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Dey S, Roy D, Sinhamahapatra P, Ghosh A. Efficacy and safety of an early response-based tapering regimen of tocilizumab in children with systemic juvenile idiopathic arthritis. Int J Rheum Dis 2024; 27:e15196. [PMID: 38769886 DOI: 10.1111/1756-185x.15196] [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: 10/01/2023] [Revised: 03/30/2024] [Accepted: 05/02/2024] [Indexed: 05/22/2024]
Abstract
INTRODUCTION Systemic juvenile idiopathic arthritis (sJIA) is a distinct disease subset, with a poorer prognosis compared with other JIA subsets. Tocilizumab has an important role in the management of sJIA refractory to standard initial therapy. However, no specific guidelines exist for the tapering of tocilizumab therapy in sJIA, which could have implications on the overall cost and side effects of treatment. METHODS This was an observational study which included 21 children with refractory sJIA, who were initially put on injection tocilizumab every 2 weekly, with subsequent dosing tapered to 4 weekly and 6 weekly intervals based on JIA ACR 70 responses at 12 and 24 weeks, respectively. The primary outcome at week 36 included JIA ACR 30, 50, 70, and 90 response rates with other efficacy and safety measures as secondary outcomes. RESULTS At 36 weeks, JIA ACR 30, 50, 70, and 90 responses were observed in 90.5%, 90.5%, 71.4%, and 52.4% patients respectively along with significant improvement in hematological and inflammatory parameters. The mean prednisolone dose could be reduced from 0.54 to 0.13 mg/kg/day and around 29% patients were able to discontinue steroids altogether. No serious adverse events were recorded. With drug tapering, we could curtail on 26% of the total tocilizumab dose that would have been otherwise required on the continuous 2 weekly protocol. CONCLUSIONS Tocilizumab, used in an early response-based tapering regimen, was both safe and efficacious in children with sJIA refractory to standard therapy. Larger and longer duration studies are required to further validate our observations.
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Affiliation(s)
- Soumya Dey
- Department of Clinical Immunology and Rheumatology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Debaditya Roy
- Department of Clinical Immunology and Rheumatology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Pradyot Sinhamahapatra
- Department of Clinical Immunology and Rheumatology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Alakendu Ghosh
- Department of Clinical Immunology and Rheumatology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
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Shenoi S, Nanda K, Schulert GS, Bohnsack JF, Cooper AM, Edghill B, Gillispie-Taylor MC, Goldberg B, Halyabar O, Mason TG, Ronis T, Schneider R, Vehe RK, Onel K. Physician practices for withdrawal of medications in inactive systemic juvenile arthritis, Childhood Arthritis and Rheumatology Research Alliance (CARRA) survey. Pediatr Rheumatol Online J 2019; 17:48. [PMID: 31331351 PMCID: PMC6647107 DOI: 10.1186/s12969-019-0342-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 06/12/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND We describe a Childhood Arthritis and Rheumatology Research Alliance (CARRA) survey of North American pediatric rheumatologists that assesses physician attitudes on withdrawal of medications in systemic juvenile idiopathic arthritis (SJIA). METHODS A REDCap anonymous electronic survey was distributed to 100 random CARRA JIA workgroup physician-voting members. The survey had three broad sections including: A) demographic information; B) physicians' opinions on clinical inactive disease (CID) in SJIA and C) existing practices for withdrawing medications in SJIA. RESULTS The survey had an 86% response rate. 88 and 93% of participants agreed with the current criteria for CID and clinical remission on medications (CRM) respectively. 78% thought it necessary to meet CRM before tapering medications except steroids. 76% use CARRA SJIA consensus treatment plans always or the majority of the time. All participants weaned steroids first in SJIA patients on combination therapy, 47% waited > 6 months before tapering additional medications. 35% each tapered methotrexate over > 6 months and 2-6 months; however, 39% preferred tapering anakinra, canakinumab and tocilizumab more quickly over 2-6 months and favored spacing the dosing interval for canakinumab and tocilizumab. When patients are on combination therapy with methotrexate and biologics, 58% preferred tapering methotrexate first while others considered patient/family preference and adverse effects to guide their choice. CONCLUSION Most CARRA members surveyed use published consensus treatment plans for SJIA and agree with validated definitions of CID and CRM. There was agreement with tapering steroids first in SJIA. There was considerable variability with tapering decisions of all other medications.
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Affiliation(s)
- Susan Shenoi
- Department of Pediatrics, Division of Rheumatology, University of Washington School of Medicine & Seattle Children's Hospital and Research Center, MA.7.110, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
| | - Kabita Nanda
- 0000000122986657grid.34477.33Department of Pediatrics, Division of Rheumatology, University of Washington School of Medicine & Seattle Children’s Hospital and Research Center, MA.7.110, 4800 Sand Point Way NE, Seattle, WA 98105 USA
| | - Grant S. Schulert
- 0000 0001 2179 9593grid.24827.3bDivision of Rheumatology, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - John F. Bohnsack
- 0000 0004 0415 0524grid.417538.cDivision of Pediatric Rheumatology, University of Utah Hospital, Salt Lake City, UT USA
| | - Ashley M. Cooper
- 0000 0001 2179 926Xgrid.266756.6Division of Pediatric Rheumatology, Children’s Mercy Kansas City, Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO USA
| | - Bridget Edghill
- Parent of systemic juvenile arthritis patient representative, Kansas City, USA
| | - Miriah C. Gillispie-Taylor
- 0000 0001 1034 1720grid.410711.2Department of Pediatrics, Rheumatology, Levine Children’s Hospital/Carolinas Healthcare System, University, North Carolina, Chapel Hill, NC USA
| | - Baruch Goldberg
- 0000 0000 9206 2401grid.267308.8Department of Pediatrics, Division of Pulmonary Allergy Immunology and Rheumatology, University of Texas Health Science Center at Houston, Houston, USA
| | - Olha Halyabar
- Department of Pediatrics Boston Children’s Hospital, Division of Immunology, Boston, MA USA
| | - Thomas G. Mason
- 0000 0004 0459 167Xgrid.66875.3aDepartments of Medicine and Pediatrics, Mayo Clinic College of Medicine, Rochester, MN USA
| | - Tova Ronis
- 0000 0004 1936 9510grid.253615.6Division of Pediatric Rheumatology, Children’s National Health System, Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC USA
| | - Rayfel Schneider
- 0000 0004 0473 9646grid.42327.30The Department of Paediatrics, University of Toronto, Hospital for Sick Children, Toronto, Ontario Canada
| | - Richard K. Vehe
- 0000000419368657grid.17635.36Division of Pediatric Rheumatology, Department of Pediatrics, University of Minnesota Medical School & University of Minnesota Masonic Children’s Hospital, Minneapolis, MN USA
| | - Karen Onel
- 000000041936877Xgrid.5386.8Division of Pediatric Rheumatology, Hospital for Special Surgery, Department of Pediatrics, Weill Cornell Medical College, New York, NY USA
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