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Butler S, Sculley D, Santos D, Girones X, Singh-Grewal D, Coda A. Paediatric Rheumatology Fails to Meet Current Benchmarks, a Call for Health Equity for Children Living with Juvenile Idiopathic Arthritis, Using Digital Health Technologies. Curr Rheumatol Rep 2024; 26:214-221. [PMID: 38466514 PMCID: PMC11116247 DOI: 10.1007/s11926-024-01145-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 03/13/2024]
Abstract
PURPOSE OF REVIEW This critical review begins by presenting the history of Juvenile Idiopathic Arthritis (JIA) management. To move the conversation forward in addressing the current shortcomings that exist in the clinical management of children living with JIA, we argue that to date, the advancement of successful treatments for JIA has been historically slow. Factors implicated in this situation include a lack of rigorous research, JIA being considered a rare disease, and JIA's idiopathic and complex pathophysiology. RECENT FINDINGS Despite the well-intended legislative changes to increase paediatric research, and the major advancements seen in molecular medicine over the last 30 years, globally, paediatric rheumatology services are still failing to meet the current benchmarks of best practice. Provoking questions on how the longstanding health care disparities of poor access and delayed treatment for children living with JIA can be improved, to improve healthcare outcomes. Globally, paediatric rheumatology services are failing to meet the current benchmarks of best practice. Raising awareness of the barriers hindering JIA management is the first step in reducing the current health inequalities experienced by children living with JIA. Action must be taken now, to train and well-equip the paediatric rheumatology interdisciplinary workforce. We propose, a resource-efficient way to improve the quality of care provided could be achieved by embedding digital health into clinical practice, to create an integrative care model between the children, general practice and the paediatric rheumatology team. To improve fragmented service delivery and the coordination of interdisciplinary care, across the healthcare system.
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Affiliation(s)
- Sonia Butler
- School of Bioscience and Pharmacy, University of Newcastle, 10 Chittaway Rd, Ourimbah, NSW, 2258, Australia.
| | - Dean Sculley
- School of Bioscience and Pharmacy, University of Newcastle, 10 Chittaway Rd, Ourimbah, NSW, 2258, Australia
| | - Derek Santos
- School of Health Sciences, Queen Margaret University, Musselburgh, EH21 6UU, UK
| | - Xavier Girones
- Faculty of Health Sciences, Universities de Catalunya, Via Laietana, 2. Planta 4, 08003, Barcelona, Spain
| | - Davinder Singh-Grewal
- Department of Rheumatology, Sydney Children's Hospitals Network, Randwick and Westmead, Westmead, NSW, 2145, Australia
- John Hunter Children's Hospital, New Lambton Heights, NSW, 2305, Australia
- Discipline of Child and Adolescent Health, University of Sydney, Camperdown, NSW, 2006, Australia
- School of Women's and Children's Health, University of NSW, Sydney, NSW, 2052, Australia
| | - Andrea Coda
- School of Health Sciences, University of Newcastle, Chittaway Rd, Ourimbah, NSW, 2258, Australia
- 'Equity in Health and Wellbeing Research Program' at the Hunter Medical Research Institute (HMRI), Lot 1, Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia
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Correia Marques M, Ombrello MJ, Schulert GS. New discoveries in the genetics and genomics of systemic juvenile idiopathic arthritis. Expert Rev Clin Immunol 2024:1-12. [PMID: 38641907 DOI: 10.1080/1744666x.2024.2345868] [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: 02/15/2024] [Accepted: 04/17/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION Systemic juvenile idiopathic arthritis (sJIA) is a severe inflammatory condition with onset in childhood. It is sporadic, but elements of its stereotypical innate immune responses are likely genetically encoded by both common variants with small effect sizes and rare variants with larger effects. AREAS COVERED Genomic investigations have defined the unique genetic architecture of sJIA. Identification of the class II HLA locus as the strongest sJIA risk factor for the first time brought attention to T lymphocytes and adaptive immune mechanisms in sJIA. The importance of the human leukocyte antigen (HLA) locus was reinforced by recognition that HLA-DRB1*15 alleles are strongly associated with development of drug reactions and sJIA-associated lung disease (sJIA-LD). At the IL1RN locus, genetic variation relates to both risk of sJIA and may also predict non-response to anakinra. Finally, rare genetic variants may have critical roles in disease complications, such as homozygous LACC1 mutations in families with an sJIA-like illness, and hemophagocytic lymphohistiocytosis (HLH) gene variants in some children with macrophage activation syndrome (MAS). EXPERT OPINION Genetic and genomic analysis of sJIA holds great promise for both basic discovery of the course and complications of sJIA, and may help guide personalized medicine and therapeutic decision-making.
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Affiliation(s)
- Mariana Correia Marques
- Translational Genetics and Genomics Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, USA
| | - Michael J Ombrello
- Translational Genetics and Genomics Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, USA
| | - Grant S Schulert
- Division of Rheumatology, Cincinnati Children's Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Teh KL, Das L, Book YX, Hoh SF, Gao X, Arkachaisri T. Anti-tumor necrosis factor (aTNF) weaning strategy in juvenile idiopathic arthritis (JIA): does duration matter? Clin Rheumatol 2024; 43:1723-1733. [PMID: 38443603 DOI: 10.1007/s10067-024-06928-1] [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: 01/15/2024] [Revised: 02/20/2024] [Accepted: 02/29/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND To compare outcomes of a short and long weaning strategy of anti-tumor necrosis factor (aTNF) in our prospective juvenile idiopathic arthritis (JIA) cohort. RESEARCH DESIGN AND METHODS JIA patients on subcutaneous adalimumab with at least 6 months of follow-up were recruited (May 2010-Jan 2022). Once clinical remission on medication (CRM) was achieved, adalimumab was weaned according to two protocols-short (every 4-weekly for 6 months and stopped) and long (extending dosing interval by 2 weeks for three cycles until 12-weekly intervals and thereafter stopped) protocols. Outcomes assessed were flare rates, time to flare, and predictors. RESULTS Of 110 JIA patients, 77 (83% male, 78% Chinese; 82% enthesitis-related arthritis) underwent aTNF weaning with 53% on short and 47% on long weaning protocol. The total flare rate during and after stopping aTNF was not different between the two groups. The time to flare after stopping aTNF was not different (p = 0.639). Positive anti-nuclear antibody increased flare risk during weaning in long weaning group (OR 7.0, 95%CI: 1.2-40.8). Positive HLA-B27 (OR 6.5, 95%CI: 1.1-30.4) increased flare risks after stopping aTNF. CONCLUSION Duration of weaning aTNF may not minimize flare rate or delay time to flare after stopping treatment in JIA patients. Recapture rates for inactive disease at 6 months remained high for patients who flared after weaning or discontinuing medication.
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Affiliation(s)
- Kai Liang Teh
- Rheumatology and Immunology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Children's Tower, Level 3, Zone B, Singapore, 229899, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Lena Das
- Rheumatology and Immunology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Children's Tower, Level 3, Zone B, Singapore, 229899, Singapore
| | - Yun Xin Book
- Rheumatology and Immunology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Children's Tower, Level 3, Zone B, Singapore, 229899, Singapore
| | - Sook Fun Hoh
- Division of Nursing, KK Women's and Children's Hospital, Singapore, Singapore
| | - Xiaocong Gao
- Division of Nursing, KK Women's and Children's Hospital, Singapore, Singapore
| | - Thaschawee Arkachaisri
- Rheumatology and Immunology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Children's Tower, Level 3, Zone B, Singapore, 229899, Singapore.
- Duke-NUS Medical School, Singapore, Singapore.
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Tiller G, Hernandez BL, Buckle J, Allen R, Munro J, Gowdie P, Cox A, Akikusa J. Three- and five-year outcomes of an inception cohort of Australian children with juvenile idiopathic arthritis. Int J Rheum Dis 2024; 27:e15189. [PMID: 38769844 DOI: 10.1111/1756-185x.15189] [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: 07/27/2023] [Revised: 01/08/2024] [Accepted: 04/27/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND To describe the 3- and 5-year outcomes of an inception cohort of Australian children with JIA for whom 1-year outcomes have previously been published. METHODS Data regarding clinical outcomes of the original cohort of 134 patients at 3 and 5 years were sought. Relevant clinical features and medication exposures entered prospectively into an electronic record were collected and analyzed using descriptive statistics. RESULTS Data were available for 110 and 98 patients at 3 and 5 years, respectively. The proportion of patients with active joints progressively decreased from 34% at 12 months to 21% at 3 years and 16% at 5 years. Cumulative exposure to methotrexate increased between 3 and 5 years (75%-80%), however, point prevalence use decreased (45%-41%). Cumulative exposure and point prevalence use of bDMARDS both increased between 3 and 5 years; 30%-42% and 29%-33%, respectively. Thirty-five percent of patients had inactive joint disease off medications at 5 years, which occurred most frequently in patients with sJIA and oligoarthritis. CONCLUSION Five-year outcomes of Australian children with JIA are good, with only a small minority having ongoing active joint disease at 5 years. bDMARDS play an increasing role in management over time; however, methotrexate use remains significant. A majority of children remain on medications at 5 years.
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Affiliation(s)
- Georgina Tiller
- Department of Rheumatology, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | | | - Joanne Buckle
- Department of Rheumatology, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Roger Allen
- Department of Rheumatology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Jane Munro
- Department of Rheumatology, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Peter Gowdie
- Department of Rheumatology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Angela Cox
- Department of Rheumatology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Jonathan Akikusa
- Department of Rheumatology, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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Velez-Arteaga M, Carrera-Barriga GC, Moreno-Montenegro K, Gallegos C, Nicolalde B, Leon B, Guijarro K. Rhupus syndrome in the pediatric population: A comprehensive systematic literature review. Medicine (Baltimore) 2024; 103:e36451. [PMID: 38579098 PMCID: PMC10994449 DOI: 10.1097/md.0000000000036451] [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: 08/22/2023] [Accepted: 11/13/2023] [Indexed: 04/07/2024] Open
Abstract
INTRODUCTION The term "Rhupus" was employed to descriptively illustrate the overlap observed in some pediatric patients displaying features of both juvenile idiopathic arthritis (JIA) and systemic lupus erythematosus (SLE). Although "Rhupus" is traditionally used in adults, we applied it broadly to emphasize this clinical overlap. METHODS We sought to identify studies that registered signs, symptoms, imaging characteristics, and treatments given to patients with JIA and SLE. We searched four databases using a Boolean search string, resulting in 231 articles after duplicate removal. Title and abstract screening yielded 57 articles for full-text assessment. Full reviewed 13 extracted data regarding sex, age of onset, serologic and imaging findings, and management strategies. The NIH quality assessment tool was applied to ensure the internal validity of the articles. RESULTS From the 13 articles evaluated that meet inclusion criteria, none had standardized diagnostic algorithms. The total number of patients in those articles is 26, without discussing treatment guidelines. DISCUSSION Clinical presentation, diagnostic parameters, and treatment of pediatric Rhupus were synthesized in this review. Fundamental keys help distinguish the joint presentation when Juvenile Idiopathic Arthritis or Lupus is present, compared with the signs and symptoms when developing the overlapping syndrome. We highlight the importance of physicians knowing about this rare condition and call all specialists to report new cases of the disease so a consensus can be reached to establish standardized guidelines for diagnosing and treating Rhupus syndrome.
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Affiliation(s)
| | | | | | | | | | - Beatriz Leon
- Universidad San Francisco de Quito, Quito, Ecuador
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Semalulu T, Berard R, Beattie K, Basodan D, Boire G, Bolaria R, Cabral D, Chhabra A, Gerschman T, Johnson N, Herrington J, Houghton K, Lim L, Miettunen PMH, Park J, Proulx-Gauthier JP, Schmeling H, Scuccimarri R, Tam H, Tucker L, Guzman J, Batthish M. Clinical Characteristics of Adolescents With Juvenile Idiopathic Arthritis Transitioning to Adult Rheumatology Care in Canada: Results From the CAPRI Registry. J Rheumatol 2024; 51:403-407. [PMID: 38302168 DOI: 10.3899/jrheum.2023-0783] [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] [Accepted: 12/22/2023] [Indexed: 02/03/2024]
Abstract
OBJECTIVE Using Canadian Alliance of Pediatric Rheumatology Investigators (CAPRI) juvenile idiopathic arthritis (JIA) registry data, we describe (1) clinical characteristics of patients with JIA transitioning to adult care, (2) prevalence of disease-related damage and complications, and (3) changes in disease activity during the final year prior to transfer. METHODS Registry participants who turned 17 years between February 2017 and November 2021 were included. Clinical characteristics and patient-reported outcomes (PROs) at the last recorded pediatric rheumatology visit, and changes observed in the year prior to that visit were analyzed. Physicians completed an additional questionnaire characterizing cumulative disease-related damage and adverse events by age 17 years. RESULTS At their last visit, 88 of 131 participants (67%) had inactive and 42 (32%) had active disease. Overall, 96 (73%) were on medications and 41 (31%) were on biologic disease-modifying antirheumatic drugs. Among 80 participants for whom the additional questionnaire was completed, 26% had clinically detected joint damage, 31% had joint damage on imaging, 14% had uveitis, and 7.5% had experienced at least 1 serious adverse event. During the final year, 44.2% of patients were in remission, 28.4% attained inactive disease, and 27.4% became or remained active. Mean scores of PROs were stable overall during that last year, but a minority reported marked worsening. CONCLUSION A substantial proportion of youth with JIA transitioning to adult care in Canada had a high disease burden, which was reflected by their degree of disease activity, joint damage, or ongoing medication use. These results will inform pediatric and adult providers of anticipated needs during transition of care.
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Affiliation(s)
- Teresa Semalulu
- T. Semalulu, MD, Division of Rheumatology, Department of Medicine, McMaster University, Hamilton, Ontario
| | - Roberta Berard
- R. Berard, MD, MSc, J. Park, MD, Division of Rheumatology, Department of Pediatrics, Western University, London, Ontario
| | - Karen Beattie
- K. Beattie, PhD, J. Herrington, PT, MSc, M. Batthish, MD, MSc, Division of Rheumatology, Department of Pediatrics, McMaster University, Hamilton, Ontario
| | - Daniah Basodan
- D. Basodan, MBBS, L. Lim, MD, MPH, Division of Rheumatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta
| | - Gilles Boire
- G. Boire, MD, MSc, Division of Rheumatology, Department of Medicine, Sherbrooke University, Sherbrooke, Quebec
| | - Roxana Bolaria
- R. Bolaria, MD, D. Cabral, MD, T. Gerschman, MD, MSc, K. Houghton, MD, H. Tam, MBBS, MSc, L. Tucker, MD, J. Guzman, MD, Division of Rheumatology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia
| | - David Cabral
- R. Bolaria, MD, D. Cabral, MD, T. Gerschman, MD, MSc, K. Houghton, MD, H. Tam, MBBS, MSc, L. Tucker, MD, J. Guzman, MD, Division of Rheumatology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia
| | - Amieleena Chhabra
- A. Chhabra, MD, Interior Health Authority, Mary Pack Arthritis Society, University of British Columbia, Vancouver, British Columbia
| | - Tommy Gerschman
- R. Bolaria, MD, D. Cabral, MD, T. Gerschman, MD, MSc, K. Houghton, MD, H. Tam, MBBS, MSc, L. Tucker, MD, J. Guzman, MD, Division of Rheumatology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia
| | - Nicole Johnson
- N. Johnson, MD, MSc, P.M.H. Miettunen, MD, H. Schmeling, MD, Division of Rheumatology, Department of Pediatrics, University of Calgary, Calgary, Alberta
| | - Julie Herrington
- K. Beattie, PhD, J. Herrington, PT, MSc, M. Batthish, MD, MSc, Division of Rheumatology, Department of Pediatrics, McMaster University, Hamilton, Ontario
| | - Kristin Houghton
- R. Bolaria, MD, D. Cabral, MD, T. Gerschman, MD, MSc, K. Houghton, MD, H. Tam, MBBS, MSc, L. Tucker, MD, J. Guzman, MD, Division of Rheumatology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia
| | - Lillian Lim
- D. Basodan, MBBS, L. Lim, MD, MPH, Division of Rheumatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta
| | - Paivi Maria Hannele Miettunen
- N. Johnson, MD, MSc, P.M.H. Miettunen, MD, H. Schmeling, MD, Division of Rheumatology, Department of Pediatrics, University of Calgary, Calgary, Alberta
| | - Jonathan Park
- R. Berard, MD, MSc, J. Park, MD, Division of Rheumatology, Department of Pediatrics, Western University, London, Ontario
| | - Jean-Philippe Proulx-Gauthier
- J.P. Proulx-Gauthier, MD, Division of Rheumatology, Department of Pediatrics, CHU de Québec-Université Laval, Quebec City, Quebec
| | - Heinrike Schmeling
- N. Johnson, MD, MSc, P.M.H. Miettunen, MD, H. Schmeling, MD, Division of Rheumatology, Department of Pediatrics, University of Calgary, Calgary, Alberta
| | - Rosie Scuccimarri
- R. Scuccimarri, MD, Division of Rheumatology, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Herman Tam
- R. Bolaria, MD, D. Cabral, MD, T. Gerschman, MD, MSc, K. Houghton, MD, H. Tam, MBBS, MSc, L. Tucker, MD, J. Guzman, MD, Division of Rheumatology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia
| | - Lori Tucker
- R. Bolaria, MD, D. Cabral, MD, T. Gerschman, MD, MSc, K. Houghton, MD, H. Tam, MBBS, MSc, L. Tucker, MD, J. Guzman, MD, Division of Rheumatology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia
| | - Jaime Guzman
- R. Bolaria, MD, D. Cabral, MD, T. Gerschman, MD, MSc, K. Houghton, MD, H. Tam, MBBS, MSc, L. Tucker, MD, J. Guzman, MD, Division of Rheumatology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia
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Collin M, Christidis N, Hagelberg S, Arvidsson LZ, Larheim TA, Ernberg M, Hedenberg-Magnusson B. Temporomandibular involvement in children and adolescents with juvenile idiopathic arthritis: a 2-year prospective cohort study. Sci Rep 2024; 14:5512. [PMID: 38448491 PMCID: PMC10917773 DOI: 10.1038/s41598-024-56174-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 03/03/2024] [Indexed: 03/08/2024] Open
Abstract
This study aimed to clinically evaluate temporomandibular joint (TMJ) involvement in juvenile idiopathic arthritis (JIA) and the ability to identify and/or predict development of TMJ-deformities over time using cone beam computed tomography (CBCT). The predictive value of self-reported TMJ pain was also assessed. A prospective longitudinal cohort study comprising 54 children with JIA, 39 girls and 15 boys, was performed. All children had active disease at baseline, 50% with the subtype oligoarthritis. Repeated clinical orofacial and CBCT examinations were performed over a two-year period. At baseline, 39% had radiographic TMJ deformities (24% unilateral, 15% bilateral), at 2-year follow-up, 42% (p > 0.05). Both progressing and improving TMJ deformities were observed. An association was found between TMJ-deformities and self-reported TMJ pain at baseline (p = 0.01). Maximum unassisted mouth opening (MUO) was smaller for children with TMJ-deformities (p < 0.05). The prevalence of palpatory muscle pain was high (48-59%) but not predictive of development of TMJ-deformities. TMJ noises increased over time and crepitations were associated with TMJ-deformities (p < 0.05). In conclusion, in children with JIA, self-reported TMJ pain and dysfunction were common and predictive of TMJ deformities. TMJ deformities were associated with smaller MUO and palpatory TMJ pain as well as crepitations. Trial registration. ClinicalTrials.gov Protocol id: 2010/2089-31/2.
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Affiliation(s)
- Malin Collin
- Division of Oral Diagnostics and Rehabilitation, Department of Dental Medicine, Karolinska Institutet, 141 04, Huddinge, Sweden.
- Department of Orofacial Pain and Jaw Function, Folktandvården, Sörmland AB, Mälarsjukhuset, 611 32, Nyköping, Sweden.
| | - Nikolaos Christidis
- Division of Oral Diagnostics and Rehabilitation, Department of Dental Medicine, Karolinska Institutet, 141 04, Huddinge, Sweden
| | - Stefan Hagelberg
- Department of Women's and Children's Health, Karolinska Institute, Karolinska University Hospital, 17176, Stockholm, Sweden
| | - Linda Z Arvidsson
- Department of Maxillofacial Radiology, Institute of Clinical Dentistry, University of Oslo, Oslo, Norway
| | - Tore A Larheim
- Department of Maxillofacial Radiology, Institute of Clinical Dentistry, University of Oslo, Oslo, Norway
| | - Malin Ernberg
- Division of Oral Diagnostics and Rehabilitation, Department of Dental Medicine, Karolinska Institutet, 141 04, Huddinge, Sweden
| | - Britt Hedenberg-Magnusson
- Division of Oral Diagnostics and Rehabilitation, Department of Dental Medicine, Karolinska Institutet, 141 04, Huddinge, Sweden
- Department of Orofacial Pain and Jaw Function, Folktandvården Stockholms Län AB, 11382, Stockholm, Sweden
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Schulert G, Vastert SJ, Grom AA. The 4th NextGen therapies for SJIA and MAS: part 2 phenotypes of refractory SJIA and the landscape for clinical trials in refractory SJIA. Pediatr Rheumatol Online J 2024; 21:87. [PMID: 38183098 PMCID: PMC10768071 DOI: 10.1186/s12969-023-00865-0] [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] [Indexed: 01/07/2024] Open
Abstract
Although the introduction of the IL-1 and IL-6 inhibiting biologics in 2012 has revolutionized the treatment and markedly improved outcomes for many patients with SJIA, about 20% of these patients continue to have active disease, have markedly decreased quality of life and high disease activity as well as treatment-related morbidity and mortality. There is a clear need to define these disease states, and then use these definitions as the basis for further studies into the prevalence, clinical features, and pathophysiologic mechanisms. While such patients are most likely to benefit from novel therapies, they are very difficult to enroll in the ongoing clinical trials given the unique features of their disease and large numbers of background medications. The discussions at the NextGen 2022 conference focused on strategies to overcome these obstacles and accelerate studies in refractory SJIA.
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Affiliation(s)
- Grant Schulert
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA.
| | - Sebastiaan J Vastert
- Department of Pediatric Rheumatology & Immunology and Center for Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Alexei A Grom
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
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Welzel T, Golhen K, Atkinson A, Gotta V, Ternant D, Kuemmerle-Deschner JB, Michler C, Koch G, van den Anker JN, Pfister M, Woerner A. Prospective study to characterize adalimumab exposure in pediatric patients with rheumatic diseases. Pediatr Rheumatol Online J 2024; 22:5. [PMID: 38167019 PMCID: PMC10763375 DOI: 10.1186/s12969-023-00930-8] [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: 08/30/2023] [Accepted: 11/15/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND In pediatric rheumatic diseases (PRD), adalimumab is dosed using fixed weight-based bands irrespective of methotrexate co-treatment, disease activity (DA) or other factors that might influence adalimumab pharmacokinetics (PK). In rheumatoid arthritis (RA) adalimumab exposure between 2-8 mg/L is associated with clinical response. PRD data on adalimumab is scarce. Therefore, this study aimed to analyze adalimumab PK and its variability in PRD treated with/without methotrexate. METHODS A two-center prospective study in PRD patients aged 2-18 years treated with adalimumab and methotrexate (GA-M) or adalimumab alone (GA) for ≥ 12 weeks was performed. Adalimumab concentrations were collected 1-9 (maximum concentration; Cmax), and 10-14 days (minimum concentration; Cmin) during ≥ 12 weeks following adalimumab start. Concentrations were analyzed with enzyme-linked immunosorbent assay (lower limit of quantification: 0.5 mg/L). Log-normalized Cmin were compared between GA-M and GA using a standard t-test. RESULTS Twenty-eight patients (14 per group), diagnosed with juvenile idiopathic arthritis (71.4%), non-infectious uveitis (25%) or chronic recurrent multifocal osteomyelitis (3.6%) completed the study. GA-M included more females (71.4%; GA 35.7%, p = 0.13). At first study visit, children in GA-M had a slightly longer exposure to adalimumab (17.8 months [IQR 9.6, 21.6]) compared to GA (15.8 months [IQR 8.5, 30.8], p = 0.8). Adalimumab dosing was similar between both groups (median dose 40 mg every 14 days) and observed DA was low. Children in GA-M had a 27% higher median overall exposure compared to GA, although median Cmin adalimumab values were statistically not different (p = 0.3). Cmin values ≥ 8 mg/L (upper limit RA) were more frequently observed in GA-M versus GA (79% versus 64%). Overall, a wide range of Cmin values was observed in PRD (0.5 to 26 mg/L). CONCLUSION This study revealed a high heterogeneity in adalimumab exposure in PRD. Adalimumab exposure tended to be higher with methotrexate co-treatment compared to adalimumab monotherapy although differences were not statistically significant. Most children showed adalimumab exposure exceeding those reported for RA with clinical response, particularly with methotrexate co-treatment. This highlights the need of further investigations to establish model-based personalized treatment strategies in PRD to avoid under- and overexposure. TRIAL REGISTRATION NCT04042792 , registered 02.08.2019.
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Affiliation(s)
- Tatjana Welzel
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland.
- Division of Pediatric Rheumatology, Department of Pediatrics and Autoinflammation Reference Centre Tuebingen (arcT), University Hospital Tuebingen, Tuebingen, Germany.
- Pediatric Rheumatology, University Children's Hospital Basel, University of Basel, Basel, Switzerland.
- Pediatric Research Center, University Children's Hospital Basel, University of Basel, Basel, Switzerland.
| | - Klervi Golhen
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Andrew Atkinson
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
- Pediatric Research Center, University Children's Hospital Basel, University of Basel, Basel, Switzerland
- Division of Infectious Diseases, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Verena Gotta
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - David Ternant
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
- Université de Tours, service de pharmacologie médicale, Tours France, Université de Tours, EA 4245 T2I, Tours, France
| | - Jasmin B Kuemmerle-Deschner
- Division of Pediatric Rheumatology, Department of Pediatrics and Autoinflammation Reference Centre Tuebingen (arcT), University Hospital Tuebingen, Tuebingen, Germany
| | - Christine Michler
- Division of Pediatric Rheumatology, Department of Pediatrics and Autoinflammation Reference Centre Tuebingen (arcT), University Hospital Tuebingen, Tuebingen, Germany
| | - Gilbert Koch
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Johannes N van den Anker
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Marc Pfister
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Andreas Woerner
- Pediatric Rheumatology, University Children's Hospital Basel, University of Basel, Basel, Switzerland
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10
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Erkens RGA, Calis JJA, Verwoerd A, De Roock S, Ter Haar NM, Den Engelsman G, Van der Veken LT, Ernst RF, Van Deutekom HWM, Pickering A, Scholman RC, Jansen MHA, Swart JF, Sinha R, Roth J, Schulert GS, Grom AA, Van Loosdregt J, Vastert SJ. Recombinant Interleukin-1 Receptor Antagonist Is an Effective First-Line Treatment Strategy in New-Onset Systemic Juvenile Idiopathic Arthritis, Irrespective of HLA-DRB1 Background and IL1RN Variants. Arthritis Rheumatol 2024; 76:119-129. [PMID: 37471469 DOI: 10.1002/art.42656] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 06/07/2023] [Accepted: 07/07/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE Human leukocyte antigen (HLA)-DRB1*15:01 has been recently associated with interstitial lung disease (LD), eosinophilia, and drug reactions in systemic juvenile idiopathic arthritis (sJIA). Additionally, genetic variants in IL1RN have been linked to poor response to anakinra. We sought to reproduce these findings in a prospective cohort study of patients with new-onset sJIA treated with anakinra as first-line therapy. METHODS HLA and IL1RN risk alleles were identified via whole-genome sequencing. Treatment responses and complications were compared between carriers versus noncarriers. RESULTS Seventeen of 65 patients (26%) carried HLA-DRB1*15:01, comparable with the general population, and there was enrichment for HLA-DRB1*11:01, a known risk locus for sJIA. The rates of clinical inactive disease (CID) at 6 months, 1 year, and 2 years were generally high, irrespective of HLA-DRB1 or IL1RN variants, but significantly lower in carriers of an HLA-DRB1*11:01 allele. One patient, an HLA-DRB1*15:01 carrier, developed sJIA-LD. Of the three patients with severe drug reactions to biologics, one carried HLA-DRB1*15:01. The prevalence of eosinophilia did not significantly differ between HLA-DRB1*15:01 carriers and noncarriers at disease onset (6.2% vs 14.9%, P = 0.67) nor after the start of anakinra (35.3% vs 37.5% in the first 2 years of disease). CONCLUSION We observed high rates of CID using anakinra as first-line treatment irrespective of HLA-DRB1 or IL1RN variants. Only one of the 17 HLA-DRB1*15:01 carriers developed sJIA-LD, and of the three patients with drug reactions to biologics, only one carried HLA-DRB1*15:01. Although thorough monitoring for the development of drug hypersensitivity and refractory disease courses in sJIA, including sJIA-LD, remains important, our data support the early start of biologic therapy in patients with new-onset sJIA irrespective of HLA-DRB1 background or IL1RN variants.
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Affiliation(s)
- Remco G A Erkens
- University Medical Center Utrecht and University of Utrecht, Utrecht, The Netherlands
| | - Jorg J A Calis
- University Medical Center Utrecht and University of Utrecht, Utrecht, The Netherlands
| | - Anouk Verwoerd
- University Medical Center Utrecht and University of Utrecht, Utrecht, The Netherlands
| | - Sytze De Roock
- University Medical Center Utrecht and University of Utrecht, Utrecht, The Netherlands
| | - Nienke M Ter Haar
- University Medical Center Utrecht and University of Utrecht, Utrecht, The Netherlands
| | - Gerda Den Engelsman
- University Medical Center Utrecht and University of Utrecht, Utrecht, The Netherlands
| | - Lars T Van der Veken
- University Medical Center Utrecht and University of Utrecht, Utrecht, The Netherlands
| | - Robert F Ernst
- University Medical Center Utrecht and University of Utrecht, Utrecht, The Netherlands
| | | | | | - Rianne C Scholman
- University Medical Center Utrecht and University of Utrecht, Utrecht, The Netherlands
| | - Marc H A Jansen
- University Medical Center Utrecht and University of Utrecht, Utrecht, The Netherlands
| | - Joost F Swart
- University Medical Center Utrecht and University of Utrecht, Utrecht, The Netherlands
| | - Rashmi Sinha
- Systemic Juvenile Idiopathic Arthritis Foundation, Cincinnati, Ohio
| | | | - Grant S Schulert
- Cincinnati Children's Hospital and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alexei A Grom
- Cincinnati Children's Hospital and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jorg Van Loosdregt
- University Medical Center Utrecht and University of Utrecht, Utrecht, The Netherlands
| | - Sebastiaan J Vastert
- University Medical Center Utrecht and University of Utrecht, Utrecht, The Netherlands
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11
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Hagström N, Lövestam E, Koochek A, Berntson L. A qualitative evaluation of the specific carbohydrate diet for juvenile idiopathic arthritis based on children's and parents' experiences. Pediatr Rheumatol Online J 2023; 21:127. [PMID: 37858222 PMCID: PMC10588234 DOI: 10.1186/s12969-023-00914-8] [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: 08/19/2023] [Accepted: 10/12/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Insights into the immunological role of the gastrointestinal tract in autoimmune conditions have led to the investigation of diet as a potential adjunctive treatment option for juvenile idiopathic arthritis (JIA). The specific carbohydrate diet (SCD) has shown promising results. However, studies on participants' experiences of dietary interventions in JIA are rare. In this study we investigated the experiences of children and parents' who had participated in a four-week intervention with SCD aiming to examine the potential anti-inflammatory effects. OBJECTIVES To conduct a qualitative evaluation exploring children's and parents' experiences of the dietary intervention, how they navigated challenges, and their support requirements. METHODS Semi-structured interviews were conducted with 12 children and 15 parents from 13 families, who were interviewed individually and together. The transcripts were analysed using systematic text condensation. RESULTS Most participants interviewed found the intervention beneficial, with 12 out of 13 reporting positive effects, such as reduced pain and morning stiffness, and improved gastrointestinal function. Many participants reported being willing to repeat the intervention in the current form. Despite facing challenges, all children followed the diet for one to three months, with some continuing to follow a modified version. Facing the socio-emotional consequences of adhering to the diet was challenging for children. These were handled by focusing on the positive aspects and by relying on the supportive environment available. Parents struggled with practical issues since the diet required hard work, time, and money. Areas identified as requiring additional support include finding simple, quick, and child-friendly solutions, strengthening organizational food skills such as meal planning, and preparation prior to starting the intervention regarding socio-emotional aspects. CONCLUSION Navigating the dietary treatment was considered challenging, practically for the parents and socio-emotionally for the children. Based on the reported challenges and participants' suggestions the intervention could be optimised by providing support and solutions in relation to the practical issues and better preparation regarding dealing with the socio-emotional consequences. Despite the difficulties, the participants reported overall positive experiences of, and attitudes towards, the current setup. Consequently, dietary interventions, such as the SCD, may be regarded as suitable targets for further research.
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Affiliation(s)
- Naima Hagström
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Elin Lövestam
- Department of Food Studies, Nutrition and Dietetics, Uppsala University, Uppsala, Sweden
| | - Afsaneh Koochek
- Department of Food Studies, Nutrition and Dietetics, Uppsala University, Uppsala, Sweden
| | - Lillemor Berntson
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
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12
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Chen K, Zeng H, Togizbayev G, Martini A, Zeng H. New classification criteria for juvenile idiopathic arthritis. Int J Rheum Dis 2023; 26:1889-1892. [PMID: 37807617 DOI: 10.1111/1756-185x.14813] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/16/2023] [Accepted: 06/20/2023] [Indexed: 10/10/2023]
Affiliation(s)
- Kexin Chen
- Department of Pediatric Allergy, Immunology and Rheumatology, Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Haisheng Zeng
- Department of Rheumatology and Immunology, Dongguan Children's Hospital, Dongguan, Guangdong Province, China
| | | | - Alberto Martini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Child and Maternal Health, University of Genoa, Genoa, Italy
| | - Huasong Zeng
- Department of Pediatric Allergy, Immunology and Rheumatology, Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
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13
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Lukjanoviča K, Šlēziņa I, Dāvidsone Z, Šantere R, Budarina K, Staņēviča V. Systemic Juvenile Idiopathic Arthritis and Secondary Macrophage Activation Syndrome in Latvia from 2009 to 2020: A Nationwide Retrospective Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040798. [PMID: 37109756 PMCID: PMC10144400 DOI: 10.3390/medicina59040798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/12/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023]
Abstract
Background and Objectives: Systemic juvenile idiopathic arthritis (sJIA) is a distinctive JIA subtype with mostly nonspecific systemic clinical features, which can be a diagnostic challenge. This study aimed to analyze our experience with sJIA in Latvia for twelve years: assessing clinical and epidemiological characteristics, the efficacy of therapy, and disease outcomes, including the development of macrophage activation syndrome (MAS). Materials and methods: This is a descriptive study in which we conducted a retrospective case review of all patients with sJIA diagnosis admitted to the only pediatric tertiary centre in Latvia during the period 2009-2020. Results: sJIA was diagnosed in 35 patients with a mean annual incidence rate of 0.85 patients per 100,000 children. Major clinical signs at the first visit were: fever, rash, arthritis, and lymphadenopathy. Almost half of the patients, 48.5%, had a monocyclic disease course, and only 20% of patients had persistent disease. MAS developed in 28.6% of patients. Biological therapy was administered to 48.6% of patients, mostly by tocilizumab, which induced remission in 75% after one year, and in 81.2% after two years without any serious therapy-related complications. In our study, none of the patients had interstitial lung disease, drug reaction with eosinophilia and systemic symptoms (DRESS)-like syndrome, or fatal disease. Conclusions: The incidence and clinical characteristics of sJIA correlate with the literature findings, although MAS was more common than described in other studies. There is a tendency for the persistent disease to decrease with the use of biological therapy. Tocilizumab is an efficient choice of treatment with a good safety profile.
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Affiliation(s)
- Kristīne Lukjanoviča
- Department of Pediatric Rheumatology, Children's Clinical University Hospital, LV-1004 Riga, Latvia
- Faculty of Residency, Riga Stradins University, LV-1007 Riga, Latvia
| | - Ieva Šlēziņa
- Faculty of Residency, Riga Stradins University, LV-1007 Riga, Latvia
| | - Zane Dāvidsone
- Department of Pediatric Rheumatology, Children's Clinical University Hospital, LV-1004 Riga, Latvia
- Department of Pediatrics, Riga Stradins University, LV-1004 Riga, Latvia
| | - Ruta Šantere
- Department of Pediatric Rheumatology, Children's Clinical University Hospital, LV-1004 Riga, Latvia
| | - Kristīna Budarina
- Department of Pediatric Rheumatology, Children's Clinical University Hospital, LV-1004 Riga, Latvia
| | - Valda Staņēviča
- Department of Pediatric Rheumatology, Children's Clinical University Hospital, LV-1004 Riga, Latvia
- Department of Pediatrics, Riga Stradins University, LV-1004 Riga, Latvia
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14
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Li J, Zhu Y, Guo G. Enthesitis-related arthritis: the clinical characteristics and factors related to MRI remission of sacroiliitis. BMC Musculoskelet Disord 2022; 23:1054. [DOI: 10.1186/s12891-022-06028-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 11/25/2022] [Indexed: 12/04/2022] Open
Abstract
Abstract
Background
To describe the clinical characteristics and explore the factors related to the MRI remission of sacroiliitis in patients with enthesitis-related arthritis (ERA).
Methods
Patients with ERA from 2018–2022 in our medical center were retrospectively reviewed, which identified according to Pediatric Rheumatology International Trials Organization (PRINTO) criteria. Demographics, clinical characteristics, examinations, and treatments were described. Univariate and multivariate logistic regression models were used to analyze the factors related to MRI remission of sacroiliitis in ERA.
Results
This retrospective study included 160 ERA patients (51.9% male) with a mean onset age of 9.2 ± 3.0 years. There were 144 cases (81.9%) with peripheral arthritis, and the hip, knee, and ankle joints were the most commonly involved joints. Enthesitis occurred in 48 cases (30.0%), and sacroiliitis occurred in 142 cases (88.5%) at diagnosis. Human leukocyte antigen (HLA)-B27 was positive in 33 cases (17.1%), and acute uveitis occurred in 3 cases (1.9%). The majority of patients (93.7%) were treated with disease-modifying anti-rheumatic drugs (DMARDs), and 60% with biologics. Among 62 patients with MRI-defined sacroiliitis, 27 (43.5%) cases showed improvement in the sacroiliac joint lesion after treatment. Multivariate logistic regression analysis showed that duration from onset to diagnosis of less than 3 months (OR = 3.609, 95% CI: 1.068–12.192) and active joints of more than 4 (OR = 4.916, 95% CI: 1.006–24.037) were independent factors.
Conclusion
We highlighted differences in ERA clinical characteristics. Patients with a shorter diagnosis time and more joint involvement improved more significantly in sacroiliac joint lesions after treatment.
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15
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Synovial fluid mesenchymal progenitor cells from patients with juvenile idiopathic arthritis demonstrate limited self-renewal and chondrogenesis. Sci Rep 2022; 12:16530. [PMID: 36192450 PMCID: PMC9530167 DOI: 10.1038/s41598-022-20880-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 09/20/2022] [Indexed: 11/11/2022] Open
Abstract
Juvenile idiopathic arthritis (JIA) is a heterogeneous group of inflammatory diseases affecting joints with a prevalence of one in a thousand children. There is a growing body of literature examining the use of mesenchymal stem/progenitor cells (MPCs) for the treatment of adult and childhood arthritis, however, we still lack a clear understanding of how these MPC populations are impacted by arthritic disease states and how this could influence treatment efficacy. In the current study we examined the immunophenotyping, self-renewal ability and chondrogenic capacity (in vitro and in vivo) of synovial derived MPCs from normal, JIA and RA joints. Synovial MPCs from JIA patients demonstrated reduced self-renewal ability and chondrogenic differentiation capacity. Furthermore, they did not induce cartilage regeneration when xenotransplanted in a mouse cartilage injury model. Synovial MPCs from JIA patients are functionally compromised compared to MPCs from normal and/or RA joints. The molecular mechanisms behind this loss of function remain elusive. Further study is required to see if these cells can be re-functionalized and used in cell therapy strategies for these JIA patients, or if allogenic approaches should be considered.
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16
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Costello RE, Kearsley-Fleet L, McDonagh JE, Hyrich K, Humphreys JH. Continuing specialist care into adulthood in young people with juvenile idiopathic arthritis: a retrospective cohort study using electronic health records in England. Rheumatology (Oxford) 2022; 62:1936-1943. [PMID: 36135794 PMCID: PMC10152295 DOI: 10.1093/rheumatology/keac497] [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: 05/04/2022] [Revised: 07/18/2022] [Accepted: 08/18/2022] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES This study aimed to measure 1) the proportion of children who continue to receive specialist care (rheumatology/ophthalmology) as adults, 2) the characteristics associated with continuing specialist care, and 3) the frequency of specialist care appointments in both paediatric and adult services. METHODS A retrospective cohort of young people with JIA was identified from UK primary care electronic health records (Clinical Practice Research Datalink (CPRD)) between 01/04/2003-31/12/2018. To be included in the study cases needed to have at least one year registration at their GP beyond age 18 and linkage to Hospital Episodes Statistics (HES) data for secondary care information. All specialist care outpatient visits were identified from HES outpatient data. RESULTS There were 666 young people included in the study. Of those, 427 (64%) received specialist care beyond age 18, 90 (13%) had their last recorded contact between 16-17 years and 149 (22%) did not continue after 16 years. Older age at diagnosis, female gender, greater deprivation and a childhood diagnosis of uveitis were associated with continuing specialist care beyond age 18. Of those continuing beyond 18, 35% (n = 153) were subsequently discharged by study end date. Of all those discharged, 32% had a missed appointment recorded after the last attended visit suggesting failure to attend. CONCLUSIONS Two-thirds of young people with JIA continue to receive specialist care beyond age 18. This is useful information for children and young people with JIA and their families planning for their future, and for clinicians planning healthcare services.
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Affiliation(s)
- Ruth E Costello
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester Academic Health Centre, Manchester, UK
| | - Lianne Kearsley-Fleet
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester Academic Health Centre, Manchester, UK
| | - Janet E McDonagh
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester Academic Health Centre, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Trust, Manchester, UK.,Department of Paediatric and Adolescent Rheumatology, Royal Manchester Children's Hospital, Manchester University Hospitals NHS Trust, Manchester, UK
| | - Kimme Hyrich
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester Academic Health Centre, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Trust, Manchester, UK.,Kellgren Centre for Rheumatology, Manchester Royal Infirmary, Manchester University Hospitals NHS Trust, Manchester, UK
| | - Jenny H Humphreys
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester Academic Health Centre, Manchester, UK.,Kellgren Centre for Rheumatology, Manchester Royal Infirmary, Manchester University Hospitals NHS Trust, Manchester, UK
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17
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Welzel T, Oefelein L, Twilt M, Pfister M, Kuemmerle-Deschner JB, Benseler SM. Tapering of biological treatment in autoinflammatory diseases: a scoping review. Pediatr Rheumatol Online J 2022; 20:67. [PMID: 35964053 PMCID: PMC9375310 DOI: 10.1186/s12969-022-00725-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Biological treatment and treat-to-target approaches guide the achievement of inactive disease and clinical remission in Autoinflammatory Diseases (AID). However, there is limited evidence addressing optimal tapering strategies and/or discontinuation of biological treatment in AID. This study evaluates available evidence of tapering biological treatment and explores key factors for successful tapering. METHODS A systematic literature search was conducted in Embase, MEDLINE, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials using the OVID platform (1990-08/2020). Bibliographic search of relevant reviews was also performed. Studies/case series (n ≥ 5) in AID patients aged ≤ 18 years with biological treatment providing information on tapering/treatment discontinuation were included. After quality assessment aggregated data were extracted and synthesized. Tapering strategies were explored. RESULTS A total of 6035 records were identified. Four papers were deemed high quality, all focused on systemic juvenile idiopathic arthritis (sJIA) (1 open-label randomized trial, 2 prospective, 1 retrospective observational study). Biological treatment included anakinra (n = 2), canakinumab (n = 1) and tocilizumab (n = 1). Strategies in anakinra tapering included alternate-day regimen. Canakinumab tapering was performed randomized for dose reduction or interval prolongation, whereas tocilizumab was tapered by interval prolongation. Key factors identified included early start of biological treatment and sustained inactive disease. CONCLUSION Tapering of biological treatment after sustained inactive disease should be considered. Guidance for optimal strategies is limited. Future studies may leverage therapeutic drug monitoring in combination with pharmacometric modelling to further enhance personalized "taper-to-target" strategies respecting individual patients and diseases aspects.
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Affiliation(s)
- Tatjana Welzel
- Pediatric Rheumatology and autoinflammation reference center Tuebingen (arcT), Department of Pediatrics, Member of the European Reference Network for rare or low prevalence complex diseases, network Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN RITA), University Children`s Hospital Tuebingen, Tuebingen, Germany. .,Pediatric Pharmacology and Pharmacometrics, Pediatric Rheumatology, University Children`s Hospital Basel (UKBB), University of Basel, Spitalstrasse 33, CH, 4031, Basel, Switzerland.
| | - Lea Oefelein
- grid.488549.cPediatric Rheumatology and autoinflammation reference center Tuebingen (arcT), Department of Pediatrics, Member of the European Reference Network for rare or low prevalence complex diseases, network Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN RITA), University Children`s Hospital Tuebingen, Tuebingen, Germany
| | - Marinka Twilt
- grid.22072.350000 0004 1936 7697Rheumatology, Department of Pediatrics, Alberta Children`s Hospital, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB Canada
| | - Marc Pfister
- grid.412347.70000 0004 0509 0981Pediatric Pharmacology and Pharmacometrics, Pediatric Rheumatology, University Children`s Hospital Basel (UKBB), University of Basel, Spitalstrasse 33, CH 4031 Basel, Switzerland
| | - Jasmin B. Kuemmerle-Deschner
- grid.488549.cPediatric Rheumatology and autoinflammation reference center Tuebingen (arcT), Department of Pediatrics, Member of the European Reference Network for rare or low prevalence complex diseases, network Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN RITA), University Children`s Hospital Tuebingen, Tuebingen, Germany
| | - Susanne M. Benseler
- grid.22072.350000 0004 1936 7697Rheumatology, Department of Pediatrics, Alberta Children`s Hospital, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB Canada
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18
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Gillard L, Pouchot J, Cohen-Aubart F, Koné-Paut I, Mouterde G, Michaud M, Reumaux H, Savey L, Belot A, Fautrel B, Mitrovic S. JAK inhibitors in difficult-to-treat adult-onset Still's disease and systemic-onset juvenile idiopathic arthritis. Rheumatology (Oxford) 2022; 62:1594-1604. [PMID: 35920788 DOI: 10.1093/rheumatology/keac440] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/22/2022] [Accepted: 07/22/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Excessive and inappropriate production of pro-inflammatory cytokines plays a key role in Still's disease. JAK inhibitor (JAKi) agents mainly block pro-inflammatory cytokine pathways, notably IL-6 and IFN. The objective was to assess the efficacy and safety of JAKi agents in difficult-to-treat systemic juvenile idiopathic arthritis (SJIA) or adult-onset Still's disease (AOSD). METHODS This retrospective study was based on a national survey conducted in the departments of rheumatology, paediatric rheumatology and internal medicine of French hospitals regarding SJIA and AOSD patients who received JAKi agents. The data were collected with a standardised questionnaire and analysed at different times (treatment initiation, months 1, 3, and 6 and the end of follow-up). RESULTS Nine patients (7 adults) were included. All patients showed inadequate response to corticosteroids or conventional synthetic or biologic disease-modifying anti-rheumatic drugs. Baricitinib was used in 5 patients, ruxolitinib in 2, tofacitinib in 2, and upadacitinib in 1. A JAKi was used combined with corticosteroids in all but 2 patients. A JAKi was associated with anakinra and corticosteroids in one patient, and with methotrexate, anakinra and corticosteroids in another. The median follow-up was 16 [1-33] months. Two cases out 9 showed complete remission, 3/9 partial response and 4/9 treatment failure. At the last visit, corticosteroids could be decreased but not stopped. Tolerance of the JAKi was acceptable (no severe adverse events). CONCLUSION JAKi agents may be a therapeutic option for some patients with difficult-to-treat Still's disease, especially those with partial response to medium- or high-dose corticosteroids or biologics.
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Affiliation(s)
- Louise Gillard
- Service de Rhumatologie, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, AP-HP, France
| | - Jacques Pouchot
- Service de Médecine Interne, Hôpital Européen Georges Pompidou, Université Paris Cité, AP-HP, Paris, France
| | - Fleur Cohen-Aubart
- Service de Médecine Interne 2, Hôpital Pitié-Salpêtrière, Sorbonne Université, AP-HP, Paris, France
| | - Isabelle Koné-Paut
- Service de Rhumatologie Pédiatrique, Hôpital de Bicêtre, Université de Paris Saclay, AP-HP, Le Kremlin-Bicêtre, France.,Centre de Référence des Maladies Autoinflammatoires et des Amyloses (CéRéMAIA), Paris, France
| | - Gaël Mouterde
- Service de Rhumatologie, CHU de Montpellier, Université de Montpellier, Montpellier, France
| | - Martin Michaud
- Service de Médecine Interne, Clinique Ambroise Paré, Toulouse, France
| | - Héloïse Reumaux
- Service de Rhumatologie Pédiatrique, Hôpital Jeanne de Flandres, Université de Lille, CHU de Lille, Lille, France
| | - Lea Savey
- Service de Médecine Interne, Hôpital Tenon, Sorbonne Université, AP-HP, Paris, France
| | - Alexandre Belot
- Centre International de Recherche en Infectiologie, Inserm, U1111, Université Claude Bernard, Lyon 1, Centre National de la Recherche Scientifique, UMR5308, ENS de Lyon, Lyon, France.,Centre de référence pour les maladies rhumatologiques et inflammatoires pédiatriques (RAISE), Hopital Femme Mère Enfant, Lyon, France.,Service de Néphrologie, Rhumatologie et Néphrologie Pédiatriques, Unité de rhumatologie, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France
| | - Bruno Fautrel
- Service de Rhumatologie, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, AP-HP, France.,Centre de Référence des Maladies Autoinflammatoires et des Amyloses (CéRéMAIA), Paris, France.,Institut d'Epidémiologie et de Santé Publique Pierre Louis, UMR S1136, Equipe PEPITES, Paris, France
| | - Stéphane Mitrovic
- Service de Rhumatologie, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, AP-HP, France.,Centre de Référence des Maladies Autoinflammatoires et des Amyloses (CéRéMAIA), Paris, France.,Département de Médecine Interne, Unité de Rhumatologie, Institut Mutualiste Montsouris, Paris, France
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Zic C. Considerations for the Primary Care Provider Caring for Patients with Juvenile Idiopathic Arthritis Receiving Biologic Therapy. Pediatr Ann 2022; 51:e54-e56. [PMID: 35156891 DOI: 10.3928/19382359-20220118-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Juvenile idiopathic arthritis (JIA) is the most common rheumatologic condition in children. JIA is a chronic autoimmune disease with no known cure affecting more than 1 in 1,000 children. With the development of targeted biologic therapies for JIA in the late 1990s, the outlook for children with JIA dramatically improved. Since that time, many children have received biologic therapies, allowing for better disease control and even disease remission. Given the frequency of JIA and increasing use of biologic medications, primary care providers require a basic understanding about these medications and their side effects as well as how the primary care provider can best support the patients who are receiving biologic therapy. [Pediatr Ann. 2022;51(2):e54-e56.].
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El Tal T, Ryan ME, Feldman BM, Bingham A, Burnham J, Batthish M, Bullock D, Ferraro K, Gilbert M, Gillispie-Taylor M, Gottlieb B, Harris JG, Hazen M, Laxer RM, Lee TC, Lovell D, Mannion M, Noonan L, Oberle E, Taylor J, Weiss JE, Yildirim Toruner C, Morgan EM. Consensus Approach to a Treat to Target Strategy in Juvenile Idiopathic Arthritis Care: Report from the 2020 PR-COIN Consensus Conference. J Rheumatol 2022; 49:497-503. [DOI: 10.3899/jrheum.210709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2022] [Indexed: 11/22/2022]
Abstract
Objective Treat to target (T2T) is a strategy of adjusting treatment until a target is reached. An international task force recommended T2T for juvenile idiopathic arthritis (JIA) treatment. Implementing T2T in a standard and reliable way in clinical practice requires agreement on critical elements of: (1) target setting, (2) T2T strategy, (3) identifying barriers to implementation, and (4) eligible patients. A consensus conference was held amongst Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN) stakeholders to inform a statement of understanding regarding the PR-COIN approach to T2T. Methods PR-COIN stakeholders including health care providers (16) and parents (4), were invited to form a voting panel. Using the nominal group technique, two rounds of voting were held to address the above four areas to select the top 10 responses in rank order. Results Incorporation of patient goals ranked most important when setting a treatment target. Use of shared decision making (SDM), tracking measurable outcomes, and adjusting treatment to achieve goals were voted as top elements of T2T strategy. Workflow considerations, and provider buy-in were identified as key barriers to T2T implementation. Patients with JIA, with poor prognostic factors and at risk for high disease burden were leading candidates for a T2T approach. Conclusion This consensus conference identified the importance of incorporating patient goals as part of target setting, and influence of patient stakeholder involvement in drafting treatment recommendations. The network approach to T2T will be modified to address the above findings including solicitation of patient goals, optimizing SDM, and better workflow integration.
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Abstract
Juvenile idiopathic arthritis (JIA) is an umbrella term for arthritis of unknown origin, lasting for >6 weeks with onset before 16 years of age. JIA is the most common chronic inflammatory rheumatic condition of childhood. According to the International League Against Rheumatism (ILAR) classification, seven mutually exclusive categories of JIA exist based on disease manifestations during the first 6 months of disease. Although the ILAR classification has been useful to foster research, it has been criticized mainly as it does not distinguish those forms of chronic arthritis observed in adults and in children from those that may be unique to childhood. Hence, efforts to provide a new evidence-based classification are ongoing. Similar to arthritis observed in adults, pathogenesis involves autoimmune and autoinflammatory mechanisms. The field has witnessed a remarkable improvement in therapeutic possibilities of JIA owing to the availability of new potent drugs and the possibility to perform controlled trials with support from legislative interventions and large networks availability. The goal of drug therapy in JIA is to rapidly reduce disease activity to inactive disease or clinical remission, minimize drug side effects and achieve a quality of life comparable to that of healthy peers. As JIA can influence all aspects of a child's and their family's life, researchers increasingly recognize improvement of health-related quality of life as a key treatment goal.
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Guzman J, Petty RE. A Moving Target: Lessons from
Long‐Term
Studies in Juvenile Idiopathic Arthritis. Arthritis Care Res (Hoboken) 2022; 74:716-718. [DOI: 10.1002/acr.24858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 11/22/2021] [Accepted: 01/06/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Jaime Guzman
- British Columbia Children’s Hospital and the University of British Columbia Vancouver British Columbia Canada
| | - Ross E. Petty
- British Columbia Children’s Hospital and the University of British Columbia Vancouver British Columbia Canada
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Glerup M, Arnstad ED, Rypdal V, Peltoniemi S, Aalto K, Rygg M, Nielsen S, Fasth A, Berntson L, Nordal E, Herlin T. Changing patterns in treatment, remission status and categories in a long‐term Nordic cohort study of juvenile idiopathic arthritis. Arthritis Care Res (Hoboken) 2022; 74:719-727. [DOI: 10.1002/acr.24857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 11/22/2021] [Accepted: 01/06/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Mia Glerup
- Department of Pediatrics Aarhus University Hospital Aarhus Denmark
| | - Ellen D. Arnstad
- Department of Clinical and Molecular Medicine NTNU ‐ Norwegian University of Science and Technology Trondheim Norway
- Department of Pediatrics Levanger Hospital, Nord‐Trøndelag Hospital Trust Levanger Norway
| | - Veronika Rypdal
- Department of Pediatrics, University Hospital of North Norway, and Department of Clinical Medicine UiT The Arctic University of Norway Tromsø Norway
| | - Suvi Peltoniemi
- Department of Rheumatology Helsinki University Hospital Helsinki Finland
| | - Kristiina Aalto
- Hospital for Children and Adolescents University of Helsinki, and Pediatric Research Center, University of Helsinki Helsinki Finland
| | - Marite Rygg
- Department of Clinical and Molecular Medicine NTNU ‐ Norwegian University of Science and Technology Trondheim Norway
- Department of Pediatrics, St. Olavs Hospital University hospital of Trondheim Trondheim Norway
| | - Susan Nielsen
- Department of Pediatrics, Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Anders Fasth
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Lillemor Berntson
- Department of Women’s and Children’s Health Uppsala University Uppsala Sweden
| | - Ellen Nordal
- Department of Pediatrics, University Hospital of North Norway, and Department of Clinical Medicine UiT The Arctic University of Norway Tromsø Norway
| | - Troels Herlin
- Department of Pediatrics Aarhus University Hospital Aarhus Denmark
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Bhattad S, Mohite R, Singh N. Growth and development in children with rheumatic diseases: Maintaining a balance between drugs and disease activity. INDIAN JOURNAL OF RHEUMATOLOGY 2022. [DOI: 10.4103/injr.injr_54_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Roß J, Foeldvari I, Krajewski KL, Butscheidt S, Beil FT, Stücker R, Spiro AS. Does Juvenile Idiopathic Arthritis Affect the Course of Legg-Calvé-Perthes Disease? A Case-Control Study with a Mean Follow-Up of 8 Years. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8111014. [PMID: 34828727 PMCID: PMC8621236 DOI: 10.3390/children8111014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/17/2021] [Accepted: 11/02/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND This study aimed to determine the clinical and radiological course in children who had Legg-Calvé-Perthes disease (LCPD) associated with juvenile idiopathic arthritis (JIA). METHODS In a retrospective chart review between 2007 and 2019, eight consecutive JIA patients diagnosed with concomitant LCPD were identified and compared with a case-control group of 10 children with LCPD only. RESULTS LCPD was diagnosed at a mean age of 8.1 years (3.0-14.7) in children with JIA as compared to 6.1 years (2.9-10.0) in controls. According to the modified Harris Hip Score (mHHS), four children with JIA and all controls had an excellent result. Regarding the fragmentation severity and the duration of each stage, we found no differences using the lateral pillar and modified Elizabethtown classification. Five hips were classified as Stulberg I/II, two hips as Stulberg III, and one hip as Stulberg V with no evidence of hip dysplasia or severe overcoverage in either group. CONCLUSIONS The radiological outcome of LCPD did not differ between both groups, while the clinical outcome was slightly better in controls. Physicians should be aware that children with LCPD may have JIA too. In suspicious cases, further investigations are recommended, and patients should be referred to pediatric rheumatologists.
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Affiliation(s)
- Julien Roß
- Department of Pediatric Orthopedics, Altonaer Children’s Hospital, Bleickenallee 38, D-22763 Hamburg, Germany; (J.R.); (R.S.)
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany; (S.B.); (F.T.B.)
| | - Ivan Foeldvari
- Hamburg Center for Pediatric and Adolescence Rheumatology, Dehnhaide 120, D-22081 Hamburg, Germany;
| | - Kara L. Krajewski
- Department of Pediatric Neurosurgery, Altonaer Children’s Hospital, Bleickenallee 38, D-22763 Hamburg, Germany;
| | - Sebastian Butscheidt
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany; (S.B.); (F.T.B.)
| | - Frank Timo Beil
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany; (S.B.); (F.T.B.)
| | - Ralf Stücker
- Department of Pediatric Orthopedics, Altonaer Children’s Hospital, Bleickenallee 38, D-22763 Hamburg, Germany; (J.R.); (R.S.)
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany; (S.B.); (F.T.B.)
| | - Alexander S. Spiro
- Department of Pediatric Orthopedics, Altonaer Children’s Hospital, Bleickenallee 38, D-22763 Hamburg, Germany; (J.R.); (R.S.)
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany; (S.B.); (F.T.B.)
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Erkens R, Esteban Y, Towe C, Schulert G, Vastert S. Pathogenesis and Treatment of Refractory Disease Courses in Systemic Juvenile Idiopathic Arthritis: Refractory Arthritis, Recurrent Macrophage Activation Syndrome and Chronic Lung Disease. Rheum Dis Clin North Am 2021; 47:585-606. [PMID: 34635293 DOI: 10.1016/j.rdc.2021.06.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Systemic juvenile idiopathic arthritis is a distinct and heterogeneous disease presently classified under the umbrella of juvenile idiopathic arthritis, with some patients following a monophasic remitting course, whereas others have persistent disease with chronic organ- and life-threatening complications. Although biologic therapies have revolutionized treatment, recent follow-up studies report significant numbers of children with persistently active disease on long term follow-up. This review focuses on refractory disease courses, specifically refractory arthritis, systemic juvenile idiopathic arthritis with recurrent, or longstanding signs of macrophage activation syndrome, and systemic juvenile idiopathic arthritis associated with suspected, probable, or definite lung disease.
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Affiliation(s)
- Remco Erkens
- Division of Pediatric Rheumatology & Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; Center for Translational Immunology, University Medical Center Utrecht, University of Utrecht, the Netherlands
| | - Ysabella Esteban
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Christopher Towe
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Grant Schulert
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sebastiaan Vastert
- Division of Pediatric Rheumatology & Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; Center for Translational Immunology, University Medical Center Utrecht, University of Utrecht, the Netherlands.
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García-Rodríguez F, Gamboa-Alonso A, Jiménez-Hernández S, Ochoa-Alderete L, Barrientos-Martínez VA, Alvarez-Villalobos NA, Luna-Ruíz GA, Peláez-Ballestas I, Villarreal-Treviño AV, de la O-Cavazos ME, Rubio-Pérez N. Economic impact of Juvenile Idiopathic Arthritis: a systematic review. Pediatr Rheumatol Online J 2021; 19:152. [PMID: 34627296 PMCID: PMC8502332 DOI: 10.1186/s12969-021-00641-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 09/26/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Juvenile Idiopathic Arthritis (JIA) requires complex care that generate elevated costs, which results in a high economic impact for the family. The aim of this systematic review was to collect and cluster the information currently available on healthcare costs associated with JIA after the introduction of biological therapies. METHODS We comprehensively searched in MEDLINE, EMBASE, Web of Science, Scopus, and Cochrane Databases for studies from January 2000 to March 2021. Reviewers working independently and in duplicate appraised the quality and included primary studies that report total, direct and/or indirect costs related to JIA for at least one year. The costs were converted to United States dollars and an inflationary adjustment was made. RESULTS We found 18 eligible studies including data from 6,540 patients. Total costs were reported in 10 articles, ranging from $310 USD to $44,832 USD annually. Direct costs were reported in 16 articles ($193 USD to $32,446 USD), showing a proportion of 55 to 98 % of total costs. Those costs were mostly related to medications and medical appointments. Six studies reported indirect costs ($117 USD to $12,385 USD). Four studies reported costs according to JIA category observing the highest in polyarticular JIA. Total and direct costs increased up to three times after biological therapy initiation. A high risk of reporting bias and inconsistency of the methodology used were found. CONCLUSION The costs of JIA are substantial, and the highest are derived from medication and medical appointments. Indirect costs of JIA are underrepresented in costs analysis.
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Affiliation(s)
- Fernando García-Rodríguez
- Department of Pediatrics, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Madero y Gonzalitos SN, Col. Mitras Centro, C.P. 64460, Monterrey, Mexico
| | - Augusto Gamboa-Alonso
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit México), Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Sol Jiménez-Hernández
- Department of Pediatrics, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Madero y Gonzalitos SN, Col. Mitras Centro, C.P. 64460, Monterrey, Mexico
| | - Lucero Ochoa-Alderete
- Department of Pediatrics, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Madero y Gonzalitos SN, Col. Mitras Centro, C.P. 64460, Monterrey, Mexico
| | - Valeria Alejandra Barrientos-Martínez
- Department of Pediatrics, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Madero y Gonzalitos SN, Col. Mitras Centro, C.P. 64460, Monterrey, Mexico
| | | | | | | | - Ana Victoria Villarreal-Treviño
- Department of Pediatrics, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Madero y Gonzalitos SN, Col. Mitras Centro, C.P. 64460, Monterrey, Mexico
| | - Manuel Enrique de la O-Cavazos
- Department of Pediatrics, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Madero y Gonzalitos SN, Col. Mitras Centro, C.P. 64460, Monterrey, Mexico
| | - Nadina Rubio-Pérez
- Department of Pediatrics, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Madero y Gonzalitos SN, Col. Mitras Centro, C.P. 64460, Monterrey, Mexico.
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Alzyoud RM, Alsuweiti MO, Almaaitah HQ, Aladaileh BN, Alnoubani MK, Alwahadneh AM. Juvenile idiopathic arthritis in Jordan: single center experience. Pediatr Rheumatol Online J 2021; 19:90. [PMID: 34118940 PMCID: PMC8196540 DOI: 10.1186/s12969-021-00572-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 05/20/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Juvenile idiopathic arthritis (JIA) is a heterogeneous group of disorders, including all forms of arthritis, which develops in children who are less than 16 years old. This study aimed to evaluate the clinical and laboratory features of JIA in a single center in Jordan. METHODS A retrospective analysis of the electronic medical records of Pediatric patients diagnosed with JIA based on the International League of Associations for Rheumatology (ILAR) criteria during the period from 2015 to 2019 at the Pediatric Rheumatology Clinic in the Queen Rania Children's Hospital. All patients were below the age of 14 years at the time of diagnosis and followed for at least 6 months. Collected data consisted of age, gender, age at initial presentation and diagnosis, JIA subtype, laboratory data, treatment options, and outcome. RESULTS A total of 210 patients were included in this cohort (94 males and 116 females) with the mean age at diagnosis and mean age at onset of 5.33 ± 3.40 years and 5.08 ± 3.40 years (range: 7 months - 14 years), respectively. Oligoarticular JIA was the commonest subtype (54.7%), followed by systemic arthritis (17.1%) and polyarticular arthritis (12.3%). ANA was positive in 70 patients (33.6%). Uveitis occurred in 30 (14.2%) patients. CONCLUSION To the best of our knowledge, this study on this cohort is the first report on JIA in Jordan, in comparison with other regionally and internationally published reports. Oligoarticular JIA was found to be the most common subtype. For detailed knowledge on JIA characteristics and patterns, a population-based, rather than a single center study, should be conducted in Jordan.
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Affiliation(s)
- Raed M Alzyoud
- Pediatric Immunology, Allergy and Rheumatology Division, Queen Rania Children's Hospital, Royal Medical Services, King Abdullah II St 226, P. O Box 11855, Amman, Jordan.
| | - Motasem O Alsuweiti
- Pediatric Immunology, Allergy and Rheumatology Division, Queen Rania Children's Hospital, Royal Medical Services, King Abdullah II St 226, P. O Box 11855, Amman, Jordan
| | - Heba Q Almaaitah
- Pediatric Immunology, Allergy and Rheumatology Division, Queen Rania Children's Hospital, Royal Medical Services, King Abdullah II St 226, P. O Box 11855, Amman, Jordan
| | - Bushra N Aladaileh
- Pediatric Immunology, Allergy and Rheumatology Division, Queen Rania Children's Hospital, Royal Medical Services, King Abdullah II St 226, P. O Box 11855, Amman, Jordan
| | - Mohammad K Alnoubani
- Pediatric Immunology, Allergy and Rheumatology Division, Queen Rania Children's Hospital, Royal Medical Services, King Abdullah II St 226, P. O Box 11855, Amman, Jordan
| | - Adel M Alwahadneh
- Pediatric Immunology, Allergy and Rheumatology Division, Queen Rania Children's Hospital, Royal Medical Services, King Abdullah II St 226, P. O Box 11855, Amman, Jordan
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Smith JA, Burgos-Vargas R. Outcomes in Juvenile-Onset Spondyloarthritis. Front Med (Lausanne) 2021; 8:680916. [PMID: 34124112 PMCID: PMC8192716 DOI: 10.3389/fmed.2021.680916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/30/2021] [Indexed: 01/31/2023] Open
Abstract
Some studies have suggested children with juvenile onset spondyloarthritis (JoSpA) have a relatively poor outcome compared to other juvenile idiopathic arthritis (JIA) categories, in regards to functional status and failure to attain remission. Thus, in the interest of earlier recognition and risk stratification, awareness of the unique characteristics of this group is critical. Herein, we review the clinical burden of disease, prognostic indicators and outcomes in JoSpA. Of note, although children exhibit less axial disease at onset compared to adults with spondyloarthritis (SpA), 34–62% have magnetic resonance imaging (MRI) evidence for active inflammation in the absence of reported back pain. Furthermore, some studies have reported that more than half of children with “enthesitis related arthritis” (ERA) develop axial disease within 5 years of diagnosis. Axial disease, and more specifically sacroiliitis, portends continued active disease. The advent of TNF inhibitors has promised to be a “game changer,” given their relatively high efficacy for enthesitis and axial disease. However, the real world experience in various cohorts since the introduction of more widespread TNF inhibitor usage, in which greater than a third still have persistently active disease, suggests there is still work to be done in developing new therapies and improving the outlook for JoSpA.
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Affiliation(s)
- Judith A Smith
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Ruben Burgos-Vargas
- Departamento de Reumatologia, Hospital General de Mexico, Mexico City, Mexico
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Enthesitis Related Arthritis in a Longitudinal Southeast Asian Registry: High Prevalence of HLA-B27, Different Sacroiliitis Risk Factors and Less Common Drug-Free Remission. J Clin Med 2021; 10:jcm10040568. [PMID: 33546269 PMCID: PMC7913299 DOI: 10.3390/jcm10040568] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 01/29/2021] [Accepted: 01/30/2021] [Indexed: 12/26/2022] Open
Abstract
Objective. To describe the clinical characteristics, predictors and treatment of children with Enthesitis Related Arthritis (ERA) in a Singapore longitudinal cohort over 11 years. Methods. ERA patients were recruited from our registry (2009–2019). Nonparametric descriptive statistics including median (interquartile range, IQR) were used to describe data. Kaplan–Meier survival and logistic/Cox regression analyses were used to estimate the probabilities and determine predictors of clinical variables, respectively. The significance level was set at <0.05. Results. One hundred and forty-six ERA patients (87% male, 82% Chinese) were included. Median onset age was 11.9 years (IQR 9.4–14.0) and median disease duration was 4.9 years (IQR 2.6–8.3). Family history of Human Leukocyte Antigen (HLA)-B27 associated diseases was positive in 7.5%. Acute uveitis occurred in 3.4%. Oligoarthritis was present in 89.7%. Hip, knee and ankle joints were among the most common joints involved. One-fourth had enthesitis at diagnosis (Achilles tendon entheses, 82.9%). Sacroiliitis occurred in 61%. Probabilities of sacroiliitis development were 0.364, 0.448 and 0.578 at 1, 2 and 5 years after onset, respectively. Negative HLA-B27, female, older age at onset and hip arthritis at diagnosis were associated with shorter time for sacroiliitis development (p = 0.001–0.049). Methotrexate (MTX) remained the most common disease modifying anti-rheumatic drug (DMARD) used (77.4%). However, 77.9% required anti-TNF (aTNF) therapy secondary to MTX failure. Among MTX-treated sacroiliitis patients, 85.3% failed, requiring aTNF, as compared to 63.2%patients without axial disease. Longer duration to diagnosis (p = 0.038) and MTX use (p = 0.007) predicted aTNF therapy. None had joint deformity. Conclusions. This study underscores differences in ERA clinical characteristics, predictors and treatment responses. Our ERA population had many unique findings but good functional outcomes.
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Teh KL, Tanya M, Das L, Hoh SF, Gao X, Arkachaisri T. Outcomes and predictors of juvenile idiopathic arthritis in Southeast Asia: a Singapore longitudinal study over a decade. Clin Rheumatol 2020; 40:2339-2349. [PMID: 33236179 DOI: 10.1007/s10067-020-05520-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/10/2020] [Accepted: 11/19/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess short- and long-term outcomes and predictors of juvenile idiopathic arthritis (JIA) children treated with contemporary therapy and compare those with reports elsewhere. METHODS Children with JIA were recruited from our web-based REgistry for Childhood Onset Rheumatic Diseases (RECORD) from 1997 to 2015. Disease status was defined using modified Wallace criteria. Nonparametric statistics described the data. Kaplan-Meier survival and logistic regression analyses were used to estimate probabilities and to determine predictors of outcomes. RESULTS A total of 251 children with JIA (62% males, 71% Chinese) were included. Median follow-up duration was 2.9 years (range 0.1-17.5). Short-term clinical inactive disease (CID) was attained in 37% with 62% systemic JIA (sJIA) and 47% persistent oligoarthritis (oJIA). Methotrexate (OR 0.34) decreased but sJIA (OR 3.25) increased chance of attaining CID at 6 months. Overall, 79% of patients achieved CID within 2 years (sJIA 92%, the highest, and RF+ polyarthritis 50%, the lowest probability). Biologics were associated with CID attainment (OR 2.73). One-half of patients flare after CID, median 1.2 years (IQR 0.71-1.97). Late CID achievement predicted flare (OR 2.15). Only 15% had clinical remission off medication (none RF+ polyarthritis and 7% ERA). Only 13% of patients had active arthritis as young adults and 22% had active arthritis at last visit. CONCLUSION Despite high proportion of JIA patients attaining CID, only one-fourth could stop all medications for at least 1 year. Persistent oJIA patients were less likely to achieve clinical remission on medication and ERA patients had the least chance stopping medications. One-tenth of patients had active arthritis as young adults. Key Points • Majority of Asian children with JIA attained inactive disease within 2 years after diagnosis. • Outcome predictors were different from reports from the West. • Despite high inactive disease numbers, only one-in-four JIA patients discontinued treatment within 5 years.
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Affiliation(s)
- Kai Liang Teh
- Rheumatology and Immunology Service, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Children's Tower, Level 3, zone B, Singapore, 229899, Singapore
| | - Manasita Tanya
- Rheumatology and Immunology Service, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Children's Tower, Level 3, zone B, Singapore, 229899, Singapore
| | - Lena Das
- Rheumatology and Immunology Service, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Children's Tower, Level 3, zone B, Singapore, 229899, Singapore
| | - Sook Fun Hoh
- Division of Nursing, KK Women's and Children's Hospital, Singapore, Singapore
| | - Xiaocong Gao
- Division of Nursing, KK Women's and Children's Hospital, Singapore, Singapore
| | - Thaschawee Arkachaisri
- Rheumatology and Immunology Service, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Children's Tower, Level 3, zone B, Singapore, 229899, Singapore.
- Duke-NUS Medical School, Singapore, Singapore.
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