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Rohekar S, Chan J, Tse SM, Haroon N, Chandran V, Bessette L, Mosher D, Flanagan C, Keen KJ, Adams K, Mallinson M, Thorne C, Rahman P, Gladman DD, Inman RD. 2014 Update of the Canadian Rheumatology Association/Spondyloarthritis Research Consortium of Canada Treatment Recommendations for the Management of Spondyloarthritis. Part II: Specific Management Recommendations. J Rheumatol 2015; 42:665-81. [DOI: 10.3899/jrheum.141001] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2014] [Indexed: 01/01/2023]
Abstract
Objective.The Canadian Rheumatology Association (CRA) and the Spondyloarthritis Research Consortium of Canada (SPARCC) have collaborated to update the recommendations for the management of spondyloarthritis (SpA).Methods.A working group was assembled and consisted of the SPARCC executive committee, rheumatologist leaders from SPARCC collaborating sites, Canadian rheumatologists from across the country with an interest in SpA (both academic and community), a rheumatology trainee with an interest in SpA, an epidemiologist/health services researcher, a member of the CRA executive, a member of the CRA therapeutics committee, and a patient representative from the Canadian Spondylitis Association. An extensive review was conducted of literature published from 2007 to 2014 involving the management of SpA. The working group created draft recommendations using multiple rounds of Web-based surveys and an in-person conference.Results.Recommendations for the management of SpA were created. Part II: Specific Management Recommendations addresses management with nonpharmacologic methods, nonsteroidal anti-inflammatories and analgesics, disease-modifying antirheumatic drugs, antibiotics, tumor necrosis factor inhibitors, other biologic agents, and surgery. Also included are 10 modifications for application to juvenile SpA.Conclusion.These recommendations were developed based on current literature and applied to a Canadian healthcare context. It is hoped that implementation of these recommendations will promote best practices in the treatment of SpA.
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Stanevicha V, Eglite J, Zavadska D, Sochnevs A, Lazareva A, Guseinova D, Shantere R, Gardovska D. HLA B27 allele types in homogeneous groups of juvenile idiopathic arthritis patients in Latvia. Pediatr Rheumatol Online J 2010; 8:26. [PMID: 20946671 PMCID: PMC2964715 DOI: 10.1186/1546-0096-8-26] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Accepted: 10/14/2010] [Indexed: 01/04/2023] Open
Abstract
UNLABELLED Juvenile idiopathic arthritis (JIA) is a heterogeneous condition and therapeutic strategies vary in different JIA types. The routinely accepted practice to start with Sulphasalazine (SS) as the first line treatment in patients with HLA B27 positive JIA proves to be ineffective in a large proportion of children. OBJECTIVE to investigate HLA B27 positive JIA patients clinical characteristics, determined HLA B27 allele types and their connection with antirheumatic treatment in homogenous patient groups. MATERIALS AND METHODS 56 patients diagnosed with JIA and observed over the period 2006 to 2009 included in the study. HLAB27 allele types were determined using PCR method. RESULTS In HLA B27 positive JIA patients mean disease onset was 12.34 ± 3.3 years. Most common (44%) JIA type was enthesitis related arthritis. Positive response to the treatment with SS was found in 32% of patients, Methotrexate (MTX) - in 43%, combined treatment - SS with MTX was effective in 12.5%. 12.5% of patients required combination MTX with Enbrel.Eight HLA B27 allele types were found in JIA patients in Latvia: *2702, *2703, *2704, *2705, *2710, *2715, *2717, *2728. The most common was *2705 - in 55% of cases. Among all the patients enthesitis related arthritis most commonly occurred in patients with HLAB*2705 allele (OR = 2.01, p < 0.02), oligoarthritis in patients with *2710 allele (OR = 3.0, p < 0.04) and polyarthritis with *2717 allele (OR = 3.0, p < 0.05). In patients with *2705 allele effective treatment was MTX (OR = 1.13, p < 0.03) and MTX with SS (OR = 2.02, p < 0.05), but in patients having *2703 allele - MTX with Enbrel (OR = 2.94, p < 0.02). CONCLUSIONS There are 8 different HLA B27 alleles in JIA patients in Latvia and the most common is *2705, but in order to assert them to be disease associated alleles, more extensive studies are needed, including control group of HLA B27 positive healthy individuals. Standard treatment approach with SS proves to be unsatisfactory in the majority of JIA patients. To improve children's quality of life achieving rapid disease control, the first line treatment in HLA B27 positive patients should be MTX. In order to start with the most appropriate drug it is necessary to determine HLAB 27 type at the onset of disease.
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Affiliation(s)
- Valda Stanevicha
- Department of Pediatrics, Riga Stradins University, Latvia Vienības gatve 45, Rīga, LV 1004, Latvia.
| | - Jelena Eglite
- Laboratory of clinical immunology and immunogenetics, Riga Stradins University, Latvia Biķernieku iela 29- 30, Rīga, LV 1039, Latvia
| | - Dace Zavadska
- Department of Pediatrics, Riga Stradins University, Latvia Vienības gatve 45, Rīga, LV 1004, Latvia
| | - Arturs Sochnevs
- Laboratory of clinical immunology and immunogenetics, Riga Stradins University, Latvia Kr.Valdemāra iela 111- 3, Rīga, LV 1010, Latvia
| | - Arina Lazareva
- Department of Pediatrics, Riga Stradins University, Latvia Adrese: Aviācijas iela 5- 46, Rīga, LV 5- 46, Latvia
| | - Dinara Guseinova
- Children University hospital, Department of Rheumatology Vienības gatve 45, Rīga, LV 1004, Latvia
| | - Ruta Shantere
- Children University hospital, Department of Rheumatology Vienības gatve 45, Rīga, LV 1004, Latvia
| | - Dace Gardovska
- Department of Pediatrics, Riga Stradins University, Latvia Vienības gatve 45, Rīga, LV 1004, Latvia
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Abstract
Juvenile idiopathic arthritis (JIA) includes several forms of chronic arthritis in children. Treatments are chosen according to the type and severity of the disease. Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids remain the mainstays of therapy. Traditional slower acting anti-rheumatic drugs, such as gold therapy, penicillamine, sulfasalazine, tiopronin and hydroxychloroquine, are usually poorly active in children. In addition, adverse effects are common, including severe macrophage activation syndrome with gold therapy or sulfasalazine. Low dose, once weekly methotrexate has emerged as the therapeutic agent of choice for children who fail to respond adequately to the administration of an NSAID, especially in those with the extended oligoarticular subtype of the disease. Other immunosuppressive agents, such as cyclosporin, are sometimes combined with methotrexate. In recent years, novel treatments have been developed. Autologous hematopoietic stem cell transplantation is effective in a number of children with severe JIA, whose disease has been refractory to conventional therapy. However, only short term follow-up data are currently available for this novel therapy. In addition, severe infections complicated by macrophage activation syndrome and death have been reported. Finally, anti-tumour necrosis factor-alpha therapy has shown efficacy in more than two-thirds of children with JIA and polyarthritis, and other cytokine inhibitors may be soon available.
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Affiliation(s)
- A M Prieur
- Department of Paediatric Immunohaematology and Paediatric Rheumatology, Hôpital Necker-Enfants Malades, Paris, France.
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Abstract
Prognostic factors in juvenile rheumatoid arthritis (JRA) include polyarticular onset, polyarticular disease course, and rheumatoid factor positivity; in the systemic onset subtype, persistence of systemic features at 6 months after onset confers a worse prognosis. Timely diagnosis and appropriate aggressive treatment of patients with poor prognostic features improve quality of life and outcome. After nonsteroidal anti-inflammatory drugs, methotrexate is the most commonly used second-line agent. However, approximately one third of patients do not respond to methotrexate adequately. Randomized, placebo-controlled, clinical trials in patients with JRA are few, but one such trial with the tumor necrosis factor inhibitor etanercept shows that this drug is effective and well-tolerated. Other recently approved agents for rheumatoid arthritis, including infliximab, leflunomide, celecoxib, and rofecoxib, have not been adequately studied in pediatric patients, and the role of these agents in children with JRA remains to be determined.
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Affiliation(s)
- Norman T Ilowite
- Division of Rheumatology, Schneider Children's Hospital, New Hyde Park, New York, USA.
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van Rossum MA, Fiselier TJ, Franssen MJ, ten Cate R, van Suijlekom-Smit LW, Wulffraat NM, van Luijk WH, Oostveen JC, Kuis W, Dijkmans BA, van Soesbergen RM. Effects of sulfasalazine treatment on serum immunoglobulin levels in children with juvenile chronic arthritis. Scand J Rheumatol 2001; 30:25-30. [PMID: 11252688 DOI: 10.1080/030097401750065283] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
This article describes the effects of sulfasalazine (SSZ) treatment on serum immunoglobulin (Ig) levels in 6 children with oligoarticular- or polyarticular onset juvenile chronic arthritis (JCA). None of the children who developed dysimmunoglobulinemia during treatment showed clinical symptoms of this adverse event, in particular none developed severe infections. All patients regained normal immunoglobulin levels after discontinuing SSZ treatment. One patient with a partial IgA deficiency at the start of SSZ treatment showed a slow increase in the IgA level during treatment. During follow-up (4-6 years), one patient spontaneously developed a dysimmunoglobulinemia and one patient developed diabetes mellitus. Based on these case reports and review of the literature we advocate monitoring of serum immunoglobulin levels while on SSZ treatment.
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Affiliation(s)
- M A van Rossum
- Department of Paediatrics, Leiden University Medical Centre, The Netherlands
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De Keyser F, Elewaut D, De Vos M, De Vlam K, Cuvelier C, Mielants H, Veys EM. Bowel inflammation and the spondyloarthropathies. Rheum Dis Clin North Am 1998; 24:785-813, ix-x. [PMID: 9891711 DOI: 10.1016/s0889-857x(05)70042-9] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The concept of spondyloarthropathies gathers together a group of chronic diseases in which not only the locomotor system is involved but also other organs, especially the gastrointestinal tract. In humans, ileocolonoscopic studies demonstrated the presence of inflammatory gut lesions in all the diseases in the spondyloarthropathy group; their presence varied in the different diseases between 20% and 70%. The inflammation could be related to specific disease features in the spondyloarthropathies. Further research supports the hypothesis of subclinical inflammatory bowel disease in some patients with spondyloarthropathy, in which the locomotor inflammation was the only clinical manifestation. The link between gut inflammation and arthropathy has also been demonstrated in animal models, notably the human leukocyte antigen B27 transgenic rats. The temporal relationship between activity and severity of colonic involvement and flares of peripheral arthritis directs treatment of choice. For all forms of enterogenic arthropathies, nonsteroidal anti-inflammatory drugs remain the acute treatment form. Caution is in order, however, because of their possible harmful effects on intestinal integrity, permeability, and even on gut inflammation.
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Affiliation(s)
- F De Keyser
- Department of Rheumatology, University Hospital, Ghent, Belgium
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7
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Abstract
Patients with oligoarticular onset of juvenile arthritis form a large group that is heterogeneous with regard to clinical presentation, further evolution and outcome. The three established subgroups do not cover the whole patient population and are not always easily distinguishable at onset. Therefore, the outcome of children with oligoarticular onset is still, on the whole, unpredictable. Treatment has been very conservative, but, as part of it, the use of intra-articular corticosteroids is increasing and should be encouraged. The question of whether to give slow-acting anti-rheumatic drugs is a difficult one, as these have neither been studied nor recommended for use in persistently oligoarticular patients.
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Affiliation(s)
- P M Pelkonen
- Hospital for Children and Adolescents, Helsinki University Central Hospital, Finland
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8
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van Rossum MA, Fiselier TJ, Franssen MJ, Zwinderman AH, ten Cate R, van Suijlekom-Smit LW, van Luijk WH, van Soesbergen RM, Wulffraat NM, Oostveen JC, Kuis W, Dijkstra PF, van Ede CF, Dijkmans BA. Sulfasalazine in the treatment of juvenile chronic arthritis: a randomized, double-blind, placebo-controlled, multicenter study. Dutch Juvenile Chronic Arthritis Study Group. ARTHRITIS AND RHEUMATISM 1998; 41:808-16. [PMID: 9588731 DOI: 10.1002/1529-0131(199805)41:5<808::aid-art6>3.0.co;2-t] [Citation(s) in RCA: 151] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To assess the efficacy, tolerability, and safety of sulfasalazine (SSZ) in the treatment of juvenile chronic arthritis (JCA). METHODS We conducted a 24-week randomized, placebo-controlled, double-blind, multicenter study of patients with active JCA of both oligoarticular and polyarticular onset. Patients were treated with a dosage of 50 mg/kg/day of SSZ (maximum 2,000 mg/day) or placebo. The efficacy variables were joint scores, physician's, parents', and patient's overall assessments, and laboratory parameters of inflammation. RESULTS Of the 69 patients enrolled, 52 (75%) completed the trial. Six patients (18%) withdrew from the placebo group, and 11 (31%) withdrew from the SSZ group (P = 0.18). In the intention-to-treat analysis of end point efficacy, between-group differences were significant for the overall articular severity score (P = 0.02), all global assessments (P = 0.01), and the laboratory parameters (P < 0.001). Adverse events occurred more frequently in the SSZ group and were the main reason for withdrawal (P < 0.001), but in all instances, these events were transient or reversible upon cessation of treatment. CONCLUSION The results of this first placebo-controlled study show that SSZ is effective and safe in the treatment of children with oligoarticular- and polyarticular-onset JCA, although it was not well tolerated in one-third of the patients.
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Ansell BM, Chamberlain MA. Children with chronic arthritis: the management of transition to adulthood. BAILLIERE'S CLINICAL RHEUMATOLOGY 1998; 12:363-73. [PMID: 9890102 DOI: 10.1016/s0950-3579(98)80023-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Idiopathic juvenile arthritis occurs throughout childhood; the young child needs a major paediatric input while the adolescent, at whatever age the disease started, will need help in achieving a satisfactory transfer to adulthood, perhaps using the 'young adult team'. Throughout, an appropriate team of paediatrician, rheumatologist, physiotherapists, occupational therapists and social workers is important in dealing with such young people and their families. They not only treat the disease but give information to parents and children that will aid the day-to-day management of the condition, and help maintain normal education (progressing to further and higher education) and training leading, hopefully, to an acceptable adult lifestyle.
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Affiliation(s)
- B M Ansell
- Rheumatology and Rehabilitation Research Unit, University of Leeds, UK
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10
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Mielants H, Veys EM, Cuvelier C, De Vos M. Course of gut inflammation in spondylarthropathies and therapeutic consequences. BAILLIERE'S CLINICAL RHEUMATOLOGY 1996; 10:147-64. [PMID: 8674145 DOI: 10.1016/s0950-3579(96)80010-0] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Gut inflammation plays a crucial role in the pathogenesis of spondylarthropathies (SpA) since ileocolonoscopic studies have demonstrated the presence of gut inflammation in different forms of this concept: in ankylosing spondylitis (AS) (60%), in enterogenic (90%) and urogenital reactive arthritis (20%), in undifferentiated SpA (65%), in the pauciarticular and axial forms of psoriatic arthritis (16%), in late onset pauciarticular juvenile chronic arthritis (80%) and in acute anterior uveitis (66%). The strong relationship between gut and joint inflammation was demonstrated by performing a second ileocolonoscopy: remission of the joint inflammation was always connected with a disappearance of gut inflammation, whereas persistence of locomotor inflammation was mostly associated with the persistence of gut inflammation. During further evolution 20% of the non-ankylosing spondylitis SpA patients can develop AS. About 6% of the total group SpA patients, in whom inflammatory bowel disease (IBD) was excluded, developed Crohn's disease 5 to 9 years later. All these patients initially presented with gut inflammation, which indicates that this finding has prognostic value. The high prevalence of evolution to IBD in SpA patients confirms the thesis that both disease entities bear common pathogenic mechanisms, and confirms the place of IBD in the concept of SPA. Sulphasalazine (SASP), a successful drug in the treatment of IBD, has demonstrated its effectiveness in the treatment of SpA. The beneficial effect of the drug in this disease entity could be due to its anti-inflammatory effect on the gut wall, by normalizing its permeability and by preventing the entrance of antigens through the defective gut wall. However, SASP could not prevent the evolution to IBD.
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Affiliation(s)
- H Mielants
- Department of Rheumatology, University Hospital, Ghent, Belgium
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Kümmerle-Deschner J, Dannecker G. Sulphasalazine desensitization in a paediatric patient with juvenile chronic arthritis. Acta Paediatr 1995; 84:952-4. [PMID: 7488828 DOI: 10.1111/j.1651-2227.1995.tb13803.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Sulphasalazine is an effective drug for the treatment of rheumatoid arthritis in adults. In paediatric patients, the drug has been used to treat inflammatory bowel disease and is currently under investigation for the treatment of juvenile chronic arthritis. Although sulphasalazine has a rather low incidence of serious side effects, one of the most common is skin rash, thought to be an allergic reaction. In adults, sulphasalazine desensitization programmes have proven to be effective for the treatment of this side effect. We present the case of a 7-year-old boy suffering from HLA-B 27 positive juvenile chronic arthritis. After initiation of treatment with sulphasalazine he developed an allergic skin rash, but tolerated the drug well after completion of a desensitization programme. To our knowledge, this is the first report of a paediatric patient with juvenile chronic arthritis successfully desensitized with sulphasalazine.
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