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Wood S, Branch J, Vasquez P, DeGuzman MM, Brown A, Sagcal-Gironella AC, Singla S, Ramirez A, Vogel TP. Th17/1 and ex-Th17 cells are detected in patients with polyarticular juvenile arthritis and increase following treatment. Pediatr Rheumatol Online J 2024; 22:32. [PMID: 38431635 PMCID: PMC10908086 DOI: 10.1186/s12969-024-00965-5] [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: 10/30/2023] [Accepted: 02/11/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND A better understanding of the pathogenesis of polyarticular juvenile idiopathic arthritis (polyJIA) is needed to aide in the development of data-driven approaches to guide selection between therapeutic options. One inflammatory pathway of interest is JAK-STAT signaling. STAT3 is a transcription factor critical to the differentiation of inflammatory T helper 17 cells (Th17s). Previous studies have demonstrated increased STAT3 activation in adult patients with rheumatoid arthritis, but less is known about STAT3 activation in polyJIA. We hypothesized that Th17 cells and STAT3 activation would be increased in treatment-naïve polyJIA patients compared to pediatric controls. METHODS Blood from 17 patients with polyJIA was collected at initial diagnosis and again if remission was achieved (post-treatment). Pediatric healthy controls were also collected. Peripheral blood mononuclear cells were isolated and CD4 + T cell subsets and STAT activation (phosphorylation) were evaluated using flow cytometry. Data were analyzed using Mann-Whitney U and Wilcoxon matched-pairs signed rank tests. RESULTS Treatment-naïve polyJIA patients had increased Th17 cells (CD3 + CD4 + interleukin(IL)-17 +) compared to controls (0.15% v 0.44%, p < 0.05), but Tregs (CD3 + CD4 + CD25 + FOXP3 +) from patients did not differ from controls. Changes in STAT3 phosphorylation in CD4 + T cells following ex vivo stimulation were not significantly different in patients compared to controls. We identified dual IL-17 + and interferon (IFN)γ + expressing CD4 + T cells in patients, but not controls. Further, both Th17/1 s (CCR6 + CD161 + IFNγ + IL-17 +) and ex-Th17s (CCR6 + CD161 + IFNγ + IL-17neg) were increased in patients' post-treatment (Th17/1: 0.3% v 0.07%, p < 0.05 and ex-Th17s: 2.3% v 1.4%, p < 0.05). The patients with the highest IL-17 expressing cells post-treatment remained therapy-bound. CONCLUSIONS Patients with polyJIA have increased baseline Th17 cells, potentially reflecting higher tonic STAT3 activation in vivo. These quantifiable immune markers may identify patients that would benefit upfront from pathway-focused biologic therapies. Our data also suggest that inflammatory CD4 + T cell subsets not detected in controls but increased in post-treatment samples should be further evaluated as a tool to stratify patients in remission on medication. Future work will explore these proposed diagnostic and prognostic biomarkers.
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Affiliation(s)
- Stephanie Wood
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA
- Center for Human Immunobiology, Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA
| | - Justin Branch
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA
- Center for Human Immunobiology, Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA
| | - Priscilla Vasquez
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA
| | - Marietta M DeGuzman
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA
| | - Amanda Brown
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA
| | - Anna Carmela Sagcal-Gironella
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA
| | - Saimun Singla
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA
| | - Andrea Ramirez
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA
| | - Tiphanie P Vogel
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA.
- Center for Human Immunobiology, Texas Children's Hospital, 1102 Bates Street Suite 330, Houston, TX, 77030, USA.
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Aringer M, Mosca M. SLE criteria are by necessity still based on clinical (and immunological) criteria items. Expert Rev Clin Immunol 2024; 20:305-311. [PMID: 38073566 DOI: 10.1080/1744666x.2023.2292188] [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: 09/20/2023] [Accepted: 12/04/2023] [Indexed: 02/16/2024]
Abstract
INTRODUCTION The 2019 European League Against Rheumatism/American College of Rheumatology (EULAR/ACR) classification criteria for systemic lupus erythematosus (SLE) rely on clinical and routine immunological items. The criteria have anti-nuclear antibodies (ANA) as an obligatory entry criterion; items are weighted and ordered in domains. While demonstrating good sensitivity and specificity, the lack of a more molecular approach to some came as a disappointment. AREAS COVERED Based on a non-systematic literature search, this review covers items investigated in the EULAR/ACR classification criteria project, but not included in the set of criteria. It demonstrates data on the importance of the criteria and analyses implications of multiomics studies started around the same time as the criteria project. We also discuss data on the type-I interferon signature and on other cytokines, as well as on complement proteins and their split products. The final part deals with the variability in disease and the apparently random pattern of autoantibodies and organ manifestations in individual patients. EXPERT OPINION We believe that the EULAR/ACR criteria are a relevant step toward the right direction. A more uniform molecular approach will not be feasible as long as the molecular mechanisms underlying the tendency toward producing multiple autoantibodies are not better understood.
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Affiliation(s)
- Martin Aringer
- Chief Division of Rheumatology, Department of Medicine III, and Director, interdisciplinary University Center for Autoimmune and Rheumatic Entities (UCARE), University Medical Center and Faculty of Medicine Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Marta Mosca
- Department of Clinical and Experimental Medicine, University of Pisa, Chief Division of Rheumatology, Azienda Ospedaliero Universitaria Pisana, Italy, Pisa
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Triaille C, Quartier P, De Somer L, Durez P, Lauwerys BR, Verschueren P, Taylor PC, Wouters C. Patterns and determinants of response to novel therapies in juvenile and adult-onset polyarthritis. Rheumatology (Oxford) 2024; 63:594-607. [PMID: 37725352 PMCID: PMC10907821 DOI: 10.1093/rheumatology/kead490] [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: 07/14/2023] [Revised: 08/23/2023] [Accepted: 08/29/2023] [Indexed: 09/21/2023] Open
Abstract
Biologic and targeted synthetic DMARDs (b/tsDMARDs) have revolutionized the management of multiple rheumatic inflammatory conditions. Among these, polyarticular JIA (pJIA) and RA display similarities in terms of disease pathophysiology and response pattern to b/tsDMARDs. Indeed, the therapeutic efficacy of novel targeted drugs is variable among individual patients, in both RA and pJIA. The mechanisms and determinants of this heterogeneous response are diverse and complex, such that the development of true 'precision'-medicine strategies has proven highly challenging. In this review, we will discuss pathophysiological, patient-specific, drug-specific and environmental factors contributing to individual therapeutic response in pJIA in comparison with what is known in RA. Although some biomarkers have been identified that stratify with respect to the likelihood of either therapeutic response or non-response, few have proved useful in clinical practice so far, likely due to the complexity of treatment-response mechanisms. Consequently, we propose a pragmatic, patient-centred and clinically based approach, i.e. personalized instead of biomarker-based precision medicine in JIA.
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Affiliation(s)
- Clément Triaille
- Pôle de Pathologies Rhumatismales Systémiques et Inflammatoires, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
- Department of Pediatric Hematology, Oncology, Immunology and Rheumatology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Division of Pediatric Rheumatology, Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | - Pierre Quartier
- Department of Pediatric Immunology, Hematology and Rheumatology, Necker-Enfants Malades Hospital, AP-HP, Paris, France
- Université Paris-Cité, Paris, France
- Member of the European Reference Network for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases – Project ID No. 739543
| | - Lien De Somer
- Division of Pediatric Rheumatology, Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
- Member of the European Reference Network for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases – Project ID No. 739543
- Department of Microbiology and Immunology, University of Leuven, Leuven, Belgium
| | - Patrick Durez
- Pôle de Pathologies Rhumatismales Systémiques et Inflammatoires, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
- Department of Rheumatology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Bernard R Lauwerys
- Pôle de Pathologies Rhumatismales Systémiques et Inflammatoires, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Patrick Verschueren
- Member of the European Reference Network for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases – Project ID No. 739543
- Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Peter C Taylor
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Carine Wouters
- Division of Pediatric Rheumatology, Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
- Department of Pediatric Immunology, Hematology and Rheumatology, Necker-Enfants Malades Hospital, AP-HP, Paris, France
- Member of the European Reference Network for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases – Project ID No. 739543
- Department of Microbiology and Immunology, University of Leuven, Leuven, Belgium
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Foeldvari I, Petrushkin H. How should we approach management of childhood onset chronic anterior uveitis refractory to adalimumab? Expert Rev Clin Immunol 2024; 20:267-276. [PMID: 37990508 DOI: 10.1080/1744666x.2023.2284845] [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: 06/26/2023] [Accepted: 11/14/2023] [Indexed: 11/23/2023]
Abstract
INTRODUCTION The management of refractory juvenile idiopathic associated uveitis (JIAU) or childhood-onset chronic anterior uveitis (CAU) is a challenge. There is no clear consensus or evidence base for to suggest the most appropriate therapy after primary or secondary failure of biweekly adalimumab. In this scenario, most clinicians advocate switching to another anti-tumor necrosis factor alpha inhibitor; however, there are a variety of other disease modifying agents to choose from albeit with a differing levels of evidence. AREAS COVERED We discuss how to define nonresponse and potential treatment options for patients with JIAU and CAU refractory to biweekly adalimumab. EXPERT OPINION Uncontrolled CAU and JIAU remain one of the most challenging diseases to manage and can lead to irreversible loss of vision in a third of those affected. Amongst the possible choices, weekly adalimumab, infliximab, tocilizumab and abatacept have more evidence to support their use. JAK inhibitors seem to be a promising option. Golimumab and Rituximab has also been thought to be partially effective in some refractory cases, whereas IL-17, IL-23, and IL-12 inhibition along with apremilast seem not to be a therapeutic option currently. The route of administration should also be considered as there can be significant pros and cons for different children.
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Affiliation(s)
- Ivan Foeldvari
- Hamburger Zentrum für Kinder- und Jugendrheumatologie, Centre for Treatment of Scleroderma and Uveitis in Childhood and Adolescence An der Schön Klinik Hamburg Eilbek, Hamburg, Germany
- Teaching Unit of the Asklepios Campus of the Semmelweis Medical School, Budapest, Hungary
| | - Harry Petrushkin
- Moorfields Eye Hospital, NHS Foundation Trust, London, UK
- Great Ormond Street Hospital For Children, NHS Foundation Trust, London, UK
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Sunar Yayla EN, Yıldız Ç, Esmeray Şenol P, Karaçayır N, Gezgin Yıldırım D, Bakkaloğlu SA. How Safe Are Biological Agents in Pediatric Rheumatology? Turk Arch Pediatr 2024; 59:185-192. [PMID: 38454228 PMCID: PMC11059757 DOI: 10.5152/turkarchpediatr.2024.23221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 02/06/2024] [Indexed: 03/09/2024]
Abstract
OBJECTIVE Biologic therapy has changed the prognosis of patients with rheumatologic disease. Despite all benefits of the biological agents, adverse events may occur due to their long-term use. The aim of this study is to analyze the adverse events observed in pediatric patients who received biological treatment. MATERIALS AND METHODS This retrospective observational cohort study was conducted between January 2010 and January 2022. File records of 139 patients used biological agents for rheumatologic diseases in a pediatric rheumatology clinic were evaluated. Diagnosis, received treatment, the rationale for stopping treatment, requirement of tuberculosis prophylaxis, presence of an adverse event, and results were recorded. RESULTS The most used biological therapy was etanercept (41.7%). Anakinra, adalimumab, canakinumab were used in 30.9%, 27.3%, 23.7% of patients, and the others in less than 10%. Totally 491 adverse events (97.9/100 patient-years) were encountered during the duration of biological treatment. The most often adverse event was recurrent upper respiratory tract infection in the patients (31.9/100 patient-years). Elevated aminotransferase levels (10.4/100 patient-years), abdominal pain (7/100 patient-years), and headache (5.2/100 patient-years) were among the other common side effects. Isoniazid (INH) prophylaxis was needed before biological treatment in 20.9% of the patients. Tuberculosis developed in none of the patients followed-up for latent tuberculosis, however, it developed in a patient while receiving etanercept due to noncompliance with his scheduled outpatient visits during etanercept treatment. CONCLUSION The most commonly used biological treatments were TNFi and IL-antagonists, and the majority of side effects were infections and laboratory abnormalities. Although the rate of serious adverse events is quite low, close follow-up of patients receiving biological therapy is very important.
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Affiliation(s)
- Emine Nur Sunar Yayla
- Division of Pediatric Rheumatology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
- Clinic of Pediatric Rheumatology, Ankara Etlik City Hospital, Ankara, Turkey
| | - Çisem Yıldız
- Division of Pediatric Rheumatology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Pelin Esmeray Şenol
- Division of Pediatric Rheumatology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Nihal Karaçayır
- Division of Pediatric Rheumatology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Deniz Gezgin Yıldırım
- Division of Pediatric Rheumatology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Sevcan A. Bakkaloğlu
- Division of Pediatric Rheumatology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
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Bettinetti-Luque M, Trujillo-Estrada L, Garcia-Fuentes E, Andreo-Lopez J, Sanchez-Varo R, Garrido-Sánchez L, Gómez-Mediavilla Á, López MG, Garcia-Caballero M, Gutierrez A, Baglietto-Vargas D. Adipose tissue as a therapeutic target for vascular damage in Alzheimer's disease. Br J Pharmacol 2024; 181:840-878. [PMID: 37706346 DOI: 10.1111/bph.16243] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 08/11/2023] [Accepted: 09/01/2023] [Indexed: 09/15/2023] Open
Abstract
Adipose tissue has recently been recognized as an important endocrine organ that plays a crucial role in energy metabolism and in the immune response in many metabolic tissues. With this regard, emerging evidence indicates that an important crosstalk exists between the adipose tissue and the brain. However, the contribution of adipose tissue to the development of age-related diseases, including Alzheimer's disease, remains poorly defined. New studies suggest that the adipose tissue modulates brain function through a range of endogenous biologically active factors known as adipokines, which can cross the blood-brain barrier to reach the target areas in the brain or to regulate the function of the blood-brain barrier. In this review, we discuss the effects of several adipokines on the physiology of the blood-brain barrier, their contribution to the development of Alzheimer's disease and their therapeutic potential. LINKED ARTICLES: This article is part of a themed issue From Alzheimer's Disease to Vascular Dementia: Different Roads Leading to Cognitive Decline. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v181.6/issuetoc.
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Affiliation(s)
- Miriam Bettinetti-Luque
- Departamento de Biología Celular, Genética y Fisiología, Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma BIONAND, Facultad de Ciencias, Universidad de Málaga, Málaga, Spain
| | - Laura Trujillo-Estrada
- Departamento de Biología Celular, Genética y Fisiología, Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma BIONAND, Facultad de Ciencias, Universidad de Málaga, Málaga, Spain
- CIBER de Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
| | - Eduardo Garcia-Fuentes
- Unidad de Gestión Clínica Aparato Digestivo, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma BIONAND, Málaga, Spain
- CIBER de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Juana Andreo-Lopez
- Departamento de Biología Celular, Genética y Fisiología, Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma BIONAND, Facultad de Ciencias, Universidad de Málaga, Málaga, Spain
| | - Raquel Sanchez-Varo
- Departamento de Biología Celular, Genética y Fisiología, Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma BIONAND, Facultad de Ciencias, Universidad de Málaga, Málaga, Spain
- CIBER de Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
- Departamento de Fisiología Humana, Histología Humana, Anatomía Patológica y Educación Física y Deportiva, Facultad de Medicina, Universidad de Málaga, Málaga, Spain
| | - Lourdes Garrido-Sánchez
- CIBER de Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma BIONAND, Málaga, Spain
| | - Ángela Gómez-Mediavilla
- Departamento de Farmacología, Facultad de Medicina. Instituto Teófilo Hernando para la I+D de Fármacos, Universidad Autónoma de Madrid, Madrid, Spain
| | - Manuela G López
- Departamento de Farmacología, Facultad de Medicina. Instituto Teófilo Hernando para la I+D de Fármacos, Universidad Autónoma de Madrid, Madrid, Spain
- Instituto de Investigaciones Sanitarias (IIS-IP), Hospital Universitario de la Princesa, Madrid, Spain
| | - Melissa Garcia-Caballero
- Departamento de Biología Molecular y Bioquímica, Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma BIONAND, Facultad de Ciencias, Universidad de Málaga, Málaga, Spain
| | - Antonia Gutierrez
- Departamento de Biología Celular, Genética y Fisiología, Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma BIONAND, Facultad de Ciencias, Universidad de Málaga, Málaga, Spain
- CIBER de Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
| | - David Baglietto-Vargas
- Departamento de Biología Celular, Genética y Fisiología, Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma BIONAND, Facultad de Ciencias, Universidad de Málaga, Málaga, Spain
- CIBER de Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
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Edwards KM. The Therapy of SARS-CoV-2 Infection in Children. J Clin Med 2023; 13:120. [PMID: 38202127 PMCID: PMC10779459 DOI: 10.3390/jcm13010120] [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: 11/23/2023] [Revised: 12/11/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
The impact of SARS-CoV-2 infections in children has fortunately been lower than what has been seen in adults. However, even previously healthy children have developed severe disease, sometimes with subsequent mortality, and those who are infants or adolescents, are from racial and ethnic minority groups, or have certain chronic conditions are at higher risk of these outcomes. During the pandemic, extensive studies of therapeutic agents, including antivirals and immunomodulators, were conducted in adults. Few trials included children, and most were in older children and adolescents. Thus, the potential benefits of therapies in children must be extrapolated from adult evidence. Despite these limitations, advisory committees of the National Institute of Health (NIH), the Infectious Disease Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS) were constituted, and expert consensus guidelines were developed. This review provides a synthesis of those comprehensive recommendations for therapy in children. These address treatment during the early infectious period with antiviral agents, including remdesivir and nirmatrelvir/ritonavir, as well as treatment in the later period of immune dysregulation with corticosteroids and immunomodulators. In addition, the therapeutic approach for multisystem inflammatory syndrome in children (MIS-C), also referred to as Pediatric Inflammatory Multisystem Syndrome temporally associated with SARS-CoV-2 (PIMS-TS), is also provided.
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Affiliation(s)
- Kathryn M Edwards
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
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Li T, Wang D, Wei H, Xu X. Cytokine storm and translating IL-6 biology into effective treatments for COVID-19. Front Med 2023; 17:1080-1095. [PMID: 38157195 DOI: 10.1007/s11684-023-1044-4] [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: 05/15/2023] [Accepted: 10/23/2023] [Indexed: 01/03/2024]
Abstract
As of May 3, 2023, the Coronavirus disease 2019 (COVID-19) pandemic has resulted in more than 760 million confirmed cases and over 6.9 million deaths. Several patients have developed pneumonia, which can deteriorate into acute respiratory distress syndrome. The primary etiology may be attributed to cytokine storm, which is triggered by the excessive release of proinflammatory cytokines and subsequently leads to immune dysregulation. Considering that high levels of interleukin-6 (IL-6) have been detected in several highly pathogenic coronavirus-infected diseases, such as severe acute respiratory syndrome in 2002, the Middle East respiratory syndrome in 2012, and COVID-19, the IL-6 pathway has emerged as a key in the pathogenesis of this hyperinflammatory state. Thus, we review the history of cytokine storm and the process of targeting IL-6 signaling to elucidate the pivotal role played by tocilizumab in combating COVID-19.
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Affiliation(s)
- Tiantian Li
- Department of Geriatric Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, China
| | - Dongsheng Wang
- Respiratory and Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, China
| | - Haiming Wei
- Institute of Immunology and the CAS Key Laboratory of Innate Immunity and Chronic Disease, School of Life Science and Medical Center, University of Science and Technology of China, Hefei, 230001, China
- Hefei National Laboratory for Physical Sciences at Microscale, University of Science and Technology of China, Hefei, 230001, China
| | - Xiaoling Xu
- Respiratory and Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, China.
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Ruperto N, Lovell DJ, Berman A, Anton J, Viola DO, Lauwerys B, Rama ME, Bohnsack J, Breedt J, Fischbach M, Lutz T, Minden K, Ally M, Rubio-Pérez N, Gervais E, Van Zyl R, Wong R, Askelson M, Martini A, Brunner HI. Abatacept as Monotherapy and in Combination With Methotrexate in Patients With Juvenile Idiopathic Arthritis: Analysis of 2 Phase III Trials. J Rheumatol 2023; 50:1471-1480. [PMID: 37453737 DOI: 10.3899/jrheum.2022-1320] [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: 07/04/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE To describe the efficacy and safety data of children with polyarticular-course juvenile idiopathic arthritis (pcJIA) treated with abatacept (ABA) + methotrexate (MTX) or ABA monotherapy when prior MTX use was either ineffective or not tolerated. METHODS Posthoc analysis of 2 phase III trials of subcutaneous (SC) and intravenous (IV) ABA over 2 years in patients with pcJIA (aged 2-17 years). Patients were stratified by treatment with ABA + MTX or ABA monotherapy and further by prior biologic use. Efficacy outcomes included JIA-American College of Rheumatology (JIA-ACR) responses, Juvenile Arthritis Disease Activity Score in 27 joints using C-reactive protein (JADAS27-CRP), and safety. Descriptive pharmacokinetic analyses were also performed. RESULTS Efficacy responses (JIA-ACR and JADAS27-CRP) were similar between patients receiving ABA + MTX (n = 310) or ABA monotherapy (n = 99) and persisted over 2 years. Clinical response rates were similar in biologic-naïve patients and prior biologic users; this was independent of MTX use. Across both studies, ABA + MTX and ABA monotherapy displayed similar safety profiles. Pharmacokinetic results revealed similar minimum steady-state trough ABA concentrations between studies. Further, baseline MTX did not influence ABA clearance and was not a significant predictor of JIA-ACR responses. CONCLUSION ABA monotherapy (SC and IV) was effective and well tolerated in children with pcJIA when prior MTX use was ineffective or not tolerated. Treatment effects of ABA appear to be independent of MTX coadministration. Consequently, ABA monotherapy can be considered for those with prior biologic therapy if MTX use is inappropriate. (ClinicalTrials.gov: NCT01844518 and NCT00095173).
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Affiliation(s)
- Nicolino Ruperto
- N. Ruperto, MD, MPH, IRCCS Istituto Giannina Gaslini, Gaslini Trial Centre/Servizio di Sperimentazioni Cliniche Pediatriche, PRINTO, Genoa, Italy;
| | - Daniel J Lovell
- D.J. Lovell, MD, MPH, H.I. Brunner, MD, MSc, MBA, Cincinnati Children's Hospital Medical Center, Division of Rheumatology, Cincinnati, Ohio, USA
| | - Alberto Berman
- A. Berman, MD, Centro Medico Privado De Reumatologia, Rheumatology Section, San Miguel de Tucuman, Argentina
| | - Jordi Anton
- J. Anton, MD, PhD, Hospital Sant Joan de Déu, Universitat de Barcelona, Division of Pediatric Rheumatology, Esplugues de Llobregat (Barcelona), Spain
| | - Diego O Viola
- D.O. Viola, MD, Instituto CAICI, Rheumatology, Rosario, Argentina
| | - Bernard Lauwerys
- B. Lauwerys, PhB, MBChD, PhD, MD, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain & Service de Rhumatologie, Cliniques Universitaires Saint-Luc, now with UCB Pharma, Brussels, Belgium
| | - Maria E Rama
- M.E. Rama, MD, Hospital de Niños de la Santísima Trinidad, Rheumatology Section, Cordoba, Argentina
| | - John Bohnsack
- J. Bohnsack, MD, Eccles Primary Children's Outpatient Services, Pediatric Rheumatology, Salt Lake City, Utah, USA
| | - Johannes Breedt
- J. Breedt, MD, Eugene Marais Hospital, Rheumatology Private Practice, Pretoria, South Africa
| | - Michel Fischbach
- M. Fischbach, MD, Hautepierre University Hospital, Pediatrics, Strasbourg, France
| | - Thomas Lutz
- T. Lutz, MD, Center for Rheumatology, Heidelberg, Germany
| | - Kirsten Minden
- K. Minden, MD, German Rheumatism Research Centre Berlin, and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt - Universität zu Berlin, Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Berlin, Germany
| | - Mahmood Ally
- M. Ally, MBChB, University of Pretoria, Pretoria, South Africa
| | - Nadina Rubio-Pérez
- N. Rubio-Pérez, MD, Universidad Autónoma de Nuevo León, Facultad de Medicina, Departamento de Pediatria, Hospital Universitario "Dr. J. E. González", Monterrey, Nuevo León, Mexico
| | - Elisabeth Gervais
- E. Gervais, PhD, University Hospital Rheumatology and LITEC Laboratory Poitiers, Rheumatology, Poitiers, France
| | - Riana Van Zyl
- R. Van Zyl, MBChB, Universitas Hospital, Department of Paediatrics and Child Health, University of the Free State, Bloemfontein, South Africa
| | - Robert Wong
- R. Wong, MD, M. Askelson, MS, Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Margarita Askelson
- R. Wong, MD, M. Askelson, MS, Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Alberto Martini
- A. Martini, MD, Università degli Studi di Genova, Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DiNOGMI), Genoa, Italy
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10
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Schanberg LE, Mulugeta LY, Akinlade B, Brunner HI, Chen J, Colbert RA, Delgaizo V, Gastonguay MR, Glaser R, Imundo L, Lovell DJ, Leu JH, Mostafa NM, Nelson RM, Nigrovic PA, Nikolov NP, Rider LG, Rothwell R, Sahajwalla C, Singh R, Sinha V, Yancey CL, Yao L. Therapeutic Development in Polyarticular Course Juvenile Idiopathic Arthritis: Extrapolation, Dose Selection, and Clinical Trial Design. Arthritis Rheumatol 2023; 75:1856-1866. [PMID: 37067688 DOI: 10.1002/art.42534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 03/15/2023] [Accepted: 04/04/2023] [Indexed: 04/18/2023]
Abstract
OBJECTIVE Stakeholders met to address persistent challenges facing the development of therapeutics for polyarticular juvenile idiopathic arthritis (pJIA), which result in fewer approved therapies for children with pJIA than adults with rheumatoid arthritis (RA) and long lag times from adult RA approval to pediatric labeling. Ensuring that new medications are authorized in a timely manner to meet the needs of JIA patients worldwide is critically important to multiple stakeholders. METHODS The Food and Drug Administration in collaboration with the University of Maryland Center for Regulatory Science and Innovation held a public workshop entitled "Accelerating Drug Development for pJIA" on October 2, 2019, to address challenges surrounding access to new medications for children and adolescents with pJIA. Regulatory, academic, and industry stakeholders, as well as patient representatives, participated in the workshop, which consisted of 4 sessions, including panel discussions. RESULTS The workshop facilitated broad public discussion of challenges facing the development of pJIA therapeutics, highlighting areas of need and outlining opportunities to expedite development, while underscoring the necessity of close collaboration between all stakeholders, including patients and families. CONCLUSION This report summarizes key aspects of the workshop, including the appropriate application of innovative approaches to the development of pJIA therapeutics, including extrapolation, to address current challenges and provide timely access to newer safe and effective treatments. Long-term safety assessment is of pressing concern to stakeholders and cannot be fully extrapolated from adult studies but requires consistent postmarketing long-term follow-up.
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Affiliation(s)
- Laura E Schanberg
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Lily Yeruk Mulugeta
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | | | | | - Jianmeng Chen
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Robert A Colbert
- Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | | | - Rachel Glaser
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Lisa Imundo
- Columbia University Irving Medical Center, New York, New York
| | - Daniel J Lovell
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jocelyn H Leu
- Janssen Research and Development, Spring House, Pennsylvania
| | | | | | - Peter A Nigrovic
- Division of Immunology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School and Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Nikolay P Nikolov
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Lisa G Rider
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences, NIH, Bethesda, Maryland
| | - Rebecca Rothwell
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Chandrahas Sahajwalla
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Renu Singh
- Gilead Sciences, Foster City, California
| | - Vikram Sinha
- Novartis Pharmaceutical Corporation, One Health Plaza, East Hanover NJ, 07936, USA
| | - Carolyn L Yancey
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Lynne Yao
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
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11
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Nieto-González JC, Garulo DC, Boteanu A, Trives-Folguera L, García-Fernández A, Navarro PG, Robledillo JCL, Monteagudo-Saéz I. What to Expect When Systemic Treatment in Juvenile Idiopathic Arthritis Is Withdrawn? J Rheumatol 2023; 50:1326-1332. [PMID: 37527855 DOI: 10.3899/jrheum.2022-1305] [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: 05/19/2023] [Indexed: 08/03/2023]
Abstract
OBJECTIVE The goal of juvenile idiopathic arthritis (JIA) treatment is to maintain clinical remission. It is also important to reduce drug exposure, whenever possible, in order to avoid or decrease potential side effects. We aimed to analyze remission survival after systemic treatment withdrawal and to determine which factors can influence it. METHODS We conducted a multicenter, observational, longitudinal study. All patients included had a diagnosis of JIA. We analyzed remission survival using Kaplan-Meier curves according to the systemic treatment received (methotrexate [MTX] alone or in combination with biologic disease-modifying antirheumatic drugs [bDMARDs]) and JIA subgroups (oligoarticular and polyarticular course, juvenile spondyloarthritis, and systemic JIA). In addition, risk factors were examined using multivariate analysis. RESULTS We included 404 patients with JIA; 370 of them (92%) had received systemic treatment at some point and half of them (185 patients) had withdrawn on at least 1 occasion. There were 110 patients who flared (59%) with a median time of 2.3 years. There were no differences in remission survival between JIA subcategories. Twenty-nine percent of patients with JIA who received MTX and bDMARDs, in which MTX alone was withdrawn, flared; median time to flare of 6.3 years. However, if only the bDMARD was withdrawn, flares occurred 57% of the time; median time to flare of 1.1 years. CONCLUSION Flares are frequent when systemic treatment is withdrawn, and uveitis or joint injections could be related risk factors. In MTX and biologic-naïve patients, the frequency of flares occurred in more than half of patients, although they were less frequent when clinical remission lasted for > 1 year.
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Affiliation(s)
- Juan Carlos Nieto-González
- J.C. Nieto-González, MD, PhD, L. Trives-Folguera, MD, I. Monteagudo-Saéz, MD, PhD, Department of Rheumatology, Hospital General Universitario Gregorio Marañón;
| | - Daniel Clemente Garulo
- D. Clemente Garulo, MD, PhD, J.C. López Robledillo, MD, Pediatric Rheumatology Unit, Hospital Infantil Universitario Niño Jesús
| | - Alina Boteanu
- A. Boteanu, MD, A. García-Fernández, MD, Department of Rheumatology, Hospital Universitario Ramón y Cajal
| | - Laura Trives-Folguera
- J.C. Nieto-González, MD, PhD, L. Trives-Folguera, MD, I. Monteagudo-Saéz, MD, PhD, Department of Rheumatology, Hospital General Universitario Gregorio Marañón
| | - Antía García-Fernández
- A. Boteanu, MD, A. García-Fernández, MD, Department of Rheumatology, Hospital Universitario Ramón y Cajal
| | - Pablo González Navarro
- P. González Navarro, MSc, Biostatistical Unit, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Juan Carlos López Robledillo
- D. Clemente Garulo, MD, PhD, J.C. López Robledillo, MD, Pediatric Rheumatology Unit, Hospital Infantil Universitario Niño Jesús
| | - Indalecio Monteagudo-Saéz
- J.C. Nieto-González, MD, PhD, L. Trives-Folguera, MD, I. Monteagudo-Saéz, MD, PhD, Department of Rheumatology, Hospital General Universitario Gregorio Marañón
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12
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Maleki A, Patel PD, Foster CS. Juvenile idiopathic arthritis and its associated uveitis. Expert Rev Clin Immunol 2023; 19:1157-1169. [PMID: 37401872 DOI: 10.1080/1744666x.2023.2231154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 06/26/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION Juvenile idiopathic arthritis is the most common chronic rheumatologic disease in children. Uveitis is the most common extra-articular manifestation of JIA, and it can be a sight-threatening condition. AREAS COVERED In this review article, we discussed epidemiology, risk factors, clinical presentation, supportive laboratory tests, treatment options, and complications of Juvenile idiopathic arthritis and Juvenile idiopathic arthritis associated uveitis. We covered conventional immunomodulatory therapy and biologic response modifiers agents for different types of Juvenile idiopathic arthritis and their associated uveitis. Finally, we discussed the course of disease, functional outcome, and the quality of life of Juvenile idiopathic arthritis and Juvenile idiopathic arthritis-associated uveitis. EXPERT OPINION Although clinical outcomes of Juvenile idiopathic arthritis and its associated uveitis have been improved over the past three decades by biologic response modifier agents, a significant proportion of patients require active treatment into adult life therefore screening and monitoring of these patients is required during the patient's entire life. The limited number of food and drug administration approved biologic response modifier agents for the treatment of Juvenile idiopathic arthritis associated uveitis justify more randomized clinical trials with new medications in this field.
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Affiliation(s)
- Arash Maleki
- Department of Ophthalmology, University of Florida, Gainesville, FL, USA
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA
- The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - Priya D Patel
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA
- The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - C Steven Foster
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA
- The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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13
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Chausset A, Lambert C, Belot A, Merlin E, Cannizzaro E, Kone-Paut I, Ballot C, Devauchelle V, Poignant S, Carlomagno R, Lohse A, Barbier C, Despert V, Carbasse A, Sparsa L, Adank E, Vanoni F, Reumaux H, Pillet P, Kaiser D, Hofer M, Freychet C, Schott AM. Individual and environmental determinants associated with longer times to access pediatric rheumatology centers for patients with juvenile idiopathic arthritis, a JIR cohort study. Pediatr Rheumatol Online J 2023; 21:24. [PMID: 36918902 PMCID: PMC10015663 DOI: 10.1186/s12969-023-00809-8] [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: 09/18/2022] [Accepted: 03/07/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Despite guidelines, poor access to appropriate care for juvenile idiopathic arthritis (JIA) patients remains a global issue. Prompt referral to a pediatric rheumatology (PR) center and effective care is known to be critical for changing the natural history of the disease and improving long-term prognosis. This project assesses socio-economic factors of delayed referral to a pediatric rheumatologist (PRst) for JIA patients in France and Switzerland within the Juvenile Inflammatory Rheumatism (JIR) Cohort. METHODS All patients diagnosed with JIA, presenting at one center of the JIRcohort in France or Switzerland with additional data on referral pathway were included. Patient characteristics at first visit to the PR center, dates of visits to healthcare providers during referral, and parent characteristics were extracted from the JIRcohort database. RESULTS Two hundred fifty children were included. The overall median time to first PR assessment was 2.4 months [1.3; 6.9] and ranged widely across the JIA subtypes, from 1.4 months [0.6; 3.8] for children with systemic juvenile idiopathic arthritis (sJIA) to 5.3 months [2.0; 19.1] for children with enthesitis-related arthritis (ERA). A diagnosis of ERA and an appointment with an orthopedist during the referral pathway were significantly associated with a longer time before the first PR visit (hazard ratio HR 0.50 [95% CI: 0.29; 0.84]) and HR 0.68 [95% CI: 0.49; 0.93], respectively) in multivariable analysis. Having a mother with a post-graduate educational attainment level was tendentially associated with a shorter time before the first PR visit, (HR 1.32 [95% CI: 0.99; 1.78]). CONCLUSIONS Time to first PRst visit was most often short compared to other studies and close to the British recommendations. However, this time remained too long for many patients. We observed no social inequities in access to a PRst, but we show the need to improve effective pathway and access to a PR center for JIA patients.
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Affiliation(s)
- Aurélie Chausset
- CRECHE Unit, INSERM CIC 1405, Department of Pediatrics, CHU Clermont-Ferrand, Clermont-Ferrand, France.
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Claude Bernard University Lyon 1, Lyon, France.
- Pédiatrie, CHU Estaing, 1 Place Lucie & Raymond Aubrac, Clermont-Fd cedex1, 63003, France.
| | - Céline Lambert
- Biostatistics Unit, DRCI, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Alexandre Belot
- Pediatric Nephrology, Rheumatology, Dermatology, HFME, Hospices Civils de Lyon, National Referee Centre RAISE & INSERM U1111, Lyon University, Lyon, France
| | - Etienne Merlin
- CRECHE Unit, INSERM CIC 1405, Department of Pediatrics, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Elvira Cannizzaro
- Department of Rheumatology, University Children's Hospital, University of Zurich, Zurich, Switzerland
| | - Isabelle Kone-Paut
- Department of Pediatrics & Pediatric Rheumatology, Centre de référence maladies auto-inflammatoires rares et amylose inflammatoire (CEREMAIA), Bicêtre University, Paris Sud Hospital, Le Kremlin-Bicêtre, France
| | - Claire Ballot
- Pediatric Hematology, Jean-Minjoz Hospital, Besançon, France
| | - Valérie Devauchelle
- Rheumatology Department, CHU Brest and Brest University, INSERM UMR 1227, Brest, France
| | | | - Raffaella Carlomagno
- Pediatric Immuno-Rheumatology of Western Switzerland, Department Women-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
- University Hospital, Geneva, Switzerland
| | - Anne Lohse
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France
| | | | | | - Aurélia Carbasse
- Department of Pediatrics, Hôpital Arnaud de Villeneuve, CHRU Montpellier, Montpellier, France
| | | | - Eva Adank
- Department of Pediatrics, Kantonsspital Graubünden, Chur, Switzerland
| | - Federica Vanoni
- Institute of Pediatrics of Southern Switzerland, EOC, Bellinzona, Switzerland
| | - Héloise Reumaux
- Pediatric Rheumatology, Lille University Hospital, Lille, France
| | - Pascal Pillet
- Department of Pediatrics, Hôpital des Enfants, CHRU Bordeaux, Bordeaux, France
| | - Daniela Kaiser
- Department of Pediatrics, Centre Hospitalier Cantonal Luzern, Lucerne, Switzerland
| | - Michael Hofer
- Pediatric Immuno-Rheumatology of Western Switzerland, Department Women-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
- University Hospital, Geneva, Switzerland
| | - Caroline Freychet
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Claude Bernard University Lyon 1, Lyon, France
- Pediatric Nephrology, Rheumatology, Dermatology, HFME, Hospices Civils de Lyon, National Referee Centre RAISE & INSERM U1111, Lyon University, Lyon, France
- Pediatrics, CHU Saint-Etienne, Saint-Etienne, France
| | - Anne-Marie Schott
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Claude Bernard University Lyon 1, Lyon, France
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14
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Weiss PF, Brandon TG, Ryan ME, Treemarcki EB, Armendariz S, Wright TB, Godiwala C, Stoll ML, Xiao R, Lovell D. Development and Validation of a Juvenile Spondyloarthritis Disease Flare Measure: Ascertaining Flare in Patients With Inactive Disease. Arthritis Care Res (Hoboken) 2023; 75:373-380. [PMID: 34363343 PMCID: PMC8818809 DOI: 10.1002/acr.24763] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/26/2021] [Accepted: 08/03/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Our objective was to develop and validate a composite disease flare definition for juvenile spondyloarthritis (SpA) that would closely approximate the clinical decision made to reinitiate or not reinitiate systemic therapy after therapy de-escalation. METHODS Retrospective chart reviews of children with SpA who underwent systemic therapy de-escalation of biologic or conventional disease-modifying antirheumatic drugs were used to develop and validate the flare outcome. Data on independent cohorts for development (1 center) and validation (4 centers) were collected from large tertiary health care systems. Core measure thresholds and candidate disease flare outcomes were assessed using sensitivity, specificity, positive predictive values (PPVs) and negative predictive values (NPVs), and the receiver operating characteristic (ROC) area under the curve (AUC), with physician assessment of active disease plus re-initiation of standard dose of systemic therapy as the reference standard. RESULTS Of the candidate definitions, clinically meaningful worsening in ≥3 of the following 5 core measures performed best: caregiver/patient assessment of well-being; physician assessment of disease activity; caregiver/patient assessment of pain, physical function, and active joint count. The ROC AUC was 0.91, PPV 87.5%, NPV 98.1%, sensitivity 82.4%, and specificity 98.7%. Cronbach's α was 0.81, signifying internal consistency, and factor analysis demonstrated that the outcome measured 1 construct. The Juvenile SpA Flare measure had face validity according to 21 surveyed pediatric rheumatologists. Juvenile SpA Flare had an ROC AUC of 0.85, a PPV of 92.3%, and an NPV of 96.8% in the validation cohort. CONCLUSION There is initial support for the validity of the Juvenile SpA Flare measure as a tool to identify disease flare in juvenile SpA patients de-escalating therapy, and the measure is potentially applicable in clinical practice, observational studies, and therapeutic trials.
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Affiliation(s)
- Pamela F Weiss
- University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia
| | | | - Meghan E Ryan
- University of Minnesota Masonic Children's Hospital, Minneapolis
| | | | | | - Tracey B Wright
- University of Texas Southwestern Medical Center and Scottish Rite Hospital for Children, Dallas
| | | | | | - Rui Xiao
- University of Pennsylvania, Philadelphia
| | - Daniel Lovell
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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15
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Harsini S, Rezaei N. Autoimmune diseases. Clin Immunol 2023. [DOI: 10.1016/b978-0-12-818006-8.00001-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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16
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Murias S, Boteanu A, Calvo I, Nuñez E, Bravo B, Bustabad S, Camacho M, Clemente D, Graña J, de Inocencio J, Lacruz L, Mesa-Del-Castillo P, Nieto-González JC, Pinedo MDC, Quesada E, Vargas C, Antón J. What drives the decision to optimise biological treatment in children and youngsters with juvenile idiopathic arthritis? A discrete-choice experiment. REUMATOLOGIA CLINICA 2023; 19:26-33. [PMID: 36603964 DOI: 10.1016/j.reumae.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 12/16/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To analyse factors involved in the decision to optimise biologics in juvenile idiopathic arthritis. METHODS A "discrete-choice" methodology was used. In a nominal group meeting, factors which may influence physicians' decisions to optimise biological dose were identified, together with decision nodes. 1000Minds® was used to create multiple fictitious clinical scenarios based on the factors identified, and to deploy surveys that were sent to a panel of experts. These experts decided for each item which of two clinical scenarios prompted them to optimise the dose of biologic. A conjoint analysis was carried out, and the partial-value functions and the weights of relative importance calculated. RESULTS In the nominal group, three decision nodes were identified: (1) time to decide; (2) to maintain/reduce or prolong interval; (3) what drug to reduce. The factors elicited were different for each node and included patient and drug attributes. The presence of macrophage activation syndrome (MAS), systemic involvement, or subclinical inflammation made the decision easier (highest weights). The presence of joints of difficult control and year of debut influenced the decision in some but not all, and in different directions. Immunogenicity, adherence, and concomitant treatments were also aspects taken into account. CONCLUSIONS The decision to optimise the dose of biological therapy in children and youngster can be divided into several nodes, and the factors, both patient and therapy-related, leading to the decision can be detailed. These decisions taken by experts may be transported to practice, study designs, and guidelines.
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Affiliation(s)
- Sara Murias
- Hospital Universitario La Paz, Madrid, Spain.
| | | | | | | | - Beatriz Bravo
- Hospital Universitario Virgen de las Nieves, Granada, Spain
| | | | | | | | - Jenaro Graña
- Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | | | - Lucía Lacruz
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | | | | | | | - Carmen Vargas
- Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Jordi Antón
- Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain
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Gieling J, van den Bemt B, Hoppenreijs E, Schatorjé E. Discontinuation of biologic DMARDs in non-systemic JIA patients: a scoping review of relapse rates and associated factors. Pediatr Rheumatol Online J 2022; 20:109. [PMID: 36471348 PMCID: PMC9721079 DOI: 10.1186/s12969-022-00769-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 11/08/2022] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND Biologic disease-modifying antirheumatic drugs (bDMARDs) have changed the treatment of juvenile idiopathic arthritis (JIA) patients notably, as bDMARDs enable substantially more patients to achieve remission. When sustained remission is achieved, tapering or even discontinuation of the bDMARD is advocated, to reduce side effects and costs. However, when and how to discontinue bDMARD therapy and what happens afterwards, is less known. OBJECTIVES With this scoping review we aim to collect available data in current literature on relapse rate, time to relapse (TTR) and possible flare associated variables (such as time spent in remission and method of discontinuation) after discontinuing bDMARDs in non-systemic JIA patients. METHODS We performed a literature search until July 2022 using the Pubmed database. All original studies reporting on bDMARD discontinuation in non-systemic JIA patients were eligible. Data on patient- and study characteristics, the applied discontinuation strategy, relapse rates and time to relapse were extracted in a standardized template. RESULTS Of the 680 records screened, 28 articles were included in this review with 456 non-systemic JIA patients who tapered and/or stopped bDMARD therapy. Relapse rate after discontinuation of bDMARDs, either abruptly or following tapering, were 40-48%, 36.8-45.0% and 60-78% at 6, 8 and 12 months respectively. Total relapse rate ranged from 26.3% to 100%, with mean time to relapse (TTR) of 2 to 8.4 months, median TTR 3 to 10 months. All studies stated a good response after restart of therapy after flare. JIA subtype, type of bDMARD, concomitant methotrexate use, treatment duration, tapering method, age, sex, and time in remission could not conclusively be related to relapse rate or TTR. However, some studies reported a positive correlation between flare and antinuclear antibodies positivity, younger age at disease onset, male sex, disease duration and delayed remission, which were not confirmed in other studies. CONCLUSION Flares seem to be common after bDMARD discontinuation, but little is known about which factors influence these flares in JIA patients. Follow up after discontinuation with careful registration of patient variables, information about tapering methods and flare rates are required to better guide tapering and/or stopping of bDMARDs in JIA patients in the future.
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Affiliation(s)
- Job Gieling
- Department of Pediatric Rheumatology, Pediatrics, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Bart van den Bemt
- grid.10417.330000 0004 0444 9382Departments of Pharmacy, Sint Maartenskliniek / Radboud University Medical Center, Nijmegen, the Netherlands
| | - Esther Hoppenreijs
- grid.10417.330000 0004 0444 9382Department of Pediatric Rheumatology, Pediatrics, Sint Maartenskliniek / Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ellen Schatorjé
- grid.10417.330000 0004 0444 9382Department of Pediatric Rheumatology, Pediatrics, Sint Maartenskliniek / Radboud University Medical Center, Nijmegen, the Netherlands
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18
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Miraldi Utz V, Angeles-Han ST, Mwase N, Cassedy A, Hennard T, Lovell DJ, Lopper S, Brunner HI, Dosunmu EO, Grom AA, Henrickson M, Huggins JL, Sisk RA, Ting TV, Kaufman AH. Alternative Biologic Therapy in Children Failing Conventional TNFα Inhibitors for Refractory, Noninfectious, Chronic Anterior Uveitis. Am J Ophthalmol 2022; 244:183-195. [PMID: 35863492 DOI: 10.1016/j.ajo.2022.06.024] [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: 03/29/2022] [Revised: 06/25/2022] [Accepted: 06/30/2022] [Indexed: 01/30/2023]
Abstract
PURPOSE A significant number of children with noninfectious, chronic anterior uveitis (CAU) fail to respond to conventional therapy; however, successful alternative biologic treatments (ABT) have not been well described. This study aims to review the clinical and treatment characteristics of children with CAU who require ABT. DESIGN Retrospective, nonrandomized clinical study. METHODS Setting: Tertiary center. STUDY POPULATION Children with noninfectious CAU. OBSERVATION PROCEDURES Clinical characteristics, uveitis course, complications, and treatment were compared among patients treated with methotrexate (MTX) monotherapy, conventional TNFα inhibitors (cTNFi), and ABT for >3 months. MAIN OUTCOME MEASURE Success of ABT (abatacept, tocilizumab, and/or golimumab) in children failing conventional treatment. RESULTS Of the 52 children with CAU, 75% had juvenile idiopathic arthritis. CAU was controlled in 15 children receiving MTX monotherapy, 28 receiving cTNFi, and 9 receiving ABT (n = 1, abatacept; n = 3, tocilizumab; n = 5, golimumab). Patients in the ABT group had a greater number of total ocular complications per person before ABT than those in the control groups (3.4 vs 0.7 [MTX], P < .001, and 1.5 [cTNFi], P < .001, respectively). In all 9 children on ABT, treatment led to control of CAU and topical glucocorticoids tapered to ≤2 drops/d with no new ocular complications. CONCLUSIONS In this study, alternative biologics (abatacept, golimumab, and tocilizumab) were useful for treating CAU in children who fail MTX and cTNFi therapy. Patients who were controlled on ABT had more disease activity, ocular complications, and anti-cTNFi neutralizing antibodies (before ABT) than those managed with conventional therapy. Larger studies are required to confirm these findings.
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Affiliation(s)
- Virginia Miraldi Utz
- From the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.)
| | - Sheila T Angeles-Han
- From the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Department of Ophthalmology (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.).
| | - Najima Mwase
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.)
| | - Amy Cassedy
- University of Cincinnati, and Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center (A.C.)
| | - Theresa Hennard
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.)
| | - Daniel J Lovell
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.)
| | - Sarah Lopper
- From the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Department of Ophthalmology (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.)
| | - Hermine I Brunner
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.)
| | - Eniolami O Dosunmu
- From the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Department of Ophthalmology (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.)
| | - Alexei A Grom
- From the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.)
| | - Michael Henrickson
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.)
| | - Jennifer L Huggins
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.)
| | - Robert A Sisk
- From the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Department of Ophthalmology (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Cincinnati Eye Institute (R.A.S., A.H.K.), Cincinnati, Ohio, USA
| | - Tracy V Ting
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics (S.T.A.-H., N.M., T.H., D.J.L., H.I.B., A.A.G., M.H., J.L.H., T.V.T.)
| | - Adam H Kaufman
- From the Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Department of Ophthalmology (V.M.U., S.T.A.-H., S.L., E.O.D., R.A.S., A.H.K.); Cincinnati Eye Institute (R.A.S., A.H.K.), Cincinnati, Ohio, USA
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19
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Poutoglidou F, Pourzitaki C, Manthou ME, Samoladas E, Saitis A, Malliou F, Kouvelas D. The inhibitory effect of tocilizumab on systemic bone loss and tendon inflammation in a juvenile Collagen-Induced arthritis rat model. Connect Tissue Res 2022; 63:577-589. [PMID: 35175165 DOI: 10.1080/03008207.2022.2042275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF THE STUDY Reduced Bone Mineral Density (BMD) is a prevalent comorbidity in Juvenile Idiopathic Arthritis (JIA). Enthesitis and other tendon abnormalities, such as tenosynovitis, tendinitis and tendon ruptures are, also, common extra-articular manifestations of the disease. The aim of the present study was to investigate the effect of tocilizumab, an antibody that binds the Interleukin-6 (IL-6) Receptor, on inflammation-related bone loss and tendon inflammation in an animal model of JIA. MATERIALS AND METHODS The Collagen-Induced Arthritis (CIA) model was induced in male rats followed by intraperitoneal administration of tocilizumab for 8 weeks. Methotrexate, the most widely used Disease-Modifying Antirheumatic Drug in the management of JIA, was, also, administered, either as a monotherapy or as an add-on therapy to tocilizumab. BMD was evaluated with Micro-Computed Tomography (Micro-CT) and histopathological examination. Tendon damage was, also, assessed histologically. Finally, two pro-inflammatory cytokines, Tumor Necrosis Factor-alpha (TNF-a) and Interleukin-23 (IL-23) were quantified in tendon tissues by ELISA analysis. RESULTS Tocilizumab-treated animals exhibited a significantly improved trabecular microarchitecture on micro-CT analysis and histological examination. Tendon morphology was also improved. Anti-IL-6 treatment led to a significant decrease in TNF-a and IL-23 expression in tendon tissue. CONCLUSIONS The results of the present study provide evidence that tocilizumab reduces inflammation-related bone loss and suppresses tendon inflammation in a juvenile CIA rat model. These findings offer perspectives for the management of osteoporosis and enthesitis in JIA.
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Affiliation(s)
- Frideriki Poutoglidou
- Department of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece
| | - Chryssa Pourzitaki
- Department of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece
| | - Maria Eleni Manthou
- Laboratory of Histology and Embryology, School of Medicine, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece
| | - Efthimios Samoladas
- Orthopaedics Division, "Genimatas" Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Athanasios Saitis
- Department of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece
| | - Foteini Malliou
- Department of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece
| | - Dimitrios Kouvelas
- Department of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece
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20
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Kuster S, Jordan S, Elhai M, Held U, Steigmiller K, Bruni C, Cacciapaglia F, Vettori S, Siegert E, Rednic S, Codullo V, Airo P, Braun-Moscovici Y, Hunzelmann N, Joao Salvador M, Riccieri V, Gheorghiu AM, Alegre Sancho JJ, Romanowska-Prochnicka K, Castellví I, Kötter I, Truchetet ME, López-Longo FJ, Novikov PI, Giollo A, Shirai Y, Belloli L, Zanatta E, Hachulla E, Smith V, Denton C, Ionescu RM, Schmeiser T, Distler JHW, Gabrielli A, Hoffmann-Vold AM, Kuwana M, Allanore Y, Distler O. Effectiveness and safety of tocilizumab in patients with systemic sclerosis: a propensity score matched controlled observational study of the EUSTAR cohort. RMD Open 2022; 8:rmdopen-2022-002477. [DOI: 10.1136/rmdopen-2022-002477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/14/2022] [Indexed: 11/06/2022] Open
Abstract
ObjectivesTocilizumab showed trends for improving skin fibrosis and prevented progression of lung fibrosis in systemic sclerosis (SSc) in randomised controlled clinical trials. We aimed to assess safety and effectiveness of tocilizumab in a real-life setting using the European Scleroderma Trial and Research (EUSTAR) database.MethodsPatients with SSc fulfilling the American College of Rheumatology (ACR)/EULAR 2013 classification criteria, with baseline and follow-up visits at 12±3 months, receiving tocilizumab or standard of care as the control group, were selected. Propensity score matching was applied. Primary endpoints were the modified Rodnan skin score (mRSS) and FVC at 12±3 months compared between the groups. Secondary endpoints were the percentage of progressive/regressive patients for skin and lung at 12±3 months.ResultsNinety-three patients with SSc treated with tocilizumab and 3180 patients with SSc with standard of care fulfilled the inclusion criteria. Comparison between groups did not show significant differences, but favoured tocilizumab across all predefined primary and secondary endpoints: mRSS was lower in the tocilizumab group (difference −1.0, 95% CI −3.7 to 1.8, p=0.48). Similarly, FVC % predicted was higher in the tocilizumab group (difference 1.5 (−6.1 to 9.1), p=0.70). The percentage of progressive/regressive patients favoured tocilizumab over controls. These results were robust regarding the sensitivity analyses. Safety analysis confirmed previously reported adverse event profiles.ConclusionAlthough this large, observational, controlled, real-life EUSTAR study did not show significant effectiveness of tocilizumab on skin and lung fibrosis, the consistency of direction of all predefined endpoints generates hypothesis for potential effectiveness in a broader SSc population.
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21
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Rosina S, Giancane G, Ruperto N. Emerging therapies for juvenile arthritis: agents in early clinical trials. Expert Opin Investig Drugs 2022; 31:1109-1124. [PMID: 36066506 DOI: 10.1080/13543784.2022.2121698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Juvenile idiopathic arthritis (JIA) is the most common chronic inflammatory rheumatic condition in childhood. The management of JIA has been revolutionized thanks to the development of new powerful drugs and the possibility to conduct controlled clinical trials with support from legislative initiatives and availability of international collaborative networks. Trials are still needed in children because we now have new drugs related to specific JIA category. AREAS COVERED The review is centered on the latest achievements in the field, focusing on new investigational drugs which are currently or have been recently tested for JIA treatment, encompassing agents in early phase of clinical development. EXPERT OPINION Despite the tremendous improvement witnessed in the field of JIA treatment in the past 20 years, there are still many unmet needs to be prioritized. Studies on disease pathogenesis will hopefully help in the identification of new treatment targets for individual JIA categories, that could possibly favor a stricter disease control and contribute to solve the issue of refractory JIA. Novel strategies aimed at the prevention of the risk of long-term joint damage are also desirable, as well as the discovery of predictive biomarkers for treatment efficacy and safety in the individual patient.
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Affiliation(s)
- Silvia Rosina
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Gabriella Giancane
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genova, Italy.,Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DiNOGMI), Università degli Studi di Genova, Genova, Italy
| | - Nicolino Ruperto
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genova, Italy.,UOSID Centro trial, IRCCS Istituto Giannina Gaslini, Genova, Italy
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22
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Kastrati K, Aletaha D, Burmester GR, Chwala E, Dejaco C, Dougados M, McInnes IB, Ravelli A, Sattar N, Stamm TA, Takeuchi T, Trauner M, van der Heijde D, Voshaar MJH, Winthrop K, Smolen JS, Kerschbaumer A. A systematic literature review informing the consensus statement on efficacy and safety of pharmacological treatment with interleukin-6 pathway inhibition with biological DMARDs in immune-mediated inflammatory diseases. RMD Open 2022; 8:rmdopen-2022-002359. [PMID: 36260501 PMCID: PMC9462104 DOI: 10.1136/rmdopen-2022-002359] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/30/2022] [Indexed: 11/08/2022] Open
Abstract
Objectives Informing an international task force updating the consensus statement on efficacy and safety of biological disease-modifying antirheumatic drugs (bDMARDs) selectively targeting interleukin-6 (IL-6) pathway in the context of immune-mediated inflammatory diseases. Methods A systematic literature research of all publications on IL-6 axis inhibition with bDMARDs published between January 2012 and December 2020 was performed using MEDLINE, EMBASE and Cochrane CENTRAL databases. Efficacy and safety outcomes were assessed in clinical trials including their long-term extensions and observational studies. Meeting abstracts from ACR, EULAR conferences and results on clinicaltrials.gov were taken into consideration. Results 187 articles fulfilled the inclusion criteria. Evidence for positive effect of IL-6 inhibition was available in various inflammatory diseases such as rheumatoid arthritis, juvenile idiopathic arthritis, giant cell arteritis, Takayasu arteritis, adult-onset Still’s disease, cytokine release syndrome due to chimeric antigen receptor T cell therapy and systemic sclerosis-associated interstitial lung disease. Newcomers like satralizumab and anti-IL-6 ligand antibody siltuximab have expanded therapeutic approaches for Castleman’s disease and neuromyelitis optica, respectively. IL-6 inhibition did not provide therapeutic benefits in psoriatic arthritis, ankylosing spondylitis and certain connective tissue diseases. In COVID-19, tocilizumab (TCZ) has proven to be therapeutic in advanced disease. Safety outcomes did not differ from other bDMARDs, except higher risks of diverticulitis and lower gastrointestinal perforations. Inconsistent results were observed in several studies investigating the risk for infections when comparing TCZ to TNF-inhibitors. Conclusion IL-6 inhibition is effective for treatment of several inflammatory diseases with a safety profile that is widely comparable to other bDMARDs.
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Affiliation(s)
- Kastriot Kastrati
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Wien, Austria
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Wien, Austria
| | - Gerd R Burmester
- Rheumatology and Clinical Immunology, Charite University Hospital Berlin, Berlin, Germany
| | - Eva Chwala
- University Library, Medical University of Vienna, Wien, Austria
| | - Christian Dejaco
- Rheumatology, Medical University of Graz, Graz, Austria
- Rheumatology, Hospital of Bruneck, Bruneck, Italy
| | - Maxime Dougados
- Hopital Cochin, Rheumatology, Université Paris Descartes, Paris, France
| | - Iain B McInnes
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
| | - Angelo Ravelli
- UO Pediatria II-Reumatologia, Istituto Giannina Gaslini, Genova, Italy
| | - Naveed Sattar
- Glasgow Cardiovascular Research Center, University of Glasgow, Glasgow, UK
| | - Tanja A Stamm
- Section for Outcomes Research, Medical University of Vienna, Vienna, Austria
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine Graduate School of Medicine, Shinjuku-ku, Japan
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Medical University of Vienna Department of Medicine III, Wien, Austria
| | | | - Marieke J H Voshaar
- Department of Pharmacy and Department of Research & Innovation, Sint Maartenskliniek, Ubbergen, The Netherlands
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kevin Winthrop
- Schools of Medicine and Public Health, Oregon Health and Science University, Portland, Oregon, USA
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Wien, Austria
| | - Andreas Kerschbaumer
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Wien, Austria
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23
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Oommen PT, Strauss T, Baltruschat K, Foeldvari I, Deuter C, Ganser G, Haas JP, Hinze C, Holzinger D, Hospach A, Huppertz HI, Illhardt A, Jung M, Kallinich T, Klein A, Minden K, Mönkemöller K, Mrusek S, Neudorf U, Dückers G, Niehues T, Schneider M, Schoof P, Thon A, Wachowsky M, Wagner N, Bloedt S, Hofer M, Tenbrock K, Schuetz C. Update of evidence- and consensus-based guidelines for the treatment of juvenile idiopathic arthritis (JIA) by the German Society of Pediatric and Juvenile Rheumatic Diseases (GKJR): New perspectives on interdisciplinary care. Clin Immunol 2022; 245:109143. [DOI: 10.1016/j.clim.2022.109143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 11/15/2022]
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24
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Lim LSH, Lokku A, Pullenayegum E, Ringold S. Probability of Response in the First Sixteen Weeks After Starting Biologics: An Analysis of Juvenile Idiopathic Arthritis Biologics Trials. Arthritis Care Res (Hoboken) 2022; 75:1238-1249. [PMID: 36651601 DOI: 10.1002/acr.25003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 07/07/2022] [Accepted: 08/16/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Most juvenile idiopathic arthritis (JIA) biologic disease-modifying antirheumatic drugs (bDMARDs) trials used an open-label run-in period followed by randomized medication withdrawal. We used data from the run-in period of 4 bDMARD trials to 1) delineate early response trajectory to bDMARDs and 2) identify predictors of early response. METHODS Data from the first 16 weeks of 4 bDMARD trials were used. The primary outcome was the American College of Rheumatology (ACR) Pediatric 50 (Pedi 50) response criteria: clinically significant response defined as ACR Pedi 50 or greater. The secondary outcome was the clinical Juvenile Arthritis Disease Activity Score in 10 joints (cJADAS10) minimal disease activity state. Response transition rates and predictors were modeled using an inhomogeneous Markov multistate model. RESULTS Five hundred thirty-two participants (70% receiving methotrexate, 41% prednisone) were included. By month 4, the probability of attaining ACR Pedi 50 or greater was 0.698. If ACR Pedi 50 or more was not achieved by month 1, the probability of achieving it by month 4 was 0.60. If ACR Pedi 50 or more was not achieved by month 3, the probability of achieving this by month 4 was 0.31. Age at diagnosis, disease duration, baseline rheumatoid factor, and active joint counts predicted ACR and cJADAS state transitions, adjusted for concomitant treatment. CONCLUSIONS No response ACR Pedi 50 or more by month 1 after treatment was associated with a 0.60 probability of responding by month 4, but not responding by month 3 was associated with a 0.31 probability of response by month 4. Baseline disease duration, rheumatoid factor, and active joint counts predicted early treatment response (ACR and cJADAS10 states).
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25
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Aletaha D, Kerschbaumer A, Kastrati K, Dejaco C, Dougados M, McInnes IB, Sattar N, Stamm TA, Takeuchi T, Trauner M, van der Heijde D, Voshaar M, Winthrop KL, Ravelli A, Betteridge N, Burmester GRR, Bijlsma JW, Bykerk V, Caporali R, Choy EH, Codreanu C, Combe B, Crow MK, de Wit M, Emery P, Fleischmann RM, Gabay C, Hetland ML, Hyrich KL, Iagnocco A, Isaacs JD, Kremer JM, Mariette X, Merkel PA, Mysler EF, Nash P, Nurmohamed MT, Pavelka K, Poor G, Rubbert-Roth A, Schulze-Koops H, Strangfeld A, Tanaka Y, Smolen JS. Consensus statement on blocking interleukin-6 receptor and interleukin-6 in inflammatory conditions: an update. Ann Rheum Dis 2022; 82:773-787. [PMID: 35953263 DOI: 10.1136/ard-2022-222784] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/18/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Targeting interleukin (IL)-6 has become a major therapeutic strategy in the treatment of immune-mediated inflammatory disease. Interference with the IL-6 pathway can be directed at the specific receptor using anti-IL-6Rα antibodies or by directly inhibiting the IL-6 cytokine. This paper is an update of a previous consensus document, based on most recent evidence and expert opinion, that aims to inform on the medical use of interfering with the IL-6 pathway. METHODS A systematic literature research was performed that focused on IL-6-pathway inhibitors in inflammatory diseases. Evidence was put in context by a large group of international experts and patients in a subsequent consensus process. All were involved in formulating the consensus statements, and in the preparation of this document. RESULTS The consensus process covered relevant aspects of dosing and populations for different indications of IL-6 pathway inhibitors that are approved across the world, including rheumatoid arthritis, polyarticular-course and systemic juvenile idiopathic arthritis, giant cell arteritis, Takayasu arteritis, adult-onset Still's disease, Castleman's disease, chimeric antigen receptor-T-cell-induced cytokine release syndrome, neuromyelitis optica spectrum disorder and severe COVID-19. Also addressed were other clinical aspects of the use of IL-6 pathway inhibitors, including pretreatment screening, safety, contraindications and monitoring. CONCLUSIONS The document provides a comprehensive consensus on the use of IL-6 inhibition to treat inflammatory disorders to inform healthcare professionals (including researchers), patients, administrators and payers.
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Affiliation(s)
- Daniel Aletaha
- Division of Rheumatology, Medical University of Vienna, Wien, Austria
| | | | - Kastriot Kastrati
- Division of Rheumatology, Medical University of Vienna, Wien, Austria
| | - Christian Dejaco
- Rheumatology, Medical University of Graz, Graz, Austria.,Rheumatology, Brunico Hospital, Brunico, Italy
| | - Maxime Dougados
- Rheumatology, Universite Paris Descartes Faculte de Medecine Site Cochin, Paris, France
| | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, Glasgow, UK
| | - Tanja A Stamm
- Section for Outcomes Research, Medical University of Vienna, Wien, Austria
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine Graduate School of Medicine, Shinjuku-ku, Japan
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Medical University of Vienna, Wien, Austria
| | - Désirée van der Heijde
- Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Marieke Voshaar
- Department of Psychology, Health and Technology, Enschede, Netherlands and Stichting Tools Patient Empowerment, University of Twente, Enschede, The Netherlands
| | - Kevin L Winthrop
- Schools of Medicine and Public Health, Division of Infectious Diseases, Oregon Health & Science University, Portland, Oregon, USA
| | - Angelo Ravelli
- UO Pediatria II-Reumatologia, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | | | - Johannes Wj Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Vivian Bykerk
- Rheumatology, University of Toronto, Toronto, Ontario, Canada
| | - Roberto Caporali
- Department of Clinical Sciences and Community Health, ASS G. Pini, University of Milan, Milano, Italy
| | - Ernest H Choy
- CREATE Centre, Section of Rheumatology, School of Medicine, Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Catalin Codreanu
- Rheumatology, Carol Davila University of Medicine and Pharmacy, Bucuresti, Romania
| | - Bernard Combe
- Immunorhumatologie, CHU Lapeyronie, Montpellier, France
| | - Mary K Crow
- Mary Kirkland Center for Lupus Research, Hospital for Special Surgery, New York City, New York, USA
| | - Maarten de Wit
- Medical Humanities, Amsterdam University Medical Centres, Duivendrecht, The Netherlands
| | - Paul Emery
- University of Leeds, Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, UK.,Leeds Teaching Hospitals NHS Trust, NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Roy M Fleischmann
- Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Cem Gabay
- Division of Rheumatology, Geneva University Hospitals, Geneve, Switzerland
| | - Merete Lund Hetland
- Department of Clinical Medicine, Copenhagen University Hospital, Kobenhavn, Denmark.,Department of Clinical Medicine, University of Copenhagen, Kobenhavn, Denmark
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Annamaria Iagnocco
- Scienze Cliniche e Biologiche, Università degli Studi di Torino, Torino, Italy
| | - John D Isaacs
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Joel M Kremer
- Medicine Rheumatology, Albany Medical College, Albany, New York, USA
| | - Xavier Mariette
- Rheumatology, Assistance Publique-Hôpitaux de Paris, Paris, France.,Center for Immunology of Viral Infections and Auto-immune Diseases, Université Paris-Sud, Gif-sur-Yvette, France
| | - Peter A Merkel
- Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eduardo F Mysler
- Organización Médica de Investigación SA, Buenos Aires, Argentina
| | - Peter Nash
- Griffith University School of Medicine, Gold Coast, Queensland, Australia
| | | | - Karel Pavelka
- Rheumatology Department, Charles University, Praha, Czech Republic
| | - Gyula Poor
- National Institute of Rheumatology & Physiology, Semmelweis University, Budapest, Hungary
| | - Andrea Rubbert-Roth
- Division of Rheumatology, Kantonsspital Sankt Gallen, Sankt Gallen, Switzerland
| | - Hendrik Schulze-Koops
- Division of Rheumatology and Clinical Immunology, Internal Medicine IV, Ludwig-Maximilians-Universitat Munchen, Munchen, Germany
| | - Anja Strangfeld
- Forschungsbereich Epidemiologie, Deutsches Rheuma-Forschungszentrum Berlin, Berlin, Germany
| | - Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Josef S Smolen
- Division of Rheumatology, Medical University of Vienna, Wien, Austria
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Ruperto N, Lovell DJ, Berman A, Ávila-Zapata F, Horneff G, Alessio M, Becker ML, Belot A, Burgos-Vargas R, Gamir ML, Goldenstein-Schainberg C, Scheibel IM, Terreri MT, Zemel L, Zhuo J, Askelson M, Wong R, Martini A, Brunner HI. Patient-Reported Outcomes Among Patients Ages Two to Seventeen Years With Polyarticular-Course Juvenile Idiopathic Arthritis Treated With Subcutaneous Abatacept: Two-Year Results From an International Phase III Study. Arthritis Care Res (Hoboken) 2022. [PMID: 36710243 DOI: 10.1002/acr.24989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 07/07/2022] [Accepted: 07/26/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To describe longitudinal changes in patient-reported outcomes (PROs) in children with polyarticular-course juvenile idiopathic arthritis (pJIA) treated with subcutaneous abatacept. METHODS Secondary analysis of a single-arm, open-label 24-month study of patients ages 6-17 years and 2-5 years. PROs included Childhood Health Assessment Questionnaire-Disability Index (CHAQ-DI), parent global assessment of child well-being (PaGA), pain assessment, and Activity Limitation Questionnaire (ALQ). Clinical outcomes included 50% or greater improvement in JIA American College of Rheumatology (ACR) criteria, clinically inactive disease, and Juvenile Arthritis Disease Activity Score. RESULTS For the 6- to 17-year-old (n = 173) and 2- to 5-year-old (n = 46) cohorts, respectively, median (Q1, Q3) changes from baseline in CHAQ-DI at months 4 and 24 were -0.3 (-0.8, 0.0) and -0.5 (-1.0, -0.1), and -0.4 (-0.8, 0.0) and -0.5 (-1.0--0.1). Median pain scores were below cutoff threshold for clinically relevant pain (<35 mm) by month 1 (6 to 17 years, 32.3 mm; 2 to 5 years, 25.7 mm), reaching a nadir at month 24 (6 to 17 years, 6.0 mm; 2 to 5 years, 2.0 mm). For the 6- to 17-year-old and 2- to 5-year-old cohorts, respectively, median PaGA scores were 47.8 (n = 172) and 42.1 (n = 46) at baseline and 6.3 (n = 107) and 2.0 (n = 37) at month 24. In both cohorts, ALQ components improved from baseline to month 4 and were largely maintained to month 24. Clinical outcomes improved through to month 24. CONCLUSION Early and sustained PRO improvements were reported in this phase III, open-label trial of subcutaneous abatacept in patients with pJIA.
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Affiliation(s)
- Nicolino Ruperto
- IRCCS Istituto G. Gaslini Clinica Pediatrica e Reumatologia, UOSID Centro Trial, PRINTO, Genova, Italy
| | - Daniel J Lovell
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Alberto Berman
- Universidad Nacional de Tucuman, San Miguel de Tucumán, Argentina
| | | | - Gerd Horneff
- Asklepios Clinical Sankt Augustin, Sankt Augustin, Germany, and University of Cologne, Cologne, Germany
| | | | - Mara L Becker
- Duke University School of Medicine, Durham, North Carolina
| | | | | | | | | | | | | | | | - Joe Zhuo
- Bristol Myers Squibb, Princeton, New Jersey
| | | | | | | | - Hermine I Brunner
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
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27
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Lim LSH, Shobhan S, Lokku A, Ringold S, Pullenayegum E. Latent classes of early response trajectories to biologics initiation in juvenile idiopathic arthritis: an analysis of four trials. Pediatr Rheumatol Online J 2022; 20:57. [PMID: 35907978 PMCID: PMC9338501 DOI: 10.1186/s12969-022-00719-1] [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: 03/03/2022] [Accepted: 07/18/2022] [Indexed: 12/03/2022] Open
Abstract
AIMS 1) To delineate latent classes of treatment response to biologics in juvenile idiopathic arthritis (JIA) patients in the first 16 weeks after initiation. 2) To identify predictors of early disease response. METHODS The study population was drawn from four biologics trials in polyarticular course JIA: Etanercept 2000, Abatacept 2008, TRial of Early Aggressive Therapy (TREAT) 2012 and Tocilizumab 2014. The outcome was active joint counts (AJC). Semiparametric latent class trajectory analysis was applied to identify latent classes of response to treatment; AJC was transformed for this modelling. We tested baseline disease and treatment characteristics for their abilities to predict class membership of response. RESULTS There were 480 participants, 74% females. At baseline, 26% were rheumatoid factor positive. 67% were on methotrexate at enrollment. Three latent class solution provided the best fit. Baseline AJC was the sole best predictor of class membership. Participants classified by their highest membership probabilities into high baseline AJC (> 30) and slow response (26.5%), low baseline AJC (< 10), early and sustained response (29.7%), and moderate baseline AJC progressive response (43.8%). Participants were classified into the latent classes with a mean class membership posterior probability of 0.97. Those on methotrexate at baseline were less likely to belong to high baseline AJC class. CONCLUSIONS Three latent classes of responses were detectable in the first 16 weeks of biologics therapy. Those with the highest baseline AJC demonstrated very slow response in this window and were less likely to be on concomitant methotrexate. TRIALS REGISTRATION TREAT 2012 (NCT NCT00443430 ) (Wallace et. al, Arthritis Rheum 64:2012-21, 2012), tocilizumab trial 2014 ( NCT00988221 ), abatacept trial 2008 ( NCT00095173 ). Etanercept 2000 from Amgen does not have a trial registration number.
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Affiliation(s)
- Lily Siok Hoon Lim
- Department of Pediatrics, Children's Hospital Research Institute of Manitoba, University of Manitoba, 501F-715 McDermot Ave, Winnipeg, Manitoba, R3E 0V9, Canada.
| | - Shamsia Shobhan
- grid.21613.370000 0004 1936 9609Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Armend Lokku
- grid.17063.330000 0001 2157 2938Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Sarah Ringold
- grid.240741.40000 0000 9026 4165Seattle Children’s Hospital, Seattle, USA
| | - Eleanor Pullenayegum
- grid.17063.330000 0001 2157 2938Dalla Lana School of Public Health, University of Toronto, Toronto, Canada ,grid.42327.300000 0004 0473 9646Child Health Evaluative Sciences, SickKids, Toronto, Canada
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28
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Henderson LA, Canna SW, Friedman KG, Gorelik M, Lapidus SK, Bassiri H, Behrens EM, Kernan KF, Schulert GS, Seo P, Son MBF, Tremoulet AH, VanderPluym C, Yeung RSM, Mudano AS, Turner AS, Karp DR, Mehta JJ. American College of Rheumatology Clinical Guidance for Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 and Hyperinflammation in Pediatric COVID-19: Version 3. Arthritis Rheumatol 2022; 74:e1-e20. [PMID: 35118829 PMCID: PMC9011620 DOI: 10.1002/art.42062] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/22/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To provide guidance on the management of Multisystem Inflammatory Syndrome in Children (MIS-C), a condition characterized by fever, inflammation, and multiorgan dysfunction that manifests late in the course of SARS-CoV-2 infection. Recommendations are also provided for children with hyperinflammation during COVID-19, the acute, infectious phase of SARS-CoV-2 infection. METHODS The Task Force is composed of 9 pediatric rheumatologists and 2 adult rheumatologists, 2 pediatric cardiologists, 2 pediatric infectious disease specialists, and 1 pediatric critical care physician. Preliminary statements addressing clinical questions related to MIS-C and hyperinflammation in COVID-19 were developed based on evidence reports. Consensus was built through a modified Delphi process that involved anonymous voting and webinar discussion. A 9-point scale was used to determine the appropriateness of each statement (median scores of 1-3 for inappropriate, 4-6 for uncertain, and 7-9 for appropriate). Consensus was rated as low, moderate, or high based on dispersion of the votes. Approved guidance statements were those that were classified as appropriate with moderate or high levels of consensus, which were prespecified before voting. RESULTS The guidance was approved in June 2020 and updated in November 2020 and October 2021, and consists of 41 final guidance statements accompanied by flow diagrams depicting the diagnostic pathway for MIS-C and recommendations for initial immunomodulatory treatment of MIS-C. CONCLUSION Our understanding of SARS-CoV-2-related syndromes in the pediatric population continues to evolve. This guidance document reflects currently available evidence coupled with expert opinion, and will be revised as further evidence becomes available.
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Affiliation(s)
| | - Scott W. Canna
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| | - Kevin G. Friedman
- Boston Children's Hospital and Harvard Medical SchoolBostonMassachusetts
| | - Mark Gorelik
- Morgan Stanley Children’s Hospital and Columbia UniversityNew YorkNew York
| | - Sivia K. Lapidus
- Joseph M. Sanzari Children’s Hospital at Hackensack University Medical Center and Hackensack Meridian School of MedicineHackensackNew Jersey
| | - Hamid Bassiri
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| | - Edward M. Behrens
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| | - Kate F. Kernan
- University of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Grant S. Schulert
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of MedicineCincinnatiOhio
| | - Philip Seo
- Johns Hopkins University School of MedicineBaltimoreMaryland
| | - Mary Beth F. Son
- Boston Children's Hospital and Harvard Medical SchoolBostonMassachusetts
| | - Adriana H. Tremoulet
- University of California San Diego and Rady Children’s Hospital San DiegoCalifornia
| | | | - Rae S. M. Yeung
- The Hospital for Sick Children and University of TorontoTorontoOntarioCanada
| | | | | | - David R. Karp
- University of Texas Southwestern Medical CenterDallas
| | - Jay J. Mehta
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
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29
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Li J, Li YR, Glessner JT, Yang J, March ME, Kao C, Vaccaro CN, Bradfield JP, Li J, Mentch FD, Qu H, Qi X, Chang X, Hou C, Abrams DJ, Qiu H, Wei Z, Connolly JJ, Wang F, Snyder J, Flatø B, Thompson SD, Langefeld CD, Lie BA, Munro JE, Wise C, Sleiman PMA, Hakonarson H. Identification of Novel Loci Shared by Juvenile Idiopathic Arthritis Subtypes through Integrative Genetic Analysis. Arthritis Rheumatol 2022; 74:1420-1429. [PMID: 35347896 PMCID: PMC9542075 DOI: 10.1002/art.42129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 03/11/2022] [Accepted: 03/25/2022] [Indexed: 11/25/2022]
Abstract
Objective Juvenile idiopathic arthritis (JIA) is the most common chronic immune‐mediated joint disease among children and encompasses a heterogeneous group of immune‐mediated joint disorders classified into 7 subtypes according to clinical presentation. However, phenotype overlap and biologic evidence suggest a shared mechanistic basis between subtypes. This study was undertaken to systematically investigate shared genetic underpinnings of JIA subtypes. Methods We performed a heterogeneity‐sensitive genome‐wide association study encompassing a total of 1,245 JIA cases (classified into 7 subtypes) and 9,250 controls, followed by fine‐mapping of candidate causal variants at each genome‐wide significant locus, functional annotation, and pathway and network analysis. We further identified candidate drug targets and drug repurposing opportunities by in silico analyses. Results In addition to the major histocompatibility complex locus, we identified 15 genome‐wide significant loci shared between at least 2 JIA subtypes, including 10 novel loci. Functional annotation indicated that candidate genes at these loci were expressed in diverse immune cell types. Conclusion This study identified novel genetic loci shared by JIA subtypes. Our findings identified candidate mechanisms underlying JIA subtypes and candidate targets with drug repurposing opportunities for JIA treatment.
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Affiliation(s)
- Jin Li
- Department of Cell Biology, the Province and Ministry Co-sponsored Collaborative Innovation Center for Medical Epigenetics, School of Basic Medical Sciences, Tianjin Medical University, Tianjin, China
| | - Yun R Li
- The Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,City of Hope Comprehensive Cancer Center, 1500 E Duarte Rd, Duarte, CA, 91010, USA.,Division of Quantitative Medicine & Systems Biology, Translational Genomics Research Institute, Phoenix, AZ, 85004, USA
| | - Joseph T Glessner
- The Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jie Yang
- Department of Cell Biology, the Province and Ministry Co-sponsored Collaborative Innovation Center for Medical Epigenetics, School of Basic Medical Sciences, Tianjin Medical University, Tianjin, China
| | - Michael E March
- The Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Charlly Kao
- The Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Courtney N Vaccaro
- The Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jonathan P Bradfield
- The Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Junyi Li
- Department of Cell Biology, the Province and Ministry Co-sponsored Collaborative Innovation Center for Medical Epigenetics, School of Basic Medical Sciences, Tianjin Medical University, Tianjin, China
| | - Frank D Mentch
- The Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Huiqi Qu
- The Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Xiaohui Qi
- Department of Cell Biology, the Province and Ministry Co-sponsored Collaborative Innovation Center for Medical Epigenetics, School of Basic Medical Sciences, Tianjin Medical University, Tianjin, China
| | - Xiao Chang
- The Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Cuiping Hou
- The Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Debra J Abrams
- The Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Haijun Qiu
- The Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Zhi Wei
- Department of Computer Science, New Jersey Institute of Technology, Newark, New Jersey, USA
| | - John J Connolly
- The Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Fengxiang Wang
- The Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - James Snyder
- The Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Berit Flatø
- Department of Rheumatology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Susan D Thompson
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Carl D Langefeld
- Department of Biostatistics and Data Science, Center for Precision Medicine, Wake Forest University School of Medicine, 27157, Winston-Salem, NC, USA
| | - Benedicte A Lie
- Department of Immunology, Oslo University Hospital, 0027 Rikshospitalet, Oslo, Norway
| | - Jane E Munro
- Murdoch Children's Research Institute, 3052 Parkville, Victoria, VIC, Australia.,Paediatric Rheumatology Unit, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Carol Wise
- Center for Pediatric Bone Biology and Translational Research, Scottish Rite for Children, 75219 Dallas, TX, USA
| | - Patrick M A Sleiman
- The Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Hakon Hakonarson
- The Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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30
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Shah R, Shah J, Gohil J, Revathi G, Surani S. Secondary Infections in Patients with COVID-19 Pneumonia Treated with Tocilizumab Compared to Those Not Treated with Tocilizumab: A Retrospective Study at a Tertiary Hospital in Kenya. Int J Gen Med 2022; 15:2415-2425. [PMID: 35264878 PMCID: PMC8901262 DOI: 10.2147/ijgm.s356547] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/17/2022] [Indexed: 02/05/2023] Open
Abstract
Introduction From the first case of SARS-Co-2 in Wuhan, China, to the virus being declared as a pandemic in March 2020, the world has witnessed morbidity and mortality on a global scale. Scientists have worked at a record pace to deliver a vaccine for the prevention of this deadly disease. Tocilizumab, an interleukin-6 (IL-6) blocker, received an emergency use authorization (EUA) by the Federal Drug Agency (FDA) in June 2021. Methods This retrospective observational cohort study was conducted at the Aga Khan University Hospital, Nairobi, from March 8, 2020, to December 31, 2020. All patients with PCR confirmed COVID-19 pneumonia were included. Data were obtained from the medical records, and the admission registry was used to identify the patients, and both their electronic and paper-based files were retrieved from the medical records. Patient demographic data, medical history, baseline comorbidities, clinical characteristics, and outcome data were collected to study the infectious complications of Tocilizumab in patients affected by COVID-19 pneumonia. Results A total of 913 patients who were diagnosed with COVID-19 were included. The overall superinfection infection rate among the COVID-19 patients was 6%. Superinfection in patients who received the Tocilizumab was 17.2% and in the non-Tocilizumab group was 4.8%. The superinfection rate among severe and critically ill patients was even higher at 41.8% and 69.9% (Tocilizumab group) and 2.1% and 11.8% (non-Tocilizumab group), respectively (p < 0.001). There was no difference in mortality observed between the groups (p = 0.846). Infection among HIV co-infection was very low at 2.3%. Conclusion Contrary to some studies, a higher rate of infection was observed among the Tocilizumab group, and no difference in mortality was observed between Tocilizumab and the non-Tocilizumab group. Infection among patients with HIV remains low in this susceptible population.
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Affiliation(s)
- Reena Shah
- Department of Internal Medicine, The Aga Khan University, Nairobi, Kenya
- Correspondence: Reena Shah, Tel +254735338003, Email
| | - Jasmit Shah
- Department of Internal Medicine, The Aga Khan University, Nairobi, Kenya
| | - Jaimini Gohil
- Department of Pharmacy and Therapeutics, The Aga Khan University, Nairobi, Kenya
| | - Gunturu Revathi
- Department of Pathology, The Aga Khan University, Nairobi, Kenya
| | - Salim Surani
- Department of Pulmonology & Internal Medicine, Texas A&M University, Corpus Christi, Texas, USA
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31
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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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32
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Alhazzani W, Alshahrani M, Alshamsi F, Aljuhani O, Eljaaly K, Hashim S, Alqahtani R, Alsaleh D, Al Duhailib Z, Algethamy H, Al-Musawi T, Alshammari T, Alqarni A, Khoujah D, Tashkandi W, Dahhan T, Almutairi N, Alserehi HA, Al-Yahya M, Al-Judaibi B, Arabi YM, Abualenain J, Alotaibi JM, Al Bshabshe A, Alharbi R, Al-Hameed F, Elhazmi A, Almaghrabi RS, Almaghlouth F, Abedalthagafi M, Al Khathlan N, Al-Suwaidan FA, Bunyan RF, Baw B, Alghamdi G, Al Hazmi M, Mandourah Y, Assiri A, Enani M, Alawi M, Aljindan R, Aljabbary A, Alrbiaan A, Algurashi F, Alsaawi A, Alenazi TH, Alsultan MA, Alqahtani SA, Memish Z, Al-Tawfiq JA, Al-Jedai A. The Saudi Critical Care Society practice guidelines on the management of COVID-19 in the ICU: Therapy section. J Infect Public Health 2022; 15:142-151. [PMID: 34764042 PMCID: PMC8527699 DOI: 10.1016/j.jiph.2021.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/24/2021] [Accepted: 10/07/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The rapid increase in coronavirus disease 2019 (COVID-19) cases during the subsequent waves in Saudi Arabia and other countries prompted the Saudi Critical Care Society (SCCS) to put together a panel of experts to issue evidence-based recommendations for the management of COVID-19 in the intensive care unit (ICU). METHODS The SCCS COVID-19 panel included 51 experts with expertise in critical care, respirology, infectious disease, epidemiology, emergency medicine, clinical pharmacy, nursing, respiratory therapy, methodology, and health policy. All members completed an electronic conflict of interest disclosure form. The panel addressed 9 questions that are related to the therapy of COVID-19 in the ICU. We identified relevant systematic reviews and clinical trials, then used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach as well as the evidence-to-decision framework (EtD) to assess the quality of evidence and generate recommendations. RESULTS The SCCS COVID-19 panel issued 12 recommendations on pharmacotherapeutic interventions (immunomodulators, antiviral agents, and anticoagulants) for severe and critical COVID-19, of which 3 were strong recommendations and 9 were weak recommendations. CONCLUSION The SCCS COVID-19 panel used the GRADE approach to formulate recommendations on therapy for COVID-19 in the ICU. The EtD framework allows adaptation of these recommendations in different contexts. The SCCS guideline committee will update recommendations as new evidence becomes available.
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Affiliation(s)
- Waleed Alhazzani
- Department of Medicine, McMaster University, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada; GUIDE Center, St. Joseph's Healthcare Hamilton, Hamilton, Canada.
| | - Mohammed Alshahrani
- Department of Emergency and Critical Care, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Ohoud Aljuhani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Khalid Eljaaly
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Samaher Hashim
- Department of Medicine, University of Tabuk, Tabuk, Saudi Arabia
| | - Rakan Alqahtani
- Department of Critical Care Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Doaa Alsaleh
- Department of Population Health Science and Policy, Icahn's School of Medicine at Mount Sinai, NYC, USA; King Abdullah International Medical Research Center, NGHA, Riyadh, Saudi Arabia
| | - Zainab Al Duhailib
- Critical Care Medicine Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Haifa Algethamy
- Department of Anesthesia and Critical Care, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Tariq Al-Musawi
- Department of Critical Care Medicine, Dr Sulaiman AlHabib Hospital, AlKhobar, Saudi Arabia; Royal College of Surgeons in Ireland- Medical University of Bahrain, Bahrain
| | - Thamir Alshammari
- Medication Safety Research Chair, King Saud University, Riyadh, Saudi Arabia; College of Pharmacy, Riyadh Elm University, Riyadh, Saudi Arabia
| | - Abdullah Alqarni
- Department of Emergencies, Disasters, and Medical Transportation, Ministry of Health, Riyadh, Saudi Arabia
| | - Danya Khoujah
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Wail Tashkandi
- Department of Surgery, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Critical Care, Fakeeh Care Group, Jeddah, Saudi Arabia
| | - Talal Dahhan
- Critical Care Medicine Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Duke University, Durham, USA
| | - Najla Almutairi
- Department of Emergencies, Disasters, and Medical Transportation, Ministry of Health, Riyadh, Saudi Arabia
| | | | - Maytha Al-Yahya
- Department of Emergency Medicine, King AbdulAziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | | | - Yaseen M Arabi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
| | - Jameel Abualenain
- Department of Emergency Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Jawaher M Alotaibi
- Department of Medicine, King Faisal Specialist Hospital and Research Center Riyadh, Saudi Arabia
| | - Ali Al Bshabshe
- Department of Medicine/Adult Critical Care, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Reham Alharbi
- Critical Care Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Fahad Al-Hameed
- Department of Intensive Care, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Alyaa Elhazmi
- Dr. Sulaiman Al-Habib Medical Group, Critical Care Department, Riyadh, Saudi Arabia
| | - Reem S Almaghrabi
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Saudi Arabia
| | - Fatma Almaghlouth
- Respiratory Care Department, Faculty of Rehabilitation Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Malak Abedalthagafi
- Genomics Research Department, Saudi Human Genome Project, King Fahad Medical City and King Abdulaziz City for Science and Technology, Riyadh, Saudi Arabia
| | - Noor Al Khathlan
- Respiratory Care Department, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Faisal A Al-Suwaidan
- Clinical Excellence Administration and King Fahad Medical City, Second Health Cluster in Riyadh, Ministry of Health, Saudi Arabia
| | - Reem F Bunyan
- Center for Improving Value in Health, Saudi Arabia; Department of Neurology, King Fahad Specialist Hospital Dammam, Saudi Arabia
| | - Bandar Baw
- Department of Medicine, McMaster University, Canada; Department of Emergency Medicine, King AbdulAziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Ghassan Alghamdi
- Department of Medicine and Intensive Care, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Manal Al Hazmi
- Department of Medicine, King Fahad Specialist-Dammam, E1 Cluster, Dammam, Saudi Arabia
| | - Yasser Mandourah
- General Directorate of Military Medical Services, Ministry of Defense, Saudi Arabia
| | - Abdullah Assiri
- Infection Prevention and Control, Ministry of Health, Riyadh, Saudi Arabia
| | - Mushira Enani
- Section of Infectious Diseases Medical Specialties Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Maha Alawi
- Department of Medical Microbiology, Parasitology, Infection Control and Environmental Health Unit, King Abdulaziz Hospital, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Reem Aljindan
- Department of Microbiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Ahmed Aljabbary
- Department of Intensive Care, Security Forces Hospital Program in Riyadh, Saudi Arabia
| | - Abdullah Alrbiaan
- Critical Care Medicine Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Fahd Algurashi
- Division of Anesthesia and Critical Care, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Abdulmohsen Alsaawi
- Department of Emergency Medicine, King AbdulAziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Thamer H Alenazi
- King Abdulaziz Medical City, King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | | | - Saleh A Alqahtani
- Liver Transplant Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, USA
| | - Ziad Memish
- Research and Innovation Center, King Saud Medical City, Ministry of Health, & College of Medicine, Alfaisal University, Riyadh, Saudi Arabia; Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jaffar A Al-Tawfiq
- Infectious Disease Division, Indiana University School of Medicine, IN, USA; Infectious Disease Division, Johns Hopkins University School of Medicine, Baltimore, USA; Quality Department, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Ahmed Al-Jedai
- Colleges of Medicine and Pharmacy, Alfaisal University, Riyadh, Saudi Arabia; Therapeutic Affairs, Ministry of Health, Riyadh, Saudi Arabia
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Ionescu IC, Trotsenburg PAS, Paridaens D, Tanck M, Mooij CF, Cagienard E, Kalmann R, Pakdel F, Meeren S, Saeed P. Pediatric Graves' orbitopathy: a multicentre study. Acta Ophthalmol 2021; 100:e1340-e1348. [PMID: 34951116 DOI: 10.1111/aos.15084] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 12/07/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Graves' orbitopathy (GO) is a rare condition in children often considered to be a less severe condition than at an older age. The aim of our study was to analyse if there are any factors that distinguish paediatric from adult GO in order to provide guidelines for assessing and managing paediatric GO. METHODS Study design is a multicentre retrospective observational case series; 115 paediatric patients diagnosed with GO who visited our university medical centres in the Netherlands and Iran between 2003 and 2019 were submitted for complete ophthalmological examinations, serological testing and/or orbital imaging. Main outcome measures focussed on the natural course and clinical picture as well as medical and surgical treatment in paediatric GO. RESULTS Clinical findings included proptosis (n = 97; 84.3%), eyelid retraction (n = 77; 67%) and diplopia (n = 13; 11.3%). Ninety-two patients (80%) presented with mild disease, 21 (18.3%) with moderate-severe disease and two (1.7%) with severe GO. Five patients (4.3%) underwent intravenous glucocorticoids and 25 patients underwent orbital decompression surgery. Strabismus surgery due to primary involvement of extraocular muscles was performed in two patients (1.7%). Overall, rehabilitative surgical treatment was planned in 31 patients (26.9%) with inactive disease. Two patients experienced reactivation of the disease. CONCLUSION Despite the fact that paediatric and adult GO are considered two separate entities, they might be the same disease with two different clinical phenotypes. Paediatric GO population presents with a comparable clinical picture regarding both soft tissue involvement and proptosis, which may require surgical intervention. Proptosis was present in the majority of paediatric GO patients. Orbital decompression was performed in 21.7% of patients.
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Affiliation(s)
- Ioana C. Ionescu
- Department of Ophthalmology Orbital Center Amsterdam University Medical Centers University of Amsterdam Amsterdam The Netherlands
| | - Paul A. S. Trotsenburg
- Department of Pediatric Endocrinology Emma Children’s Hospital Amsterdam University Medical Centers University of Amsterdam Amsterdam The Netherlands
| | - Dion Paridaens
- Orbital Center Rotterdam (The Rotterdam Eye Hospital & Erasmus Medical Center Rotterdam) Rotterdam The Netherlands
| | - Michael Tanck
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics Amsterdam Public Health Amsterdam University Medical Centers University of Amsterdam Amsterdam The Netherlands
| | - Christiaan F. Mooij
- Department of Pediatric Endocrinology Emma Children’s Hospital Amsterdam University Medical Centers University of Amsterdam Amsterdam The Netherlands
| | - Eliane Cagienard
- Department of Ophthalmology Orbital Center Amsterdam University Medical Centers University of Amsterdam Amsterdam The Netherlands
| | - Rachel Kalmann
- Department of Ophthalmology University Medical Center Utrecht Utrecht The Netherlands
| | - Farzad Pakdel
- Ophthalmic Plastic and Reconstructive Surgery Department Farabi Hospital Tehran University of Medical Sciences Tehran Iran
| | - Stijn Meeren
- Department of Ophthalmology Leiden University Medical Center Leiden The Netherlands
| | - Peerooz Saeed
- Department of Ophthalmology Orbital Center Amsterdam University Medical Centers University of Amsterdam Amsterdam The Netherlands
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Ruperto N, Brunner HI, Synoverska O, Ting TV, Mendoza CA, Spindler A, Vyzhga Y, Marzan K, Grebenkina L, Tirosh I, Imundo L, Jerath R, Kingsbury DJ, Sozeri B, Vora SS, Prahalad S, Zholobova E, Butbul Aviel Y, Chasnyk V, Lerman M, Nanda K, Schmeling H, Tory H, Uziel Y, Viola DO, Posner HB, Kanik KS, Wouters A, Chang C, Zhang R, Lazariciu I, Hsu MA, Suehiro RM, Martini A, Lovell DJ. Tofacitinib in juvenile idiopathic arthritis: a double-blind, placebo-controlled, withdrawal phase 3 randomised trial. Lancet 2021; 398:1984-1996. [PMID: 34767764 DOI: 10.1016/s0140-6736(21)01255-1] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/30/2021] [Accepted: 05/25/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Tofacitinib is an oral Janus kinase inhibitor. This trial assessed the efficacy and safety of tofacitinib versus placebo in patients with polyarticular course juvenile idiopathic arthritis (JIA). METHODS This double-blind, withdrawal phase 3 trial enrolled patients with polyarticular course JIA (extended oligoarthritis, rheumatoid factor-positive or rheumatoid factor-negative polyarthritis, or systemic JIA without active systemic features) aged 2 years to younger than 18 years, and was done at 64 centres of the Paediatric Rheumatology International Trials Organisation and Pediatric Rheumatology Collaborative Study Group networks in 14 countries. Patients with psoriatic arthritis or enthesitis-related arthritis were enrolled for exploratory endpoints. During part 1 of the study, patients received oral open-label tofacitinib (weight-based doses; 5 mg twice daily or lower) for 18 weeks. Patients achieving at least JIA/American College of Rheumatology 30 response were randomly assigned (1:1) using an Interactive Response Technology system to continue tofacitinib or switch to placebo in part 2 of the study for 26 weeks. The primary endpoint was JIA flare rate by week 44 in part 2 in patients with polyarticular course JIA; the intention-to-treat principle was applied. Safety was evaluated throughout part 1 and part 2 of the study in all patients who received one dose or more of study medication. This trial is registered with ClinicalTrials.gov, NCT02592434. FINDINGS Between June 10, 2016, and May 16, 2019, of 225 patients enrolled, 184 (82%) patients had polyarticular course JIA, 20 (9%) had psoriatic arthritis, and 21 (9%) had enthesitis-related arthritis. 147 (65%) of 225 patients received concomitant methotrexate. In part 2, 142 patients with polyarticular course JIA were assigned to tofacitinib (n=72) or placebo (n=70). Flare rate by week 44 was significantly lower with tofacitinib (21 [29%] of 72 patients) than with placebo (37 [53%] of 70 patients; hazard ratio 0·46, 95% CI 0·27-0·79; p=0·0031). In part 2 of the study, adverse events occurred in 68 (77%) of 88 patients receiving tofacitinib and 63 (74%) of 85 in the placebo group. Serious adverse events occurred in one (1%) and two (2%), respectively. In the entire tofacitinib exposure period, 107 (48%) of 225 patients had infections or infestations. There were no deaths during this study. INTERPRETATION The results of this pivotal trial show that tofacitinib is an effective treatment in patients with polyarticular course JIA. New oral therapies are particularly relevant for children and adolescents, who might prefer to avoid injections. FUNDING Pfizer.
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Affiliation(s)
- Nicolino Ruperto
- IRCCS Istituto Giannina Gaslini, UOSID Centro Trial, PRINTO, Genova, Italy.
| | - Hermine I Brunner
- College of Medicine, University of Cincinnati, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Tracy V Ting
- College of Medicine, University of Cincinnati, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Carlos Abud Mendoza
- Regional Unit of Rheumatology and Osteoporosis at Central Hospital, Faculty of Medicine, San Luis Potosí, Mexico
| | | | - Yulia Vyzhga
- Vinnytsya National Medical University N Pirogov, Vinnytsya, Ukraine
| | - Katherine Marzan
- Division of Rheumatology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Irit Tirosh
- Pediatric Rheumatology Unit and Department of Pediatrics, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lisa Imundo
- Adolescent Rheumatology Columbia University Medical Center, New York, NY, USA
| | - Rita Jerath
- Augusta University Medical Center, Augusta, GA, USA
| | - Daniel J Kingsbury
- Augusta University Medical Center, Augusta, GA, USA; Randall Children's Hospital at Legacy Emanuel, Portland, OR, USA
| | - Betul Sozeri
- Department of Pediatric Rheumatology, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Sheetal S Vora
- Pediatric Rheumatology, Atrium Health Levine Children's Hospital, Charlotte, NC, USA
| | - Sampath Prahalad
- Departments of Pediatrics and Human Genetics, Emory University School of Medicine, and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Elena Zholobova
- Institute of Children's Health, University Children's Clinical Hospital, Sechenov University, Moscow, Russia
| | - Yonatan Butbul Aviel
- Pediatric Rheumatology Service, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Vyacheslav Chasnyk
- Saint Petersburg State Pediatric Medical University, Saint-Petersburg, Russia
| | - Melissa Lerman
- Division of Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kabita Nanda
- Division of Rheumatology, Seattle Children's Hospital, Seattle, WA, USA
| | - Heinrike Schmeling
- Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Heather Tory
- Division of Rheumatology, Connecticut Children's Medical Center, Hartford, and Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Yosef Uziel
- Pediatric Rheumatology Unit, Department of Pediatrics, Meir Medical Centre, Kfar Saba, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | | | | | | | | | | | | | | | | | - Daniel J Lovell
- College of Medicine, University of Cincinnati, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Greenbaum CJ, Serti E, Lambert K, Weiner LJ, Kanaparthi S, Lord S, Gitelman SE, Wilson DM, Gaglia JL, Griffin KJ, Russell WE, Raskin P, Moran A, Willi SM, Tsalikian E, DiMeglio LA, Herold KC, Moore WV, Goland R, Harris M, Craig ME, Schatz DA, Baidal DA, Rodriguez H, Utzschneider KM, Nel HJ, Soppe CL, Boyle KD, Cerosaletti K, Keyes-Elstein L, Long SA, Thomas R, McNamara JG, Buckner JH, Sanda S. IL-6 receptor blockade does not slow β cell loss in new-onset type 1 diabetes. JCI Insight 2021; 6:150074. [PMID: 34747368 PMCID: PMC8663550 DOI: 10.1172/jci.insight.150074] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 09/22/2021] [Indexed: 12/30/2022] Open
Abstract
BackgroundIL-6 receptor (IL-6R) signaling drives development of T cell populations important to type 1 diabetes pathogenesis. We evaluated whether blockade of IL-6R with monoclonal antibody tocilizumab would slow loss of residual β cell function in newly diagnosed type 1 diabetes patients.MethodsWe conducted a multicenter, randomized, placebo-controlled, double-blind trial with tocilizumab in new-onset type 1 diabetes. Participants were screened within 100 days of diagnosis. Eligible participants were randomized 2:1 to receive 7 monthly doses of tocilizumab or placebo. The primary outcome was the change from screening in the mean AUC of C-peptide collected during the first 2 hours of a mixed meal tolerance test at week 52 in pediatric participants (ages 6-17 years).ResultsThere was no statistical difference in the primary outcome between tocilizumab and placebo. Immunophenotyping showed reductions in downstream signaling of the IL-6R in T cells but no changes in CD4 memory subsets, Th17 cells, Tregs, or CD4+ T effector cell resistance to Treg suppression. A DC subset decreased during therapy but regressed to baseline once therapy stopped. Tocilizumab was well tolerated.ConclusionTocilizumab reduced T cell IL-6R signaling but did not modulate CD4+ T cell phenotypes or slow loss of residual β cell function in newly diagnosed individuals with type 1 diabetes.Trial RegistrationClinicalTrials.gov NCT02293837.FundingNIH National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and National Institute of Allergy and Infectious Diseases (NIAID) UM1AI109565, UL1TR000004 from NIH/National Center for Research Resources (NCRR) Clinical and Translational Science Award (CTSA), NIH/NIDDK P30DK036836, NIH/NIDDK U01DK103266, NIH/NIDDK U01DK103266, 1UL1TR000064 from NIH/NCRR CTSA, NIH/National Center for Advancing Translational Sciences (NCATS) UL1TR001878, UL1TR002537 from NIH/CTSA; National Health and Medical Research Council Practitioner Fellowship (APP1136735), NIH/NIDDK U01-DK085476, NIH/CTSA UL1-TR002494, Indiana Clinical and Translational Science Institute Award UL1TR002529, Vanderbilt Institute for Clinical and Translational Research UL1TR000445. NIH/NCATS UL1TR003142, NIH/CTSA program UL1-TR002494, Veteran Affairs Administration, and 1R01AI132774.
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Affiliation(s)
- Carla J Greenbaum
- Center for Interventional Immunology and Diabetes Program, Benaroya Research Institute, Seattle, Washington, USA
| | | | - Katharina Lambert
- Center for Interventional Immunology and Diabetes Program, Benaroya Research Institute, Seattle, Washington, USA
| | | | | | - Sandra Lord
- Center for Interventional Immunology and Diabetes Program, Benaroya Research Institute, Seattle, Washington, USA
| | | | | | - Jason L Gaglia
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Philip Raskin
- University of Texas, Southwestern, Dallas, Texas, USA
| | | | - Steven M Willi
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Linda A DiMeglio
- Riley Children's Hospital, Indiana University, Indianapolis, Indiana, USA
| | | | - Wayne V Moore
- University of Missouri, Kansas City, Kansas City, Missouri, USA
| | | | - Mark Harris
- Children's Health Queensland Hospital, South Brisbane, Australia.,University of Queensland, Queensland, Brisbane, Australia
| | - Maria E Craig
- University of Sydney, Sydney New South Wales, Australia
| | | | | | | | | | - Hendrik J Nel
- University of Queensland, Queensland, Brisbane, Australia
| | | | | | - Karen Cerosaletti
- Center for Interventional Immunology and Diabetes Program, Benaroya Research Institute, Seattle, Washington, USA
| | | | - S Alice Long
- Center for Interventional Immunology and Diabetes Program, Benaroya Research Institute, Seattle, Washington, USA
| | - Ranjeny Thomas
- University of Queensland, Queensland, Brisbane, Australia
| | - James G McNamara
- National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland, USA
| | - Jane H Buckner
- Center for Interventional Immunology and Diabetes Program, Benaroya Research Institute, Seattle, Washington, USA
| | - Srinath Sanda
- Immune Tolerance Network, Seattle, Washington, USA.,University of California, San Francisco, San Francisco, California, USA
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Reiff DD, Stoll ML, Cron RQ. Precision medicine in juvenile idiopathic arthritis-has the time arrived? THE LANCET. RHEUMATOLOGY 2021; 3:e808-e817. [PMID: 38297525 DOI: 10.1016/s2665-9913(21)00252-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/07/2021] [Accepted: 07/28/2021] [Indexed: 12/14/2022]
Abstract
The introduction of disease-modifying anti-rheumatic drug therapies for treating children and adolescents with chronic arthritis (ie, juvenile idiopathic arthritis [JIA]) has revolutionised care and outcomes. The biologic revolution continues to expand, with ever-changing immunological targets coming to market after basic research and clinical trials. The first class of biologics that was beneficial for children with JIA was tumour necrosis factor (TNF) inhibitors. If used early and aggressively, TNF inhibitors are capable of inducing disease remission for most of the seven subtypes of JIA, with the exception of systemic JIA (which more frequently responds to interleukin [IL]-1 or IL-6 inhibition). Nevertheless, there are still subsets of patients with JIA with disease that is difficult to treat or who develop extra-articular features that require a different therapeutic approach. Although finding an effective biological therapy for individual children with JIA can be trial and error, ongoing research and clinical trials are providing insight into a more personalised approach to care. In addition, redefining the JIA classification, in part based on shared similarities with various adult arthritides, could allow for extrapolation of knowledge from studies in adults with chronic arthritis.
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Affiliation(s)
- Daniel D Reiff
- Department of Pediatrics, Division of Rheumatology, University of Alabama, Birmingham, AL, USA
| | - Matthew L Stoll
- Department of Pediatrics, Division of Rheumatology, University of Alabama, Birmingham, AL, USA
| | - Randy Q Cron
- Department of Pediatrics, Division of Rheumatology, University of Alabama, Birmingham, AL, USA.
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Al-Jomah N, Al-Mohanna FH, Aboussekhra A. Tocilizumab suppresses the pro-carcinogenic effects of breast cancer- associated fibroblasts through inhibition of the STAT3/AUF1 pathway. Carcinogenesis 2021; 42:1439-1448. [PMID: 34718441 DOI: 10.1093/carcin/bgab102] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 08/23/2021] [Accepted: 10/26/2021] [Indexed: 11/14/2022] Open
Abstract
Active breast cancer-associated fibroblasts (CAFs), the most influential cells in breast tumor microenvironment (TME), express/secrete high levels of the proinvasive/metastatic interleukin-6 (IL-6). Therefore, we have tested here the effect of the IL-6 receptor (IL-6R) inhibitor tocilizumab (Actemra) on different active breast CAFs. We have shown that tocilizumab potently and persistently suppresses the expression of various CAF biomarkers, namely α-SMA, SDF-1 as well as the STAT3 pathway and its downstream target AUF1. Tocilizumab also inhibited the proliferation, migration, and invasion abilities of active breast CAF cells. Additionally, tocilizumab repressed the ability of CAF cells in promoting epithelial-to-mesenchymal transition, and enhancing the migratory/invasive and proliferative capacities of breast cancer cells in vitro. Importantly, these findings were confirmed in orthotopic humanized breast tumors in mice. Furthermore, tocilizumab suppressed the expression of the pro-angiogenic factor VEGF-A and its transactivator HIF-1α in CAF cells, and consequently inhibited the angiogenic-promoting effect of active CAFs both in vitro and in orthotopic tumor xenografts. These results indicate that inhibition of the IL-6/STAT3/AUF1 pathway by tocilizumab can normalize active breast CAFs and suppress their paracrine pro-carcinogenic effects, which paves the way towards development of specific CAF-targeting therapy, badly needed for more efficient breast cancer treatments.
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Affiliation(s)
- Naif Al-Jomah
- Molecular Oncology Department, Research Center, King Faisal Specialist Hospital and Research Centre, P.O. Box 3354, Riyadh 11211, Saudi Arabia
| | - Falah H Al-Mohanna
- Department of Comparative Medicine, King Faisal Specialist Hospital and Research Center, Riyadh 11211, Saudi Arabia
| | - Abdelilah Aboussekhra
- Molecular Oncology Department, Research Center, King Faisal Specialist Hospital and Research Centre, P.O. Box 3354, Riyadh 11211, Saudi Arabia
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Abstract
The advent of biologic disease-modifying antirheumatic drugs targeting specific cytokines or cell-cell interactions has dramatically changed the outlook of patients with juvenile idiopathic arthritis. However, safety concerns remain around the use of therapeutic agents for children with juvenile idiopathic arthritis. Foremost among these are the risks of serious infections and malignancy. This article provides an overview of methodologies for pharmacosurveillance in juvenile idiopathic arthritis, including spontaneous reporting systems and the use of diverse data sources, such as electronic health records, administrative claims, and clinical registries. The risks of infections and malignancies are then briefly reviewed.
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Affiliation(s)
- Natalie J Shiff
- Department of Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Room 3250 - East Wing - Health Sciences Boulevard, 104 Clinic Place, Saskatoon, Saskatchewan S7N 2Z4, Canada
| | - Timothy Beukelman
- Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, 1600 7th Avenue South, CPPN G10, Birmingham, AL 35233, USA.
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Kumar S, Çalışkan DM, Janowski J, Faist A, Conrad BCG, Lange J, Ludwig S, Brunotte L. Beyond Vaccines: Clinical Status of Prospective COVID-19 Therapeutics. Front Immunol 2021; 12:752227. [PMID: 34659259 PMCID: PMC8519339 DOI: 10.3389/fimmu.2021.752227] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/14/2021] [Indexed: 12/15/2022] Open
Abstract
Since November 2019 the SARS-CoV-2 pandemic has caused nearly 200 million infection and more than 4 million deaths globally (Updated information from the World Health Organization, as on 2nd Aug 2021). Within only one year into the pandemic, several vaccines were designed and reached approval for the immunization of the world population. The remarkable protective effects of the manufactured vaccines are demonstrated in countries with high vaccination rates, such as Israel and UK. However, limited production capacities, poor distribution infrastructures and political hesitations still hamper the availability of vaccines in many countries. In addition, due to the emergency of SARS-CoV-2 variants with immune escape properties towards the vaccines the global numbers of new infections as well as patients developing severe COVID-19, remains high. New studies reported that about 8% of infected individuals develop long term symptoms with strong personal restrictions on private as well as professional level, which contributes to the long socioeconomic problems caused by this pandemic. Until today, emergency use-approved treatment options for COVID-19 are limited to the antiviral Remdesivir, a nucleoside analogue targeting the viral polymerase, the glucocorticosteroide Dexamethasone as well as neutralizing antibodies. The therapeutic benefits of these treatments are under ongoing debate and clinical studies assessing the efficiency of these treatments are still underway. To identify new therapeutic treatments for COVID-19, now and by the post-pandemic era, diverse experimental approaches are under scientific evaluation in companies and scientific research teams all over the world. To accelerate clinical translation of promising candidates, repurposing approaches of known approved drugs are specifically fostered but also novel technologies are being developed and are under investigation. This review summarizes the recent developments from the lab bench as well as the clinical status of emerging therapeutic candidates and discusses possible therapeutic entry points for the treatment strategies with regard to the biology of SARS-CoV-2 and the clinical course of COVID-19.
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Affiliation(s)
- Sriram Kumar
- Institute of Virology, University of Münster, Münster, Germany
- EvoPAD Research Training Group 2220, University of Münster, Münster, Germany
| | - Duygu Merve Çalışkan
- Institute of Virology, University of Münster, Münster, Germany
- EvoPAD Research Training Group 2220, University of Münster, Münster, Germany
| | - Josua Janowski
- Institute of Virology, University of Münster, Münster, Germany
- SP BioSciences Graduate Program, University of Münster, Münster, Germany
| | - Aileen Faist
- Institute of Virology, University of Münster, Münster, Germany
- CiM-IMPRS Graduate Program, University of Münster, Münster, Germany
| | | | - Julius Lange
- Institute of Virology, University of Münster, Münster, Germany
| | - Stephan Ludwig
- Institute of Virology, University of Münster, Münster, Germany
- EvoPAD Research Training Group 2220, University of Münster, Münster, Germany
- CiM-IMPRS Graduate Program, University of Münster, Münster, Germany
- Interdisciplinary Centre for Medical Research, University of Münster, Münster, Germany
| | - Linda Brunotte
- Institute of Virology, University of Münster, Münster, Germany
- Interdisciplinary Centre for Medical Research, University of Münster, Münster, Germany
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Abstract
PURPOSE OF REVIEW Biologics and novel targeted therapeutics have transformed the management of pediatric rheumatic diseases over the past two decades; however, questions about short-term and long-term safety remain. Safety data gathered from recent clinical trials, long-term extensions of prior trials, registries, and other real-world evidence are summarized here for biologics and novel therapeutics commonly prescribed for pediatric rheumatic diseases. RECENT FINDINGS With nearly 20 years of therapeutic experience, tumor necrosis inhibitors (TNFi) are generally well tolerated, although infections, malignancy, and development of new autoimmunity remain a concern. Risk of infections may be higher in IL-1 and IL-6 inhibitors, and lower in abatacept, compared with TNFi. Safety data for B-cell-targeted therapeutics and janus kinase inhibitors are emerging, but remain limited, especially in children. SUMMARY Biologic and novel targeted therapeutics offer a promising future for children with pediatric rheumatic disease. However, long-term safety data in children remain limited for several agents. With any therapeutic option, both short-term and long-term safety concerns must be weighed against individual clinical needs when choosing the optimal treatment for each child.
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Affiliation(s)
- Rachel L. Randell
- Department of Pediatrics, Division of Rheumatology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mara L. Becker
- Department of Pediatrics, Division of Rheumatology, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
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Morel J, Tournadre A, Sellam J, Bouhnik Y, Cornec D, Devauchelle-Pensec V, Dieudé P, Goupille P, Kluger N, Lazaro E, Le Goff B, de Lédinghen V, Lequerré T, Nocturne G, Seror R, Truchetet ME, Verhoeven F, Pham T, Richez C. Practical Management of patients on anti-IL6R therapy: Practical guidelines drawn up by the Club Rhumatismes et Inflammation (CRI). Joint Bone Spine 2021; 88:105221. [PMID: 34183155 DOI: 10.1016/j.jbspin.2021.105221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jacques Morel
- Service de Rhumatologie, CHU Montpellier, Montpellier, France
| | - Anne Tournadre
- Service de Rhumatologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Jérémie Sellam
- Service de Rhumatologie, CHU Saint-Antoine, Paris, France
| | - Yoram Bouhnik
- Service de Gastro-entérologie, CHU Hôpital Beaujon, Clichy, France
| | - Divi Cornec
- Service de Rhumatologie, CHRU La Cavale Blanche, Brest, France
| | | | - Philippe Dieudé
- Service de Rhumatologie, CHU Bichat-Claude Bernard, Paris, France
| | | | - Nicolas Kluger
- Dpt Dermatology, Helsinki, Finland & Service de Dermatologie, CHU Bichat-Claude Bernard, Paris, France
| | - Estibaliz Lazaro
- Service de Médecine interne, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac, France
| | | | - Victor de Lédinghen
- Unité d'Hépatologie et transplantation hépatique, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac, France
| | | | | | - Raphaèle Seror
- Service de Rhumatologie, Bicêtre, Le Kremlin-Bicêtre, France
| | | | | | - Thao Pham
- Service de Rhumatologie, CHU Sainte-Marguerite, Marseille, France
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Kostik MM, Makhova MA, Maletin AS, Magomedova SM, Sorokina LS, Tsukasaki M, Okamoto K, Takayanagi H, Vasiliev DS, Kozlova DI, Mushkin AY. Cytokine profile in patients with chronic non-bacterial osteomyelitis, juvenile idiopathic arthritis, and insulin-dependent diabetes mellitus. Cytokine 2021; 143:155521. [PMID: 33863633 DOI: 10.1016/j.cyto.2021.155521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Our study aimed to evaluate the cytokine levels in pediatric chronic non-bacterial osteomyelitis (CNO) patients and compare these with other immune-mediated diseases and healthy controls. METHODS In this prospective study, we included 42 children with CNO, 28 patients with non-systemic juvenile idiopathic arthritis (JIA), 17 children with insulin-dependent diabetes mellitus (IDDM), and 30 healthy age-matched controls. In each of the CNO patients and comparison groups, the levels of 14-3-3-η protein, S100A8/A9 protein, interleukin-4 (IL-4), interleukin-17 (IL-17), interleukin-18 (IL-18), interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-α) were measured by ELISA assay. RESULTS All studied cytokines in the CNO patients were significantly higher than controls, and IDDM, 14-3-3-η protein, IL-18, IL-4, IL-17, IL-1β, and TNF-α were less than in JIA patients. In the discriminant analysis, ESR, 14-3-3 protein, S100A8/A9, IL-18, IL-4, and TNF-α can discriminate CNO from JIA, and 14-3-3 protein, S100A8/A9, IL-18, IL-17, IL-4, and TNF-α can distinguish CNO from other diseases and HC. CONCLUSION The increased level of pro-inflammatory cytokines confirms the role of monocyte-driven inflammation in CNO patients. Cytokines may prove valuable as biomarkers and potential therapeutic targets for CNO.
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Affiliation(s)
- Mikhail M Kostik
- Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russian Federation.
| | - Maria A Makhova
- Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russian Federation
| | - Alexei S Maletin
- Science Research Institute of Phthisiopulmonology, Saint-Petersburg, Russian Federation
| | - Shamai M Magomedova
- Republican Children's Clinical Hospital, Makhachkala, Russian Federation; Dagestan State Medical University, Makhachkala, Russian Federation
| | - Lybov S Sorokina
- Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russian Federation
| | - Masayuki Tsukasaki
- Department of Immunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, 113-0033 Tokyo, Japan
| | - Kazuo Okamoto
- Department of Osteoimmunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, 113-0033 Tokyo, Japan
| | - Hiroshi Takayanagi
- Department of Immunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, 113-0033 Tokyo, Japan
| | - Dmitriy S Vasiliev
- Sechenov Institute of Evolutionary Physiology and Biochemistry, Saint Petersburg, Russian Federation
| | - Darya I Kozlova
- Department of Osteoimmunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, 113-0033 Tokyo, Japan
| | - Alexander Yu Mushkin
- Science Research Institute of Phthisiopulmonology, Saint-Petersburg, Russian Federation
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Muzaffer MA, Abdelgalil AA. Tocilizumab in management of refractory juvenile idiopathic arthritis, 10 years of experience at tertiary university hospital. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2021. [DOI: 10.1186/s43166-021-00074-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Juvenile idiopathic arthritis (JIA) is the most prevalent pediatric rheumatic disorder. Progress in modalities of therapy improves the disease outcome. We aimed to determine the efficacy and safety of tocilizumab (TCZ) in the management of systemic (sJIA) and polyarticular (pJIA) in children who are resistant to conventional as well as other biological therapies. In this retrospective study, we selected JIA patients according to the International League of Association for Rheumatology (ILAR) criteria and were treated with TCZ. Response to TCZ was assessed using Juvenile Arthritis Disease Activity Score-10 (JADAS-10) and also outcomes were assessed according to the American College of Rheumatology (ACR) remission criteria. Safety of the drug was assessed by documenting possibly related adverse effects (AE). Statistical analysis using SPSS version 25 with statistical significance is considered if p ≤ 0.05. We included 16 JIA patients aged ≤ 18 years but 2 of them were excluded as they developed severe reaction during the TCZ 1st dose, so finally, 14 patients were included.
Results
The median age of our patients was 12 years. Of these 14 patients, 9 (64.3%) had sJIA and 5 (35.7%) had pJIA. TCZ use led to significant improvement in the JADAS-10 from mean 22.4 (± 7.9) when it was initially assessed and then 3, 6, 12, and 24 months after TCZ initiation with means 5.7 (± 3.9), 4.4 (± 3.7), 3.5 (± 3.1), and 2.7 (± 2.2), (P = 0.001, 0.001, 0.005, 0.012), respectively. Five patients exhibited TCZ possibly expected side effects. Neutropenia and infusion-related reactions were the most frequent AE.
Conclusions
Tocilizumab seems to be generally effective and safe drug in the management of sJIA and pJIA especially in cases refractory to conventional as well as other biologic agents.
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Quartier P. Juvenile Idiopathic Arthritis-Associated Chronic Uveitis: Recent Therapeutic Approaches. J Clin Med 2021; 10:2934. [PMID: 34208973 PMCID: PMC8269439 DOI: 10.3390/jcm10132934] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/25/2021] [Accepted: 06/28/2021] [Indexed: 11/23/2022] Open
Abstract
Pediatric patients with early onset (before the age of 6 years), antinuclear antibody positive, oligoarticular or polyarticular juvenile idiopathic arthritis (JIA), and some children with no arthritis may develop chronic, anterior uveitis. Recent recommendations insist on the need to perform slit lamp examination every 3 months for at least 5 years in early onset JIA patients in order to diagnose uveitis before complications develop. Local steroid therapy is usually the first-line treatment. However, in patients requiring steroid eye drops for several months, systemic immunomodulatory therapy is indicated. Methotrexate (MTX) is then prescribed in most cases; however, some patients also need anti-tumor necrosis factor alpha monoclonal antibody therapy and, in some cases, other biologics to control uveitis and avoid long-term ocular damage. Expert ophthalmologists and pediatricians must be involved in taking care of such patients. Immunomodulatory treatment must not be too easily interrupted and may even be intensified in some cases, particularly if there is a need for optimal disease control before ophthalmologic surgery. In good responders to MTX and/or biologics, treatment must be maintained at least 1 year, possibly even 2 years after achieving remission before tapering treatment intensity.
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Affiliation(s)
- Pierre Quartier
- Pediatric Immunology, Hematology and Rheumatology Unit, Necker-Enfants Malades Hospital, Assistance Publique-Hopitaux de Paris, 75015 Paris, France;
- RAISE Reference Centre for Rare Diseases, IMAGINE Institute, Necker-Enfants Malades Hospital, Assistance Publique-Hopitaux de Paris, 75015 Paris, France
- INSERM Unit 1163, Université de Paris, 75005 Paris, France
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Murray GM, Sen ES, Ramanan AV. Advancing the treatment of juvenile idiopathic arthritis. THE LANCET. RHEUMATOLOGY 2021; 3:e294-e305. [PMID: 38279412 DOI: 10.1016/s2665-9913(20)30426-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/05/2020] [Accepted: 12/02/2020] [Indexed: 01/28/2024]
Abstract
Treatment for juvenile idiopathic arthritis has undergone substantial changes in recent decades. These changes are partly due to the availability of new treatments, mainly biological agents, as well as developments in treatment strategies, including a focus on concepts such as treat-to-target. In addition, the creation of large paediatric research networks has improved patient access to, and design of, clinical trials for rare paediatric diseases. Although these advances have resulted in improvements in care for most patients with juvenile idiopathic arthritis, certain subgroups of patients continue to have a poor prognosis. Further research aims to identify patients in these subgroups early, to personalise their care, improve functional outcomes, and minimise long-term damage and harm. Optimising the duration of therapy for those individuals who require systemic immunosuppression is also of importance. Incorporation of novel biomarkers in combination with validated clinical measures in an effort to predict outcomes and target therapy accordingly is an exciting development.
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Affiliation(s)
- Grainne M Murray
- Department of Paediatric Rheumatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Ethan S Sen
- Department of Paediatric Rheumatology, Great North Children's Hospital, Newcastle upon Tyne, UK; Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK; Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
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Update on the treatment of nonsystemic juvenile idiopathic arthritis including treatment-to-target: is (drug-free) inactive disease already possible? Curr Opin Rheumatol 2021; 32:403-413. [PMID: 32657803 DOI: 10.1097/bor.0000000000000727] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW This review concerns the outcome for nonsystemic juvenile idiopathic arthritis (JIA) with emphasis on treatment-to-target (T2T) and treatment strategies aiming at inactive disease by giving an overview of recent articles. RECENT FINDINGS More efficacious therapies and treatment strategies/T2T with inactive disease as target, have improved the outcome for JIA significantly. Recent studies regarding treatment strategies have shown 47-68% inactive disease after 1 year. Moreover, probability of attaining inactive disease at least once in the first year seems even higher in recent cohort-studies, reaching 80%, although these studies included relatively high numbers of oligoarticular JIA patients. However, 26-76% of patients flare upon therapy withdrawal and prediction of flares is still difficult. SUMMARY Remission can be achieved and sustained in (some) JIA patients, regardless of initial treatment. Cornerstone principles in the management of nonsystemic JIA treatment are early start of DMARD therapy, striving for inactive disease and T2T by close and repeated monitoring of disease activity. T2T and tight control appear to be more important than a specific drug in JIA. Next to inactive disease, it is important that patients/parents are involved in personal targets, like reduction of pain and fatigue. Future studies should focus on predictors (based on imaging-methods or biomarkers) for sustained drug-free remission and flare.
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Biologic disease modifying antirheumatic drugs and Janus kinase inhibitors in paediatric rheumatology - what we know and what we do not know from randomized controlled trials. Pediatr Rheumatol Online J 2021; 19:46. [PMID: 33766063 PMCID: PMC7995584 DOI: 10.1186/s12969-021-00514-4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 03/04/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Biologic disease modifying antirheumatic drugs (bDMARDs) and Janus Kinase (JAK) inhibitors are prescribed in adult and paediatric rheumatology. Due to age-dependent changes, disease course, and pharmacokinetic processes paediatric patients with inflammatory rheumatic diseases (PiRD) differ from adult rheumatology patients. METHODS A systematic literature search for randomized clinical trials (RCTs) in PiRD treated with bDMARDs/JAK inhibitors was conducted on Medline, clinicaltrials.gov , clinicaltrialsregister.eu and conference abstracts as of July 2020. RCTs were included if (i) patients were aged ≤20 years, (ii) patients had a predefined rheumatic diagnosis and (iii) RCT reported predefined outcomes. Selected studies were excluded in case of (i) observational or single arm study or (ii) sample size ≤5 patients. Study characteristics were extracted. RESULTS Out of 608 screened references, 65 references were selected, reporting 35 unique RCTs. All 35 RCTs reported efficacy while 34/3 provided safety outcomes and 16/35 provided pharmacokinetic data. The most common investigated treatments were TNF inhibitors (60%), IL-1 inhibitors (17%) and IL-6 inhibitors (9%). No RCTs with published results were identified for baricitinib, brodalumab, certolizumab pegol, guselkumab, risankizumab, rituximab, sarilumab, secukinumab, tildrakizumab, or upadacitinib. In patients with juvenile idiopathic arthritis (JIA) 25/35 RCTs were conducted. The remaining 10 RCTs were performed in non-JIA patients including plaque psoriasis, Kawasaki Disease, systemic lupus erythematosus and non-infectious uveitis. In JIA-RCTs, the control arm was mainly placebo and the concomitant treatments were either methotrexate, non-steroidal anti-inflammatory drugs (NSAID) or corticosteroids. Non-JIA patients mostly received NSAID. There are ongoing trials investigating abatacept, adalimumab, baricitinib, brodalumab, certolizumab pegol, etanercept, guselkumab, infliximab, risankizumab, secukinumab, tofacitinib and tildrakizumab. CONCLUSION Despite the FDA Modernization Act and support of major paediatric rheumatology networks, such as the Pediatric Rheumatology Collaborative Study Group (PRCSG) and the Paediatric Rheumatology International Trials Organization (PRINTO), which resulted in drug approval for PiRD indications, there are limited RCTs in PiRD patients. As therapy response is influenced by age-dependent changes, pharmacokinetic processes and disease course it is important to consider developmental changes in bDMARDs/JAK inhibitor use in PiRD patients. As such it is critical to collaborate and conduct international RCTs to appropriately investigate and characterize efficacy, safety and pharmacokinetics of bDMARDs/JAK inhibitors in paediatric rheumatology.
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Giancane G, Rosina S, Consolaro A, Ruperto N. Outcome Scores in Pediatric Rheumatology. Curr Rheumatol Rep 2021; 23:23. [PMID: 33683471 DOI: 10.1007/s11926-021-00988-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2021] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Providing a summary of the latest research on outcome measures in juvenile idiopathic arthritis, childhood -onset systemic lupus erythematosus, and juvenile dermatomyositis. RECENT FINDINGS A rational management of patients with pediatric rheumatic diseases requires the regular assessment of the level of disease activity and damage, as well as the evaluation of therapeutic response through validated and standardized outcome measures. Ideally, such tools should be simple, feasible, and easily applicable in routine care. Recently, there has been a great deal of effort to refine existing tools and devise novel outcome measures, aiming to address the various aspects of disease impact and to improve the reliability of research studies and clinical trials. The newest outcome tools in pediatric rheumatology have markedly enlarged the spectrum of health domains assessable in a standardized way, thus increasing the reliability of evaluation of clinical response and fostering future clinical trials.
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Affiliation(s)
- Gabriella Giancane
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DiNOGMI), Università degli Studi di Genova, Genoa, Italy
| | - Silvia Rosina
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Alessandro Consolaro
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DiNOGMI), Università degli Studi di Genova, Genoa, Italy
| | - Nicolino Ruperto
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
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Singh R, Ivaturi VD, Penzenstadler J, Liu T, Chen J, Marathe A, Ji P, Glaser R, Nikolov N, Sahajwalla C. Response Similarity Assessment Between Polyarticular Juvenile Idiopathic Arthritis and Adult Rheumatoid Arthritis for Biologics. Clin Pharmacol Ther 2021; 110:98-107. [PMID: 33626206 DOI: 10.1002/cpt.2218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 02/04/2021] [Indexed: 01/06/2023]
Abstract
Polyarticular juvenile idiopathic arthritis (pJIA) is a pediatric chronic inflammatory arthritis, much like rheumatoid arthritis (RA) in adults. Drug development for pJIA can potentially be expedited by using extrapolation of efficacy from adult RA; however, the lack of understanding of the response and exposure relationship between pJIA and RA to therapeutic interventions has been a major roadblock. To address this, the objective of our analysis was to conduct a systematic response and exposure comparison between pJIA and RA trials for biologic products. Data from registration RA and pJIA clinical trials (parallel or withdrawal design) for infliximab, tocilizumab, golimumab, and adalimumab were utilized. First, exposure was compared between the pJIA trials and RA pivotal trials. Subsequently, the pJIA vs. RA response similarity was assessed by comparing similar individual subcomponents of the American College of Rheumatology (ACR) scores between the two populations. The exposure comparison demonstrated that at the pJIA trial dose, exposure in pediatric patients was similar to or higher than adults for all biologics evaluated except infliximab, where lower exposure was observed in pJIA patients ≤ 35 kg. Response comparison for individual subcomponents indicated that in a majority of the cases, pJIA response was similar or higher as compared with response from RA trials. Overall, this analysis suggests response similarity between pJIA and RA across the biologic products when exposures are matched between the two populations. These analyses provide support for the use of pharmacokinetic exposure-matching for extrapolation of efficacy from adult RA to pediatric pJIA for the products with established mechanism(s) of action.
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Affiliation(s)
- Renu Singh
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Vijay D Ivaturi
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Justin Penzenstadler
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Tao Liu
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jianmeng Chen
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Anshu Marathe
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Ping Ji
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rachel Glaser
- Division of Rheumatology and Transplant Medicine, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Nikolay Nikolov
- Division of Rheumatology and Transplant Medicine, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Chandrahas Sahajwalla
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
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Thiele F, Klein A, Windschall D, Hospach A, Foeldvari I, Minden K, Weller-Heinemann F, Horneff G. Comparative risk of infections among real-world users of biologics for juvenile idiopathic arthritis: data from the German BIKER registry. Rheumatol Int 2021; 41:751-762. [PMID: 33590331 PMCID: PMC7952348 DOI: 10.1007/s00296-020-04774-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 12/17/2020] [Indexed: 01/30/2023]
Abstract
To examine whether treatment with interleukin (IL)-1-, IL-6-, tumour necrosis factor α (TNFα)-inhibitors or Abatacept is associated with an increased risk of common infections, infections requiring hospitalization (SAE) or opportunistic infections among real-world juvenile idiopathic arthritis (JIA) patients. Furthermore, the influence of other patient-related covariates on the occurrence of infections was investigated. Patients diagnosed with JIA and treated with biologics were selected from the German BIKER registry. Incidence rates (IR) of infections per 100 person years were calculated and compared between the different cohorts. Using multivariate logistic regression, odds ratios with 95% confidence intervals (CI) were determined for the influence of patient-related covariates (age, diagnosis, laboratory data, concomitant medication, JIA activity, comorbidities, and premedication) on the occurrence of infections. 3258 patients entered the analysis. A total of 3654 treatment episodes were distributed among TNFα- (Etanercept, Adalimumab, Golimumab, Infliximab, n = 3044), IL-1- (Anakinra, Canakinumab, n = 105), IL-6- (Tocilizumab, n = 400) and T-cell activation inhibitors (Abatacept, n = 105). 813 (22.2%) patients had at least one infection, 103 (2.8%) patients suffered from an SAE infection. Both common and SAE infections were significantly more frequent in IL-1 (IR 17.3, 95% CI 12.5/24 and IR 4.3, 95% CI 2.3/8.3) and IL-6 cohort (IR 16.7, 95% CI 13.9/20 and IR 2.8, 95% CI 1.8/4.4) compared to TNFα-inhibitor cohort (IR 8.7, 95% CI 8.1/9.4 and IR 1, 95% CI 0.8/1.3). When comparing the influencing factors for various infectious diseases, the use of corticosteroids, younger age, cardiac comorbidities and higher JIA-activity are the most striking risk factors. Relative to TNFα inhibitors and Abatacept, IL-1 and IL-6 inhibitors were associated with an increased risk of common and SAE infections. The influencing covariates identified may be helpful for the choice of a suitable biologic to treat JIA.
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Affiliation(s)
- Franz Thiele
- Centre for Paediatric Rheumatology, Department of General Paediatrics, Asklepios Clinic Sankt Augustin, 53757, Sankt Augustin, Germany.
| | - Ariane Klein
- Centre for Paediatric Rheumatology, Department of General Paediatrics, Asklepios Clinic Sankt Augustin, 53757, Sankt Augustin, Germany.,Medical Faculty, University of Cologne, Cologne, Germany
| | - Daniel Windschall
- Clinic for Paediatric and Adolescent Rheumatology, St. Josef-Stift Sendenhorst, Northwest German Center for Rheumatology, Sendenhorst, Germany
| | - Anton Hospach
- Centre for Paediatric Rheumatology, Klinikum Stuttgart, Germany
| | - Ivan Foeldvari
- Hamburger Zentrum Für Kinder- Und Jugendrheumatologie, Hamburg, Germany
| | | | | | - Gerd Horneff
- Centre for Paediatric Rheumatology, Department of General Paediatrics, Asklepios Clinic Sankt Augustin, 53757, Sankt Augustin, Germany.,Medical Faculty, University of Cologne, Cologne, Germany
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