis in a population-based nation-wide study in Germany: suggested modification of the current screening guidelines

OBJECTIVES

To analyse the prevalence and complications of uveitis and their predictors in a large cohort of patients with juvenile idiopathic arthritis (JIA).

METHODS

Data of 3271 JIA patients as classified by International League of Associations for Rheumatology (ILAR) criteria included in a national database during 1 yr were analysed.

RESULTS

Uveitis prevalence was 12% of all JIA patients. The most frequent were oligoarthritis extended (25%) and persistent (16%). JIA patients with uveitis were significantly younger at onset of arthritis (3.8 vs 7.0 yrs) or ANA-positive (86% vs 42%) than the patients without uveitis. Predictors of uveitis included age at onset (P= 0.03) and ANA-positivity (P< 0.01) besides the presence of a certain JIA subgroup (P= 0.04). Uveitis was clinically silent in 75% of the oligoarthritis but in none of the enthesitis-related arthritis patients. The median onset of uveitis was 5.5 months after arthritis manifestation. In 73%, 77% and 90%, uveitis developed within 1, 2 and 4 yrs after arthritis, respectively. Anterior uveitis was the most common anatomic type of uveitis (83%). Uveitis complications at mean follow-up of 5.6 yrs were common (56%), and predictors for complications included presence of complications at first visit (P< 0.001) and uveitis manifestation before arthritis (P= 0.001), but not ANA positivity.

CONCLUSIONS

The JIA subgroups markedly differ with respect to the prevalence and course of associated uveitis. Ophthalmological screening should be initiated early after arthritis onset and the intervals be related to the JIA subgroup. A modification of the current screening guidelines is suggested.

[Epidemiology of uveitis in juvenile idiopathic arthritis from a national paediatric rheumatologic and ophthalmologic database]

BACKGROUND

Uveitis is a frequent and potentially vision-threatening manifestation of juvenile idiopathic arthritis (JIA). There are only a few population-based studies providing data on the frequency and severity of uveitis.

METHODS

Documentation of patients with JIA was collected in a national database. An analysis of the paediatric rheumatologic and ophthalmologic data collected from all patients that were included in 2002 was performed.

RESULTS

Uveitis was documented in 12 % of a total of 3271 JIA patients: extended oligoarthritis (25 %), persistent oligoarthritis (16 %), seronegative polyarthritis (4 %), seropositive polyarthritis (2 %), psoriatic arthritis (10 %), enthesitis-related arthritis (ERA) (7 %), systemic arthritis (1 %), other arthritis forms (11 %). Ophthalmologic data were available from 115 uveitis patients (28 %). Mean age at onset of uveitis was 5.2 (SD 3.2) years. JIA patients with uveitis were significantly younger at onset of arthritis (3.8 vs. 7.0 years), and were more often girls (74 vs. 63 %) or ANA-positive (86 vs. 42 %) than the patients without uveitis. Uveitis complications were present in 45 % at initial presentation of uveitis. After a mean duration of 5.6 years, complications were noted in 56 %, and included band keratopathy (29 %), posterior synechiae (27 %), cataract (26 %), glaucoma (8 %), and macula oedema (6 %). Final visual acuity was less than 20/50 in 31 % and less than 20/200 in 12 % of eyes. In patients with uveitis, immunosuppressive or immunomodulatory drugs were used significantly more often than in patients without uveitis (75 % vs. 43 %).

CONCLUSIONS

The nationwide data documents the spectrum of uveitis in patients with JIA, the complications and the therapy for uveitis. The high rate of uveitis complications at the time of diagnosis points out the need for early ophthalmologic screening and therapy, and for a close collaboration between ophthalmologist and paediatric rheumatologist.

[Transition clinic--it is not always a simple segue in rheumatology for adults]

Chronic inflammatory rheumatic diseases with onset in childhood often persist into adulthood and result in a considerable number of patients in impairments of body functions and structures, activities at the individual level and participation in society. Continuation of health care beyond adolescence is, therefore, necessary. Its provision should be of high quality, coordinated, uninterrupted, patient-centred and developmentally appropriate to ensure smooth transitions between children's and adult services and positive outcomes of transition for the young people themselves. Existing research is very persuasive on the need to improve transitions for young people with rheumatic diseases. To achieve effective transition, not only disease specific, but also aspects of growth and development have to be taken into account. Paediatric and adult rheumatologists should establish close cooperation and implement specific transition programs to meet the special health care needs of these patients.

The German etanercept registry for treatment of juvenile idiopathic arthritis

OBJECTIVE

To describe a registry set up to monitor children treated with etanercept in Germany and Austria.

METHODS

Giannini's criteria, duration of morning stiffness, number of swollen, tender and contracted joints, adverse events, and reasons for discontinuation were assessed.

RESULTS

322 patients with juvenile idiopathic arthritis (JIA) and 12 additional patients with non-JIA rheumatic diagnoses were included. Therapeutic efficacy was observed from one month after treatment was started. The number of patients with significant improvement and the degree of improvement increased during the first year. The mean (SD) number of tender and swollen joints decreased from 9 (9) and 8.4 (9) to 3.0 (6.5) and 4.5 (7) after one month, and to 2.2 (5.5) and 3.3 (5.5) after three months; morning stiffness decreased from 45 (65) minutes to 12 (30) and 7 (19) after one and three months (p<0.001 for all). Using Gianinni's criteria of 30%, 50%, and 70% improvement, a therapeutic response in JIA patients was achieved in, respectively, 66%, 54%, and 30% after one month, 78%, 61%, and 38% after three months, and 83%, 72%, and 52% after six months. Therapeutic efficacy was lower in patients with systemic onset arthritis. Overall tolerability was good: in 592 patient treatment-years there were 69 reports of adverse events in 56 patients, including one CNS demyelination. There were no opportunistic infections or lupus-like reactions. Treatment was discontinued in 53 JIA patients, in 25 because of lack of efficacy.

CONCLUSION

Etanercept treatment was safe and led to a significant improvement in most JIA patients resistant to conventional treatment.

Gastrointestinal symptoms and permeability in patients with juvenile idiopathic arthritis

OBJECTIVE

Examining for gastrointestinal involvement in juvenile idiopathic arthritis is an important part of diagnostic and therapeutic procedures. Only few scientific data are available.

METHODS

In a prospective study, 41 patients with juvenile idiopathic arthritis were examined for clinical and laboratory data of gastrointestinal involvement. Sugar absorption tests with lactulose, mannitol, and sucrose were applied to assess gastric and intestinal mucosal lesions. Faecal albumin and alpha 1-antitrypsin levels were measured to examine gastrointestinal protein loss, a test for occult blood in stool was administered and Helicobacter pylori serology was performed.

RESULTS

39% of our study population complained of chronic abdominal pain. The patient group showed increased sucrose excretion (p = 0.002), but a normal lactulose/mannitol ratio compared with healthy controls (p = 0.472). 21% of the patients had an elevated faecal alpha 1-antitrypsin level, but only one patient showed occult blood loss. There was no correlation between risk factors and clinical or laboratory signs of gastrointestinal involvement.

CONCLUSION

We conclude that a high percentage of children and adolescents with juvenile idiopathic arthritis treated with non-steroidal antiinflammatory drugs show clinical or laboratory signs of gastrointestinal involvement.

Arthrosonography of hip and knee joints in the follow up of juvenile rheumatoid arthritis

OBJECTIVE

To evaluate sensitivity of arthrosonography of hip and knee joints for monitoring disease activity in juvenile rheumatoid arthritis (JRA).

METHODS

Twenty eight patients with JRA with active disease at entry in 15 hips and 38 knee joints were followed up three times in intervals of 4-6 weeks. Sonographic, clinical, and laboratory findings were documented at the same time in clinically active and inactive disease. As controls of the sonographic variables 10 children without a history of arthritis were examined by ultrasound.

RESULTS

In active arthritis of the hip joint 19/31 (61%) examinations showed a pathological widening of the synovial joint space. There was no significant correlation between sonographic and clinical measures of disease activity in coxitis. Marked effusion within the suprapatellar pouch was seen in 87% and thickening of the synovial membrane in 92% of cases of active gonarthritis in patients with JRA. There was a significant difference in the number of patients with joint effusion and in the mean joint effusion between patients with clinically active gonarthritis at entry and inactive arthritis at follow up (p<0.001). In contrast, synovial thickening persisted in about 80% after induction of clinical remission.

CONCLUSION

The data confirm the high sensitivity of arthrosonography in imaging changes in hip and knee joints of patients with JRA. Sonographic effusion of the knee provided the highest correlation with measures of clinical disease activity. Further prospective studies should evaluate whether persistent thickening of the synovial membrane detected by ultrasound in clinically inactive arthritis indicates residual inflammatory activity and an increased risk of relapse.

[Body complaints and neuroticism in pediatric patients with rheumatism]

BACKGROUND

Pain and aches are part of subjective experience. Caring for chronically ill children and adolescents not only objective results but also the children s subjective perception of their illness should be taken into consideration. We have tried to record the extent of subjective suffering of a group of pediatric rheumatic patients and to correlate our findings with personality traits.

PATIENTS AND METHOD

We interviewed thirty-one 8 to 18 years old children and adolescents (average age 12 years) by means of a standardized questionnaire (Giessener Beschwerdefragebogen) and of a standardized personality questionnaire (HANES,KJ). The tested group comprised of 9 boys and 22 girls. 14 patients suffered from a chronic oligoarthritis, 9 from a chronic polyarthritis, 8 from a other rheumatic disease. Percentiles of more than 89 percent have been considered significant compared to norm collectives.

RESULTS

28% of the patients showed augmented values on the scales "exhaustion" and "intestinal pain", 25% on the scale "pain in joints". Only 3 respectively 2 patients showed augmented values on the scales "heart" and "symptoms of cold". 28% showed augmented values on the overall scale "feeling of discomfort". 35% showed augmented values on neuroticism, 61% values > 89. percentile on the scale "extraversion". There is a significant connection between augmented strong feelings of discomfort and augmented values of neuroticism on the level 0.1%. A context to the duration of the illness was not found.

CONCLUSION

Experience of physical pains is not only limited to isolated symptoms of the basic illness but also associated with general features of personality.