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Vitale A, Caggiano V, Sfikakis PP, Dagna L, Lopalco G, Ragab G, La Torre F, Almaghlouth IA, Maggio MC, Sota J, Tufan A, Hinojosa-Azaola A, Iannone F, Loconte R, Laskari K, Direskeneli H, Ruscitti P, Morrone M, Mayrink Giardini HA, Panagiotopoulos A, Di Cola I, Martín-Nares E, Monti S, De Stefano L, Kardas RC, Duran R, Campochiaro C, Tomelleri A, Alabdulkareem AM, Gaggiano C, Tarsia M, Bartoloni E, Romeo M, Hussein MA, Laymouna AH, Parente de Brito Antonelli I, Dagostin MA, Fotis L, Bindoli S, Navarini L, Alibaz-Oner F, Sevik G, Frassi M, Ciccia F, Iacono D, Crisafulli F, Portincasa P, Jaber N, Kawakami-Campos PA, Wiesik-Szewczyk E, Iagnocco A, Simonini G, Sfriso P, Balistreri A, Giacomelli R, Conti G, Frediani B, Fabiani C, Cantarini L. Efficacy of canakinumab in patients with Still's disease across different lines of biologic therapy: real-life data from the International AIDA Network Registry for Still's Disease. Front Med (Lausanne) 2023; 10:1256243. [PMID: 38148914 PMCID: PMC10749954 DOI: 10.3389/fmed.2023.1256243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 11/08/2023] [Indexed: 12/28/2023] Open
Abstract
Introduction The effectiveness of canakinumab may change according to the different times it is used after Still's disease onset. This study aimed to investigate whether canakinumab (CAN) shows differences in short- and long-term therapeutic outcomes, according to its use as different lines of biologic treatment. Methods Patients included in this study were retrospectively enrolled from the AutoInflammatory Disease Alliance (AIDA) International Registry dedicated to Still's disease. Seventy-seven (51 females and 26 males) patients with Still's disease were included in the present study. In total, 39 (50.6%) patients underwent CAN as a first-line biologic agent, and the remaining 38 (49.4%) patients were treated with CAN as a second-line biologic agent or subsequent biologic agent. Results No statistically significant differences were found between patients treated with CAN as a first-line biologic agent and those previously treated with other biologic agents in terms of the frequency of complete response (p =0.62), partial response (p =0.61), treatment failure (p >0.99), and frequency of patients discontinuing CAN due to lack or loss of efficacy (p =0.2). Of all the patients, 18 (23.4%) patients experienced disease relapse during canakinumab treatment, 9 patients were treated with canakinumab as a first-line biologic agent, and nine patients were treated with a second-line or subsequent biologic agent. No differences were found in the frequency of glucocorticoid use (p =0.34), daily glucocorticoid dosage (p =0.47), or concomitant methotrexate dosage (p =0.43) at the last assessment during CAN treatment. Conclusion Canakinumab has proved to be effective in patients with Still's disease, regardless of its line of biologic treatment.
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Affiliation(s)
- Antonio Vitale
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, University of Siena, Siena, Italy
- Azienda Ospedaliero-Universitaria Senese, European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center, Siena, Italy
| | - Valeria Caggiano
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, University of Siena, Siena, Italy
- Azienda Ospedaliero-Universitaria Senese, European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center, Siena, Italy
| | - Petros P. Sfikakis
- Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Lorenzo Dagna
- Division of Immunology, Transplants and Infectious Diseases, Università Vita-Salute San Raffaele, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giuseppe Lopalco
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J) Policlinic Hospital, University of Bari, Bari, Italy
| | - Gaafar Ragab
- Rheumatology and Clinical Immunology Unit, Internal Medicine Department, Faculty of Medicine, Cairo University, Giza, Egypt
- Faculty of Medicine, Newgiza University, 6th of October City, Egypt
| | - Francesco La Torre
- Department of Pediatrics, Pediatric Rheumatology Center, Giovanni XXIII Pediatric Hospital, University of Bari, Bari, Italy
| | - Ibrahim A. Almaghlouth
- Rheumatology Unit, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- College of Medicine Research Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Maria Cristina Maggio
- University Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Palermo, Italy
| | - Jurgen Sota
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, University of Siena, Siena, Italy
- Azienda Ospedaliero-Universitaria Senese, European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center, Siena, Italy
| | - Abdurrahman Tufan
- Department of Internal Medicine, Division of Rheumatology, Gazi University Hospital, Ankara, Türkiye
| | - Andrea Hinojosa-Azaola
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Florenzo Iannone
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J) Policlinic Hospital, University of Bari, Bari, Italy
| | - Roberta Loconte
- Department of Pediatrics, Pediatric Rheumatology Center, Giovanni XXIII Pediatric Hospital, University of Bari, Bari, Italy
| | - Katerina Laskari
- Joint Academic Rheumatology Program, The First Department of Propaedeutic and Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Haner Direskeneli
- Department of Internal Medicine, Division of Rheumatology, Marmara University, Faculty of Medicine, Istanbul, Türkiye
| | - Piero Ruscitti
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Maria Morrone
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J) Policlinic Hospital, University of Bari, Bari, Italy
| | - Henrique A. Mayrink Giardini
- Rheumatology Division, Faculdade de Medicina, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Alexandros Panagiotopoulos
- Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ilenia Di Cola
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Eduardo Martín-Nares
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Sara Monti
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Internal Medicine and Therapeutics, Università di Pavia, Pavia, Italy
| | - Ludovico De Stefano
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Internal Medicine and Therapeutics, Università di Pavia, Pavia, Italy
| | - Rıza Can Kardas
- Department of Internal Medicine, Division of Rheumatology, Gazi University Hospital, Ankara, Türkiye
| | - Rahime Duran
- Department of Internal Medicine, Division of Rheumatology, Gazi University Hospital, Ankara, Türkiye
| | - Corrado Campochiaro
- Division of Immunology, Transplants and Infectious Diseases, Università Vita-Salute San Raffaele, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alessandro Tomelleri
- Division of Immunology, Transplants and Infectious Diseases, Università Vita-Salute San Raffaele, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Carla Gaggiano
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, University of Siena, Siena, Italy
- Azienda Ospedaliero-Universitaria Senese, European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center, Siena, Italy
| | - Maria Tarsia
- Azienda Ospedaliero-Universitaria Senese, European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center, Siena, Italy
- , Department of Molecular Medicine and DevelopmentClinical Pediatrics, University of Siena, Siena, Italy
| | - Elena Bartoloni
- Rheumatology Unit, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Mery Romeo
- Pediatric Nephrology and Rheumatology Unit, Azienda Ospedaliera Universitaria (AOU), "G. Martino", Messina, Italy
| | - Mohamed A. Hussein
- Rheumatology and Clinical Immunology Unit, Internal Medicine Department, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Ahmed Hatem Laymouna
- Rheumatology and Clinical Immunology Unit, Internal Medicine Department, Faculty of Medicine, Cairo University, Giza, Egypt
| | | | - Marilia Ambiel Dagostin
- Rheumatology Division, Faculdade de Medicina, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Lampros Fotis
- Department of Pediatrics, Attikon General Hospital, National and Kapodistrian University of Athens, Zografou, Greece
| | - Sara Bindoli
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Luca Navarini
- Clinical and Research Section of Rheumatology and Clinical Immunology, Fondazione Policlinico Campus Bio-Medico, Rome, Italy
- Rheumatology, Immunology and Clinical Medicine Unit, Department of Medicine, School of Medicine, University of Rome “Campus Biomedico”, Rome, Italy
| | - Fatma Alibaz-Oner
- Department of Internal Medicine, Division of Rheumatology, Marmara University, Faculty of Medicine, Istanbul, Türkiye
| | - Gizem Sevik
- Department of Internal Medicine, Division of Rheumatology, Marmara University, Faculty of Medicine, Istanbul, Türkiye
| | - Micol Frassi
- Spedali Civili and Department of Clinical and Experimental Sciences, Rheumatology and Clinical Immunology, University of Brescia, European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center, Brescia, Italy
| | - Francesco Ciccia
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Daniela Iacono
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesca Crisafulli
- Spedali Civili and Department of Clinical and Experimental Sciences, Rheumatology and Clinical Immunology, University of Brescia, European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center, Brescia, Italy
| | - Piero Portincasa
- Clinica Medica "A. Murri", Division of Internal Medicine, Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J), University of Bari Aldo Moro, Bari, Italy
| | - Nour Jaber
- Clinica Medica "A. Murri", Division of Internal Medicine, Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J), University of Bari Aldo Moro, Bari, Italy
| | - Perla Ayumi Kawakami-Campos
- Department of Ophthalmology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ewa Wiesik-Szewczyk
- Department of Internal Medicine, Pneumonology, Allergology and Clinical Immunology, Central Clinical Hospital of the Ministry of National Defense, Military Institute of Medicine, National Research Institute, Warsaw, Poland
| | - Annamaria Iagnocco
- Academic Rheumatology Centre, Dipartimento Scienze Cliniche e Biologiche, Università degli Studi di Torino, Torino, Italy
| | - Gabriele Simonini
- NEUROFARBA Department, Rheumatology Unit, Meyer Children's Hospital IRCCS, University of Florence, Florence, Italy
| | - Paolo Sfriso
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Alberto Balistreri
- Bioengineering and Biomedical Data Science Lab, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Roberto Giacomelli
- Clinical and Research Section of Rheumatology and Clinical Immunology, Fondazione Policlinico Campus Bio-Medico, Rome, Italy
- Rheumatology, Immunology and Clinical Medicine Unit, Department of Medicine, School of Medicine, University of Rome “Campus Biomedico”, Rome, Italy
| | - Giovanni Conti
- Pediatric Nephrology and Rheumatology Unit, Azienda Ospedaliera Universitaria (AOU), "G. Martino", Messina, Italy
| | - Bruno Frediani
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, University of Siena, Siena, Italy
- Azienda Ospedaliero-Universitaria Senese, European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center, Siena, Italy
| | - Claudia Fabiani
- Azienda Ospedaliero-Universitaria Senese, European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center, Siena, Italy
- Ophthalmology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Luca Cantarini
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, University of Siena, Siena, Italy
- Azienda Ospedaliero-Universitaria Senese, European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center, Siena, Italy
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Oommen PT, Strauss T, Baltruschat K, Foeldvari I, Deuter C, Ganser G, Haas JP, Hinze C, Holzinger D, Hospach A, Huppertz HI, Illhardt A, Jung M, Kallinich T, Klein A, Minden K, Mönkemöller K, Mrusek S, Neudorf U, Dückers G, Niehues T, Schneider M, Schoof P, Thon A, Wachowsky M, Wagner N, Bloedt S, Hofer M, Tenbrock K, Schuetz C. Update of evidence- and consensus-based guidelines for the treatment of juvenile idiopathic arthritis (JIA) by the German Society of Pediatric and Juvenile Rheumatic Diseases (GKJR): New perspectives on interdisciplinary care. Clin Immunol 2022; 245:109143. [DOI: 10.1016/j.clim.2022.109143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 11/15/2022]
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Demirkaya E, Lanni S, Bovis F, Galasso R, Ravelli A, Palmisani E, Consolaro A, Pederzoli S, Marafon D, Simianer S, Martini A, Ruperto N, Pistorio A. A Meta-Analysis to Estimate the Placebo Effect in Randomized Controlled Trials in Juvenile Idiopathic Arthritis. Arthritis Rheumatol 2017; 68:1540-50. [PMID: 26749157 DOI: 10.1002/art.39583] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 01/05/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To estimate the placebo effect in juvenile idiopathic arthritis (JIA) through a meta-analysis of phase III clinical trials with placebo comparator. METHODS A systematic literature search was carried out up to December 2014. For parallel design studies the outcome was evaluated as a single 1-dimensional (1-D) variable or as a composite score; outcomes of withdrawal studies were evaluated only as composite scores. RESULTS We included 26 of 224 trials (12%). In trials with parallel study design and a 1-D outcome, the placebo effect was 0.35 (95% confidence interval [95% CI] 0.27-0.43). Among trials with parallel study design and a composite score outcome, the placebo rate response was higher in trials that included patients with nonsystemic JIA (0.35 [95% CI 0.29-0.42]) than in trials that included only patients with systemic JIA (0.17 [95% CI 0.10-0.30]). In the withdrawal design trials, the percentages of patients receiving placebo who had disease flares during the double-blind phase were lower in trials that included patients with nonsystemic JIA (0.55 [95% CI 0.47-0.64]) than in trials that included only patients with systemic JIA (0.68 [95% CI 0.33-0.90]). CONCLUSION In trials with a parallel study design a sizable number of patients seem to benefit from a placebo effect, although this effect is smaller in patients with systemic JIA. In trials with a withdrawal design the inverse placebo effect is similar among the different JIA categories. This placebo effect should be considered when evaluating the effectiveness of proposed interventions and for future calculations of sample size.
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Affiliation(s)
| | | | | | | | - Angelo Ravelli
- Istituto Giannina Gaslini and Università degli Studi di Genova, Genoa, Italy
| | | | | | | | | | | | - Alberto Martini
- Istituto Giannina Gaslini and Università degli Studi di Genova, Genoa, Italy
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Hissink Muller PCE, Brinkman DMC, Schonenberg D, Koopman-Keemink Y, Brederije ICJ, Bekkering WP, Kuijpers TW, van Rossum MAJ, van Suijlekom-Smit LWA, van den Berg JM, Allaart CF, ten Cate R. A comparison of three treatment strategies in recent onset non-systemic Juvenile Idiopathic Arthritis: initial 3-months results of the BeSt for Kids-study. Pediatr Rheumatol Online J 2017; 15:11. [PMID: 28166785 PMCID: PMC5294738 DOI: 10.1186/s12969-017-0138-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 01/19/2017] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Combination therapy with prednisone or etanercept may induce earlier and/or more improvement in disease activity in Disease Modifying Anti Rheumatic Drug (DMARD) naïve non-systemic Juvenile Idiopathic Arthritis (JIA) patients. Here we present three months clinical outcome of initial treatments of the BeSt-for-Kids study. METHODS Included patients were randomized to either: 1. initial DMARD-monotherapy (sulfasalazine (SSZ) or methotrexate (MTX)), 2. Initial MTX / prednisolone-bridging, 3. Initial combination MTX/etanercept. Percentage inactive disease, adjusted (a) ACR Pedi30, 50 and 70 and JADAS after 6 and 12 weeks of treatment (intention to treat analysis) and side effects are reported. RESULTS 94 patients (67% girls, 32 (arm 1), 32 (arm 2) and 30 (arm 3) with median (InterQuartileRange) age of 9.1 (4.7-12.9) years were included. 38% were ANA positive, 10 had oligo-articular disease, 68 polyarticular JIA and 16 psoriatic arthritis. Baseline median (IQR) ACRpedi-scores: VAS physician 49 (40-58) mm, VAS patient 54 (37-70) mm, ESR 6.5 (2-14.8)mm/hr, active joint count 8 (5-12), limited joint count 3 (1-5), CHAQ score 0.88 (0.63-1.5). In arm 1, 17 started with MTX, 15 with SSZ. After 3 months, aACR Pedi 50 was reached by 10/32 (31%), 12/32(38%) and 16/30 (53%) (p = 0.19) and aACR Pedi 70 was reached by 8/32 (25%), 6/32(19%) and 14/30(47%) in arms 1-3 (p = 0.04). Toxicity was similar. Few serious adverse events were reported. CONCLUSION After 3 months of treatment in a randomized trial, patients with recent-onset JIA achieved significantly more clinical improvement (aACRPedi70) on initial combination therapy with MTX / etanercept than on initial MTX or SSZ monotherapy. TRIAL REGISTRATION NTR1574 . Registered 3 December 2008.
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Affiliation(s)
- P. C. E. Hissink Muller
- 0000000089452978grid.10419.3dDepartment of Pediatrics/Pediatric Rheumatology, Leiden University Medical Center, Leiden, The Netherlands ,000000040459992Xgrid.5645.2Department of Pediatrics/Pediatric Rheumatology, Erasmus MC Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - D. M. C. Brinkman
- 0000000089452978grid.10419.3dDepartment of Pediatrics/Pediatric Rheumatology, Leiden University Medical Center, Leiden, The Netherlands ,Department of Pediatrics, Alrijne Hospital Leiderdorp, Leiderdorp, The Netherlands
| | - D. Schonenberg
- Department of Pediatric Hematology, Immunology, Rheumatology and Infectious Diseases, Emma Children’s Hospital AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Y. Koopman-Keemink
- grid.414786.8Department of Pediatrics, Hagaziekenhuis Juliana Children’s Hospital, The Hague, The Netherlands
| | - I. C. J. Brederije
- 0000000089452978grid.10419.3dDepartment of Pediatrics/Pediatric Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - W. P. Bekkering
- 0000000089452978grid.10419.3dDepartment of Pediatrics/Pediatric Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - T. W. Kuijpers
- Department of Pediatric Hematology, Immunology, Rheumatology and Infectious Diseases, Emma Children’s Hospital AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M. A. J. van Rossum
- Department of Pediatric Rheumatology, Amsterdam Rheumatology and Immunology Center location Reade Amsterdam, Amsterdam, The Netherlands
| | - L. W. A. van Suijlekom-Smit
- 000000040459992Xgrid.5645.2Department of Pediatrics/Pediatric Rheumatology, Erasmus MC Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - J. M. van den Berg
- Department of Pediatric Hematology, Immunology, Rheumatology and Infectious Diseases, Emma Children’s Hospital AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - C. F. Allaart
- 0000000089452978grid.10419.3dDepartment of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - R. ten Cate
- 0000000089452978grid.10419.3dDepartment of Pediatrics/Pediatric Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
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Abstract
Juvenile idiopathic arthritis (JIA) comprises a group of heterogeneous disorders of chronic arthritis in childhood and remains the commonest pediatric rheumatic disease associated with significant long-term morbidity. Advances in understanding of the pathogenesis, better definition of disease control/remission measures, and the arrival of biological agents have improved the outcomes remarkably. Methotrexate (Mtx) remains the first-line disease modifying (DMARD) therapy for most children with JIA due to its proven efficacy and safety. Sulphosalazine (SSz) (especially for enthesitis) and leflunomide may also have a secondary role. Tumor necrosis factor inhibitors (TNF-I), alone or in combination with Mtx have shown tremendous benefit in children with polyarticular JIA, enthesitis related arthritis (ERA) and psoriatic arthritis. Tocilizumab appears very efficacious in systemic arthritis and abatacept and tocilizumab also appear to benefit polyarticular JIA; the role of rituximab remains unclear, though clearly beneficial in adult RA. TNF-I with Mtx is also effective in uveitis associated with JIA. Biologicals have demonstrated an impressive safety record in children with JIA, although close monitoring for rare but potentially dangerous adverse events, such as tuberculosis and other infections; paradoxical development of additional autoimmune diseases; and possibly an increased risk of cancers is warranted.
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Stoll ML, Cron RQ. Treatment of juvenile idiopathic arthritis: a revolution in care. Pediatr Rheumatol Online J 2014; 12:13. [PMID: 24782683 PMCID: PMC4003520 DOI: 10.1186/1546-0096-12-13] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 04/10/2014] [Indexed: 01/19/2023] Open
Abstract
A generation ago, children with arthritis faced a lifetime of pain and disability. Today, there are a multitude of treatment options, including a variety of biologics targeting key cytokines and other inflammatory mediators. While non-steroidal anti-inflammatory drugs and corticosteroids were once the mainstay of therapy, they are now largely used as bridge or adjunctive therapies. Among the conventional disease-modifying anti-rheumatic drugs, methotrexate remains first-line therapy for most children with juvenile idiopathic arthritis (JIA) due to its long track record of safety and effectiveness in the management of peripheral arthritis. Sulfasalazine and leflunomide may also have a secondary role. The tumor necrosis factor inhibitors (TNFi) have shown tremendous benefit in children with polyarticular JIA and likely in enthesitis-related arthritis and psoriatic JIA as well. There may be additional benefit in combining TNFi with methotrexate. Abatacept and tocilizumab also appear to benefit polyarticular JIA; the role of rituximab remains unclear. For the treatment of systemic JIA, while the TNFi are of less benefit, blockade of interleukin-1 or interleukin-6 is highly effective. Additionally, interleukin-1 blockade appears to be effective treatment of macrophage activation syndrome, one of the most dangerous complications of JIA; specifically, anakinra in combination with cyclosporine and corticosteroids may obviate the need for cytotoxic approaches. In contrast, methotrexate along with the TNFi and abatacept are effective agents for the management of uveitis, another complication of JIA. Overall, the biologics have demonstrated an impressive safety record in children with JIA, although children do need to be monitored for rare but potentially dangerous adverse events, such as tuberculosis and other infections; paradoxical development of additional autoimmune diseases; and possibly an increased risk of malignancy. Finally, there may be a window of opportunity during which children with JIA will demonstrate most optimal responses to aggressive therapy, underscoring the need for rapid diagnosis and initiation of treatment.
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Affiliation(s)
- Matthew L Stoll
- University of Alabama at Birmingham, CPP N 210 M, 1600 7th Avenue South, Birmingham, AL 35233-1711, USA
| | - Randy Q Cron
- University of Alabama at Birmingham, CPP N 210 M, 1600 7th Avenue South, Birmingham, AL 35233-1711, USA
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Mori M, Naruto T, Imagawa T, Murata T, Takei S, Tomiita M, Itoh Y, Fujikawa S, Yokota S. Methotrexate for the treatment of juvenile idiopathic arthritis: process to approval for JIA indication in Japan. Mod Rheumatol 2014. [DOI: 10.3109/s10165-008-0123-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Bertilsson L, Andersson-Gäre B, Fasth A, Petersson IF, Forsblad-D’elia H. Disease Course, Outcome, and Predictors of Outcome in a Population-based Juvenile Chronic Arthritis Cohort Followed for 17 Years. J Rheumatol 2013; 40:715-24. [DOI: 10.3899/jrheum.120602] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.To investigate disease course, outcome, and predictors of outcome in an unselected population-based cohort of individuals diagnosed with juvenile chronic arthritis (JCA) followed for 17 years.Methods.The cohort consisted of 132 incidence JCA cases identified 1984–1986 according to EULAR criteria. At 5-year followup, 129 individuals underwent joint assessment, laboratory measurements, radiographic examination, and medication and functional assessment. At 17-year followup, 86 were examined with joint assessment, laboratory measurements, medication assessment, Health Assessment Questionnaire (HAQ), Keitel functional test (KFT), and Medical Outcomes Study Short Form-36 (SF-36).Results.At 17-year followup, 40% were in remission, 44% changed subgroups, median HAQ score was 0.0 (range 0.0–1.5), and median KFT was 100 (range 54–100). SF-36 scores were significantly lower compared to a reference group. Thirty-nine percent of those in remission at 5-year followup were not in remission at 17-year followup. In multivariate analyses of variables from the 17-year followup: remission was predicted by remission at 5-year followup (OR 4.8); HAQ > 0 by rheumatoid factor (RF)-positivity at 5-year followup (OR 3.6); KFT < 100 by nonremission (OR 11.3); and RF-positivity (OR 5.6) at 5-year followup; and the SF-36 physical component summary score above average of the reference group by remission at 5-year followup (OR 5.8).Conclusion.This longterm study of 86 individuals with JCA showed large variability of disease courses and of impaired health-related quality of life. Sixty percent were not in remission at 17-year followup. Longterm outcome was best predicted by and associated with characteristics at 5-year followup rather than those at onset.
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10
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Abstract
Juvenile idiopathic arthritis (JIA) includes several forms of chronic arthritis in children. Treatments are chosen according to the type and severity of the disease. Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids remain the mainstays of therapy. Traditional slower acting anti-rheumatic drugs, such as gold therapy, penicillamine, sulfasalazine, tiopronin and hydroxychloroquine, are usually poorly active in children. In addition, adverse effects are common, including severe macrophage activation syndrome with gold therapy or sulfasalazine. Low dose, once weekly methotrexate has emerged as the therapeutic agent of choice for children who fail to respond adequately to the administration of an NSAID, especially in those with the extended oligoarticular subtype of the disease. Other immunosuppressive agents, such as cyclosporin, are sometimes combined with methotrexate. In recent years, novel treatments have been developed. Autologous hematopoietic stem cell transplantation is effective in a number of children with severe JIA, whose disease has been refractory to conventional therapy. However, only short term follow-up data are currently available for this novel therapy. In addition, severe infections complicated by macrophage activation syndrome and death have been reported. Finally, anti-tumour necrosis factor-alpha therapy has shown efficacy in more than two-thirds of children with JIA and polyarthritis, and other cytokine inhibitors may be soon available.
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Affiliation(s)
- A M Prieur
- Department of Paediatric Immunohaematology and Paediatric Rheumatology, Hôpital Necker-Enfants Malades, Paris, France.
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11
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Methotrexate for the treatment of juvenile idiopathic arthritis: process to approval for JIA indication in Japan. Mod Rheumatol 2008; 19:1-11. [PMID: 18815725 PMCID: PMC2638602 DOI: 10.1007/s10165-008-0123-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2008] [Accepted: 08/19/2008] [Indexed: 11/20/2022]
Abstract
Methotrexate (MTX), the primary treatment for the articular-type juvenile idiopathic arthritis (JIA), is effective and brings about radiological improvement. Patient compliance is good, and it is recognized that its known side effects, namely, disruption of liver function and induction of pulmonary lesions, are unlikely to be severe at the low MTX doses that are administered. In Japan, MTX was granted approval in 1999 by the then Ministry of Health and Welfare specifically for treating rheumatoid arthritis in adult patients, allowing it be generally used in medical institutions for patients having National Health Insurance. However, in the pediatric field, its use outside the indications has so far been unavoidable, and has been left to the discretion of the physician. Finally, at the present conference, expansion of the indications of MTX for JIA was approved in Japan. It is noteworthy that this expansion of indications was achieved without requiring clinical trials on children sponsored by the pharmaceutical company: it was achieved rather by collecting necessary information through ongoing efforts (including collection and analysis of information about approval status in foreign countries, adequate evidence from the literature, implementation of a clinical use survey in Japan, etc.). It also merits attention that the maximum dose (10 mg/m2) was set on the basis of pharmacokinetic data from children, rather than relying on the dosing method and dose for adults.
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12
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Ruperto N, Martini A. Network in pediatric rheumatology: the example of the Pediatric Rheumatology International Trials Organization. World J Pediatr 2008; 4:186-91. [PMID: 18822926 DOI: 10.1007/s12519-008-0034-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pediatric rheumatic diseases (PRDs) are rare conditions associated with significant sequelae affecting the quality of life and long-term outcome. The research aimed at studying new therapeutic approaches is difficult because of logistic, methodological and ethical problems. DATA SOURCES To address these problems, two international networks, the Pediatric Rheumatology Collaborative Study Group (PRCSG) and the Pediatric Rheumatology International Trials Organization (PRINTO) were established. The two networks share the goal to promote, facilitate and conduct high quality research for PRDs. RESULTS The PRINTO and PRCSG networks have standardized the evaluation of response to therapy in juvenile idiopathic arthritis (JIA), juvenile systemic lupus erythematosus, and juvenile dermatomyositis, drafted clinical remission criteria in JIA, and provided cross-cultural adapted and validated quality of life instruments including the Childhood Health Assessment Questionnaire and the Child Health Questionnaire into 32 different languages. In this paper we reviewed how the networks of the PRINTO and PRCSG have created the basic premises for the best future assessment of PRDs. CONCLUSIONS The PRINTO and PRCSG networks can be regarded as a model for international cooperation or collaboration in other pediatric subspecialties.
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Affiliation(s)
- Nicolino Ruperto
- IRCCS Istituto G. Gaslini, Pediatria II, Reumatologia, Genoa, Italy.
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13
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Abstract
Juvenile idiopathic arthritis (JIA) is one of the most common rheumatic diseases in childhood. In a significant number of JIA cases the disease is resistant to therapy with NSAIDs, intra-articular corticosteroid injections, and physiotherapy, and methotrexate is used as a second-line agent. The efficacy of methotrexate therapy in children with JIA has been demonstrated in prospective controlled trials and this agent appears to have slightly superior efficacy compared with leflunomide. Data from randomized studies indicate a starting dose of 10-15 mg/m(2)/week orally. The dose of parenteral methotrexate can be increased to 15-20 mg/m(2)/week. Combination therapy with methotrexate and an NSAID is recommended. However, there are still no data on when to initiate methotrexate in JIA and how long children should be treated. The most common adverse effects are aversion to the drug and nausea. In the case of minor adverse effects the use of folic acid at a dosage of 1 mg/day is feasible. In JIA, daily folate supplementation has only been studied in one small heterogeneous cohort with a very short observation period and, at present, a general recommendation on daily folate supplementation cannot be made. In summary, methotrexate is seen by many pediatric rheumatologists as the first-choice, second-line drug; there is good evidence of its efficacy in JIA. However, in light of the recent introduction of biologic agents, the place of methotrexate in the treatment of JIA may have to be redefined in the coming years.
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Affiliation(s)
- Tim Niehues
- Department of Pediatric Oncology, Hematology and Immunology, Pediatric Immunology and Rheumatology, Centre for Child Health, Heinrich-Heine-University, Düsseldorf, Germany.
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14
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Kalantzis A, Marshman Z, Falconer DT, Morgan PR, Odell EW. Oral effects of low-dose methotrexate treatment. ACTA ACUST UNITED AC 2006; 100:52-62. [PMID: 15953917 DOI: 10.1016/j.tripleo.2004.08.020] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Methotrexate is used increasingly in low-dose regimes for a variety of conditions, particularly rheumatoid arthritis. While certain adverse effects of low-dose methotrexate have been described in detail, oral complications have received little attention. This article includes a summary of the uses and pharmacology of low-dose methotrexate and the mechanisms that lead to general and oral toxicity. The literature relevant to potential oral adverse effects is discussed and 7 illustrative cases are presented. The oral effects noted range from nonhealing ulcers to lymphoma-like lesions. Dental practitioners should be aware of the possible oral effects of low-dose methotrexate that have so far been largely unrecognized.
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Affiliation(s)
- Athanasios Kalantzis
- Department of Oral Pathology, GKT Dental Institute, Guy's Tower, King's College London, Guy's Hospital, London, UK.
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15
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Mine T, Tanaka H, Ishida Y, Imamura R, Seki K, Taguchi T. Juvenile rheumatoid arthritis manifesting in only limping due to flexion contraction of the knee. Clin Rheumatol 2006; 26:433-5. [PMID: 16440136 DOI: 10.1007/s10067-005-0145-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2005] [Accepted: 04/14/2005] [Indexed: 11/30/2022]
Abstract
Juvenile rheumatoid arthritis (JRA) is a relatively uncommon condition. The damage to the cartilaginous tissue is often irreversible and responsible for much of the morbidity. Timely diagnosis and appropriate aggressive treatment of patients improve quality of life and outcome. A reported case of JRA is presented in which limping associated with flexion contraction of the knee developed without any systemic symptoms. Magnetic resonance imaging and arthroscopic examination were helpful with early diagnosis. Aspirin was effective. There have been no recurrence to date.
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Affiliation(s)
- Takatomo Mine
- From the Department of Orthopaedic Surgery, Yamaguchi University School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8505, Japan.
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16
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Chédeville G, Quartier P, Miranda M, Brauner R, Prieur AM. Improvements in growth parameters in children with juvenile idiopathic arthritis associated with the effect of methotrexate on disease activity. Joint Bone Spine 2005; 72:392-6. [PMID: 16087383 DOI: 10.1016/j.jbspin.2005.03.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2002] [Accepted: 03/15/2005] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess changes in growth parameters associated with the response to methotrexate (MTX) therapy in pre-pubertal children with juvenile idiopathic arthritis (JIA) and who had not been treated with steroids. METHODS We enrolled 27 pre-pubertal children with JIA who had been treated with MTX but not with steroids. The children were considered to have responded to treatment if the number of joints with active disease decreased by at least 50% 1 year after treatment initiation. We compared growth parameters (height, growth rate, weight and body mass index (BMI)) in responders and non-responders. RESULTS Twenty-one children (77.8%) responded to MTX therapy. The growth parameters were similar in the responders and non-responders before the onset of treatment. After 1 year, height (P=0.025), growth rate (P=0.03), weight (P=0.007) and BMI (P=0.05) increased significantly in the responder group, but not in the non-responder group. This increase was maintained for growth rate and weight after 2 and 3 years of treatment. After 1 year, height (P=0.023) and growth rate (P=0.0009) were significantly higher in the responders than in the non-responders, and these differences were still significant after 3 years (P=0.01 and P=0.033, respectively). CONCLUSION In pre-pubertal children with JIA, a clinical response to MTX therapy is associated with a significant increase in growth parameters.
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Affiliation(s)
- Gaëlle Chédeville
- Unité d'Immuno-Hématologie-Rhumatologie Pédiatrique, hôpital Necker-Enfants-Malades, 149 rue de Sèvres, 75743 Paris cedex 15, France.
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17
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Abstract
Although rarely a life-threatening disease, juvenile arthritis (JA) can, if poorly controlled, profoundly affect growth, development and quality of life in children. Long-term damage in children with JA rarely arises from overly aggressive therapy, but rather from an overly conservative and cautious approach in the early stages of the disease. As more potential therapeutic agents for JA become available, the physician must become skilled in viewing the data with a critical eye with regard to safety and efficacy in the paediatric population. The following review discusses the prognosis and management of JA, with a focus on new emerging agents for the treatment of this disease.
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Affiliation(s)
- Andreas Otto Reiff
- University of Southern California, USC Keck School of Medicine, Division of Rheumatology, Division of Rheumatology, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA.
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18
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Bloom AI, Shapira MY, Or R, Sasson T, Resnick IB, Zilberman I, Verstandig A, Aker M, Slavin S, Muszkat M. Intrahepatic arterial administration of low-dose methotrexate in patients with severe hepatic graft-versus-host disease: An open-label, uncontrolled trial. Clin Ther 2004; 26:407-14. [PMID: 15110133 DOI: 10.1016/s0149-2918(04)90036-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2004] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hepatic grafr-versus-host disease (GVHD) is associated with significant morbidity and mortality. Standard therapy includes systemically administered immunosuppressive drugs. More recent reports have described catheter-directed intrahepatic arterial (IHA) delivery of low-dose methotrexate (MTX) and methylprednisolone in the treatment of corticosteroid-resistant severe hepatic GVHD. OBJECTIVE This article reports on MTX toxicity and the variability in plasma drug concentrations after IHA administration of low-dose MTX in patients with severe hepatic GVHD. METHODS In this open-label, uncontrolled pilot study, MTX and methylprednisolone were administered via the hepatic artery in patients with corticosteroid-resistant grade III or IV GVHD of the liver. Patients also received standard therapy. MTX concentrations were measured in the hepatic artery 5 and 10 minutes after injection and in peripheral venous blood at 1, 2, and 24 hours. RESULTS Six patients (5 males [83.3%], I female [16.7%]; median age, 32 years; range, 8-42 years) were enrolled in the study. No hepatotoxicity was observed after IHA administration of MTX. In 5 patients with normal renal function, plasma drug concentrations 24 hours after administration of MTX ranged from 0.01 to 0.12 micromol/L (mean [SD], 0.043 [0.042] micromol/L). In 1 patient with renal failure, plasma MTX concentrations were 1.0 micromol/L 24 hours after administration and 0.07 micromol/L 5 days after administration. The severe hematologic and renal toxicity observed in this patient may have contributed to his death. Adverse events in patients with GVHD and normal renal function, who had normal plasma MTX concentrations, were comparable to those that have been reported after administration of an intravenous infusion. CONCLUSIONS In patients with GVHD and normal renal function, IHA administration of low-dose MTX was not associated with liver or bone marrow toxicity. Further study is needed to determine the optimal protocols for treating corticosteroid-resistant hepatic GVHD.
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Affiliation(s)
- Allan I Bloom
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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19
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Culy CR, Keating GM. Etanercept: an updated review of its use in rheumatoid arthritis, psoriatic arthritis and juvenile rheumatoid arthritis. Drugs 2003; 62:2493-537. [PMID: 12421111 DOI: 10.2165/00003495-200262170-00013] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Etanercept is a subcutaneously administered biological response modifier that binds and inactivates tumour necrosis factor-alpha, a proinflammatory cytokine. In patients with early active rheumatoid arthritis, etanercept 25mg twice weekly was associated with a more rapid improvement in disease activity and a significantly greater cumulative response than methotrexate over 12 months of treatment in a randomised, double-blind trial. In addition, etanercept recipients showed a slower rate of radiographic progression and a more rapid improvement in quality of life than methotrexate recipients. The efficacy of etanercept was maintained at 3 years' follow-up. Etanercept was also significantly better than placebo at reducing disease activity in patients who had an inadequate response to previous treatment with disease-modifying antirheumatic drugs (DMARDs) in several well controlled trials. At study end (after 3 or 6 months' treatment), the percentage of patients achieving an American College of Rheumatology 20% (ACR20) response with etanercept (25mg or 16 mg/m(2) twice weekly) was 59 to 75% as monotherapy and 71% in combination with methotrexate; corresponding placebo response rates were 11 to 14% and 27%, respectively. Response has been maintained in patients who continued treatment for up to 5 years. In patients with psoriatic arthritis, etanercept 25mg twice weekly significantly reduced disease activity and improved skin lesions in two double-blind, placebo-controlled, 12- to 24-week trials. In the 24-week study, ACR20 response rates (50 vs 13%), psoriatic arthritis response rates (70 vs 23%) and the median improvement in skin lesions (33 vs 0%) were significantly greater in etanercept than in placebo recipients. In patients with polyarticular-course juvenile rheumatoid arthritis, etanercept resulted in improvements in all measures of disease activity and was significantly more effective than placebo at reducing disease flare. Eighty percent of patients receiving etanercept achieved a >or=30% reduction in disease activity over 7 months of treatment, and this was maintained for up to 2 years in a trial extension. Etanercept was generally well tolerated in children and adults in clinical trials; the most commonly occurring adverse effects included injection site reactions, infection, headache, rhinitis and dizziness. In conclusion, etanercept has emerged as an important new treatment option in inflammatory arthritis. Etanercept provides rapid and sustained improvements in disease activity in patients with early and DMARD-refractory rheumatoid arthritis and has been shown to inhibit radiographic progression in those with early disease. Well controlled studies have also demonstrated the efficacy of etanercept in patients with psoriatic arthritis or polyarticular-course juvenile rheumatoid arthritis.
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MESH Headings
- Adolescent
- Adult
- Antirheumatic Agents/therapeutic use
- Arthritis, Juvenile/diagnostic imaging
- Arthritis, Juvenile/drug therapy
- Arthritis, Juvenile/economics
- Arthritis, Psoriatic/diagnostic imaging
- Arthritis, Psoriatic/drug therapy
- Arthritis, Psoriatic/economics
- Arthritis, Rheumatoid/diagnostic imaging
- Arthritis, Rheumatoid/drug therapy
- Arthritis, Rheumatoid/economics
- Child
- Child, Preschool
- Cost-Benefit Analysis
- Dose-Response Relationship, Drug
- Drug Therapy, Combination
- Etanercept
- Humans
- Immunoglobulin G/economics
- Immunoglobulin G/therapeutic use
- Immunologic Factors/economics
- Immunologic Factors/therapeutic use
- Injections, Subcutaneous
- Methotrexate/therapeutic use
- Pharmacokinetics
- Radiography
- Randomized Controlled Trials as Topic
- Receptors, Tumor Necrosis Factor/therapeutic use
- Recombinant Fusion Proteins/economics
- Recombinant Fusion Proteins/therapeutic use
- Treatment Outcome
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20
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Abstract
Juvenile rheumatoid arthritis (JRA) is the most common childhood chronic systemic autoimmune inflammatory disease. The therapeutic approach to JRA has, to date, been casual and based on extensions of clinical experiences gained in the management of adult rheumatoid arthritis (RA). The physiology of inflammation has been systemically studied and this has led to the identification of specific therapeutic targets and the development of novel approaches to the management of JRA. The classical treatments of the disease such as methotrexate, sodium aurothiomalate and sulfasalazine, are not always effective in controlling RA and JRA. This has necessitated the development of novel agents for treating RA, most of which are biological in nature and are targeted at specific sites of the inflammatory cascades. These biological therapeutic strategies in RA have proved successful and are being applied in the management of JRA. These developments have been facilitated by the advances in molecular biology which have heralded the advent of biodrugs (recombinant proteins) and gene therapy, in which specific genes can be introduced locally to enhance in vivo gene expression or suppress gene(s) of interest with a view to down-regulating inflammation. Some of these biodrugs, such as anti-tumor necrosis factor alpha (anti-TNFalpha), monoclonal antibodies (infliximab, adalimumab), TNF soluble receptor constructs (etanercept) and interleukin-1 receptor antagonist (IL-1Ra) have been tested and shown to be effective in RA. Etanercept has now been licensed for JRA. Clinical trials of infliximab in JRA are planned. Studies show that the clinical effects are transient, necessitating repeated treatments and the risk of vaccination effects. Anti-inflammatory cytokines such as IL-4, IL-10, transforming growth factor-beta and interferon-beta (IFN-beta) are undergoing clinical trials. Many of these agents have to be administered parenterally and production costs are very high; thus, there is a need, especially for pediatric use, to develop agents that can be taken orally. Long-term studies will be required to assess the tolerability and toxicity of these approaches in JRA, since cytokines and other mediators play important roles in host defenses, and the chronic inhibition, exogenous administration or constitutive over-expression of some cytokines/mediators may have undesirable effects.
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Affiliation(s)
- Ian C Chikanza
- Bone and Joint Research Unit, St. Bartholomew's and Royal London School of Medicine and Dentistry, and Department of Paediatrics, Royal London Hospital, London, United Kingdom.
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21
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Abstract
Juvenile idiopathic arthritis (JIA) is a relatively uncommon disorder in childhood. Expertise however should be the corner stone of care of children with JIA, as early appropriate treatment is mandatory to ensure best possible short and long-term outcome for children with JIA. Therefore comprehensive treatment centers (with multi disciplinary teams) should be based in tertiary level academic centers. This article deals with both specific and generic issues encountered in managing children with JIA.
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Affiliation(s)
- James N Jarvis
- Department of Pediatrics, Oklahoma University College of Medicine, Basic Sciences Bldg., #235A, Oklahoma City, OK 73104, USA
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23
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Abstract
Prognostic factors in juvenile rheumatoid arthritis (JRA) include polyarticular onset, polyarticular disease course, and rheumatoid factor positivity; in the systemic onset subtype, persistence of systemic features at 6 months after onset confers a worse prognosis. Timely diagnosis and appropriate aggressive treatment of patients with poor prognostic features improve quality of life and outcome. After nonsteroidal anti-inflammatory drugs, methotrexate is the most commonly used second-line agent. However, approximately one third of patients do not respond to methotrexate adequately. Randomized, placebo-controlled, clinical trials in patients with JRA are few, but one such trial with the tumor necrosis factor inhibitor etanercept shows that this drug is effective and well-tolerated. Other recently approved agents for rheumatoid arthritis, including infliximab, leflunomide, celecoxib, and rofecoxib, have not been adequately studied in pediatric patients, and the role of these agents in children with JRA remains to be determined.
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Affiliation(s)
- Norman T Ilowite
- Division of Rheumatology, Schneider Children's Hospital, New Hyde Park, New York, USA.
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24
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Gerloni V, Cimaz R, Gattinara M, Arnoldi C, Pontikaki I, Fantini F. Efficacy and safety profile of cyclosporin A in the treatment of juvenile chronic (idiopathic) arthritis. Results of a 10-year prospective study. Rheumatology (Oxford) 2001; 40:907-13. [PMID: 11511760 DOI: 10.1093/rheumatology/40.8.907] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE This open prospective trial was performed in order to assess the efficacy and safety of cyclosporin A in the treatment of patients with juvenile chronic arthritis (JCA). METHODS Thirty-four of the patients enrolled were affected by systemic-onset disease and seven by chronic anterior uveitis associated with JCA. The cyclosporin dose was usually 3-5 mg/kg per day. The average duration of therapy was 1.4 yr, with a maximum of 7.2 yr. RESULTS The efficacy of treatment was mainly evident in terms of control of fever and reduction of steroid therapy. The benefits with respect to arthritis, laboratory parameters and uveitis seemed to be less clear-cut. Side-effects were frequent but usually mild or reversible. Sixty-six per cent of the study population withdrew from therapy because of inefficacy or side-effects. Eight systemic patients withdrew from therapy owing to complete remission. CONCLUSION Cyclosporin can be used in the treatment of JCA, its main benefits being the control of fever and a steroid-sparing effect.
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Affiliation(s)
- V Gerloni
- Rheumatology Department, University of Milan, Centre for Rheumatic Children, Gaetano Pini Institute, Milan, Italy
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25
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Abstract
OBJECTIVE To review the classification, pathophysiology, safety, and efficacy of treatment options for juvenile rheumatoid arthritis (JRA). Etanercept, the agent most recently approved by the Food and Drug Administration for use in JRA, is featured. DATA SOURCES Articles were identified from a search of the MEDLINE database (1966 to January 2000) and through secondary sources. Meeting abstracts and posters were also evaluated. STUDY SELECTION AND DATA EXTRACTION Articles identified and retrieved from data sources were evaluated and, if determined to be relevant, were included in this review. DATA SYNTHESIS JRA represents a major cause of functional disability in children. In contrast to traditional therapeutic agents for JRA, which act through generalized antiinflammatory activity or generalized immunosuppression, new therapeutic modalities have been developed that target specific molecules involved in the pathophysiology of JRA. Etanercept inhibits the activity of tumor necrosis factor and lymphotoxin-alpha. In a clinical trial of patients with polyarticular-course JRA, etanercept-treated patients experienced less pain and swelling in their joints, decreased incidence of disease activity, less frequent flare, and a longer time to flare than patients receiving placebo. Treatment with etanercept was generally well-tolerated. CONCLUSIONS Etanercept represents an exciting new therapeutic option for the treatment of JRA. The positioning of etanercept among other therapeutic options for JRA will be more clearly established as additional safety and efficacy data are made available.
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Affiliation(s)
- C J Johnson
- Immunex Corporation, Professional Services Department, Seattle, WA 98101-2936, USA.
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26
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Abstract
One of the most important and changing areas of research in paediatric rheumatology is the optimum approach to the treatment of children with chronic arthritis. Until recently all medications for children with arthritis were nonspecific in terms of our understanding, albeit poor, of the pathogenesis of these diseases. Of current therapies, low dose, once-a-week methotrexate has emerged as the therapeutic agent of choice for children who fail to respond adequately to administration of a nonsteroidal anti-inflammatory drug. Thereby, it has displaced the more traditional slower acting anti-rheumatic drugs, although one or more of them are often combined with methotrexate in the polypharmaceutical approach to childhood arthritis. Better and more specific agents are needed, especially for systemic onset disease, unremitting polyarticular involvement, and certain complications such as resistant chronic uveitis. At this time the introduction of the cyclo-oxygenase 2 inhibitors and etanercept (soluble tumour necrosis factoralpha.p75 fusion protein) may herald an era of more specific and effective therapy.
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Affiliation(s)
- J T Cassidy
- Department of Child Health, University of Missouri, Columbia 65212, USA.
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27
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Juvenile Rheumatoid Arthritis. J Pharm Pract 1999. [DOI: 10.1177/089719009901200405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Juvenile rheumatoid arthritis (JRA) is a common disorder of childhood that can be potentially devastating physically and psychologically. Over the last several decades, therapy for JRA has changed little. Therapy for advanced JRA is based on trial and error due to the lack of significant clinical trials for both old and new pharmaceutical agents. The following article is a brief overview of the disease and a review of the different treatment options available today with a look at some of the future developments in JRA research.
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29
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Flatø B, Vinje O, Førre O. Toxicity of antirheumatic and anti-inflammatory drugs in children. Clin Rheumatol 1999; 17:505-10. [PMID: 9890680 DOI: 10.1007/bf01451288] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of the study was to describe the long-term toxicity of antirheumatic and anti-inflammatory drugs in a paediatric rheumatology clinic population. One hundred and seventeen children were studied on first admission to a paediatric rheumatology clinic and after a mean of 8.6 +/- 0.4 years of follow-up. Medical records from the intermediate period were reviewed. The patients had 155 exposures to non-steroidal anti-inflammatory drugs (NSAIDs), 88 exposures to disease-modifying antirheumatic drugs (DMARDs) and 12 exposures of prednisolone during a total of 682 patient years. Drug toxicity was measured in terms of the number of toxic events, number of drug discontinuations due to toxicity, number of side-effects per patient year of drug exposure and as a toxicity index. Side-effects were seen in 69 (27%) of the drug exposures, corresponding to 0.10 toxic events per patient year of exposure. Abdominal pain was the most common side-effect, and was reported in 21 (14%) of the exposures to NSAIDs. Five severely toxic events, all leading to hospitalisation, occurred. The toxicity of NSAIDs was not significantly different from that of DMARDs with regard to the number of toxic events (21% and 31%, respectively, NS) and drug discontinuations due to toxicity (17% and 14%, respectively, NS). Piroxicam tended to be more toxic than ibuprofen (46% versus 18% toxic events, p <0.05; 36% versus 16% discontinuations due to toxicity, NS; 0.33 versus 0.05 side-effects per patient year and a toxicity index of 1.45 versus 0.20 units per patient year). Gold tended to be more toxic than antimalarials (41% versus 15% toxic events, p<0.05; 24% versus 12% discontinuations, NS; 0.37 versus 0.08 side-effects per patient year and a toxicity index of 1.56 versus 0.23 units per patient year). It was concluded that antirheumatic and anti-inflammatory drugs led to side-effects in 27% of the exposed children during 9 years of follow-up. There was an overlap of the toxicity of certain NSAIDs and the most commonly employed DMARDs.
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Affiliation(s)
- B Flatø
- Centre for Rheumatic Diseases, The National Hospital, OSR, Oslo, Norway
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Rider LG, Feldman BM, Perez MD, Rennebohm RM, Lindsley CB, Zemel LS, Wallace CA, Ballinger SH, Bowyer SL, Reed AM, Passo MH, Katona IM, Miller FW, Lachenbruch PA. Development of validated disease activity and damage indices for the juvenile idiopathic inflammatory myopathies: I. Physician, parent, and patient global assessments. Juvenile Dermatomyositis Disease Activity Collaborative Study Group. ARTHRITIS AND RHEUMATISM 1997; 40:1976-83. [PMID: 9365086 DOI: 10.1002/art.1780401109] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To determine the reliability, content validity, and responsiveness of physician global assessments of disease activity and damage in the juvenile idiopathic inflammatory myopathies (IIM), and to investigate concordance among physician, parent, and patient global ratings. METHODS Sixteen pediatric rheumatologists rated 10 juvenile IIM paper patient cases for global disease activity and damage, and assessed the importance of 51 clinical and laboratory parameters in formulating their global assessments. Then, 117 juvenile IIM patients were enrolled in a protocol to examine the relationship between Likert and visual analog scale global assessments, their sensitivity to change, and the comparability of physician, parent, and patient global ratings. RESULTS Pediatric rheumatologists demonstrated excellent interrater reliability in their global assessments of juvenile IIM disease activity and damage (97.7% and 94.7% agreement among raters, respectively), and agreed on a core set of clinical parameters in formulating their judgments. Likert scale ratings correlated with those on a visual analog scale, and both were comparable in responsiveness (standardized response means -0.56 for disease activity, 0.02 [Likert] and 0.14 [visual analog] for damage, measured over 8 months). Parent global ratings of disease activity correlated with physician assessments, but were not colinear (Spearman's correlation [r] = 0.41-0.45). Patient global disease activity assessments correlated with those done by parents (r = 0.57-0.84) and physicians (r = 0.37-0.63), but demonstrated less responsiveness (standardized response means -0.21 and -0.12, respectively, over 8 months). CONCLUSION Physician global assessments of juvenile IIM disease activity and damage demonstrated high interrater reliability and were shown to be comprehensive measures. Both physician and parent disease activity assessments should be considered valuable as quantitative measures for evaluating therapeutic responses in juvenile IIM patients.
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Affiliation(s)
- L G Rider
- Food and Drug Administration, and National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland 20892, USA
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Singsen BH, Goldbach-Mansky R. Methotrexate in the treatment of juvenile rheumatoid arthritis and other pediatric rheumatoid and nonrheumatic disorders. Rheum Dis Clin North Am 1997; 23:811-40. [PMID: 9361157 DOI: 10.1016/s0889-857x(05)70362-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The goal of treatment for juvenile rheumatoid arthritis (JRA) and other pediatric rheumatic disorders is to minimize joint destruction, pain, and deformity and to maximize all aspects of growth and development. Oral and injectable methotrexate are now often given early in the treatment of JRA, childhood dermatomyositis, difficult-to-control arthritis in the pediatric spondyloarthropathies, SLE, sarcoidosis, several of the vasculopathies, and idiopathic iritis. Weekly low-dose MTX has become a mainstay of long-term improved control of these disorders, and is associated with strikingly few documented long-term side effects. Dosages, pharmacology, side effects, efficacy, and treatment strategies are discussed. Although formal studies are lacking, MTX for the pediatric rheumatic disorders seems to be associated with less frequent physician visits, lower total costs, improved function, and fewer late reconstructive surgeries.
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Affiliation(s)
- B H Singsen
- Department of Immunologic and Rheumatic Diseases, Cleveland Clinic Foundation, Ohio, USA
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Giannini EH, Ruperto N, Ravelli A, Lovell DJ, Felson DT, Martini A. Preliminary definition of improvement in juvenile arthritis. ACTA ACUST UNITED AC 1997. [DOI: 10.1002/art.1780400703] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Giannini EH, Ruperto N, Ravelli A, Lovell DJ, Felson DT, Martini A. Preliminary definition of improvement in juvenile arthritis. ARTHRITIS AND RHEUMATISM 1997; 40:1202-9. [PMID: 9214419 DOI: 10.1002/1529-0131(199707)40:7<1202::aid-art3>3.0.co;2-r] [Citation(s) in RCA: 724] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To identify a core set of outcome variables for the assessment of children with juvenile arthritis (JA), to use the core set to develop a definition of improvement to determine whether individual patients demonstrate clinically important improvement, and to promote this definition as a single efficacy measure in JA clinical trials. METHODS A core set of outcome variables was established using a combination of statistical and consensus formation techniques. Variables in the core set consisted of 1) physician global assessment of disease activity; 2) parent/patient assessment of overall well-being; 3) functional ability; 4) number of joints with active arthritis; 5) number of joints with limited range of motion; and 6) erythrocyte sedimentation rate. To establish a definition of improvement using this core set, 21 pediatric rheumatologists from 14 countries met, and, using consensus formation techniques, scored each of 72 patient profiles as improved or not improved. Using the physicians' consensus as the gold standard, the chi-square, sensitivity, and specificity were calculated for each of 240 possible definitions of improvement. Definitions with sensitivity or specificity of <80% were eliminated. The ability of the remaining definitions to discriminate between the effects of active agent and those of placebo, using actual trial data, was then observed. Each definition was also ranked for face validity, and the sum of the ranks was then multiplied by the kappa statistic. RESULTS The definition of improvement with the highest final score was as follows: at least 30% improvement from baseline in 3 of any 6 variables in the core set, with no more than 1 of the remaining variables worsening by >30%. The second highest scoring definition was closely related to the first; the third highest was similar to the Paulus criteria used in adult rheumatoid arthritis trials, except with different variables. This indicates convergent validity of the process used. CONCLUSION We propose a definition of improvement for JA. Use of a uniform definition will help standardize the conduct and reporting of clinical trials, and should help practitioners decide if a child with JA has responded adequately to therapy. We are in the process of prospectively validating this definition and several others that scored highly.
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Affiliation(s)
- E H Giannini
- Children's Hospital Medical Center, Cincinnati, Ohio 45229-3039, USA
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Affiliation(s)
- P N Malleson
- Department of Paediatrics, Research Centre, Vancouver, Canada
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Giannini EH, Cawkwell GD. Drug treatment in children with juvenile rheumatoid arthritis. Past, present, and future. Pediatr Clin North Am 1995; 42:1099-125. [PMID: 7567188 DOI: 10.1016/s0031-3955(16)40055-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Rheumatology made its debut as a legitimate subspecialty of pediatrics sometime in the 1940s in Europe, and in the 1970s in North America. Therapy of juvenile rheumatoid arthritis has evolved from salicylates and gold injections to newer, less toxic nonsteroidal anti-inflammatory drugs and methotrexate. Corticosteroids remain as important drugs when life-threatening complications or blinding iridocyclitis develop. Immune response modifiers and gene therapies offer considerable potential for eventually halting or curing the disease but have yet to make a substantial impact on therapy. Methods for the correct conduct and interpretation of data from clinical trials are discussed.
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Affiliation(s)
- E H Giannini
- Department of Pediatrics, University of Cincinnati, College of Medicine, Ohio, USA
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