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Foeldvari I, Bohn M, Petrushkin H, Angeles Han S, Bangsgaard R, Calzada-Hernández J, Constantin T, de Boer JH, Díaz-Cascajosa J, Edelsten C, Glerup M, Ingels H, Kramer S, Miserocchi E, Nordal E, Saurenmann RK, Simonini G, Solebo AL, Titz J, Anton J. A practical approach to uveitis screening in children with juvenile idiopathic arthritis. Br J Ophthalmol 2024:bjo-2023-324406. [PMID: 38575198 DOI: 10.1136/bjo-2023-324406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 03/17/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Juvenile idiopathic arthritis (JIA)-associated uveitis typically presents as a silent chronic anterior uveitis and can lead to blindness. Adherence to current screening guidelines is hampered by complex protocols which rely on the knowledge of specific JIA characteristics. The Multinational Interdisciplinary Working Group for Uveitis in Childhood identified the need to simplify screening to enable local eye care professionals (ECPs), who carry the main burden, to screen children with JIA appropriately and with confidence. METHODS A consensus meeting took place in January 2023 in Barcelona, Spain, with an expert panel of 10 paediatric rheumatologists and 5 ophthalmologists with expertise in paediatric uveitis. A summary of the current evidence for JIA screening was presented. A nominal group technique was used to reach consensus. RESULTS The need for a practical but safe approach that allows early uveitis detection was identified by the panel. Three screening recommendations were proposed and approved by the voting members. They represent a standardised approach to JIA screening taking into account the patient's age at the onset of JIA to determine the screening interval until adulthood. CONCLUSION By removing the need for the knowledge of JIA categories, antinuclear antibody positivity or treatment status, the recommendations can be more easily implemented by local ECP, where limited information is available. It would improve the standard of care on the local level significantly. The proposed protocol is less tailored to the individual than the 'gold standard' ones it references and does not aim to substitute those where they are being used with confidence.
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Affiliation(s)
- Ivan Foeldvari
- Hamburg Centre for Pediatric and Adolescence Rheumatology, Hamburg, Germany
| | - Marcela Bohn
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
- West Hertfordshire Teaching Hospitals NHS Foundation Trust, London, UK
| | - Harry Petrushkin
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | | | - Regitze Bangsgaard
- Department of Ophthalmology, Copenhagen University Hospital Glostrup/Rigshospitalet, Copenhagen, Denmark
| | | | | | - Joke H de Boer
- Ophthalmology, F.C. Donders Institute, Utrecht, The Netherlands
| | | | | | - Mia Glerup
- Department of Paediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Helene Ingels
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Kobenhavn, Denmark
| | | | | | - Ellen Nordal
- Department of Paediatrics, UiT The Arctic University of Norway, Tromso, Norway
| | - Rotraud K Saurenmann
- Department of Paediatrics, Kantonsspital Winterthur, Winterthur, Switzerland
- Department of Rheumatology, University Children's Hospital Zurich, Zurich, Switzerland
| | | | - Ameenat Lola Solebo
- MRC Centre of Epidemiology of Child Health, Institute of Child Health University College London, London, UK
| | - Jan Titz
- Patients Representative, Hamburg, Germany
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Ede K, Shishov M, Wershba E, Goswami N, Gorry S, Joseph M, Mirea L, O'Neil J. Screening for juvenile idiopathic arthritis associated uveitis with laser flare photometry in the pediatric rheumatology office: a prospective observational study. Pediatr Rheumatol Online J 2024; 22:22. [PMID: 38279120 PMCID: PMC10811873 DOI: 10.1186/s12969-024-00961-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 01/19/2024] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND Juvenile Idiopathic Arthritis (JIA) Associated Uveitis (JIA-U) remains one of the most serious complications of JIA in children. Historically, pediatric JIA is diagnosed by an Optometrist or Ophthalmologist; however, barriers to scheduling increase wait times that may delay diagnosis and treatment. The purpose of this study was to evaluate laser flare photometry (LFP) use to diagnose JIA-U in the Pediatric Rheumatology clinic for patients with JIA. METHODS This prospective, observational study assessed pediatric patients diagnosed with JIA without a previous history of uveitis between January 2020 and September 2022. All patients underwent at least one evaluation of both eyes using a Kowa FM-600 laser flare photometer during a routine Rheumatology appointment, as well as a standard slit lamp examination (SLE) by optometry or ophthalmology during routine clinical care. Data collected at patient visits included demographics, JIA characteristics, treatment, LFP readings, and anterior chamber (AC) cell grade score utilizing the SUN grading system. Data were summarized using descriptive analyses and the uveitis false positive rate was calculated. RESULTS The study cohort included 58 pediatric patients diagnosed with JIA. The mean age was 8.4 years (1.2-16.3 years) at diagnosis and 11.9 (4.8-16.5 years) at enrollment. The mean duration of disease at time of enrollment was 42 months (range; 0-157 months). Participants were predominantly female (n = 43, 74.1%) and white/Caucasian race (n = 37, 63.8%). The most common JIA subtypes included persistent oligoarticular JIA (n = 19, 32.8%), and RF negative polyarticular JIA (n = 12, 20.7%). There were 12 ANA positive patients (20.7%). At enrollment, 16 patients (27.6%) were not on medications, with 20 (34.5%) on methotrexate, 20 (34.5%) on adalimumab, 6 (10.3%) on tocilizumab, and 5 (8.6%) on etanercept. During the study period, no eye exams detected active uveitis based on SLE with a SUN grade over 0. However, of the 135 LFP readings, 131 (97.0%) were normal, yielding a false positive rate of 3% (95% CI: 0.8%, 7.4%). CONCLUSIONS LFP is a non-invasive tool that can be utilized in the pediatric rheumatology clinic to evaluate for JIA-U. There is a low false positive rate of LFP when compared with standard slit lamp exam.
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Affiliation(s)
- Kaleo Ede
- Division of Pediatric Rheumatology, Phoenix Children's Hospital, 1919 E Thomas Rd, 85016, Phoenix, AZ, USA.
| | - Michael Shishov
- Division of Pediatric Rheumatology, Phoenix Children's Hospital, 1919 E Thomas Rd, 85016, Phoenix, AZ, USA
| | - Elisa Wershba
- Division of Pediatric Rheumatology, Phoenix Children's Hospital, 1919 E Thomas Rd, 85016, Phoenix, AZ, USA
| | - Nikita Goswami
- Division of Pediatric Rheumatology, Phoenix Children's Hospital, 1919 E Thomas Rd, 85016, Phoenix, AZ, USA
| | - Sabrina Gorry
- Division of Pediatric Rheumatology, Phoenix Children's Hospital, 1919 E Thomas Rd, 85016, Phoenix, AZ, USA
| | - Malin Joseph
- Department of Biostatistics, Phoenix Children's Hospital, 1919 E Thomas Rd, 85016, Phoenix, AZ, USA
| | - Lucia Mirea
- Department of Biostatistics, Phoenix Children's Hospital, 1919 E Thomas Rd, 85016, Phoenix, AZ, USA
| | - James O'Neil
- Division of Pediatric Ophthalmology, Phoenix Children's Hospital, 1919 E Thomas Rd, 85016, Phoenix, AZ, USA
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Leal I, Steeples LR, Wong SW, Giuffrè C, Pockar S, Sharma V, Green EKY, Payne J, Jones NP, Chieng ASE, Ashworth J. Update on the systemic management of noninfectious uveitis in children and adolescents. Surv Ophthalmol 2024; 69:103-121. [PMID: 36682467 DOI: 10.1016/j.survophthal.2023.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 12/22/2022] [Accepted: 01/13/2023] [Indexed: 01/20/2023]
Abstract
Noninfectious uveitis (NIU) in children and adolescents is a rare but treatable cause of visual impairment in children. Treatments for pediatric NIU and their side effects, along with the risks of vision loss and the need for long-term disease monitoring, pose significant challenges for young patients and their families. Treatment includes local and systemic approaches and this review will focus on systemic therapies that encompass corticosteroids, conventional synthetic disease-modifying antirheumatic drugs (csDMARD), and biological disease-modifying antirheumatic drugs (bDMARD). Treatment is generally planned in a stepwise approach. Methotrexate is well-established as the preferential csDMARD in pediatric NIU. Adalimumab, an antitumor necrosis factor (TNF) agent, is the only bDMARD formally approved for pediatric NIU and has a good safety and efficacy profile. Biosimilars are gaining increasing visibility in the treatment of pediatric NIU. Other bDMARD with some evidence in literature for the treatment of pediatric NIU include infliximab, tocilizumab, abatacept, rituximab and, more recently, Janus kinase inhibitors. Important aspects of managing children on these systemic therapies include vaccination issues, risk of infection, and psychological distress. Also, strategies need to address regarding primary nonresponse/secondary loss of response to anti-TNF treatment, biological switching, and monitoring regimens for these drugs. Optimal management of pediatric uveitis involves a multidisciplinary team, including specialist pediatric uveitis and rheumatology nurses, pediatric rheumatologists, psychological support, orthoptic and optometry support, and play specialists.
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Affiliation(s)
- Inês Leal
- Ophthalmology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal; Visual Sciences Study Centre, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.
| | - Laura R Steeples
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK; Academic Health Science Centre, Manchester, UK
| | - Shiao Wei Wong
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Chiara Giuffrè
- Centro Europeo di Oftalmologia, Palermo, Italy; Ophthalmology Department, San Raffaele Scientific Institute, University Vita-Salute, Milan, Italy
| | - Sasa Pockar
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Vinod Sharma
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Elspeth K Y Green
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Janine Payne
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Nicholas P Jones
- School of Biological Sciences, University of Manchester, Manchester, UK
| | | | - Jane Ashworth
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK; Division of Evolution & Genomic Sciences, University of Manchester, Manchester, UK
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Dehoorne JL, Groth H, Carlé E, De Schrijver I, Sys C, Delbeke P, Kreps EO, Renson T, Bonroy C. Defining a therapeutic range for adalimumab serum concentrations in the management of pediatric noninfectious uveitis, a step towards personalized treatment. Pediatr Rheumatol Online J 2023; 21:148. [PMID: 38124137 PMCID: PMC10734081 DOI: 10.1186/s12969-023-00928-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/15/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Adalimumab is currently considered the most efficacious anti-TNFα agent for childhood noninfectious uveitis (NIU). The objective of this study was to define a therapeutic range for adalimumab trough levels in the treatment of childhood NIU. METHODS A retrospective, observational, pilot study of 36 children with NIU aged < 18 years, treated with adalimumab. Serum adalimumab through levels and adalimumab anti-drug antibodies (ADA) were analysed at least 24 weeks after start adalimumab. RESULTS Adalimumab trough levels were significantly higher in complete responders 11.8 μg/mL (range 6.9-33.0) compared to partial or non-responders 9,2 μg/mL (range 0-13.6) (p = 0,004). Receiver-operator characteristics analyses with an area under the curve of 0,749 (95% CI, 0,561-0,937) defined 9.6 µg/mL as the lower margin for the therapeutic range. This cut-off corresponds with a sensitivity of 88% and a specificity of 56% (positive predictive value, 85%; negative predictive value, 62.5%). A concentration effect curve defined 13 µg/mL as the upper margin. Approximately one-third (30.5%) of patients had an adalimumab trough concentration exceeding 13 µg/mL. Free ADA were observed in 2 patients (5.5%). CONCLUSIONS A therapeutic range of adalimumab trough levels of 9.6 to 13 µg/mL, which corresponds with an optimal clinical effect, was identified. Therapeutic drug monitoring may guide the optimisation of treatment efficacy in children with NIU in the treat-to-target era.
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Affiliation(s)
- Jo L Dehoorne
- Department of Internal Medicine and Pediatrics, Department of Pediatric Rheumatology, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.
- European Reference Network for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases at the Ghent University Hospital, Ghent, Belgium.
| | - Helena Groth
- Ghent University, Faculty of Medicine and Health Sciences, Ghent, Belgium
| | - Emma Carlé
- Ghent University, Faculty of Medicine and Health Sciences, Ghent, Belgium
| | - Ilse De Schrijver
- Department of Ophthalmology and Center for Medical Genetics Ghent, Ghent University Hospital, Ghent, Belgium
- European Reference Network for Rare Eye Diseases at the Ghent University Hospital, Ghent, Belgium
| | - Celine Sys
- Department of Ophthalmology and Center for Medical Genetics Ghent, Ghent University Hospital, Ghent, Belgium
- European Reference Network for Rare Eye Diseases at the Ghent University Hospital, Ghent, Belgium
| | | | - Elke O Kreps
- Department of Ophthalmology and Center for Medical Genetics Ghent, Ghent University Hospital, Ghent, Belgium
- European Reference Network for Rare Eye Diseases at the Ghent University Hospital, Ghent, Belgium
| | - Thomas Renson
- Department of Internal Medicine and Pediatrics, Department of Pediatric Rheumatology, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
- European Reference Network for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases at the Ghent University Hospital, Ghent, Belgium
| | - Carolien Bonroy
- Department of Diagnostic Sciences, Ghent University; Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
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Maleki A, Patel PD, Foster CS. Juvenile idiopathic arthritis and its associated uveitis. Expert Rev Clin Immunol 2023; 19:1157-1169. [PMID: 37401872 DOI: 10.1080/1744666x.2023.2231154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 06/26/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION Juvenile idiopathic arthritis is the most common chronic rheumatologic disease in children. Uveitis is the most common extra-articular manifestation of JIA, and it can be a sight-threatening condition. AREAS COVERED In this review article, we discussed epidemiology, risk factors, clinical presentation, supportive laboratory tests, treatment options, and complications of Juvenile idiopathic arthritis and Juvenile idiopathic arthritis associated uveitis. We covered conventional immunomodulatory therapy and biologic response modifiers agents for different types of Juvenile idiopathic arthritis and their associated uveitis. Finally, we discussed the course of disease, functional outcome, and the quality of life of Juvenile idiopathic arthritis and Juvenile idiopathic arthritis-associated uveitis. EXPERT OPINION Although clinical outcomes of Juvenile idiopathic arthritis and its associated uveitis have been improved over the past three decades by biologic response modifier agents, a significant proportion of patients require active treatment into adult life therefore screening and monitoring of these patients is required during the patient's entire life. The limited number of food and drug administration approved biologic response modifier agents for the treatment of Juvenile idiopathic arthritis associated uveitis justify more randomized clinical trials with new medications in this field.
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Affiliation(s)
- Arash Maleki
- Department of Ophthalmology, University of Florida, Gainesville, FL, USA
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA
- The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - Priya D Patel
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA
- The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - C Steven Foster
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA
- The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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Psychological Effects and Quality of Life in Parents and Children with Jia-Associated Uveitis. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121864. [PMID: 36553308 PMCID: PMC9777304 DOI: 10.3390/children9121864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/25/2022] [Accepted: 11/26/2022] [Indexed: 12/02/2022]
Abstract
Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disease common in children and young adults. Uveitis is the most frequent serious extra-articular JIA manifestation and can lead to severe ocular complications, vision loss, and permanent blindness. This study aims to evaluate the psychological condition and the quality of life of children affected by JIA associated with uveitis (JIA-U) and the repercussion of this condition on parents. Thirty children and adolescents with active uveitis (Uveitis group) and comorbid joint symptoms of JIA were referred to the Unit of Ophthalmology, Giovanni XXIII Hospital of Bari, and 30 age-matched healthy controls (Healthy group) were enrolled with their parents. Four questionnaires were administered: Child Behaviour Checklist (CBCL), Parent Stress Index in Short Form (PSI), Pediatric Quality of Life Inventory (PedsQL), and Coping Inventory for Stressful Situations (CISS). The data were collected from February 2021 to December 2021. No significant differences between the two groups in CBCL, PSI, or CISS tests were shown (p > 0.05). Conversely, significant differences between the two groups were observed in the PedsQL (p < 0.05). This study shows how several ocular complications, recurrent eye examinations, and the rigor of long-term treatment may negatively influence health-related quality of life in children with JIA-U.
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Renton WD, Jung J, Palestine AG. Tumor necrosis factor (TNF) inhibitors for juvenile idiopathic arthritis-associated uveitis. Cochrane Database Syst Rev 2022; 10:CD013818. [PMID: 36239193 PMCID: PMC9562090 DOI: 10.1002/14651858.cd013818.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Uveitis is the most common extra-articular manifestation of juvenile idiopathic arthritis (JIA) and a potentially sight-threatening condition characterized by intraocular inflammation. Current treatment for JIA-associated uveitis (JIA-U) is largely based on physician experience, observational evidence and consensus guidelines, resulting in considerable variations in practice. OBJECTIVES: To evaluate the effectiveness and safety of tumor necrosis factor (TNF) inhibitors used for treatment of JIA-U. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature Database (LILACS); ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We last searched the electronic databases on 3 February 2022. SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing TNF inhibitors with placebo in participants with a diagnosis of JIA and uveitis who were aged 2 to 18 years old. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology and graded the certainty of the body of evidence for seven outcomes using the GRADE classification. MAIN RESULTS We included three RCTs with 134 participants. One study conducted in the USA randomized participants to etanercept or placebo (N = 12). Two studies, one conducted in the UK (N = 90) and one in France (N = 32), randomized participants to adalimumab or placebo. All studies were at low risk of bias. Initial pooled estimates suggested that TNF-inhibitors may result in little to no difference on treatment success defined as 0 to trace cells on Standardization of Uveitis Nomenclature (SUN)-grading; or two-step decrease in activity based on SUN grading (estimated risk ratio (RR) 0.66; 95% confidence interval (CI) 0.21 to 2.10; 2 studies; 43 participants; low-certainty evidence) or treatment failure defined as a two-step increase in activity based on SUN grading (RR 0.31; 95% CI 0.01 to 7.15; 1 study; 31 participants; low-certainty evidence). Further analysis using the individual trial definitions of treatment response and failure suggested a positive treatment effect of TNF inhibitors; a RR of treatment success of 2.60 (95% CI 1.30 to 5.20; 3 studies; 124 participants; low-certainty evidence), and RR of treatment failure of 0.23 (95% CI 0.11 to 0.50; 3 studies; 133 participants). Almost all the evidence was on adalimumab and the evidence on etanercept was very limited. For secondary outcomes, one study suggests that adalimumab may have little to no effect on risk of recurrence after induction of remission at three months (RR 2.50, 95% CI 0.31 to 20.45; 90 participants; very low-certainty evidence) and visual acuity, but the evidence is very uncertain; mean difference in longitudinal logMAR score change over six months was -0.01 (95% CI -0.06 to 0.03) and -0.02 (95% CI -0.07 to 0.03) using the best and worst logMAR measurement, respectively (low-certainty evidence). Low-certainty evidence from one study suggested that adalimumab treatment results in reduction of topical steroid doses at six months (hazard ratio 3.58; 95% CI 1.24 to 10.32; 74 participants who took one or more topical steroid per day at baseline). Adverse events, including injection site reactions and infections, were more common in the TNF inhibitor group. Serious adverse events were uncommon. AUTHORS' CONCLUSIONS Adalimumab appears to increase the likelihood of treatment success and decrease the likelihood of treatment failure when compared with placebo. The evidence was less conclusive about a positive treatment effect with etanercept. Adverse events from JIA-U trials are in keeping with the known side effect profile of TNF inhibitors. Standard validated JIA-U outcome measures are required to homogenize assessment and to allow for comparison and analysis of multiple datasets.
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Affiliation(s)
- William D Renton
- Rheumatology Unit, Department of General Medicine, The Royal Children's Hospital, Melbourne, Australia
| | - Jennifer Jung
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Alan G Palestine
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora, Colorado, USA
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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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Juvenile Idiopathic Arthritis-associated Uveitis: Diagnosis, Management, Sequelae. Int Ophthalmol Clin 2022; 62:143-154. [PMID: 34965232 DOI: 10.1097/iio.0000000000000391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Childhood noninfectious uveitis leads to sight-threatening complications. Idiopathic chronic anterior uveitis and juvenile idiopathic arthritis-associated uveitis are most common. Inflammation arises from an immune response against antigens within the eye. Ophthalmic work-up evaluates anatomic involvement, disease activity, ocular complications, and disease course. Local and/or systemic glucocorticoids are initial treatment, but not as long-term sole therapy to avoid glucocorticoids-induced toxicity or persistent ocular inflammation. Children with recurrent, refractory, or severe disease require systemic immunosuppression with methotrexate and/or anti-tumor necrosis factor monoclonal antibody medications (adalimumab, infliximab). Goals of early detection and treatment are to optimize vision in childhood uveitis.
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Affiliation(s)
- Margaret H Chang
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Fegan 6, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Jessica G Shantha
- Department of Ophthalmology, Emory University, Emory Eye Center, 1365 Clifton Road, Clinic Building B, Atlanta, GA 30326, USA
| | - Jacob J Fondriest
- Department of Internal Medicine, Summa Health System, Internal Medicine Center, 55 Arch Street, Suite 1B, Akron, OH 44304, USA; Rush Eye Center, 1725 West Harrison Street, Suite 945, Chicago, IL 60612, USA
| | - Mindy S Lo
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Fegan 6, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Sheila T Angeles-Han
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, 3333 Burnett Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA; Division of Ophthalmology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Ophthalmology, University of Cincinnati, Cincinnati, OH, USA.
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Maccora I, Lombardi N, Crescioli G, Bettiol A, Bonaiuti R, Pagnini I, Maniscalco V, Marrani E, Mastrolia MV, Ravaldi C, Consolini R, Cattalini M, Vannacci A, Simonini G. OBSIDIAn - real world evidence of Originator to BioSImilar Drug switch in juvenile idiopathic arthritis. Rheumatology (Oxford) 2021; 61:1518-1528. [PMID: 34273158 DOI: 10.1093/rheumatology/keab572] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/23/2021] [Accepted: 07/05/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Limited data about use of biosimilars are available in children with Juvenile Idiopathic Arthritis (JIA). This study therefore aimed to evaluate long-term efficacy and safety of switching from etanercept (ETA) and adalimumab (ADA) originators to their biosimilars, in children with JIA, in a real-world setting. METHODS This is a retro-prospective non-interventional multicentre Italian comparative cohort study. Medical charts of JIA children treated with biosimilars of ETA or ADA were included. Efficacy and safety of TNF-inhibitors therapy was evaluated at last follow-up during originator and at 3, 6 and 12 months following the switch to biosimilar. RESULTS 59 children (42 female, median age at onset 88 months) were treated with biosimilar of ETA (21) and ADA (38). Forty-five switched from the originator to the BIO (17 ETA, 28 ADA). At time of switch, 12/17 patients on ETA and 18/28 on ADA were in remission. No significant difference has been found at 3, 6 and 12 months after the switch. Ten patients discontinued biosimilars due to disease remission (4 ETA, 3 ADA), family willing (1 ETA), occurrence of burning at injection site (1 ETA), and persistent activity (1 ADA). No statistically significant difference was observed between originator and BIOs, nor between originator and BIOs, and between ADA and ETA in time to disease remission achievement, time to relapse and number of patients who experienced AE. CONCLUSION Our real-life results seem to confirm the efficacy and safety profile of switching from originator of ADA and ETA to their respective BIOs also in paediatric patients with JIA.
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Affiliation(s)
- Ilaria Maccora
- Rheumatology Unit, Meyer Children's University Hospital; Florence, Italy.,Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence; Florence, Italy
| | - Niccolò Lombardi
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence; Florence, Italy.,Tuscan Regional Centre of Pharmacovigilance; Florence, Italy
| | - Giada Crescioli
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence; Florence, Italy.,Tuscan Regional Centre of Pharmacovigilance; Florence, Italy
| | - Alessandra Bettiol
- Department of Experimental and Clinical Medicine, University of Florence; Florence, Italy
| | - Roberto Bonaiuti
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence; Florence, Italy
| | - Ilaria Pagnini
- Rheumatology Unit, Meyer Children's University Hospital; Florence, Italy
| | - Valerio Maniscalco
- Rheumatology Unit, Meyer Children's University Hospital; Florence, Italy
| | - Edoardo Marrani
- Rheumatology Unit, Meyer Children's University Hospital; Florence, Italy
| | - Maria Vincenza Mastrolia
- Rheumatology Unit, Meyer Children's University Hospital; Florence, Italy.,Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence; Florence, Italy
| | - Claudia Ravaldi
- PeaRL - Perinatal Research Laboratory, University of Florence and CiaoLapo Foundation for Perinatal Health; Florence, Italy
| | - Rita Consolini
- Section of Clinical Immunology and Rheumatology, Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Marco Cattalini
- Pediatrics Clinic, ASST Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Alfredo Vannacci
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence; Florence, Italy.,Tuscan Regional Centre of Pharmacovigilance; Florence, Italy.,PeaRL - Perinatal Research Laboratory, University of Florence and CiaoLapo Foundation for Perinatal Health; Florence, Italy
| | - Gabriele Simonini
- Rheumatology Unit, Meyer Children's University Hospital; Florence, Italy.,Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence; Florence, Italy
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12
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Quartier P. Juvenile Idiopathic Arthritis-Associated Chronic Uveitis: Recent Therapeutic Approaches. J Clin Med 2021; 10:2934. [PMID: 34208973 PMCID: PMC8269439 DOI: 10.3390/jcm10132934] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/25/2021] [Accepted: 06/28/2021] [Indexed: 11/23/2022] Open
Abstract
Pediatric patients with early onset (before the age of 6 years), antinuclear antibody positive, oligoarticular or polyarticular juvenile idiopathic arthritis (JIA), and some children with no arthritis may develop chronic, anterior uveitis. Recent recommendations insist on the need to perform slit lamp examination every 3 months for at least 5 years in early onset JIA patients in order to diagnose uveitis before complications develop. Local steroid therapy is usually the first-line treatment. However, in patients requiring steroid eye drops for several months, systemic immunomodulatory therapy is indicated. Methotrexate (MTX) is then prescribed in most cases; however, some patients also need anti-tumor necrosis factor alpha monoclonal antibody therapy and, in some cases, other biologics to control uveitis and avoid long-term ocular damage. Expert ophthalmologists and pediatricians must be involved in taking care of such patients. Immunomodulatory treatment must not be too easily interrupted and may even be intensified in some cases, particularly if there is a need for optimal disease control before ophthalmologic surgery. In good responders to MTX and/or biologics, treatment must be maintained at least 1 year, possibly even 2 years after achieving remission before tapering treatment intensity.
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Affiliation(s)
- Pierre Quartier
- Pediatric Immunology, Hematology and Rheumatology Unit, Necker-Enfants Malades Hospital, Assistance Publique-Hopitaux de Paris, 75015 Paris, France;
- RAISE Reference Centre for Rare Diseases, IMAGINE Institute, Necker-Enfants Malades Hospital, Assistance Publique-Hopitaux de Paris, 75015 Paris, France
- INSERM Unit 1163, Université de Paris, 75005 Paris, France
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13
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Ozdel S, Baglan E, Cakıcı EK, Yazılıtas F, Yücel H, Senel S, Bulbul M. Clinical features in 305 patients with juvenile idiopathic arthritis: A single center Turkish Study. Pediatr Int 2021; 63:636-642. [PMID: 32969552 DOI: 10.1111/ped.14481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/11/2020] [Accepted: 09/15/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatologic disease of childhood. The various subtypes of JIA differ in clinical features and treatments. The aim of this study was to analyze the frequency of JIA subtypes, patient demographic and clinical features, as well as the rates of macrophage activation syndrome, uveitis, and remission in Turkish JIA patients treated at a single center, and to compare the findings to those in the literature. METHODS The files of all JIA patients treated at our pediatric rheumatology department between January 2017 and January 2019 were retrospectively reviewed. Patient demographic, clinical, and laboratory data were obtained from the patients' files and the hospital database. RESULTS The study included 305 patients (180 females) with a mean age at onset of 7.83 ± 4.62 years. Among all the JIA subtypes, the most frequent was oligoarthritis (41.6%), followed by enthesitis-related arthritis (29.2%), rheumatoid factor (RF)-negative polyarthritis (13.4%), systemic arthritis (9.5%), RF-positive polyarthritis (2.6%), psoriatic arthritis (2.0%), and undifferentiated arthritis (1.6%). At the time of data collection, 278 patients (91.0%) were in remission, whereas 27 patients (9.0%) had active disease. Macrophage activation syndrome developed in 12 of the 29 (41.0%) systemic arthritis. Uveitis was noted in 32 (10.0%) patients. Biological agents were administered in 142 of the patients. CONCLUSIONS The available data indicate that JIA as a whole is a heterogeneous disease with significant variability in course and long-term outcome. As such, each patient should be evaluated according to his / her disease subtype.
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Affiliation(s)
- Semanur Ozdel
- Departments of, Department of, Pediatric Rheumatology, Dr Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Esra Baglan
- Departments of, Department of, Pediatric Rheumatology, Dr Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Evrim Kargın Cakıcı
- Departments of, Department of, Pediatric Rheumatology, Dr Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Fatma Yazılıtas
- Departments of, Department of, Pediatric Rheumatology, Dr Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Hüsniye Yücel
- Department of, Pediatrics, Dr Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Saliha Senel
- Department of, Pediatrics, Dr Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Mehmet Bulbul
- Departments of, Department of, Pediatric Rheumatology, Dr Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
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14
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Neves LM, Haefeli LM, Hopker LM, Ejzenbaum F, Moraes do Nascimento H, Aikawa N, Hilario MO, Magalhães CS, Terreri MT, Sztajnbok F, Silva C, Rossetto JD. Monitoring and Treatment of Juvenile Idiopathic Arthritis-associated Uveitis: Brazilian Evidence-based Practice Guidelines. Ocul Immunol Inflamm 2021; 30:1384-1398. [PMID: 33826468 DOI: 10.1080/09273948.2021.1876886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Purpose: To present a national guideline for ophthalmologic care and surveillance of juvenile idiopathic arthritis-associated uveitis (JIA-uveitis).Methods: Review article based on medical literature and the experience of an Expert Committee composed of members of the Brazilian Society of Pediatric Ophthalmology/Brazilian Council of Ophthalmology and the Brazilian Society of Pediatrics/Brazilian Society of Rheumatology. Studies with a high level of evidence were selected by searching the PubMed/Medline database. The final document was approved by the experts.Results: The main recommendations are that children/adolescents with JIA should undergo screening according to their risk factors. Ophthalmological checkups should also consider ocular inflammation and therapy. Topical glucocorticoids should be the first line of therapy, with systemic glucocorticoids acting as bridge treatments in severe uveitis. Methotrexate should be the first-line systemic therapy and anti-tumor necrosis factor (anti-TNF alpha) the second for uncontrolled uveitis.Conclusions: This evidence-based guideline for JIA-uveitis will be useful for both ophthalmology and rheumatology practice.
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Affiliation(s)
- L M Neves
- Ophthalmology Department, Instituto Nacional De Saúde Da Mulher, Da Criança E Do Adolescente Fernandes Figueira- Fundação Oswaldo Cruz, Rio De Janeiro, RJ, Brazil.,Brazilian Society of Pediatric Ophthalmology (SBOP), Sao Paulo/SP, Brazil.,Brazilian Council of Ophthalmology (CBO), Sao Paulo/SP, Brazil
| | - L M Haefeli
- Ophthalmology Department, Instituto Nacional De Saúde Da Mulher, Da Criança E Do Adolescente Fernandes Figueira- Fundação Oswaldo Cruz, Rio De Janeiro, RJ, Brazil.,Brazilian Society of Pediatric Ophthalmology (SBOP), Sao Paulo/SP, Brazil.,Brazilian Council of Ophthalmology (CBO), Sao Paulo/SP, Brazil
| | - L M Hopker
- Brazilian Society of Pediatric Ophthalmology (SBOP), Sao Paulo/SP, Brazil.,Brazilian Council of Ophthalmology (CBO), Sao Paulo/SP, Brazil.,Ophthalmology Department, Hospital De Olhos Do Paraná, Curitiba/PR, Brazil.,Brazilian Society of Pediatrics (SBP), Rio de Janeiro/RJ, Brazil
| | - F Ejzenbaum
- Brazilian Society of Pediatric Ophthalmology (SBOP), Sao Paulo/SP, Brazil.,Brazilian Council of Ophthalmology (CBO), Sao Paulo/SP, Brazil.,Brazilian Society of Pediatrics (SBP), Rio de Janeiro/RJ, Brazil.,Ophthalmology Department, Santa Casa De Misericórdia De São Paulo Sao Paulo/SP, Brazil
| | - H Moraes do Nascimento
- Brazilian Council of Ophthalmology (CBO), Sao Paulo/SP, Brazil.,Ophthalmology and Visual Science Department, Federal University of Sao Paulo - UNIFESP, São Paulo, SP, Brazil
| | - N Aikawa
- Brazilian Society of Pediatrics (SBP), Rio de Janeiro/RJ, Brazil.,Pediatric Rheumatology Unit, Children's Institute, Hospital Das Clinicas HCFMUSP, Faculdade De Medicina, Universidade De Sao Paulo, SP, Brazil.,Brazilian Society of Rheumatology (SBR), Sao Paulo/SP, Brazil
| | - M O Hilario
- Brazilian Society of Pediatrics (SBP), Rio de Janeiro/RJ, Brazil.,Brazilian Society of Rheumatology (SBR), Sao Paulo/SP, Brazil.,Pediatric Department, Santa Casa De Misericórdia De Porto Alegre, Porto Alegre/RS, Brazil
| | - C S Magalhães
- Brazilian Society of Pediatrics (SBP), Rio de Janeiro/RJ, Brazil.,Brazilian Society of Rheumatology (SBR), Sao Paulo/SP, Brazil.,Pediatric Rheumatology Division, São Paulo State University (UNESP), Botucatu/SP, Brazil
| | - M T Terreri
- Brazilian Society of Pediatrics (SBP), Rio de Janeiro/RJ, Brazil.,Brazilian Society of Rheumatology (SBR), Sao Paulo/SP, Brazil.,Pediatric Rheumatology Unit, Federal University of São Paulo - UNIFESP, São Paulo/SP, Brazil
| | - F Sztajnbok
- Brazilian Society of Pediatrics (SBP), Rio de Janeiro/RJ, Brazil.,Brazilian Society of Rheumatology (SBR), Sao Paulo/SP, Brazil.,Pediatric Department, Instituto De Puericultura E Pediatria Martagão Gesteira - IPPMG/Federal University of Rio De Janeiro - UFRJ - Rio De Janeiro/RJ, Brazil
| | - Caa Silva
- Brazilian Society of Pediatrics (SBP), Rio de Janeiro/RJ, Brazil.,Pediatric Rheumatology Unit, Children's Institute, Hospital Das Clinicas HCFMUSP, Faculdade De Medicina, Universidade De Sao Paulo, SP, Brazil.,Brazilian Society of Rheumatology (SBR), Sao Paulo/SP, Brazil
| | - J D Rossetto
- Brazilian Society of Pediatric Ophthalmology (SBOP), Sao Paulo/SP, Brazil.,Brazilian Council of Ophthalmology (CBO), Sao Paulo/SP, Brazil.,Brazilian Society of Pediatrics (SBP), Rio de Janeiro/RJ, Brazil.,Ophthalmology and Visual Science Department, Federal University of Sao Paulo - UNIFESP, São Paulo, SP, Brazil.,Pediatric Department, Instituto De Puericultura E Pediatria Martagão Gesteira - IPPMG/Federal University of Rio De Janeiro - UFRJ - Rio De Janeiro/RJ, Brazil
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15
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Li Y, Mao X, Tang X, Mao H. Efficacy and Safety of Anti-TNFα Therapy for Uveitis Associated with Juvenile Idiopathic Arthritis: A Systematic Review and Meta-Analysis. Rheumatol Ther 2021; 8:711-727. [PMID: 33721267 PMCID: PMC8217376 DOI: 10.1007/s40744-021-00296-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 02/13/2021] [Indexed: 12/20/2022] Open
Abstract
Introduction To investigate the efficacy and safety of anti-TNFα therapy in patients with juvenile idiopathic arthritis associated uveitis (JIA-U). Methods Embase, PubMed, Cochrane Library, and Web of Science were systematically searched for studies reporting anti-TNFα treatment in patients with JIA-U. The primary outcome was the control of intraocular inflammation (CII). The pooled proportion of CII was assessed by the random-effects method when I2 > 50%, otherwise, by the fixed-effect method. This study was registered with PROSPERO (CRD42020161749). Results Three randomized clinical trials (RCTs), twelve case series, three retrospective cohort studies, and three case reports were identified. A total of 399 patients were receiving anti-TNFα therapy, of which 201 patients were treated with adalimumab (ADA), 139 with infliximab (IFX), 36 with etanercept (ETA), 20 with golimumab (GLM), and 3 with certolizumab pegol (CZP). The pooled proportions of CII on observational studies were 82% (95% CI 63–96%) in patients receiving ADA, 56% (95% CI 30–80%) in IFX, 38% (95% CI 8–73%) in ETA and 65% (95% CI 42–86%) in GLM, respectively. All three patients treated with CZP reached improved activity. ADA therapy led to a significantly higher proportion of CII compared to IFX therapy (χ2 = 26.24, P < 0.001), or to ETA therapy (χ2 = 13.43, P < 0.001); but no statistical difference was observed between IFX and ETA (χ2 = 0.13, P = 0.71). As to safety, most reported adverse events were tolerable and two cohort studies consistently showed that ADA was safer than IFX. Conclusions The existing evidence suggests that ADA is better than IFX regarding efficacy and safety. The effectiveness of IFX is higher than ETA with no statistical difference. GLM and CZP may be proxies for ADA but the evidence is limited. Supplementary Information The online version contains supplementary material available at 10.1007/s40744-021-00296-x.
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Affiliation(s)
- Yulu Li
- Department of Rheumatology and Immunology, National Clinical Research Center for Child Health and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaolan Mao
- Department of Rheumatology and Immunology, National Clinical Research Center for Child Health and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xuemei Tang
- Department of Rheumatology and Immunology, National Clinical Research Center for Child Health and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Huawei Mao
- Department of Rheumatology and Immunology, National Clinical Research Center for Child Health and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.
- Department of Immunology, National Center for Children's Health, Beijing Children's Hospital of Capital Medical University, Beijing, China.
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16
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Chen JL, Abiri P, Tsui E. Recent advances in the treatment of juvenile idiopathic arthritis-associated uveitis. Ther Adv Ophthalmol 2021; 13:2515841420984572. [PMID: 33681703 PMCID: PMC7897841 DOI: 10.1177/2515841420984572] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/04/2020] [Indexed: 12/14/2022] Open
Abstract
Juvenile idiopathic arthritis-associated uveitis has an estimated prevalence of 10-20% in patients with juvenile idiopathic arthritis, making it the most common cause of chronic anterior uveitis in children. Prompt treatment is important to prevent development of ocular complications and permanent vision loss. In this review, we will discuss the use of immunosuppression in treatment of juvenile idiopathic arthritis-associated uveitis. This will include the use of conventional immunosuppressants, such as methotrexate, biologic anti-tumor necrosis factor agents, such as adalimumab, as well as other anti-tumor necrosis factor agents, including infliximab and golimumab. In addition, we will discuss medications currently in clinical trials or under consideration for juvenile idiopathic arthritis-associated uveitis, including interleukin-6 inhibitors (tocilizumab) and Janus kinase inhibitors (tofacitinib, baricitinib).
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Affiliation(s)
- Judy L Chen
- Stein Eye Institute, Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Parinaz Abiri
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Edmund Tsui
- Assistant Professor of Ophthalmology, Stein Eye Institute, Department of Ophthalmology, David Geffen School of Medicine at UCLA, 200 Stein Plaza, Los Angeles, CA 90095-7003, USA
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17
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Jung J, Khachatryan N, Palestine A. Tumor necrosis factor (TNF) inhibitors for juvenile idiopathic arthritis-associated uveitis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Jennifer Jung
- Department of Ophthalmology; University of Colorado School of Medicine; Aurora Colorado USA
| | - Naira Khachatryan
- Department of Ophthalmology; University of Colorado School of Medicine; Aurora Colorado USA
| | - Alan Palestine
- Department of Ophthalmology; University of Colorado School of Medicine; Aurora Colorado USA
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18
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Çakan M, Ayaz NA, Karadağ ŞG, Ekinci DY. Why is the frequency of uveitis low in Turkish children with juvenile idiopathic arthritis? Rheumatology (Oxford) 2020; 59:679-680. [PMID: 31497847 DOI: 10.1093/rheumatology/kez399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 08/06/2019] [Indexed: 01/09/2023] Open
Affiliation(s)
| | | | | | - Dilbade Yıldız Ekinci
- Clinic of Ophthalmology, Kanuni Sultan Süleyman Research and Training Hospital, Istanbul, Turkey
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19
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Ramanan AV, Dick AD, Guly C, McKay A, Jones AP, Hardwick B, Lee RWJ, Smyth M, Jaki T, Beresford MW. Tocilizumab in patients with anti-TNF refractory juvenile idiopathic arthritis-associated uveitis (APTITUDE): a multicentre, single-arm, phase 2 trial. THE LANCET. RHEUMATOLOGY 2020; 2:e135-e141. [PMID: 32280950 PMCID: PMC7134526 DOI: 10.1016/s2665-9913(20)30008-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Uveitis associated with juvenile idiopathic arthritis is a cause of major ocular morbidity. A substantial proportion of children are refractory to systemic methotrexate and TNF inhibitors. Our aim was to study the safety and efficacy of tocilizumab in children with juvenile idiopathic arthritis-associated uveitis refractory to both methotrexate and TNF inhibitors. METHODS This multicentre, single-arm, phase 2 trial was done following a Simon's two-stage design at seven tertiary hospital sites in the UK. Patients aged 2-18 years with active juvenile idiopathic arthritis-associated uveitis were eligible. All patients had been on a stable dose of methotrexate for at least 12 weeks and had not responded to treatment with a TNF inhibitor. Patients weighing 30 kg or more were treated with 162 mg subcutaneous tocilizumab every 2 weeks for 24 weeks, and participants weighing less than 30 kg were treated with 162 mg every 3 weeks for 24 weeks. The primary outcome was treatment response defined as a two-step decrease, or decrease to zero, from baseline in the level of inflammation (anterior chamber cells) at week 12, per the standardisation of uveitis nomenclature criteria. A phase 3 trial would be justified if more than seven patients responded to treatment. An interim analysis was planned to assess whether the trial would be stopped for futility, with futility defined as two or fewer treatment responses among ten participants. Adverse events were collected up to 30 calendar days after treatment cessation. The primary analysis was done in the intention-to-treat population and the safety analysis was done in all patients who started the treatment. This trial is registered with the International Standard Randomised Controlled Trial Number registry (ISRCTN95363507) and EU Clinical Trials Register (EudraCT 2015-001323-23). FINDINGS 22 participants were enrolled to the trial between Dec 3, 2015, and March 9, 2018, and 21 participants received treatment. One participant was found to be ineligible immediately after enrolment and was therefore withdrawn. Seven of 21 (median unbiased estimate of proportion 34% [95% CI 25-57]) responded to treatment (p=0·11). Safety results were consistent with the known safety profile of tocilizumab. INTERPRETATION The primary endpoint was not met, and thus the results do not support a phase 3 trial of tocilizumab in patients with juvenile idiopathic arthritis-associated uveitis. Importantly, data on the use of tocilizumab in clinical practice is now captured in national registries. Despite this trial not meeting the threshold required to justify a larger phase 3 trial, several patients responded to treatment; as such, tocilzumab might still be a therapeutic option in some children with uveitis refractory to anti-TNF drugs, given the absence of other treatment options. FUNDING Versus Arthritis and the National Institute for Health Research Clinical Research Network: Children.
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Affiliation(s)
- Athimalaipet V Ramanan
- University Hospitals Bristol NHS Foundation Trust and Bristol Medical School, University of Bristol, Bristol, UK,Correspondence to: Prof A V Ramanan, University Hospitals Bristol NHS Foundation Trust and Bristol Medical School, University of Bristol, Bristol BS2 8BJ, UK
| | - Andrew D Dick
- Bristol Eye Hospital, Bristol, UK,School of Clinical Sciences, University of Bristol, Bristol, UK,UCL Institute of Ophthalmology and National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital, London, UK,University College London Institute of Ophthalmology, London, UK
| | | | - Andrew McKay
- Liverpool Clinical Trials Centre, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Ashley P Jones
- Liverpool Clinical Trials Centre, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Ben Hardwick
- Liverpool Clinical Trials Centre, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Richard W J Lee
- Bristol Eye Hospital, Bristol, UK,School of Clinical Sciences, University of Bristol, Bristol, UK,UCL Institute of Ophthalmology and National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital, London, UK,University College London Institute of Ophthalmology, London, UK
| | - Matthew Smyth
- Liverpool Clinical Trials Centre, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Thomas Jaki
- Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - Michael W Beresford
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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20
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Malcová H, Dallos T, Bouchalova K, Brejchová I, Brichová M, Bušányová B, Fabianová J, Fráňová J, Furdová A, Jarošová K, Kobrová K, Kostolná B, Košková E, Lokaj M, Macků M, Melocíková J, Michaličková M, Minxová L, Moravčíková D, Němcová D, Pískovský T, Říhová E, Schüller M, Skalická E, Svozílková P, Tomčíková D, Vargová V, Vrtíková E, Doležalová P, Heissigerová J. Recommendations for the Management of Uveitis Associated With Juvenile Idiopathic Arthritis: The Czech and Slovak adaptation of SHARE Initiative. CESKA A SLOVENSKA OFTALMOLOGIE : CASOPIS CESKE OFTALMOLOGICKE SPOLECNOSTI A SLOVENSKE OFTALMOLOGICKE SPOLECNOSTI 2020; 76:1-15. [PMID: 33086847 DOI: 10.31348/2020/7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children and uveitis is its most important extra-articular manifestation. Evidence-based recommendations are available only to a limited extent and therefore JIA associated uveitis management is mostly based on physicians experience. Consequently, treatment practices differ widely, both nationally and internationally. Therefore, an effort to optimize and publish recommendations for the care of children and young adults with rheumatic diseases was launched in 2012 as part of the international project SHARE (Single Hub and Access Point for Pediatric Rheumatology in Europe) to facilitate clinical practice for paediatricians and (paediatric) rheumatologists. The aim of this work was to translate published international SHARE recommendations for the diagnosis and treatment of JIA associated uveitis and to adapt them for use in the Czech and Slovak Republics. International recommendations were developed according to the standard methodology of the European League against Rheumatism (EULAR) by a group of nine experienced paediatric rheumatologists and three experts in ophthalmology. It was based on a systematic literature review and evaluated in the form of an online survey and subsequently discussed using a nominal group technique. Recommendations were accepted if > 80% agreement was reached (including all three ophthalmologists). A total of 22 SHARE recommendations were accepted: 3 on diagnosis, 5 on disease activity assessment, 12 on treatment and 2 on future recommendations. Translation of the original text was updated and modified with data specific to the czech and slovak health care systems and supplemented with a proposal for a protocol of ophthalmological dispensarization of paediatric JIA patients and a treatment algorithm for JIA associated uveitis. Conclusion: The aim of the SHARE initiative is to improve and standardize care for paediatric patients with rheumatic diseases across Europe. Therefore, recommendations for the diagnosis and treatment of JIA-associated uveitis have been formulated based on the evidence and agreement of leading European experts in this field.
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Gaggiano C, Rigante D, Tosi GM, Vitale A, Frediani B, Grosso S, Fabiani C, Cantarini L. Treating juvenile idiopathic arthritis (JIA)-related uveitis beyond TNF-α inhibition: a narrative review. Clin Rheumatol 2019; 39:327-337. [PMID: 31823144 DOI: 10.1007/s10067-019-04763-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 12/13/2022]
Abstract
Chronic anterior uveitis is the most frequent among extra-articular manifestations of juvenile idiopathic arthritis (JIA) and a relevant cause of ocular morbidity in children. Asymmetric arthritis, early onset disease, female sex, and anti-nuclear antibody (ANA) positivity are counted among risk factors for developing this complication. It usually has insidious onset and asymptomatic chronic-relapsing course, but the persistence of low-grade chronic inflammation can lead to irreversible structural ocular damage and to vision-threatening complications. For such reasons, achieving a complete absence of inflammation through early targeted and aggressive treatments is a primary therapeutic goal in these patients. This review is aimed at summarizing scientific evidence about biologic rescue therapy of JIA-related uveitis in patients who fail to achieve clinical remission, in spite of being treated with conventional disease-modifying anti-rheumatic drugs (cDMARDs) and at least one biologic tumor necrosis factor (TNF)-α inhibitor. Interleukin (IL)-6 inhibition appears a promising and safe option for refractory JIA-related uveitis. Abatacept and rituximab proved to be beneficial as well, but their efficacy together with some safety concerns needs to be more extensively evaluated.
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Affiliation(s)
- Carla Gaggiano
- Clinical Pediatrics, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Donato Rigante
- Institute of Pediatrics, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
- Periodic Fever Research Center, Università Cattolica Sacro Cuore, Rome, Italy
| | - Gian Marco Tosi
- Ophthalmology Unit, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Antonio Vitale
- Research Center of Systemic Autoinflammatory Diseases, Behçet's Disease and Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Bruno Frediani
- Research Center of Systemic Autoinflammatory Diseases, Behçet's Disease and Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Salvatore Grosso
- Clinical Pediatrics, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Claudia Fabiani
- Ophthalmology Unit, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Luca Cantarini
- Research Center of Systemic Autoinflammatory Diseases, Behçet's Disease and Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy.
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22
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Juvenile idiopathic arthritis-associated uveitis. Clin Immunol 2019; 211:108322. [PMID: 31830532 DOI: 10.1016/j.clim.2019.108322] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 12/05/2019] [Indexed: 12/25/2022]
Abstract
Juvenile idiopathic arthritis (JIA) is the commonest rheumatic disease in children and JIA-associated uveitis its most frequent extra-articular manifestation. The uveitis is potentially sight-threatening and so carries a considerable risk of morbidity. The commonest form of uveitis seen in JIA is chronic anterior uveitis which is almost always asymptomatic in the initial stages. Therefore, screening for JIA-associated uveitis in at-risk patients is essential. The aim of early detection and treatment is to minimise intra-ocular inflammation and avoid complications leading to visual loss, resulting from both disease activity and medications. There is increasing evidence for the early introduction of systemic immunosuppressive therapies in order to reduce topical and systemic glucocorticoid use. Two randomised controlled trials of adalimumab in JIA-associated uveitis provide convincing evidence for the use of this biologic in patients who fail to respond adequately to methotrexate. Tocilizumab and baricitinib are being investigated as alternatives to anti-tumour necrosis factor drugs.
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Ridley RB, Young BM, Lee J, Walsh E, Ahmed CM, Lewin AS, Ildefonso CJ. AAV Mediated Delivery of Myxoma Virus M013 Gene Protects the Retina against Autoimmune Uveitis. J Clin Med 2019; 8:jcm8122082. [PMID: 31795515 PMCID: PMC6947576 DOI: 10.3390/jcm8122082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/23/2019] [Accepted: 11/26/2019] [Indexed: 12/14/2022] Open
Abstract
Uveoretinitis is an ocular autoimmune disease caused by the activation of autoreactive T- cells targeting retinal antigens. The myxoma M013 gene is known to block NF-κB (Nuclear Factor kappa-light-chain-enhancer of activated B cells) and inflammasome activation, and its gene delivery has been demonstrated to protect the retina against lipopolysaccharide (LPS)-induced uveitis. In this report we tested the efficacy of M013 in an experimental autoimmune uveoretinitis (EAU) mouse model. B10RIII mice were injected intravitreally with AAV (adeno associated virus) vectors delivering either secreted GFP (sGFP) or sGFP-TatM013. Mice were immunized with interphotorecptor retinoid binding protein residues 161–180 (IRBP161–180) peptide in complete Freund’s adjuvant a month later. Mice were evaluated by fundoscopy and spectral domain optical coherence tomography (SD-OCT) at 14 days post immunization. Eyes were evaluated by histology and retina gene expression changes were measured by reverse transcribed quantitative PCR (RT-qPCR). No significant difference in ERG or retina layer thickness was observed between sGFP and sGFP-TatM013 treated non-uveitic mice, indicating safety of the vector. In EAU mice, expression of sGFP-TatM013 strongly lowered the clinical score and number of infiltrative cells within the vitreous humor when compared to sGFP treated eyes. Retina structure was protected, and pro-inflammatory genes expression was significantly decreased. These results indicate that gene delivery of myxoma M013 could be of clinical benefit against autoimmune diseases.
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Affiliation(s)
- Raela B. Ridley
- Department of Ophthalmology, University of Florida College of Medicine, Gainesville, FL 32610, USA; (R.B.R.); (B.M.Y.); (E.W.)
| | - Brianna M. Young
- Department of Ophthalmology, University of Florida College of Medicine, Gainesville, FL 32610, USA; (R.B.R.); (B.M.Y.); (E.W.)
| | - Jieun Lee
- Department of Molecular Genetics & Microbiology, University of Florida College of Medicine, Gainesville, FL 32610, USA; (J.L.); (C.M.A.); (A.S.L.)
| | - Erin Walsh
- Department of Ophthalmology, University of Florida College of Medicine, Gainesville, FL 32610, USA; (R.B.R.); (B.M.Y.); (E.W.)
| | - Chulbul M. Ahmed
- Department of Molecular Genetics & Microbiology, University of Florida College of Medicine, Gainesville, FL 32610, USA; (J.L.); (C.M.A.); (A.S.L.)
| | - Alfred S. Lewin
- Department of Molecular Genetics & Microbiology, University of Florida College of Medicine, Gainesville, FL 32610, USA; (J.L.); (C.M.A.); (A.S.L.)
| | - Cristhian J. Ildefonso
- Department of Ophthalmology, University of Florida College of Medicine, Gainesville, FL 32610, USA; (R.B.R.); (B.M.Y.); (E.W.)
- Correspondence: ; Tel.: +1-352-273-8786
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24
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Berthold E, Månsson B, Kahn R. Outcome in juvenile idiopathic arthritis: a population-based study from Sweden. Arthritis Res Ther 2019; 21:218. [PMID: 31661011 PMCID: PMC6816211 DOI: 10.1186/s13075-019-1994-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 09/05/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND As the treatment arsenal for children with juvenile idiopathic arthritis (JIA) has expanded during the last decades, follow-up studies are needed on children diagnosed in the era of biological treatment to evaluate if this has improved the outcome. Our aim was to study the epidemiology and outcome of JIA in southern Sweden using a population-based cohort of children with a validated diagnosis of JIA collected over 9 years. METHODS Potential cases of JIA between 2002 and 2010 were collected after a database search, using the ICD codes M08-M09. The study area was Skåne, the southernmost county of Sweden (population 1.24 million; 17.6% aged < 16 years). The JIA diagnosis was validated and subcategorized through medical record review based on the criteria defined by the International League of Associations for Rheumatism (ILAR). Parameters on disease activity and pharmacologic treatment were recorded annually until the end of the study period (December 31, 2015). RESULTS In total, 251 cases of JIA were confirmed. The mean annual incidence rate for JIA was estimated to be 12.8/100,000 children < 16 years, with the highest age-specific annual incidence at the age of 2 years (36/100,000). Oligoarthritis was the largest subgroup (44.7%), and systemic JIA was the smallest subgroup (2.8%). Methotrexate was the most common disease-modifying anti-rheumatic drug prescribed (60.6%). Tumor necrosis factor alpha inhibitors were used as treatment for 23.9% of the children. Only 40.0% of the follow-up years, with a median follow-up time of 8 years, were free of arthritis or uveitis. Uveitis occurred in 10.8% of the children (8.0% chronic uveitis), and the need for joint corrective orthopedic surgery was 9.2%. CONCLUSIONS The incidence of JIA in this well-defined, population-based cohort is slightly lower than in previously published studies from Scandinavia. The need for orthopedic surgery and the presence of uveitis are diminished compared to studies with patients diagnosed more than 20 years ago. Children with JIA however still experience disease activity more than 50% of the time. In conclusion, we still have long-term challenges in the care for children with JIA, in spite of state-of-the-art treatment.
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Affiliation(s)
- Elisabet Berthold
- Department of Rheumatology, Clinical Sciences Lund, Lund University, 221 85, Lund, Sweden.
| | - Bengt Månsson
- Department of Rheumatology, Clinical Sciences Lund, Lund University, 221 85, Lund, Sweden
| | - Robin Kahn
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden.,Wallenberg Centre of Molecular Medicine, Lund University, Lund, Sweden
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25
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Castagna I, Roszkowska AM, Alessandrello F, Oliverio GW, Tumminello G, Gallizzi R, Conti G, Aragona P. Juvenile idiopathic arthritis-associated uveitis: a retrospective analysis from a centre of South Italy. Int Ophthalmol 2019; 40:335-342. [PMID: 31586268 DOI: 10.1007/s10792-019-01184-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 09/23/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE To investigate the clinical and laboratory characteristics of the children affected by juvenile idiopathic arthritis (JIA) who developed uveitis. METHODS In this retrospective study, we have examined data of 109 patients aged from 3 to 16 years, affected by JIA and followed at Paediatrics Rheumatology Clinic and Ophthalmology Clinic of University Hospital of Messina in the period from 2007 to 2017. The main outcome measures were clinical and laboratory findings related to JIA and ocular involvement. The prevalence of ocular signs and symptoms was determined and correlated with age. RESULTS Twenty-one (19.3%) subjects developed uveitis. Two different peaks of age with ocular involvement were registered. The first occurred between 4 and 6 years and the second between 10 and 12 years. All subjects in the first group resulted to be female, presented oligoarticular arthritis and chronic anterior uveitis. In the second group, the 84% of patients were male with different types of JIA and acute anterior uveitis. The prevalence of ocular complications was higher in the first group. CONCLUSIONS Two peaks of age emerged and were characterized by different clinical outcomes of arthritis and ocular involvement. The first occurred between 4 and 6 years and interested females affected by oligoarticular JIA who develop chronic anterior uveitis. The second appeared at 10-12 years and interested older males affected by different types of JIA with acute anterior uveitis. Early diagnosis and cooperation between paediatric rheumatologist and ophthalmologist are of great importance in the proper management of JIA children with uveitis.
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Affiliation(s)
- I Castagna
- Ophthalmology Unit, Department of Biomedical Sciences, University Hospital of Messina, Messina, Italy
| | - A M Roszkowska
- Ophthalmology Section, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Kraków University, Kraków, Poland. .,A.O.U. Policlinico G. Martino Messina, Via Consolare Valeria 1, 98125, Messina, Italy.
| | - F Alessandrello
- Ophthalmology Unit, Department of Biomedical Sciences, University Hospital of Messina, Messina, Italy
| | - G W Oliverio
- Ophthalmology Unit, Department of Biomedical Sciences, University Hospital of Messina, Messina, Italy
| | - G Tumminello
- Ophthalmology Unit, Department of Biomedical Sciences, University Hospital of Messina, Messina, Italy
| | - R Gallizzi
- Unit of Pediatrics, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - G Conti
- Pediatric Nephrology and Rheumatology Unit, University Hospital of Messina, Messina, Italy
| | - P Aragona
- Ophthalmology Unit, Department of Biomedical Sciences, University Hospital of Messina, Messina, Italy
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26
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Kim L, Li A, Angeles-Han S, Yeh S, Shantha J. Update on the management of uveitis in children: an overview for the clinician. EXPERT REVIEW OF OPHTHALMOLOGY 2019; 14:211-218. [PMID: 32831897 PMCID: PMC7437956 DOI: 10.1080/17469899.2019.1663731] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 09/02/2019] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Pediatric uveitis comprises a range of ocular inflammatory diseases that may lead to vision impairment, often due to ocular complications from the disease itself or side effects of therapies. The impact on vision, visual functioning, and vision-related quality-of-life over the lifetime horizon can be substantial, underscoring the importance of appropriate ophthalmic evaluation, diagnostic testing and treatment. This review focuses on the anatomic classification, laboratory diagnosis, associated systemic diseases, and management of pediatric uveitis. AREAS COVERED A review of the literature was performed to synthesize our current understanding of the anatomic classification of pediatric uveitis, disease epidemiology, associated systemic diseases, and management principles. We also review important corticosteroid-sparing strategies including non-biologic and biologic agents such as the anti-tumor necrosis factor (TNF)-alpha family of medications, given their key role in the treatment of pediatric uveitis, particularly juvenile idiopathic arthritis (JIA). Recent advances in the assessment of vision-related quality-of-life using the Effects of Youngsters' Eyesight on Quality of Life (EYE-Q) instrument are discussed. EXPERT OPINION Pediatric uveitis can lead to long-term vision impairment if not appropriately screened and treated. JIA is the most common systemic disease associated with uveitis, is typically asymptomatic, and thus requires rigorous screening to detect uveitis and avoid secondary ocular complications. While topical and systemic corticosteroids are useful for the acute treatment of uveitis, the disease chronicity of many pediatric uveitis syndromes including JIA, often warrants early escalation of therapy to immunosuppressive medications including methotrexate (MTX) and anti-TNF-alpha inhibitors. Future directions include an improved understanding of risk factors for uveitis and better metrics to evaluate the impact of disease on vision-related quality-of-life of pediatric uveitis patients.
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Affiliation(s)
- Lucas Kim
- Mercer University School of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Alexa Li
- Emory Eye Center, Emory University School of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Sheila Angeles-Han
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Steven Yeh
- Emory Eye Center, Emory University School of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Jessica Shantha
- Emory Eye Center, Emory University School of Medicine, University of Cincinnati, Cincinnati, Ohio
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Massa H, Pipis SY, Adewoyin T, Vergados A, Patra S, Panos GD. Macular edema associated with non-infectious uveitis: pathophysiology, etiology, prevalence, impact and management challenges. Clin Ophthalmol 2019; 13:1761-1777. [PMID: 31571815 PMCID: PMC6750710 DOI: 10.2147/opth.s180580] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 07/24/2019] [Indexed: 12/20/2022] Open
Abstract
Macular edema (ME) is the most common sight-threatening complication in uveitis. The diagnostic and therapeutic management of the uveitic macular edema (UME) might be challenging due to the complex diagnostic workup and the difficulties physicians face to find the underlying cause, and due to its usually recurrent nature and the fact that it can be refractory to conventional treatment. Some of the mild cases can be treated with topical steroids, which can be combined with non-steroid anti-inflammatory drugs. However, immunomodulators such as methotrexate, tacrolimus, azathioprine, cyclosporine and mycophenolate mofetil together with anti-tumor necrosis factor-α (anti-TNF alpha) monoclonal antibodies such as adalimumab and infliximab, may be required to control the inflammation and the associated ME in refractory cases, or when an underlying disease is present. This review of the literature will focus mostly on the non-infectious UME.
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Affiliation(s)
- Horace Massa
- Department of Ophthalmology, Geneva University Hospitals, Geneva, Switzerland
| | - Spyros Y Pipis
- Eye Treatment Centre, Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
| | - Temilade Adewoyin
- Eye Treatment Centre, Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
| | - Athanasios Vergados
- Eye Treatment Centre, Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
| | - Sudeshna Patra
- Eye Treatment Centre, Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
| | - Georgios D Panos
- Eye Treatment Centre, Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
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28
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Vaidya H, Dutta Majumder P, Biswas J. Presumed tubercular choroidal nodule following adalimumab therapy for juvenile idiopathic arthritis. Indian J Ophthalmol 2019; 67:399-400. [PMID: 30777964 PMCID: PMC6407392 DOI: 10.4103/ijo.ijo_1149_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Harshit Vaidya
- Department of Vitreoretina, Medical and Vision Research Foundations, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | | | - Jyotirmay Biswas
- Department of Uvea Ocular Pathology, Medical and Vision Research Foundations, Sankara Nethralaya, Chennai, Tamil Nadu, India
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30
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Accorinti M, Okada AA, Smith JR, Gilardi M. Epidemiology of Macular Edema in Uveitis. Ocul Immunol Inflamm 2019; 27:169-180. [DOI: 10.1080/09273948.2019.1576910] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Massimo Accorinti
- Department of Ophthalmology, Sapienza University of Rome, Rome, Italy
| | - Annabelle A. Okada
- Department of Ophthalmology, Kyorin University School of Medicine, Tokyo, Japan
| | - Justine R. Smith
- Flinders University College of Medicine & Public Health, Adelaide, Australia
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31
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Yong SB, Huang JY, Chiou JY, Wei JCC. Adult outcome of juvenile idiopathic arthritis: A nationwide population-based retrospective cohort study in Taiwan. Int J Rheum Dis 2019; 22:1283-1288. [PMID: 30816022 DOI: 10.1111/1756-185x.13527] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 12/18/2018] [Accepted: 02/01/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To clarify the development of juvenile idiopathic arthritis (JIA) to adult-onset autoimmune diseases in a population-based study in Taiwan. METHODS We analyzed data of 107 433 children born between 1990 and 1997 from the National Taiwan Health Insurance Database. There were 262 JIA patients and 107 171 individuals without JIA who were selected and followed up until December 2013 to investigate their outcomes of adult-onset autoimmune diseases after reaching 16 years of age. The adjusted hazard ratios (aHRs) including 95% confidence intervals (95% CI) of adult-onset autoimmune diseases were calculated using the Cox proportional regression model among different age groups. RESULTS The incidence rate for patients with a history of JIA was 83.56 per 105 person-months for rheumatoid arthritis (RA), 16.61 for systemic lupus erythematosus (SLE), 58.39 for ankylosing spondylitis (AS), and 33.26 for psoriatic diseases. The aHRs were 29.60 for any autoimmune disease, 129.52 for RA, 10.01 for SLE, 49.62 for AS, and 8.20 for psoriatic diseases. Compared with non-JIA individuals, the aHRs of adult-onset autoimmune diseases were 34.87 (95% CI: 4.85-250.62) at the onset age of 3-5 years, 12.01 (95% CI: 2.99-48.26) at the age of 6-10 years, and 45.80 (95% CI: 29.69-70.64) at the age of 11-15 years. CONCLUSION Children with JIA were at an increased risk of developing RA, AS, psoriatic disease, and SLE in adulthood.
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Affiliation(s)
- Su-Boon Yong
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Division of Pediatric Allergy, Immunology and Rheumatology, Department of Pediatrics, Show Chwan Memorial Hospital, Changhua, Taiwan.,Department of Nursing, Meiho University, Pingtung, Taiwan
| | - Jing-Yang Huang
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Jeng-Yuan Chiou
- School of Health Policy and Management, Chung Shan Medical University, Taichung, Taiwan
| | - James Cheng-Chung Wei
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Division of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan.,Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
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Etiologic Spectrum and Follow-Up Results of Noninfectious Uveitis in Children: A Single Referral Center Experience. Arch Rheumatol 2019; 34:294-300. [PMID: 31598595 DOI: 10.5606/archrheumatol.2019.7253] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 11/20/2018] [Indexed: 11/21/2022] Open
Abstract
Objectives This study aims to investigate the etiologic spectrum, demographic features, and long-term follow-up results of children with noninfectious uveitis (NIU). Patients and methods Files of patients with NIU were reviewed between May 2010 and September 2017. The cohort consisted of 54 juvenile uveitis patients (26 males, 28 females; mean age 7.7 years; interquartile range [IQR] 9.2 years) with 93 affected eyes. Location of uveitis, laterality, age at onset of uveitis, complications of uveitis, duration of follow-up, associated systemic diseases, pertinent laboratory tests, medications used, and status of uveitis at the time of enrollment were recorded from the files. All patients had final systemic and ocular examination at the last month of enrollment. Results Twenty-seven patients (50.0%) had juvenile idiopathic arthritis (JIA), 17 (31.4%) had idiopathic uveitis, six (11.1%) had Behçet disease (BD), and four (7.5%) had tubulointerstitial nephritis and uveitis (TINU) syndrome. Median duration of follow-up for uveitis was 16 (IQR: 15) months. Anterior uveitis was seen in 81.4% of the patients (65.9% had bilateral and 34.1% had unilateral anterior uveitis). Bilateral intermediate uveitis was observed in 11.2% and bilateral panuveitis in 7.4% of the patients. At the time of enrollment, 45 uveitis patients (83.3%) were under remission. Complications of uveitis were observed in 18.5% of the patients. Conclusion Patients with JIA and BD should be regularly checked for uveitis. It is challenging to find an etiology in uveitis patients referred from ophthalmologists if initial questioning and examination do not reveal an overt rheumatologic disease. However, a simple urine test may help in establishing the diagnosis of TINU syndrome.
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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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A Case of Sporadic Blau Syndrome with an Uncommon Clinical Course. Case Rep Rheumatol 2018; 2018:6292308. [PMID: 30693132 PMCID: PMC6332973 DOI: 10.1155/2018/6292308] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 12/05/2018] [Indexed: 12/14/2022] Open
Abstract
Background Sporadic Blau syndrome (SBS), a rare systemic inflammatory disease in children, is associated with NOD2 gene mutations. SBS is often misdiagnosed as juvenile idiopathic arthritis (JIA) because of their similar clinical manifestations. Herein, we present a case of SBS with an uncommon clinical course. Case Presentation An 11-year-old girl with recurrent right ankle swelling for 4 years was referred to our hospital. One month before admission, she developed an intermittent high fever. She was diagnosed with systemic-onset JIA on the basis of physical and blood examination results. She was treated with ibuprofen, prednisolone, and methotrexate for 5 years. During this period, her joint lesion showed neither bone destruction nor joint space narrowing on radiography, which are characteristics of JIA. Twelve months after the termination of methotrexate treatment, she presented with bilateral panuveitis. A missense mutation, p.(R587C), was detected in her NOD2 gene, and she was diagnosed with SBS. Then, infliximab treatment was started, and her visual acuity recovered. Conclusion SBS may sometimes be misdiagnosed as JIA. A joint lesion without bone destruction might be a key feature to distinguish SBS from JIA. Analysis of the NOD2 gene is recommended in such cases.
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