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Vilaiyuk S, Lerkvaleekul B, Jino J, Charuvanij S, Book YX, Arkachaisri T. Comparison of the outcomes between early and late anti-tumor necrosis factor therapy in patients with enthesitis-related subcategory of juvenile idiopathic arthritis: a multi-center study in Southeast Asia. Expert Opin Biol Ther 2022; 22:1323-1332. [PMID: 35876095 DOI: 10.1080/14712598.2022.2105140] [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: 11/04/2022]
Abstract
BACKGROUND Little is known about the impact of delayed initiation of anti-tumor necrosis factor (TNF) therapy in patients with enthesitis-related arthritis (ERA). Here, we compared the impact of delayed treatment on disease outcomes of ERA patients in Southeast Asia. RESEARCH DESIGN AND METHODS This retrospective study enrolled 149 ERA patients from Thailand and Singapore. Early (e-aTNF) and late (l-aTNF) treatment groups received anti-TNF therapy starting at ≤6 months and >6 months, respectively, after diagnosis. Outcomes included mean differences in disease activity parameters, Juvenile Spondyloarthritis Disease Activity (JSpADA) score, Juvenile Arthritis Diseases Activity (JADAS)-10 score, and American College of Rheumatology Pediatric (ACR Pedi) criteria, and the frequency of clinically inactive disease and first flare event. RESULTS The mean changes in JSpADA (p = 0.002) and JADAS-10 (p < 0.001) scores over time were significantly higher in the e-aTNF group than in the l-aTNF group. A significantly higher proportion of patients in the e-aTNF group than l-aTNF group satisfied ACR Pedi 100 criteria at 2 years (p = 0.042). All other long-term outcomes were not significantly different between the groups. CONCLUSIONS Although early anti-TNF treatment improved disease activity parameters somewhat better than delayed anti-TNF therapy, there was no significant difference in long-term outcomes.
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Affiliation(s)
- Soamarat Vilaiyuk
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Butsabong Lerkvaleekul
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Janejira Jino
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sirirat Charuvanij
- Division of Rheumatology, Department of Paediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yun Xin Book
- Rheumatology and Immunology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, SingHealth, Duke-NUS medical school, Singapore, Singapore Singapore
| | - Thaschawee Arkachaisri
- Rheumatology and Immunology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, SingHealth, Duke-NUS medical school, Singapore, Singapore Singapore
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2
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Shipa MRA, Heyer N, Mansoor R, Deakin CT, Madenidou AV, Bouraioui A, Fisher C, Leandro M, Ciurtin C, Sen D. Adalimumab or Etanercept as first line biologic therapy in Enthesitis related arthritis (ERA) - a drug-survival single centre study spanning 10 years. Semin Arthritis Rheum 2022; 55:152038. [DOI: 10.1016/j.semarthrit.2022.152038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/26/2022] [Accepted: 05/27/2022] [Indexed: 10/18/2022]
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Abstract
Juvenile idiopathic arthritis is a group of heterogeneous chronic inflammatory arthropathies occurring in childhood without a known cause. This article discusses the key clinical features of juvenile idiopathic arthritis and treatment updates for oligoarthritis, polyarthritis, enthesitis-related arthritis, psoriatic arthritis, and systemic arthritis. Paradigm changes in management include the earlier use of biologic agents and the introduction of biosimilars and targeted synthetic disease modifying agents like tofacitinib. This review summarizes recent developments while considering potential areas for improvement and study.
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Affiliation(s)
- Karen Onel
- Division of Pediatric Rheumatology, Hospital for Special Surgery, Weill Cornell Medicine, 535 E 70th St 5th Floor, New York, NY 10021, USA
| | - Dax G Rumsey
- Department of Pediatrics, Division of Rheumatology, University of Alberta, 3-502 ECHA, 11405 87 Ave NW, Edmonton, AB T6G 1C9
| | - Susan Shenoi
- Division of Pediatric Rheumatology, Seattle Children's Hospital, University of Washington, MA.7.110, Sand Point Way NE, Seattle, WA 98105, USA.
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4
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van Straalen JW, Krol RM, Giancane G, Panaviene V, Ailioaie LM, Doležalová P, Cattalini M, Susic G, Sztajnbok F, Maritsi D, Constantin T, Sawhney S, Rygg M, Oliveira SK, Nordal EB, Saad-Magalhaes C, Rubio-Perez N, Jelusic M, de Roock S, Wulffraat NM, Ruperto N, Swart JF. Increased incidence of inflammatory bowel disease on etanercept in juvenile idiopathic arthritis regardless of concomitant methotrexate use. Rheumatology (Oxford) 2021; 61:2104-2112. [PMID: 34508559 PMCID: PMC9071576 DOI: 10.1093/rheumatology/keab678] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/23/2021] [Indexed: 02/07/2023] Open
Abstract
Objective To describe risk factors for IBD development in a cohort of children with JIA. Methods JIA patients who developed IBD were identified from the international Pharmachild register. Characteristics were compared between IBD and non-IBD patients and predictors of IBD were determined using multivariable logistic regression analysis. Incidence rates of IBD events on different DMARDs were calculated, and differences between therapies were expressed as relative risks (RR). Results Out of 8942 patients, 48 (0.54% ) developed IBD. These were more often male (47.9% vs 32.0%) and HLA-B27 positive (38.2% vs 21.0%) and older at JIA onset (median 8.94 vs 5.33 years) than patients without IBD development. They also had more often a family history of autoimmune disease (42.6% vs 24.4%) and enthesitis-related arthritis (39.6% vs 10.8%). The strongest predictors of IBD on multivariable analysis were enthesitis-related arthritis [odds ratio (OR): 3.68, 95% CI: 1.41, 9.40] and a family history of autoimmune disease (OR: 2.27, 95% CI: 1.12, 4.54). Compared with methotrexate monotherapy, the incidence of IBD on etanercept monotherapy (RR: 7.69, 95% CI: 1.99, 29.74), etanercept with methotrexate (RR: 5.70, 95% CI: 1.42, 22.77) and infliximab (RR: 7.61, 95% CI: 1.27, 45.57) therapy was significantly higher. Incidence on adalimumab was not significantly different (RR: 1.45, 95% CI: 0.15, 13.89). Conclusion IBD in JIA was associated with enthesitis-related arthritis and a family history of autoimmune disease. An increased IBD incidence was observed for etanercept therapy regardless of concomitant methotrexate use.
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Affiliation(s)
- Joeri W van Straalen
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Roline M Krol
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Gabriella Giancane
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DiNOGMI), Università degli Studi di Genova, Genoa, Italy
| | - Violeta Panaviene
- Children's Hospital, Affiliate of Vilnius University Hospital Santaros Clinic, Vilnius, Lithuania.,Clinic of Children's Diseases, Vilnius University, Vilnius, Lithuania
| | | | - Pavla Doležalová
- Department of Pediatrics and Inherited Metabolic Disorders, 1st Faculty of Medicine and General University Hospital, Charles University in Prague, Prague, Czech Republic
| | - Marco Cattalini
- Unita' di Immunologia e Reumatologia Pediatrica, Clinica Pediatrica dell'Universita' di Brescia, Spedali Civili, Brescia, Italy
| | - Gordana Susic
- Division of Pediatric Rheumatology, Institute of Rheumatology of Belgrade, Belgrade, Serbia
| | - Flavio Sztajnbok
- Hospital Universitario Pedro Ernesto, Nucleo de Estudos da Saúde do Adolescente, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Despoina Maritsi
- 2nd Department of Pediatrics Athens Medical School, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Tamas Constantin
- Unit of Pediatric Rheumatology-Immunology, Second Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Sujata Sawhney
- Sir Ganga Ram Hospital Marg, Centre for Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Marite Rygg
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.,Department of Pediatrics, St. Olavs University Hospital of Trondheim, Trondheim, Norway
| | - Sheila Knupp Oliveira
- Instituto de Puericultura e Pediatria Martagao Gesteira (IPPMG), Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ellen Berit Nordal
- Department of Pediatrics, University Hospital of North Norway, Tromso, Norway.,Department of Clinical Medicine, UiT the Arctic University of Norway, Tromso, Norway
| | | | - Nadina Rubio-Perez
- Departamento de Pediatria, Facultad de Medicina, Hospital Universitario "Dr. J. E. González", Universidad Autónoma de Nuevo León, Monterrey, NL, Mexico
| | - Marija Jelusic
- Department of Paediatrics, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Sytze de Roock
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Nico M Wulffraat
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Nicolino Ruperto
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Joost F Swart
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
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5
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Klotsche J, Klein A, Niewerth M, Hoff P, Windschall D, Foeldvari I, Haas JP, Horneff G, Minden K. Re-treatment with etanercept is as effective as the initial firstline treatment in patients with juvenile idiopathic arthritis. Arthritis Res Ther 2021; 23:118. [PMID: 33863349 PMCID: PMC8050932 DOI: 10.1186/s13075-021-02492-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 03/29/2021] [Indexed: 12/21/2022] Open
Abstract
Objectives To determine (i) correlates for etanercept (ETA) discontinuation after achieving an inactive disease and for the subsequent risk of flare and (ii) to analyze the effectiveness of ETA in the re-treatment after a disease flare. Methods Data from two ongoing prospective registries, BiKeR and JuMBO, were used for the analysis. Both registries provide individual trajectories of clinical data and outcomes from childhood to adulthood in juvenile idiopathic arthritis (JIA) patients treated with biologic disease-modifying anti-rheumatic drugs (bDMARDs) and conventional synthetic DMARDs (csDMARDs). Results A total of 1724 patients were treated first with ETA treatment course (338 with second, 54 with third ETA course). Similar rates of discontinuation due to ineffectiveness and adverse events could be observed for the first (19.4%/6.2%), second (18.6%/5.9%), and third (14.8%/5.6%) ETA course. A total of 332 patients (+/−methotrexate, 19.3%) discontinued ETA after achieving remission with the first ETA course. Younger age (hazard ratio (HR) 1.08, p < 0.001), persistent oligoarthritis (HR 1.89, p = 0.004), and shorter duration between JIA onset and ETA start (HR 1.10, p < 0.001), as well as good response to therapy within the first 6 months of treatment (HR 1.11, p < 0.001) significantly correlated to discontinuation with inactive disease. Reoccurrence of active disease was reported for 77% of patients with mean time to flare of 12.1 months. We could not identify any factor correlating to flare risk. The majority of patients were re-treated with ETA (n = 117 of 161; 72.7%) after the flare. One in five patients (n = 23, 19.7%) discontinued ETA again after achieving an inactive disease and about 70% of the patients achieved an inactive disease 12 months after restarting ETA. Conclusion The study confirms the effectiveness of ETA even for re-treatment of patients with JIA. Our data highlight the association of an early bDMARD treatment with a higher rate of inactive disease indicating a window of opportunity.
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Affiliation(s)
- Jens Klotsche
- German Rheumatism Research Centre, Leibniz Institute, 10117, Berlin, Germany.
| | - Ariane Klein
- Centre for Paediatric Rheumatology, Department of Paediatrics, Asklepios Clinic Sankt Augustin, Sankt Augustin, Germany.,Department of Pediatrics, Medical Faculty, University of Cologne, Cologne, Germany
| | - Martina Niewerth
- German Rheumatism Research Centre, Leibniz Institute, 10117, Berlin, Germany
| | - Paula Hoff
- Endokrinologikum Berlin, 10117, Berlin, Germany
| | - Daniel Windschall
- Department of Paediatric and Adolescent Rheumatology, North-Western German Centre for Rheumatology, St. Josef-Stift Sendenhorst, Sendenhorst, Germany
| | - Ivan Foeldvari
- Hamburg Centre for Pediatric and Adolescent Rheumatology, Hamburg, Germany
| | - Johannes-Peter Haas
- German Center for Pediatric and Adolescent Rheumatology, Garmisch-Partenkirchen, Germany
| | - Gerd Horneff
- Centre for Paediatric Rheumatology, Department of Paediatrics, Asklepios Clinic Sankt Augustin, Sankt Augustin, Germany
| | - Kirsten Minden
- German Rheumatism Research Centre, Leibniz Institute, 10117, Berlin, Germany.,Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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6
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Retrospective analyzes of adverse events during biologic agents in children with juvenile idiopathic arthritis from a single center in Turkey. Reumatologia 2021; 58:367-374. [PMID: 33456079 PMCID: PMC7792537 DOI: 10.5114/reum.2020.102001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 11/30/2020] [Indexed: 11/17/2022] Open
Abstract
Objectives Juvenile idiopathic arthritis is the most common rheumatic disease in childhood. Biologic agents have changed the course of juvenile idiopathic arthritis. However, there are concerns regarding the occurrence of serious adverse events in patients receiving biologic agents. The aim of this study was to evaluate adverse events in children with juvenile idiopathic arthritis receiving biologic agents. Material and methods This retrospective study includes juvenile idiopathic arthritis patients receiving biologic agents. Demographic features and adverse events during biologic agents were collected from medical files. Adverse events that either resulted in death, were life-threatening, required inpatient hospitalization, or resulted in persistent or significant disability/incapacity were considered as serious adverse events. Results In total, 162 juvenile idiopathic arthritis patients (55.6% female) receiving biologic agents were enrolled: 101 (62.3%) patients treated with etanercept, 27 (16.7) with tocilizumab, 14 (8.6%) with adalimumab, 15 (9.2%) with anti-interleukin 1 agents (13 canakinumab, 2 anakinra), and 5 (3.1%) with infliximab. 75.9% of the patients received concomitantly disease-modifying anti-rheumatic drugs, and 20.4% received disease-modifying anti-rheumatic drugs plus corticosteroid. The mean age at initiation of the biologic agent was 10.5 ±4.3 years. The mean age at the study enrolment was 12.1 ±4.5 years. The mean follow-up duration was 19.7 ±2.1 months. The most frequent adverse event was upper respiratory tract infections (54.3%) followed by urinary tract infections (21%). Anaphylaxis occurred in 3 patients (1.9%): 2 with tocilizumab and one with infliximab. Macrophage activation syndrome occurred in 1 patient (0.6%) receiving tocilizumab. Lung tuberculosis developed in 2 patients (1.2%) receiving canakinumab. The frequency of serious adverse events in total was 6.7%. Conclusions While the most frequent adverse events during biologic agents was upper respiratory tract infections, the frequency of serious adverse events was 6.7%; therefore, juvenile idiopathic arthritis patients receiving biologic agents should be carefully evaluated for these adverse events in clinical practice.
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7
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Abstract
Juvenile spondyloarthritis is a subset of juvenile idiopathic arthritis (JIA) with onset in late childhood and adolescence and a strong association with human leukocyte antigen (HLA) B-27 positivity and familial aggregation that has the potential for axial involvement, potentially leading to ankylosing spondylitis. Current therapy for severe disease relies heavily on tumor necrosis factor inhibitors (TNFi). Treatment paradigms in children largely consist of extrapolation from studies on adults with spondyloarthritis. Additional therapies studied in adults include non-steroidal anti-inflammatory drugs (NSAIDs), blockade of the interleukin-17 (IL-17) and IL-23 axes, blockade of T-cell stimulation, phosphodiesterase (PDE)-4 inhibition, and Janus-activated kinase (JAK) pathway alteration. IL-17 blockade and IL-23 blockade are guideline approved after TNFi failure (and even as an alternative to TNFi) in adults, depending on concomitant inflammatory bowel and skin disease, with JAK and PDE-4 inhibition options following biologic failure. Neither pediatric nor adult guidelines address IL-6 blockade, T-cell co-stimulation blockade, or combination biologic therapy.
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Affiliation(s)
- John M Bridges
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Matthew L Stoll
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
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8
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Cabrera N, Lega JC, Kassai B, Wouters C, Kondi A, Cannizzaro E, Woerner A, Chausset A, Roethlisberger S, Jeanneret C, Aeschlimann F, Malik S, Duquesne A, Kaiser D, Higel L, Maes A, Berthet G, Hentgen V, Kone-Paut I, Belot A, Hofer M. Safety of biological agents in paediatric rheumatic diseases: A real-life multicenter retrospective study using the JIRcohorte database. Joint Bone Spine 2019; 86:343-350. [DOI: 10.1016/j.jbspin.2018.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 08/28/2018] [Indexed: 12/28/2022]
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9
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Ringold S, Angeles-Han ST, Beukelman T, Lovell D, Cuello CA, Becker ML, Colbert RA, Feldman BM, Ferguson PJ, Gewanter H, Guzman J, Horonjeff J, Nigrovic PA, Ombrello MJ, Passo MH, Stoll ML, Rabinovich CE, Schneider R, Halyabar O, Hays K, Shah AA, Sullivan N, Szymanski AM, Turgunbaev M, Turner A, Reston J. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Non-Systemic Polyarthritis, Sacroiliitis, and Enthesitis. Arthritis Rheumatol 2019; 71:846-863. [PMID: 31021537 DOI: 10.1002/art.40884] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 02/27/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To develop treatment recommendations for children with juvenile idiopathic arthritis manifesting as non-systemic polyarthritis, sacroiliitis, or enthesitis. METHODS The Patient/Population, Intervention, Comparison, and Outcomes (PICO) questions were developed and refined by members of the guideline development teams. A systematic review was conducted to compile evidence for the benefits and harms associated with treatments for these conditions. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of evidence. A group consensus process was conducted among the Voting Panel to generate the final recommendations and grade their strength. A Parent and Patient Panel used a similar consensus approach to provide patient/caregiver preferences for key questions. RESULTS Thirty-nine recommendations were developed (8 strong and 31 conditional). The quality of supporting evidence was very low or low for 90% of the recommendations. Recommendations are provided for the use of nonsteroidal antiinflammatory drugs, disease-modifying antirheumatic drugs, biologics, and intraarticular and oral glucocorticoids. Recommendations for the use of physical and occupational therapy are also provided. Specific recommendations for polyarthritis address general medication use, initial and subsequent treatment, and adjunctive therapies. Good disease control, with therapeutic escalation to achieve low disease activity, was recommended. The sacroiliitis and enthesitis recommendations primarily address initial therapy and adjunctive therapies. CONCLUSION This guideline provides direction for clinicians, caregivers, and patients making treatment decisions. Clinicians, caregivers, and patients should use a shared decision-making process that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.
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Affiliation(s)
| | - Sheila T Angeles-Han
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Daniel Lovell
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | | | | | - Brian M Feldman
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | | | - Harry Gewanter
- Children's Hospital of Richmond, Virginia Commonwealth University, Richmond
| | - Jaime Guzman
- BC Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Peter A Nigrovic
- Brigham & Women's Hospital and Boston Children's Hospital, Boston, Massachusetts
| | | | | | | | | | - Rayfel Schneider
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
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10
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Ringold S, Angeles-Han ST, Beukelman T, Lovell D, Cuello CA, Becker ML, Colbert RA, Feldman BM, Ferguson PJ, Gewanter H, Guzman J, Horonjeff J, Nigrovic PA, Ombrello MJ, Passo MH, Stoll ML, Rabinovich CE, Schneider R, Halyabar O, Hays K, Shah AA, Sullivan N, Szymanski AM, Turgunbaev M, Turner A, Reston J. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Non-Systemic Polyarthritis, Sacroiliitis, and Enthesitis. Arthritis Care Res (Hoboken) 2019; 71:717-734. [PMID: 31021516 DOI: 10.1002/acr.23870] [Citation(s) in RCA: 151] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 02/27/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To develop treatment recommendations for children with juvenile idiopathic arthritis manifesting as non-systemic polyarthritis, sacroiliitis, or enthesitis. METHODS The Patient/Population, Intervention, Comparison, and Outcomes (PICO) questions were developed and refined by members of the guideline development teams. A systematic review was conducted to compile evidence for the benefits and harms associated with treatments for these conditions. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of evidence. A group consensus process was conducted among the Voting Panel to generate the final recommendations and grade their strength. A Parent and Patient Panel used a similar consensus approach to provide patient/caregiver preferences for key questions. RESULTS Thirty-nine recommendations were developed (8 strong and 31 conditional). The quality of supporting evidence was very low or low for 90% of the recommendations. Recommendations are provided for the use of nonsteroidal antiinflammatory drugs, disease-modifying antirheumatic drugs, biologics, and intraarticular and oral glucocorticoids. Recommendations for the use of physical and occupational therapy are also provided. Specific recommendations for polyarthritis address general medication use, initial and subsequent treatment, and adjunctive therapies. Good disease control, with therapeutic escalation to achieve low disease activity, was recommended. The sacroiliitis and enthesitis recommendations primarily address initial therapy and adjunctive therapies. CONCLUSION This guideline provides direction for clinicians, caregivers, and patients making treatment decisions. Clinicians, caregivers, and patients should use a shared decision-making process that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.
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Affiliation(s)
| | - Sheila T Angeles-Han
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Daniel Lovell
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | | | | | - Brian M Feldman
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | | | - Harry Gewanter
- Children's Hospital of Richmond, Virginia Commonwealth University, Richmond
| | - Jaime Guzman
- BC Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Peter A Nigrovic
- Brigham & Women's Hospital and Boston Children's Hospital, Boston, Massachusetts
| | | | | | | | | | - Rayfel Schneider
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
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11
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Mistry RR, Patro P, Agarwal V, Misra DP. Enthesitis-related arthritis: current perspectives. Open Access Rheumatol 2019; 11:19-31. [PMID: 30774484 PMCID: PMC6354696 DOI: 10.2147/oarrr.s163677] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
In this narrative review, we overview the recent literature on enthesitis-related arthritis (ERA). For the purpose of our review, we searched Scopus for recent articles on this subject from 2013 onward, including some classic older articles for perspective. ERA is a juvenile idiopathic arthritis (JIA) subtype more common in males, associated in a majority with human leucocyte antigen B27. Such children generally present with asymmetric oligoarthritis or polyarthritis, predominantly of lower limb joints, associated with enthesitis or sacroiliitis. While diagnosis remains clinical, ultrasound is being increasingly used to detect subclinical enthesitis and for guiding entheseal site injections. Spine MRI can help detect sacroiliitis, inflammatory spinal changes, and pelvic sites of enthesitis in such patients. The recent juvenile spondyloarthropathy disease activity index recognizes the key clinical features of ERA, viz enthesitis and inflammatory back pain, which other disease activity indices used in JIA did not include. Management includes NSAIDs with physical therapy. Conventional disease-modifying agents like sulfasalazine and methotrexate may be used to minimize duration of NSAID use and in those with high inflammatory burden. In patients refractory to these drugs, biologics such as antitumor necrosis factor alpha agents have proven useful, based on evidences from randomized controlled trials and retrospective registry analyses. Factors predicting a poorer outcome in such children include hip or ankle involvement or restricted spinal mobility. Considering that children with ERA have overall poorer long-term outcomes than other subtypes of JIA, there is a need to further optimize therapeutic strategies for such patients.
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Affiliation(s)
- Rutviz Rajendra Mistry
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India,
| | - Pallavi Patro
- Department of Pharmacology, Sriram Chandra Bhanja (SCB) Medical College, Cuttack, India
| | - Vikas Agarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India,
| | - Durga Prasanna Misra
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India,
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12
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Goirand M, Breton S, Chevallier F, Duong NP, Uettwiller F, Melki I, Mouy R, Wouters C, Bader-Meunier B, Job-Deslandre C, Quartier P. Clinical features of children with enthesitis-related juvenile idiopathic arthritis / juvenile spondyloarthritis followed in a French tertiary care pediatric rheumatology centre. Pediatr Rheumatol Online J 2018; 16:21. [PMID: 29609643 PMCID: PMC5879929 DOI: 10.1186/s12969-018-0238-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 03/13/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Childhood-onset spondyloarthropathies usually start with enthesitis and peripheral arthritis. However, axial disease may develop afterward. Patients are most often classified, following revised (Edmonton 2011) ILAR criteria, as enthesitis-related arthritis, psoriatic arthritis, or unclassified juvenile idiopathic arthritis, particularly in cases of psoriasis in the patient or a first-degree relative. In adults, peripheral spondyloarthritis is classified by ASAS criteria. METHODS We retrospectively studied patients with childhood-onset spondyloarthropathies followed for more than one year in our referral centre. We did not exclude patients with a personal or familial history of psoriasis. RESULTS We included 114 patients followed between January 2008 and December 2015 for a median of 2.5 years (IQR = 2.3). Sixty-nine per-cent of patients fulfilled the revised ILAR classification criteria for enthesitis-related arthritis, and 92% the ASAS criteria for peripheral spondyolarthritis (p < 0.001). Axial disease and sacroiliitis were rare at disease onset. However, they appeared during follow-up in 63% and 47% of cases respectively, after a median disease duration of 2.6 (IC 95% [2.2-4.4]) and 5.3 years (IC 95% [4.1-7.7]), respectively. Multivariable analysis showed that familial history of spondyloarthritis was associated with the presence of sacroiliitis and active disease at the latest follow-up (OR = 3.61 [1.5-8.7], p < 0.01 and 2.98 [1.2-7.3], p = 0.02, respectively). CONCLUSION Axial involvement developed in most patients within five years. Revised Edmonton criteria were less sensitive than ASAS criteria to classify patients as having childhood-onset spondyloarthropathies. The main risk factor for both sacroiliitis and persistent active disease was a familial history of spondyloarthritis.
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Affiliation(s)
- Maxime Goirand
- Pediatric Immunology, Hematology, and Rheumatology Unit, Centre de Référence pour les Rhumatismes Inflammatoires et les Maladies Auto-Immunes Systémique Rare de l'Enfant (RAISE) ; Necker-Enfants Malades Hospital, Assistance Publique Hôpitaux de Paris, 149, rue de Sèvres, 75743 Cedex15, Paris, France. .,Paris Descartes University, 12 rue de l'Ecole de Médicine, 75006, Paris, France. .,GOIRAND, CETD et EMASP pédiatrique, Hôpital Robert Debré, 48, Boulevard Serrurier, 75019, Paris, France.
| | - Sylvain Breton
- 0000 0001 2175 4109grid.50550.35Pediatric Radiology Department, Necker-Enfants Malades Hospital, Assistance Publique Hôpitaux de Paris, 149, rue de Sèvres, 75743 Cedex 15 Paris, France
| | - Frédéric Chevallier
- 0000000121496883grid.11318.3aUFR SMBH Paris 13, 74 rue Marcel Cachin, 93017 Cedex Bobigny, France
| | - Ngoc-Phoi Duong
- 0000 0001 2175 4109grid.50550.35Pediatric Immunology, Hematology, and Rheumatology Unit, Centre de Référence pour les Rhumatismes Inflammatoires et les Maladies Auto-Immunes Systémique Rare de l’Enfant (RAISE) ; Necker-Enfants Malades Hospital, Assistance Publique Hôpitaux de Paris, 149, rue de Sèvres, 75743 Cedex15 Paris, France ,0000 0004 1765 2136grid.414145.1Service de Réanimation Néonatale, Centre Hospitalier Intercommunal de Créteil, 40 avenue de Verdun, 94000 Créteil, France
| | - Florence Uettwiller
- 0000 0001 2175 4109grid.50550.35Pediatric Immunology, Hematology, and Rheumatology Unit, Centre de Référence pour les Rhumatismes Inflammatoires et les Maladies Auto-Immunes Systémique Rare de l’Enfant (RAISE) ; Necker-Enfants Malades Hospital, Assistance Publique Hôpitaux de Paris, 149, rue de Sèvres, 75743 Cedex15 Paris, France ,grid.462336.6Imagine Institute, 24 boulevard du Montparnasse, 75015 Paris, France
| | - Isabelle Melki
- 0000 0001 2175 4109grid.50550.35Pediatric Immunology, Hematology, and Rheumatology Unit, Centre de Référence pour les Rhumatismes Inflammatoires et les Maladies Auto-Immunes Systémique Rare de l’Enfant (RAISE) ; Necker-Enfants Malades Hospital, Assistance Publique Hôpitaux de Paris, 149, rue de Sèvres, 75743 Cedex15 Paris, France ,grid.462336.6Imagine Institute, 24 boulevard du Montparnasse, 75015 Paris, France ,0000 0001 2175 4109grid.50550.35General Pediatrics, Infectious Disease, and Internal Medicine Unit, Robert Debré Hospital, Assistance Publique Hôpitaux de Paris, 48 boulevard Sérurier, 75019 Paris, France ,0000000121866389grid.7429.8INSERM UMR 1163, Laboratory of Neurogenetics and Neuroinflammation, Paris, France
| | - Richard Mouy
- 0000 0001 2175 4109grid.50550.35Pediatric Immunology, Hematology, and Rheumatology Unit, Centre de Référence pour les Rhumatismes Inflammatoires et les Maladies Auto-Immunes Systémique Rare de l’Enfant (RAISE) ; Necker-Enfants Malades Hospital, Assistance Publique Hôpitaux de Paris, 149, rue de Sèvres, 75743 Cedex15 Paris, France ,grid.462336.6Imagine Institute, 24 boulevard du Montparnasse, 75015 Paris, France
| | - Carine Wouters
- 0000 0001 2175 4109grid.50550.35Pediatric Immunology, Hematology, and Rheumatology Unit, Centre de Référence pour les Rhumatismes Inflammatoires et les Maladies Auto-Immunes Systémique Rare de l’Enfant (RAISE) ; Necker-Enfants Malades Hospital, Assistance Publique Hôpitaux de Paris, 149, rue de Sèvres, 75743 Cedex15 Paris, France ,grid.462336.6Imagine Institute, 24 boulevard du Montparnasse, 75015 Paris, France
| | - Brigitte Bader-Meunier
- 0000 0001 2175 4109grid.50550.35Pediatric Immunology, Hematology, and Rheumatology Unit, Centre de Référence pour les Rhumatismes Inflammatoires et les Maladies Auto-Immunes Systémique Rare de l’Enfant (RAISE) ; Necker-Enfants Malades Hospital, Assistance Publique Hôpitaux de Paris, 149, rue de Sèvres, 75743 Cedex15 Paris, France ,grid.462336.6Imagine Institute, 24 boulevard du Montparnasse, 75015 Paris, France
| | - Chantal Job-Deslandre
- 0000 0001 2175 4109grid.50550.35Pediatric Immunology, Hematology, and Rheumatology Unit, Centre de Référence pour les Rhumatismes Inflammatoires et les Maladies Auto-Immunes Systémique Rare de l’Enfant (RAISE) ; Necker-Enfants Malades Hospital, Assistance Publique Hôpitaux de Paris, 149, rue de Sèvres, 75743 Cedex15 Paris, France
| | - Pierre Quartier
- 0000 0001 2175 4109grid.50550.35Pediatric Immunology, Hematology, and Rheumatology Unit, Centre de Référence pour les Rhumatismes Inflammatoires et les Maladies Auto-Immunes Systémique Rare de l’Enfant (RAISE) ; Necker-Enfants Malades Hospital, Assistance Publique Hôpitaux de Paris, 149, rue de Sèvres, 75743 Cedex15 Paris, France ,0000 0001 2188 0914grid.10992.33Paris Descartes University, 12 rue de l’Ecole de Médicine, 75006 Paris, France ,grid.462336.6Imagine Institute, 24 boulevard du Montparnasse, 75015 Paris, France
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Serious Adverse Events Associated with Anti-Tumor Necrosis Factor Alpha Agents in Pediatric-Onset Inflammatory Bowel Disease and Juvenile Idiopathic Arthritis in A Real-Life Setting. Paediatr Drugs 2018; 20:165-171. [PMID: 29214394 DOI: 10.1007/s40272-017-0267-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Anti-tumor necrosis factor alpha (anti-TNF-α) agents are generally well tolerated, yet they can be associated with serious adverse events (SAEs) in a minority of patients. We examined the incidence of SAEs in a pediatric referral center for chronic rheumatologic and gastroenterological inflammatory disorders. METHODS Retrospective analysis of SAEs occurring during treatment with anti-TNF-α agents in patients with juvenile idiopathic arthritis (JIA) (n = 78) or pediatric-onset inflammatory bowel disease (IBD) (n = 105) seen at the Institute for Maternal and Child Health IRCCS "Burlo Garofolo" in Trieste, Italy, between June 2001 and February 2016. Only SAEs grade 3-5 according to the Common Terminology Criteria for Adverse Events version 4.03 and/or requiring definitive therapy discontinuation were reported. RESULTS Total anti-TNF-α exposure was 390.5 patient-years (PYs). The overall incidence rate of SAEs for etanercept was 4.14/100 PYs. Four patients developed uveitis, two had anxiety disorders, one had a serious zoster infection, and one developed TNF-α antagonist-induced lupus-like syndrome (TAILS). The overall incidence rate of SAEs for infliximab was 22.49/100 PYs. The most common SAEs were anaphylactoid reactions (n = 18), followed by infectious events (n = 9) and TAILS (n = 3). The overall incidence rate of SAEs for adalimumab was 4.71/100 PYs (two infectious SAEs). No malignancies or deaths were observed. A greater incidence rate of infectious SAEs was observed in IBD patients receiving infliximab compared to JIA patients receiving etanercept (8.11 vs 0.52 per 100 PYs). CONCLUSIONS Anti-TNF-α therapy was generally well tolerated. SAEs leading to anti-TNF-α discontinuation were rare and non-fatal. Infliximab was associated with the highest incidence of SAEs. Infectious SAEs were more frequently observed in IBD patients treated with infliximab than in JIA patients receiving etanercept.
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Hassett B, Scheinberg M, Castañeda-Hernández G, Li M, Rao URK, Singh E, Mahgoub E, Coindreau J, O'Brien J, Vicik SM, Fitzpatrick B. Variability of intended copies for etanercept (Enbrel®): Data on multiple batches of seven products. MAbs 2018; 10:166-176. [PMID: 29020508 PMCID: PMC5800383 DOI: 10.1080/19420862.2017.1387346] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 09/15/2017] [Accepted: 09/28/2017] [Indexed: 12/13/2022] Open
Abstract
Fusion protein and monoclonal antibody-based tumor necrosis factor (TNF) inhibitors represent established treatment options for a range of inflammatory diseases. Regulatory authorities have outlined the structural characterization and clinical assessments necessary to establish biosimilarity of a new biotherapeutic product with the innovator biologic drug. Biologic products that would not meet the minimum World Health Organization's standard for evaluation of similar biotherapeutic products are available in some countries; in some cases relevant data to assess biosimilarity and appropriate regulatory approval pathways are lacking. Batches of seven intended copy (IC) products for etanercept (Enbrel®) were subjected to a subset of test methods used in the routine release and heightened characterization of Enbrel®, to determine key attributes of identity, quality, purity, strength, and activity. While a number of quality attributes of the IC lots tested met the release specifications for Enbrel®, none fell within these limits across all methods performed, and there were no IC lots that satisfied the criteria typically applied by the innovator to support comparability with Enbrel®. Although the consequences of these differences are largely unknown, the potential for unanticipated clinical outcomes should not be overlooked.
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Affiliation(s)
- Brian Hassett
- Pfizer, Biotechnology & Aseptic Sciences Group, Dublin, Ireland
| | - Morton Scheinberg
- Department of Rheumatology, Hospital Albert Einstein and Hospital AACD, São Paulo, Brazil
| | - Gilberto Castañeda-Hernández
- Departamento de Farmacología, Centro de Investigación y Estudios Avanzados del Instituto Politécnico Nacional, Mexico City, Mexico
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Beijing, China
| | - Uppuluri R K Rao
- Department of Rheumatology, Sri Deepti Rheumatology Center, Hyderabad, Telangana, India
| | - Ena Singh
- Pfizer, Inflammation & Immunology Global Medical Affairs, Collegeville, PA, USA
| | - Ehab Mahgoub
- Pfizer, Inflammation & Immunology Regional Medical Affairs, Collegeville, PA, USA
| | | | - Julie O'Brien
- Pfizer, Europe & International Regulatory Policy, Dublin, Ireland
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15
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Hassett B, Singh E, Mahgoub E, O'Brien J, Vicik SM, Fitzpatrick B. Manufacturing history of etanercept (Enbrel ®): Consistency of product quality through major process revisions. MAbs 2017; 10:159-165. [PMID: 29020515 DOI: 10.1080/19420862.2017.1388483] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Etanercept (ETN) (Enbrel®) is a soluble protein that binds to, and specifically inhibits, tumor necrosis factor (TNF), a proinflammatory cytokine. ETN is synthesized in Chinese hamster ovary cells by recombinant DNA technology as a fusion protein, with a fully human TNFRII ectodomain linked to the Fc portion of human IgG1. Successful manufacture of biologics, such as ETN, requires sophisticated process and product understanding, as well as meticulous control of operations to maintain product consistency. The objective of this evaluation was to show that the product profile of ETN drug substance (DS) has been consistent over the course of production. Multiple orthogonal biochemical analyses, which included evaluation of attributes indicative of product purity, potency, and quality, were assessed on >2,000 batches of ETN from three sites of DS manufacture, during the period 1998-2015. Based on the key quality attributes of product purity (assessed by hydrophobic interaction chromatography HPLC), binding activity (to TNF by ELISA), potency (inhibition of TNF-induced apoptosis by cell-based bioassay) and quality (N-linked oligosaccharide map), we show that the integrity of ETN DS has remained consistent over time. This consistency was maintained through three major enhancements to the initial process of manufacturing that were supported by detailed comparability assessments, and approved by the European Medicines Agency. Examination of results for all major quality attributes for ETN DS indicates a highly consistent process for over 18 years and throughout changes to the manufacturing process, without affecting safety and efficacy, as demonstrated across a wide range of clinical trials of ETN in multiple inflammatory diseases.
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Affiliation(s)
- Brian Hassett
- a Pfizer, Biotechnology & Aseptic Sciences Group , Dublin , Ireland
| | - Ena Singh
- b Pfizer, Inflammation & Immunology Global Medical Affairs , Collegeville , PA , USA
| | - Ehab Mahgoub
- c Pfizer, Inflammation & Immunology Regional Medical Affairs , Collegeville , PA , USA
| | - Julie O'Brien
- d Pfizer, Europe & International Regulatory Policy , Dublin , Ireland
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16
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Shannon E, Daffy J, Jones H, Paulson A, Vicik SM. Etanercept (Enbrel ®) alternative storage at ambient temperature. Clin Pharmacol 2017; 9:87-99. [PMID: 28790869 PMCID: PMC5531722 DOI: 10.2147/cpaa.s131832] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Biologic disease-modifying antirheumatic drugs, including tumor necrosis factor inhibitors such as etanercept (Enbrel®), have improved outcomes for patients with rheumatic and other inflammatory diseases, with sustained remission being the optimal goal for patients with rheumatoid arthritis. Flexible and convenient treatment options, compatible with modern lifestyle, are important in helping patients maintain treatment and manage their disease. Etanercept drug product (DP) is available in lyophilized powder (Lyo) for solution injection, prefilled syringe, and prefilled pen presentations and is typically stored under refrigerated conditions. We aimed to generate a comprehensive analytical data package from stability testing of key quality attributes, consistent with regulatory requirements, to determine whether the product profile of etanercept is maintained at ambient temperature. METHODS Test methods assessing key attributes of purity, quality, potency, and safety were performed over time, following storage of etanercept DP presentations under a range of conditions. RESULTS Results and statistical analysis from stability testing (based on size exclusion high-performance liquid chromatography, hydrophobic interaction chromatography, and sodium dodecyl sulfate-polyacrylamide gel electrophoresis Coomassie) across all etanercept presentations (10 and 25 mg/vial Lyo DP; 25 and 50 mg prefilled syringe DP; 50 mg prefilled pen DP) showed key stability-indicating parameters were within acceptable limits through the alternative storage condition of 25°C±2°C for 1 month. CONCLUSION Stability testing performed in line with regulatory requirements supports a single period of storage for etanercept DP at an alternative storage condition of 25°C±2°C for up to 1 month within the approved expiry of the product. This alternative storage condition represents further innovation in the etanercept product lifecycle, providing greater flexibility and enhanced overall convenience for patients.
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Affiliation(s)
- Edel Shannon
- Global Chemistry, Manufacturing, and Controls Regulatory
| | - Joanne Daffy
- Contract Operations Quality Assurance, Pfizer Ireland Pharmaceuticals, Clondalkin, Dublin, Ireland
| | | | | | - Steven M Vicik
- Global Supply Product Portfolio Management, Pfizer Biotech, Andover, MA, USA
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17
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Alexeeva EI, Namazova-Baranova LS, Bzarova TM, Valieva SI, Denisova RV, Sleptsova TV, Isaeva KB, Chomahidze AM, Taibulatov NI, Fetisova AN, Karaseva AV, Baranov AA. Predictors of the response to etanercept in patients with juvenile idiopathic arthritis without systemic manifestations within 12 months: results of an open-label, prospective study conducted at the National Scientific and Practical Center of Children's Health, Russia. Pediatr Rheumatol Online J 2017; 15:51. [PMID: 28615036 PMCID: PMC5471744 DOI: 10.1186/s12969-017-0178-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 06/02/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the efficacy of etanercept treatment and to identify predictors of response to therapy within 12 months in patients with juvenile idiopathic arthritis (JIA) without systemic manifestations. METHODS A total of 197 juvenile patients were enrolled in this study. Response to therapy was assessed using the ACRPedi 30/50/70/90 criteria, the Wallace criteria, and the Juvenile Arthritis Disease Activity Score 71 (JADAS-71). Univariate and multivariate logistic regression analyses were performed to identify potential baseline factors associated with treatment response in different JIA categories. RESULTS One year after treatment initiation, 179 (90.9%) patients achieved ACRPedi30; 177 (89.8%) patients achieved ACRPedi50; 168 (85.3%) patients achieved ACRPedi70; and 135 (68.5%) patients achieved ACRPedi90 response. A total of 132 (67.0%) and 92 (46.7%) patients achieved inactive disease according to the Wallace criteria and the JADAS-71 cut-off point, respectively. Excellent response (achieving ACRPedi90 and clinically inactive disease according both to the Wallace criteria and the JADAS71 cut-off point) was associated with persistent oligoarticular JIA category, shorter disease duration before the start of etanercept, a lower number of DMARDs used before the introduction of etanercept, a lower number of joints with limited motion, and lower C-reactive protein at baseline. Poor response (failure to achieve ACR 70 or active disease according to both the Wallace criteria and JADAS71 even when ACR 70 was achieved) was associated with the polyarticular or enthesitis-related JIA categories, higher disease duration before the start of etanercept, and older age at disease onset. CONCLUSION Almost half (45.7%) of the patients who initiated etanercept treatment achieved an excellent response (inactive disease and ACRPedi90) after 1 year. What may be novel is our finding that the response to etanercept therapy was strongly associated with the JIA category. The response to etanercept therapy was also associated with the disease duration before the start of etanercept treatment.
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Affiliation(s)
- Ekaterina I. Alexeeva
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia ,0000 0000 9216 2496grid.415738.cFederal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia ,0000 0000 9216 2496grid.415738.cRheumatology Department, Federal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Leyla S. Namazova-Baranova
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Tatyana M. Bzarova
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia ,0000 0000 9216 2496grid.415738.cFederal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Saniya I. Valieva
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Rina V. Denisova
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Tatyana V. Sleptsova
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Kseniya B. Isaeva
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Alexandra M. Chomahidze
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Nikolay I. Taibulatov
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Anna N. Fetisova
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Anna V. Karaseva
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Alexandr A. Baranov
- 0000 0000 9216 2496grid.415738.cFederal State Autonomous Institution “National Scientific and Practical Center of Children’s Health” Of the Ministry of Health of the Russian Federation, Moscow, Russia
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Treatment response to etanercept in methotrexate refractory juvenile idiopathic arthritis: an analysis of predictors and long-term outcomes. Clin Rheumatol 2017; 36:1997-2004. [PMID: 28540607 DOI: 10.1007/s10067-017-3682-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 04/21/2017] [Accepted: 05/14/2017] [Indexed: 10/19/2022]
Abstract
The aim of the study is to evaluate the long-term outcomes, predictors, and the role of inflammatory cytokines in methotrexate (MTx) refractory juvenile idiopathic arthritis (JIA) patients. This is a retrospective cohort study. MTx refractory JIA patients who received etanercept as their first biological agent in National Taiwan University Hospital (NTUH) were enrolled. Patients were classified into remission group, non-remission group, relapsing group, and non-relapsing group according to the criteria of disease remission and disease flares defined by Wallace et al. We compared the differences in the baseline data, therapeutic responses, time to etanercept tapering, and inflammatory cytokine (IL-12p70, TNF-α, IL-10, IL-6, and IL-1β) levels between these groups. Among the 58 patients, 30 (52%) reached remission. Seventeen of the 30 patients had episodes of disease flares. We found that more patients in the remission group achieved ACR pediatric 70 response at the fourth month after etanercept treatment (p < 0.002). When comparing the relapsing group and non-relapsing group, we found that patients were more likely to have disease flares if it took longer to achieve remission (p = 0.0008). Besides, etanercept was tapered earlier in the non-relapsing group (p = 0.0006). There was no significant difference in levels of inflammatory cytokine between groups. No parameter before treatment could be used as a single predictor of long-term outcomes. However, ACR pediatric 70 response at the fourth month after etanercept treatment might predict disease remission. Besides, patients who achieved remission more rapidly were less likely to have disease flares.
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Safety and efficacy of etanercept and adalimumab in children aged 2 to 4 years with juvenile idiopathic arthritis. Clin Rheumatol 2016; 35:2925-2931. [PMID: 27709443 DOI: 10.1007/s10067-016-3439-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 09/24/2016] [Accepted: 09/27/2016] [Indexed: 10/20/2022]
Abstract
The TNF inhibitors etanercept (ETA) and adalimumab (ADA) are approved for treating patients older than 2 years with polyarticular juvenile idiopathic arthritis (JIA). Because long-term experience of treating children younger than 4 years is limited, we evaluated the efficacy and safety of ETA or ADA in patients aged 2-4 years. This prospective, long-term, observational registry study documented baseline demographics, clinical characteristics, disease activity parameters, and safety of patients treated with ETA or ADA. Efficacy was determined using the JADAS-10, the JADAS criteria for minimal disease activity (MDA) and remission, and the PedACR response criteria after 3, 6, 12, 18, and 24 months. Between January 2001 and March 2015, 85 patients with polyarticular JIA aged 2-4 years started anti-TNF-α treatment. Seventy-four (54 girls) patients were treated with ETA and 11 (7 girls) with ADA. After 6/12/24 months of treatment, JADAS-MDA was reached by 55/58/58 % of ETA patients and 50/71/66 % of ADA patients. Furthermore, JADAS-Remission was achieved by 35/44/50 % of ETA patients and 16/28/66 % of ADA patients. PedACR 50/70/90 response was achieved by 64/54/41 % of ETA patients and 56/33/22 % of ADA patients at the last treatment observation. Discontinuation because of remission or inefficacy was recorded in 24 (29 %) and 28 (33 %) patients, respectively. Seventy-nine adverse events and four serious adverse events were reported. Administration of ETA and ADA in JIA patients younger than 4 years was efficacious, well tolerated, and safe. Patients younger than 4 years may show marked improvement following anti-TNF-alpha therapy.
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Rieter JFMM, de Horatio LT, Nusman CM, Müller LSO, Hemke R, Avenarius DFM, van Rossum MAJ, Malattia C, Maas M, Rosendahl K. The many shades of enhancement: timing of post-gadolinium images strongly influences the scoring of juvenile idiopathic arthritis wrist involvement on MRI. Pediatr Radiol 2016; 46:1562-7. [PMID: 27406611 DOI: 10.1007/s00247-016-3657-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 05/12/2016] [Accepted: 06/08/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Potential long-term side effects of treatment for juvenile idiopathic arthritis are concerning. This has necessitated accurate tools, such as MRI, to monitor treatment response and allow for personalized therapy. OBJECTIVE To examine the extent to which timing of post-contrast MR images influences the scoring of inflammatory change in the wrist in children with juvenile idiopathic arthritis. MATERIALS AND METHODS We studied two sets of post-contrast 3-D gradient echo MRI series of the wrist in 34 children with juvenile idiopathic arthritis. These images were obtained immediately after administration of intravenous contrast material and again after approximately 10 min. The dataset was drawn from a prospective multicenter project conducted 2006-2010. We assessed five wrist locations for synovial enhancement, effusion and overall inflammation. Examinations were scored by one radiologist in two sessions - the first was based on the early post-contrast images, and the later session, for which the previous findings were masked, was based on the later post-contrast images. RESULTS Fifty-two of the 170 locations (30.6%) received a higher synovial enhancement score based on the late post-contrast images as compared to the early images. Sixty of the 170 (35%) locations received a higher total inflammation score. The mean scores of synovial enhancement and total inflammation were significantly higher when based on the late post-contrast images as compared to the early post-contrast images. CONCLUSION An MRI-based scoring system for the presence and degree of synovitis should be based on a standardized MR-protocol with a fixed interval between intravenous contrast injection and post-contrast images.
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Affiliation(s)
- Jasper F M M Rieter
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Charlotte M Nusman
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Robert Hemke
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Marion A J van Rossum
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Emma Children's Hospital, Amsterdam, The Netherlands
| | - Clara Malattia
- Department of Paediatrics, Ospedale Pediatrico Gaslini, Genoa, Italy
| | - Mario Maas
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Karen Rosendahl
- Radiology Department, Section of Pediatric Radiology, Haukeland University Hospital, Pb 1400, 5021, Bergen, Norway. .,Department of Clinical Medicine, K1, University of Bergen, Bergen, Norway.
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Tappeiner C, Schenck S, Niewerth M, Heiligenhaus A, Minden K, Klotsche J. Impact of Antiinflammatory Treatment on the Onset of Uveitis in Juvenile Idiopathic Arthritis: Longitudinal Analysis From a Nationwide Pediatric Rheumatology Database. Arthritis Care Res (Hoboken) 2016. [PMID: 26212111 PMCID: PMC5064660 DOI: 10.1002/acr.22649] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Objective Based on a nationwide database, this study analyzed the influence of methotrexate (MTX), tumor necrosis factor (TNF) inhibitors, and a combination of the 2 medications on uveitis occurrence in juvenile idiopathic arthritis (JIA) patients. Methods Data from the National Paediatric Rheumatological Database in Germany were used in this study. Between 2002 and 2013, data from JIA patients were annually documented at the participating pediatric rheumatologic sites. Patients with a JIA disease duration of <12 months at initial documentation and ≥2 years of followup were included in this study. The impact of antiinflammatory treatment on the occurrence of uveitis was evaluated by discrete‐time survival analysis. Results A total of 3,512 JIA patients (mean ± SD age 8.3 ± 4.8 years, 65.7% female, 53.2% antinuclear antibody positive, and mean ± SD age at arthritis onset 7.8 ± 4.8 years) fulfilled the inclusion criteria. Mean ± SD total followup time was 3.6 ± 2.4 years. Uveitis developed in a total of 180 patients (5.1%) within 1 year after arthritis onset. Uveitis onset after the first year was observed in another 251 patients (7.1%). Disease‐modifying antirheumatic drug (DMARD) treatment in the year before uveitis onset significantly reduced the risk for uveitis as follows: MTX: hazard ratio (HR) 0.63, P = 0.022; TNF inhibitors: HR 0.56, P < 0.001; and a combination of the 2 medications: HR 0.10, P < 0.001. Patients treated with MTX within the first year of JIA had an even a lower uveitis risk (HR 0.29, P < 0.001). Conclusion The use of DMARDs in JIA patients significantly reduced the risk for uveitis onset. Early MTX use within the first year of disease and the combination of MTX with a TNF inhibitor had the highest protective effect.
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Affiliation(s)
- Christoph Tappeiner
- German Rheumatism Research Centre Berlin, Leibniz Institute, Berlin, St. Franziskus Hospital, Muenster, Germany, and Inselspital, University of Bern, Bern, Switzerland
| | - Sandra Schenck
- German Rheumatism Research Centre Berlin, Leibniz Institute, Berlin, Germany
| | - Martina Niewerth
- German Rheumatism Research Centre Berlin, Leibniz Institute, Berlin, Germany
| | - Arnd Heiligenhaus
- St. Franziskus Hospital, Muenster, and University Duisburg-Essen, Essen, Germany
| | - Kirsten Minden
- German Rheumatism Research Centre Berlin, Leibniz Institute, and Charité University Medicine Berlin, Berlin, Germany
| | - Jens Klotsche
- German Rheumatism Research Centre Berlin, Leibniz Institute, and Charité University Medicine Berlin, Berlin, Germany
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Constantin T, Foeldvari I, Vojinovic J, Horneff G, Burgos-Vargas R, Nikishina I, Akikusa JD, Avcin T, Chaitow J, Koskova E, Lauwerys BR, Calvo Penades I, Flato B, Gamir ML, Huppertz HI, Raad JJJ, Jarosova K, Anton J, Macku M, Otero Escalante WJ, Rutkowska-Sak L, Trauzeddel R, Velez-Sanchez PJ, Wouters C, Wajdula J, Zang C, Bukowski J, Woodworth D, Vlahos B, Martini A, Ruperto N. Two-year Efficacy and Safety of Etanercept in Pediatric Patients with Extended Oligoarthritis, Enthesitis-related Arthritis, or Psoriatic Arthritis. J Rheumatol 2016; 43:816-24. [DOI: 10.3899/jrheum.150430] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2015] [Indexed: 02/05/2023]
Abstract
Objective.The main objective was to determine the 2-year clinical benefit and safety of etanercept (ETN) in children with the juvenile idiopathic arthritis (JIA) categories of extended oligoarthritis (eoJIA), enthesitis-related arthritis (ERA), or psoriatic arthritis (PsA).Methods.CLIPPER was a 96-week, phase IIIb, open-label, multicenter study. Patients with eoJIA, ERA, or PsA received ETN 0.8 mg/kg once weekly (50 mg max) for up to 96 weeks. The proportions of patients reaching the JIA American College of Rheumatology (ACR) 30/50/70/90/100 and inactive disease responses at Week 96 were calculated. Adverse events (AE) were collected throughout the study (intention-to-treat sample).Results.There were 127 patients (eoJIA n = 60, ERA n = 38, PsA n = 29) who received ≥ 1 dose of ETN. The mean disease duration was 31.6 (eoJIA), 23.0 (ERA), and 21.8 (PsA) months. At Week 96, JIA ACR 30/50/70/90/100/inactive disease responses (95% CI) were achieved by 84.3% (76.7, 90.1), 83.5% (75.8, 89.5), 78.7% (70.6, 85.5), 55.1% (46.0, 63.9), 45.7% (36.8, 54.7), and 27.6% (20.0, 36.2) of patients, respectively. The most common AE (no. events, events per 100 patient-yrs) overall were headache (23, 10.7), pyrexia (12, 5.6), and diarrhea (10, 4.6). The most common infections were upper respiratory tract infection (83, 38.6), pharyngitis (50, 23.2), gastroenteritis (22, 10.2), bronchitis (19, 8.8), and rhinitis (17, 7.9). No cases of malignancy, active tuberculosis, demyelinating disorders, or death were reported.Conclusion.Over 96 weeks of therapy, ETN demonstrated sustained efficacy at treating the clinical symptoms of all 3 JIA categories, with no major safety issues.
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Taddio A, Cattalini M, Simonini G, Cimaz R. Recent advances in the use of Anti-TNFα therapy for the treatment of juvenile idiopathic arthritis. Expert Rev Clin Immunol 2016; 12:641-9. [DOI: 10.1586/1744666x.2016.1146132] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Burgos-Vargas R, Tse SML, Horneff G, Pangan AL, Kalabic J, Goss S, Unnebrink K, Anderson JK. A Randomized, Double-Blind, Placebo-Controlled Multicenter Study of Adalimumab in Pediatric Patients With Enthesitis-Related Arthritis. Arthritis Care Res (Hoboken) 2016. [PMID: 26223543 PMCID: PMC5057351 DOI: 10.1002/acr.22657] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Objective Enthesitis‐related arthritis (ERA) is a juvenile idiopathic arthritis (JIA) category, primarily affecting entheses and peripheral joints. This study evaluated efficacy, safety, and pharmacokinetics of adalimumab versus placebo in patients with ERA. Methods This is a phase III, multicenter, randomized double‐blind study in patients ages ≥6 to <18 years with ERA treated with adalimumab (24 mg/m2, maximum dose 40 mg every other week) or placebo for 12 weeks, followed by up to 192 weeks of open‐label adalimumab. The primary end point was percent change from baseline in number of active joints with arthritis (AJC) at week 12. Samples were collected to determine adalimumab serum concentrations. Adverse events (AEs) were assessed throughout the study. Results Forty‐six patients were randomized (31 adalimumab/15 placebo). At baseline, mean age was 12.9 years, mean duration of ERA symptoms was 2.6 years, mean AJC was 7.8, and mean enthesitis count was 8.1. Mean percent change from baseline in AJC at week 12 was greater in the adalimumab group versus placebo (−62.6% versus −11.6%; P = 0.039). Most secondary variables favored adalimumab versus placebo at week 12. Treatment response further increased with continued adalimumab therapy through week 52. Mean steady‐state adalimumab serum concentrations were 7.5–11.8 μg/ml, similar to patients age ≥2 years with polyarticular JIA. AE rates were similar between placebo and adalimumab: any AE (53.3% versus 67.7%), serious AEs (0% versus 3.2%), and infectious AEs (20.0% versus 29.0%). Conclusion Adalimumab reduced signs and symptoms of ERA at week 12, with improvement sustained through week 52. The safety profile was consistent with previous adalimumab studies.
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Affiliation(s)
- Rubén Burgos-Vargas
- Hospital General de Mexico, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Shirley M L Tse
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Gerd Horneff
- Asklepios Klinik Sankt Augustin, Sankt Augustin, Germany
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Guo R, Cao L, Kong X, Xue H, Li X, Shen L. Atopy in children with the enthesitis-related arthritis (ERA) subtype of juvenile idiopathic arthritis is associated with a worse outcome. Eur J Pediatr 2015; 174:1441-50. [PMID: 25935591 DOI: 10.1007/s00431-015-2553-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 03/21/2015] [Accepted: 04/21/2015] [Indexed: 01/17/2023]
Abstract
UNLABELLED We aimed to assess the influence of co-existing atopy on the prognosis of enthesitis-related arthritis (ERA). Patients diagnosed with ERA between March 2006 and August 2012 were enrolled in a prospective cohort study and followed for 2 years. Management of patients was evaluated using the American College of Rheumatology (ACR) pediatric (Pedi) 30/50/70 criteria and laboratory variables. A total of 151 ERA patients were enrolled at diagnosis and were divided into those with atopy (n = 62) and those without (n = 89). When compared with the non-atopic group, atopic patients had significantly more active joints at disease onset (4.72 vs. 3.75), more joints with limitation of motion (LOM) (1.45 vs. 0.87), more painful joints (3.61 vs. 2.80), and more swollen joints (1.02 vs. 0.69) (p < 0.05 for all comparisons). At 3, 6, 12, 18, and 24 months, fewer ERA patients with atopy reached the ACR Pedi 50 and 70 criteria (at 3 months, 25.8 vs. 60.7 % and 11.3 vs. 34.8 %, respectively; at 6 months, 50 vs. 77.5 % and 22.6 vs. 58.4 %, respectively; at 12 months, 53.2 vs. 70.8 % and 33.9 vs. 55.1 %, respectively; at 18 months, 62.9 vs. 86.5 % and 56.5 vs. 78.7 %, respectively; at 24 months, 66.1 vs. 89.9 % and 61.3 vs. 78.7 %, respectively; all p < 0.05). During the 2 years of follow-up, the number of flares was significantly higher in ERA patients with co-existing atopy (1.48 vs. 0.70, p < 0.05). CONCLUSION Co-existing atopy in children with ERA may exert an adverse influence on ERA, with atopic patients manifesting more active disease at diagnosis and poorer outcome. \
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Affiliation(s)
- Ruru Guo
- Department of Pediatrics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, 1630 Dongfang Rd, Shanghai, 200127, People's Republic of China.
| | - Lanfang Cao
- Department of Pediatrics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, 1630 Dongfang Rd, Shanghai, 200127, People's Republic of China.
| | - Xianming Kong
- Department of Pediatrics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, 1630 Dongfang Rd, Shanghai, 200127, People's Republic of China.
| | - Haiyan Xue
- Department of Pediatrics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, 1630 Dongfang Rd, Shanghai, 200127, People's Republic of China.
| | - Xiaoli Li
- Department of Pediatrics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, 1630 Dongfang Rd, Shanghai, 200127, People's Republic of China.
| | - Lijuan Shen
- Department of Pediatrics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, 1630 Dongfang Rd, Shanghai, 200127, People's Republic of China.
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Horneff G, Foeldvari I, Minden K, Trauzeddel R, Kümmerle-Deschner JB, Tenbrock K, Ganser G, Huppertz HI. Efficacy and safety of etanercept in patients with the enthesitis-related arthritis category of juvenile idiopathic arthritis: results from a phase III randomized, double-blind study. Arthritis Rheumatol 2015; 67:2240-9. [PMID: 25891010 DOI: 10.1002/art.39145] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Accepted: 03/31/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of etanercept in patients with enthesitis-related arthritis (ERA) in juvenile idiopathic arthritis (JIA). METHODS This was a 2-phase study in JIA patients with active, refractory ERA. Phase I was an open-label, uncontrolled 24-week study period in which all patients were administered etanercept. Patients considered to be treatment responders at week 24 according to the American College of Rheumatology (ACR) Pediatric 30 (Pedi 30) criteria for improvement in juvenile arthritis entered the second phase, a 24-week randomized, double-blind, placebo-controlled withdrawal study, for an additional 24 weeks, for evaluation of the primary end point, occurrence of a disease flare from week 24 to week 48, based on the ACR preliminary definition of disease flare in juvenile arthritis. RESULTS Forty-one patients were enrolled. At week 24, treatment with etanercept resulted in response rates of 93%, 93%, 80%, 56%, and 54% based on the ACR Pedi 30, Pedi 50, Pedi 70, Pedi 90, and Pedi 100 criteria, respectively. In addition, a marked decrease in all disease activity measures was observed. The mean number of tender joints, swollen joints, and joints with active arthritis decreased by 91%, 97%, and 94%, respectively. Physician's global assessment of disease activity, parent's assessment of patient's overall well-being, and the Childhood Health Assessment Questionnaire disability index improved by 91%, 80%, and 86%, respectively. The number of tender enthesis sites and total scores for back pain, nocturnal pain, Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Functional Index, and Juvenile Arthritis Disease Activity Score based on 10-joint counts (JADAS10) decreased by 75%, 72%, 81%, 72%, 85%, and 87%, respectively. In phase II, 38 patients were randomly assigned to receive placebo (n = 18) or to continue receiving etanercept (n = 20). Up to week 48, 12 disease flares occurred, in 9 patients receiving placebo and 3 patients receiving etanercept (odds ratio 6.0, P = 0.02). There were no serious infections, malignancies, or deaths. CONCLUSION In this study of patients with the ERA category of JIA, etanercept proved effective, as indicated by high ACR Pedi response rates and JADAS10 response rates at week 24. Patients who continued treatment with etanercept had significantly fewer flares than those who received placebo, although 50% of patients in the placebo group did not experience a flare. Treatment suspension may be a consideration for patients with the ERA category of JIA who achieve remission.
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Affiliation(s)
- Gerd Horneff
- Asklepios Clinic Sankt Augustin, Sankt Augustin, Germany
| | - Ivan Foeldvari
- Hamburg Center for Pediatric Rheumatology, Hamburg, Germany
| | | | | | | | | | - Gerd Ganser
- St. Josef-Stift Sendenhorst Hospital, Sendenhorst, Germany
| | - Hans-Iko Huppertz
- Prof.-Hess Children's Hospital and Gesundheit Nord Klinikverbund Bremen, Bremen, Germany
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Guo R, Cao L, Kong X, Liu X, Xue H, Shen L, Li X. Fever as an initial manifestation of enthesitis-related arthritis subtype of juvenile idiopathic arthritis: retrospective study. PLoS One 2015; 10:e0128979. [PMID: 26030261 PMCID: PMC4451976 DOI: 10.1371/journal.pone.0128979] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 05/04/2015] [Indexed: 01/22/2023] Open
Abstract
Objective We wished to determine the prevalence of fever as one of the first symptoms of the enthesitis-related arthritis (ERA) subtype of juvenile idiopathic arthritis. Also, we wished to ascertain if ERA patients with fever at disease onset differed from those without fever. Methods Consecutive cases of ERA were diagnosed and followed in a retrospective observational study from 1998 to 2013. Information about clinical/laboratory data, medications, magnetic resonance imaging (MRI), and disease activity during the study period was also recorded. Results A total of 146 consecutive ERA patients were assessed. Among them, 52 patients (35.6%) had fever as one of the first symptoms at disease onset. Compared with ERA patients without fever at disease onset, patients with fever had significantly more painful joints (3.5 vs. 2.8), more swollen joints (1.1 vs. 0.8), and more enthesitis (1.0 vs. 0.4) (p<0.05 for all comparisons). Patients with fever had significantly higher mean values of erythrocyte sedimentation rate, C-reactive protein, platelet count, and child health assessment questionnaire (CHAQ) scores (40.8 vs. 26.4 mm/h; 20.7 vs. 9.7 mg/dL; 353.2×109/L vs. 275.6×109/L; 1.0 vs. 0.8, respectively; all p<0.05). During two-year follow-up, CHAQ score, number of flares, as well as the number of patients treated with oral non-steroidal anti-inflammatory drugs, corticosteroids and combination therapy with disease-modifying anti-rheumatic drugs, were significantly higher in ERA patients with fever. Conclusions Fever was a frequent manifestation of ERA. ERA patients with fever had more active disease at disease onset and poorer outcomes than ERA patients without fever.
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Affiliation(s)
- Ruru Guo
- Department of Pediatrics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P. R. China
| | - Lanfang Cao
- Department of Pediatrics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P. R. China
- * E-mail:
| | - Xianming Kong
- Department of Pediatrics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P. R. China
| | - Xuesong Liu
- Department of Ultrasound, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P. R. China
| | - Haiyan Xue
- Department of Pediatrics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P. R. China
| | - Lijuan Shen
- Department of Pediatrics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P. R. China
| | - Xiaoli Li
- Department of Pediatrics, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P. R. China
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