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Zimmer A, Horneff G. An update on the safety of biologic therapies for the treatment of polyarticular juvenile idiopathic arthritis. Expert Opin Drug Saf 2025; 24:627-642. [PMID: 39946290 DOI: 10.1080/14740338.2025.2467179] [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: 05/18/2024] [Accepted: 01/29/2025] [Indexed: 02/18/2025]
Abstract
INTRODUCTION An increasing number of patients with polyarticular course juvenile idiopathic arthritis are treated with biologics with great efficacy. Consequently, the importance regarding safety data in general as well as especially serious infections, incident autoimmune processes, or malignancies rises. In children, this is crucial concerning occurrences that manifest rarely and only after a prolonged latency period. AREAS COVERED This study aims to analyze safety under therapy with the five most commonly used biologicals for the treatment of juvenile idiopathic arthritis in Germany: abatacept, adalimumab, etanercept, golimumab, and tocilizumab, and a control cohort, who received methotrexate. For this, data from the Biologics in Pediatric Rheumatology (BiKeR) Registry were analyzed with a focus on potential adverse drug reactions like serious infections, autoimmune processes or malignancies. EXPERT OPINION Besides JIA category-specific differences, investigating side effects like severe infections and the development of additional autoimmune processes due to therapy is crucial. Future clinical randomized double-blinded studies are essential for direct drug comparisons, enabling optimal individualized therapy considering comorbidities and individual risks. Large patient data over a (life-)long period beyond childhood are particularly important, especially concerning the risk of malignancy after prolonged latency.
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Affiliation(s)
- Angela Zimmer
- Department of Pediatric Rheumatology, Asklepios Clinic Sankt Augustin, Sankt Augustin, Germany
| | - Gerd Horneff
- Department of Pediatric Rheumatology, Asklepios Clinic Sankt Augustin, Sankt Augustin, Germany
- University Hospital of Cologne, Köln, Germany
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Xu X, Wang L, Sun Y, Yang C, Wang X, Guo P, Mei D. Unveiling the differences: infection disorders associated with tumor necrosis factor α inhibitors in pediatric patients-a pharmacovigilance study (2004-2023). Eur J Pediatr 2025; 184:324. [PMID: 40317305 DOI: 10.1007/s00431-025-06152-2] [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: 12/27/2024] [Revised: 04/15/2025] [Accepted: 04/23/2025] [Indexed: 05/07/2025]
Abstract
The increasing use of tumor necrosis factor inhibitors (TNFi) in pediatric patients has raised concerns about their potential impact on the immune system and related adverse events. Infection-related adverse events (AEs) caused by TNFi have already raised widespread concerns in real-world settings. This study aims to comprehensively analyze and summarize the infection-related AEs associated with TNFi in pediatric patients. A retrospective pharmacovigilance study was conducted to identify cases of TNFi-related infections reported to the FDA Adverse Event Reporting System (FAERS) database between Q1 2004 and Q1 2023. TNFi reports were carefully reviewed to exclude confounding factors like other AEs, concomitant medications, and prescription indications. Proportionality analysis was conducted by comparing TNFi reports to the entire FAERS database to identify infection-related AEs significantly associated with TNFi use. Infection-related AEs accounted for 8.36% of all TNFi-related adverse event reports in the FAERS database. A total of 8050 cases of TNFi-associated infections were identified in the pediatric population, with 2.57% of reports resulting in fatalities. Infliximab and golimumab showed a stronger association with infection-related AEs compared to other TNFi. Notably, only adalimumab shows a lower risk of viral infections, while it exhibits an increased risk of bacterial and mycobacterial infections, similar to other TNFi. CONCLUSIONS This study identified a significant association between TNFi use and infection-related AEs in pediatric patients, providing the foothold for further research. However, due to its retrospective nature, further investigations are warranted to confirm these findings and identify potential risk factors in a controlled, prospective study setting. WHAT IS KNOWN • There is sufficient evidence to demonstrate the infection risk associated with TNFi in adult patients. • Pediatric patients, whose immune systems are still developing, are more vulnerable to certain infections. WHAT IS NEW • There is a significant association between TNFi use and infection-related adverse events in pediatric patients, and different TNFi have distinct infection profiles.
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Affiliation(s)
- Xiaolin Xu
- Department of Pharmacy, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, 100045, China
| | - Luquan Wang
- Department of Pharmacy, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, 100045, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, 211198, China
| | - Yixin Sun
- Department of Pharmacy, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, 100045, China
| | - Changqing Yang
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, 211198, China
| | - Xiaoling Wang
- Department of Pharmacy, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, 100045, China
| | - Peng Guo
- Department of Pharmacy, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, 100045, China.
| | - Dong Mei
- Department of Pharmacy, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, 100045, China.
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Sabbagh SE, Haribhai D, Gershan JA, Verbsky J, Nocton J, Yassai M, Naumova EN, Hammelev E, Dasgupta M, Yan K, Gorski J, Williams CB. Patients with juvenile idiopathic arthritis have decreased clonal diversity in the CD8 + T cell repertoire response to influenza vaccination. Front Immunol 2024; 15:1306490. [PMID: 38873594 PMCID: PMC11169902 DOI: 10.3389/fimmu.2024.1306490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 05/02/2024] [Indexed: 06/15/2024] Open
Abstract
Recurrent exposures to a pathogenic antigen remodel the CD8+ T cell compartment and generate a functional memory repertoire that is polyclonal and complex. At the clonotype level, the response to the conserved influenza antigen, M158-66 has been well characterized in healthy individuals, but not in patients receiving immunosuppressive therapy or with aberrant immunity, such as those with juvenile idiopathic arthritis (JIA). Here we show that patients with JIA have a reduced number of M158-66 specific RS/RA clonotypes, indicating decreased clonal richness and, as a result, have lower repertoire diversity. By using a rank-frequency approach to analyze the distribution of the repertoire, we found several characteristics of the JIA T cell repertoire to be akin to repertoires seen in healthy adults, including an amplified RS/RA-specific antigen response, representing greater clonal unevenness. Unlike mature repertoires, however, there is more fluctuation in clonotype distribution, less clonotype stability, and more variable IFNy response of the M158-66 specific RS/RA clonotypes in JIA. This indicates that functional clonal expansion is altered in patients with JIA on immunosuppressive therapies. We propose that the response to the influenza M158-66 epitope described here is a general phenomenon for JIA patients receiving immunosuppressive therapy, and that the changes in clonal richness and unevenness indicate a retarded and uneven generation of a mature immune response.
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Affiliation(s)
- Sara E. Sabbagh
- Division of Rheumatology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Dipica Haribhai
- Division of Rheumatology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jill A. Gershan
- Divison of Hematology/Oncology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - James Verbsky
- Division of Rheumatology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - James Nocton
- Division of Rheumatology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Maryam Yassai
- Versiti Wisconsin, Blood Research Institute, Milwaukee, WI, United States
| | - Elena N. Naumova
- Division of the Nutrition Epidemiology and Data Science, Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, United States
| | - Erin Hammelev
- Division of Rheumatology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Mahua Dasgupta
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Ke Yan
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jack Gorski
- Versiti Wisconsin, Blood Research Institute, Milwaukee, WI, United States
| | - Calvin B. Williams
- Division of Rheumatology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
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Zentsova I, Klocperk A, Bloomfield M, Kubesova H, Malcova H, Cebecauerova D, Horvath R, Sediva A, Parackova Z. Tumor-necrosis factor α-rich environment alters type-I interferon response to viral stimuli in patients with juvenile idiopathic arthritis by altering myeloid dendritic cell phenotype. Clin Immunol 2024; 262:110170. [PMID: 38460895 DOI: 10.1016/j.clim.2024.110170] [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: 10/24/2023] [Revised: 02/27/2024] [Accepted: 03/04/2024] [Indexed: 03/11/2024]
Abstract
The balance between the tumor-necrosis factor α (TNFα) and type-I interferon (T1IFN) pathways is crucial for proper immune function. Dysregulation of either pathway can contribute to autoimmune diseases development. Even though TNFα blockade has shown promising results in various autoimmune diseases, the effect on the balance between TNFα and T1IFN is elusive. We used targeted anti-TNFα therapies in juvenile idiopathic arthritis (JIA) as an experimental approach to study the cross-regulation between TNFα and type-I IFN. We found that TNFα-rich environment affected viral defense through the attenuation of T1IFN responses and affected the phenotype and distribution of myeloid dendritic cells, which are engaged in early viral infections. Anti-TNFα therapy normalized the observed deviations in JIA patients. We hypothesize that the inadequate immune response caused by a high TNFα environment could be projected to more frequent or lengthy viral infections and possibly play a role in the process of JIA disease development.
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Affiliation(s)
- Irena Zentsova
- Department of Immunology, Second Faculty of Medicine, Charles University, University Hospital in Motol, V Uvalu 84, Prague, Czech Republic.
| | - Adam Klocperk
- Department of Immunology, Second Faculty of Medicine, Charles University, University Hospital in Motol, V Uvalu 84, Prague, Czech Republic
| | - Marketa Bloomfield
- Department of Immunology, Second Faculty of Medicine, Charles University, University Hospital in Motol, V Uvalu 84, Prague, Czech Republic
| | - Helena Kubesova
- Department of Immunology, Second Faculty of Medicine, Charles University, University Hospital in Motol, V Uvalu 84, Prague, Czech Republic
| | - Hana Malcova
- Department of Pediatric and Adult Rheumatology, University Hospital in Motol, Prague, V Uvalu 84, 150 06, Czech Republic
| | - Dita Cebecauerova
- Department of Pediatric and Adult Rheumatology, University Hospital in Motol, Prague, V Uvalu 84, 150 06, Czech Republic
| | - Rudolf Horvath
- Department of Pediatric and Adult Rheumatology, University Hospital in Motol, Prague, V Uvalu 84, 150 06, Czech Republic
| | - Anna Sediva
- Department of Immunology, Second Faculty of Medicine, Charles University, University Hospital in Motol, V Uvalu 84, Prague, Czech Republic
| | - Zuzana Parackova
- Department of Immunology, Second Faculty of Medicine, Charles University, University Hospital in Motol, V Uvalu 84, Prague, Czech Republic.
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Clemente D, Cuadros EN, Lovillo MC, Hernández JC, Martín SG, Silveira LF, Cruz MJL, Tagarro A, Rueda RMA, López López A, Aritziturri MS, Calvo C. Position statement on infection screening, prophylaxis, and vaccination of pediatric patients with rheumatic diseases and immunosuppressive therapies, part 3: precautions in situations of surgery, fever, and opportunistic infections. Eur J Pediatr 2024; 183:915-927. [PMID: 38047962 PMCID: PMC10912362 DOI: 10.1007/s00431-023-05295-4] [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: 06/18/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 12/05/2023]
Abstract
The objective of this study is to provide practical recommendations on the management of pediatric patients with immune-mediated rheumatic diseases receiving immunosuppressive therapies. The recommendations specifically address the cases of surgery, fever, and opportunistic infections (varicella, herpes-zoster, tuberculosis, invasive fungal disease). A qualitative approach was applied. A narrative literature review was performed via Medline. Primary searches were conducted using MeSH terms and free text to identify publications on infections and vaccinations in pediatric patients with immune-mediated rheumatic diseases receiving immunosuppressive therapies. The results were presented and discussed in a nominal group meeting, comprising a committee of 12 pediatric rheumatologists from the Infection Prevention and Treatment Working Group of the Spanish Society of Pediatric Rheumatology. Several recommendations were generated. A consensus procedure was implemented via a Delphi process; this was extended to members of the Spanish Society of Pediatric Rheumatology and Spanish Society of Pediatric Infectious Disease of the Spanish Association of Pediatrics. Participants produced a score ranging from 0 (totally disagree) to 10 (totally agree). Agreement was defined as a vote ≥ 7 by at least 70% of participants. The literature review included more than 400 articles. Overall, 63 recommendations (19 on surgery, fever, and opportunistic infections) were generated and voted by 59 pediatric rheumatologists and other pediatric specialists. Agreement was reached for all 63 recommendations. The recommendations on special situations cover management in cases of surgery, fever, and opportunistic infections (varicella, herpes-zoster, tuberculosis, and invasive fungal disease). Conclusions: Hereby, we provided consensus and updated of recommendations about the management of special situations such as surgery, fever, and opportunistic in children with immune-mediated rheumatic diseases receiving immunosuppressive therapies. Several of the recommendations depend largely on clinical judgement and specific balance between risk and benefit for each individual and situation. To assess this risk, the clinician should have knowledge of the drugs, the patient's previous situation as well as the current infectious disease, in addition to experience. What is Known: • Infectious diseases and related complications are a major cause of morbidity and mortality in patients with immune-mediated rheumatic diseases. • Information on how to manage the treatment in situations of fever, opportunistic infections, and surgery in children is limited, and guidelines for action are often extrapolated from adults. What is New: • In the absence of strong evidence, a literature review and a Delphi survey were conducted to establish a series of expert recommendations that could support the clinical practice, providing a practical and simple day-to-day approach to be used by pediatric rheumatologists.
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Affiliation(s)
- Daniel Clemente
- Pediatric Rheumatology Unit, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Esmeralda Núñez Cuadros
- Pediatric Rheumatology Unit, UGC Pediatría, Hospital Regional Universitario de Málaga, Instituto de investigación biomédica de Málaga (IBIMA), Málaga, Spain
| | - Marisol Camacho Lovillo
- Servicio de Inmunología, Hospital Universitario Virgen del Rocío, Reumatología e Infectología pediátricas, Seville, Spain
| | - Joan Calzada Hernández
- Unitat de Reumatologia Pediàtrica, Servei de Pediatria, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
| | - Sara Guillén Martín
- Department of Pediatrics, Hospital Universitario de Getafe, CIBERINFEC ISCIII, Carretera de Toledo Km 12, 500, 28905, Getafe, Madrid, Spain.
| | - Laura Fernández Silveira
- Servicio de Inmunología, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBIS), Reumatología e Infectología pediátricas, Seville, Spain
| | | | - Alfredo Tagarro
- Pediatrics Department. Hospital Universitario Infanta Sofía, Instituto de Investigación 12 de Octubre (imas12), Universidad Europea, Madrid, Spain
| | | | - Agustín López López
- Department of Paediatrics, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Cristina Calvo
- Department of Pediatrics, Infectious and Tropical Diseases, Hospital Universitario La Paz, La Paz Research Institute (IdiPaz), Translational Research Network of Pediatric Infectious Diseases (RITIP), CIBERINFEC ISCIII, Madrid, Spain
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