Pharmacological conditioning for juvenile idiopathic arthritis: a potential solution to reduce methotrexate intolerance

Evaluation of Methotrexate Intolerance in Children With Morphea

OBJECTIVE

Methotrexate is an immunosuppressant commonly used in dermatology. The prevalence of intolerance using the Methotrexate Intolerance Severity Score (MISS) in pediatric juvenile idiopathic arthritis (JIA) ranges from 25% to 75%, but studies in morphea patients are lacking. We sought to determine the prevalence and predictors of methotrexate intolerance in children with morphea compared with children with inflammatory skin diseases and JIA/uveitis.

METHODS

Eligible patients were ages 2 to 18 years and were taking methotrexate for at least 3 months to treat morphea, inflammatory skin disease, or uveitis/JIA. Methotrexate intolerance was calculated using the MISS. A 1-way analysis of variance compared absolute intolerance scores. Multivariate regression analysis was used to compare MISS across diseases and covariates.

RESULTS

Of 48 participants (mean ± SD age, 11.3 ± 4.1 years, 70.8% female), 15 had morphea, 16 had JIA/uveitis, and 17 had inflammatory skin diseases. The overall prevalence of intolerance was 20.8%. Age, sex, duration, and dose did not correlate with overall MISS. The MISS mean ± SD total for oral dosing was 2.5 ± 3.4, compared with 6.78 ± 6.8 for subcutaneous dosing. Patients with JIA/uveitis had the highest prevalence of intolerance (37.5%, n = 6), followed by morphea patients (20%, n = 3) and inflammatory skin disease patients (5.9%, n = 1). The OR of intolerance according to route of administration was 11.2 (95% CI, 2.03-61.89).

CONCLUSIONS

Methotrexate intolerance was highest among patients with JIA/uveitis. The only predictor for risk of intolerance was subcutaneous route of administration. Future work could examine disease activity correlations and interventions designed to minimize intolerance.

Experiences of living with Juvenile Idiopathic Arthritis: a qualitative systematic review

OBJECTIVE

The objective of this review was to investigate the available qualitative evidence to enhance understanding of the experiences of children, young adults, and their carers living with Juvenile Idiopathic Arthritis in any setting.

INTRODUCTION

Juvenile Idiopathic Arthritis is the most common chronic rheumatic disease in childhood. Despite the availability of effective treatments, persistent pain, growth retardation, physical disability, and psychological problems can occur. This may reduce the quality of life for Juvenile Idiopathic Arthritis patients by negatively affecting their family, educational, and social well-being. Patient-centered management and care for Juvenile Idiopathic Arthritis patients requires increasing attention to their self-reported quality of life and experiences, in addition to clinically measured disease activity. Furthermore, taking care of children with Juvenile Idiopathic Arthritis may have negative impacts on the lives of their carers and families. The experiences of carers have been poorly understood and studied. This review describes experiences and perspectives from patients and carers in order to inform the needs of families throughout their Juvenile Idiopathic Arthritis journey.

INCLUSION CRITERIA

Studies describing the experiences of patients aged <21 years who have been diagnosed with Juvenile Idiopathic Arthritis according to the International League of Associations for Rheumatology criteria, as well as the experiences of their carers, have been considered.

METHODS

A comprehensive search using PubMed, CINAHL, Embase, PsycINFO, Web of Science, and Google Scholar, as well as relevant conference proceedings of the American College of Rheumatology (ACR; 2018-2019), the European Pediatric Rheumatology Congress (PReS) 2018, the European League Against Rheumatism (EULAR; 2018-2019), and the Asia Pacific League of Associations for Rheumatology (APLAR; 2018-2019), was undertaken in December 2020 to identify pertinent published and unpublished studies. Studies published in English from 2001 to 2020 were included. The JBI approach to study selection, critical appraisal, data extraction, and data synthesis was used.

RESULTS

Ten studies were included in this review. A total of 61 findings were extracted and aggregated to form 12 categories. From the 12 categories, five synthesized findings were developed: i) Self-management of Juvenile Idiopathic Arthritis requires pain management, medication management, and the acquisition of knowledge and professional support; ii) A promising relationship with health care professionals but unbalanced access to services; iii) Parental financial burden and their adjustment to maintain family happiness; iv) Patients and parents support the web-based approach to communicate and develop self-management skills and acknowledge the importance of clinical trials; v) Desire to live a normal life without prejudice from school, social settings, and the workplace.

CONCLUSIONS

This review has provided a comprehensive overview of experiences and perceptions of Juvenile Idiopathic Arthritis patients and their parents. It is important to understand what they need to know and understand about the disease. This review also highlights the importance of appropriate web-based programs, career counseling, infrastructures, and school facilities. Findings in this review can guide future policy and practice in order to improve care for families and children with Juvenile Idiopathic Arthritis. Further research is required to develop management strategies for medication intolerance and evaluate the longitudinal benefits of relevant Juvenile Idiopathic Arthritis programs.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO (CRD42019133165).