1
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Saito K, Gabbeta A, Mulvihill E, Al-Jaberi L, Beukelman T, Lewis JD, Rose CD, Strom BL, Horton DB. Validation of new medication use algorithms as proxies for worsening disease activity in patients with juvenile idiopathic arthritis. Pharmacoepidemiol Drug Saf 2024; 33:e5803. [PMID: 38685851 DOI: 10.1002/pds.5803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 04/04/2024] [Accepted: 04/11/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE To facilitate claims-based research on populations with juvenile idiopathic arthritis (JIA), we sought to validate an algorithm of new medication use as a proxy for worsening JIA disease activity. METHODS Using electronic health record data from three pediatric centers, we defined new JIA medication use as (re)initiation of disease-modifying antirheumatic drugs or glucocorticoids (oral or intra-articular). Data were collected from 201 randomly selected subjects with (101) or without (100) new medication use. We assessed the positive predictive value (PPV) and negative predictive value (NPV) based on a reference standard of documented worsening of JIA disease activity. The algorithm was refined to optimize test characteristics. RESULTS Overall, the medication-based algorithm had suboptimal performance in representing worsening JIA disease activity (PPV 69.3%, NPV 77.1%). However, algorithm performance improved for definitions specifying longer times after JIA diagnosis (≥1-year post-diagnosis: PPV 82.9%, NPV 80.0%) or after initiation of prior JIA treatment (≥1-year post-treatment: PPV 89.7%, NPV 80.0%). CONCLUSION An algorithm for new JIA medication use appears to be a reasonable proxy for worsening JIA disease activity, particularly when specifying new use ≥1 year since initiating a prior JIA medication. This algorithm will be valuable for conducting research on JIA populations within administrative claims databases.
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Affiliation(s)
- Kyoko Saito
- Brown University, Providence, Rhode Island, USA
| | - Avinash Gabbeta
- St. Christopher's Hospital for Children, Philadelphia, Pennsylvania, USA
| | | | - Lina Al-Jaberi
- Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Timothy Beukelman
- Childhood Arthritis & Rheumatology Research Alliance, Washington, DC, USA
| | - James D Lewis
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Carlos D Rose
- Nemours Children's Hospital, Wilmington, Delaware, USA
| | - Brian L Strom
- Rutgers Biomedical and Health Sciences, Newark, New Jersey, USA
- Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey, USA
| | - Daniel B Horton
- Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey, USA
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey, USA
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2
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Leal I, Steeples LR, Wong SW, Giuffrè C, Pockar S, Sharma V, Green EKY, Payne J, Jones NP, Chieng ASE, Ashworth J. Update on the systemic management of noninfectious uveitis in children and adolescents. Surv Ophthalmol 2024; 69:103-121. [PMID: 36682467 DOI: 10.1016/j.survophthal.2023.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 12/22/2022] [Accepted: 01/13/2023] [Indexed: 01/20/2023]
Abstract
Noninfectious uveitis (NIU) in children and adolescents is a rare but treatable cause of visual impairment in children. Treatments for pediatric NIU and their side effects, along with the risks of vision loss and the need for long-term disease monitoring, pose significant challenges for young patients and their families. Treatment includes local and systemic approaches and this review will focus on systemic therapies that encompass corticosteroids, conventional synthetic disease-modifying antirheumatic drugs (csDMARD), and biological disease-modifying antirheumatic drugs (bDMARD). Treatment is generally planned in a stepwise approach. Methotrexate is well-established as the preferential csDMARD in pediatric NIU. Adalimumab, an antitumor necrosis factor (TNF) agent, is the only bDMARD formally approved for pediatric NIU and has a good safety and efficacy profile. Biosimilars are gaining increasing visibility in the treatment of pediatric NIU. Other bDMARD with some evidence in literature for the treatment of pediatric NIU include infliximab, tocilizumab, abatacept, rituximab and, more recently, Janus kinase inhibitors. Important aspects of managing children on these systemic therapies include vaccination issues, risk of infection, and psychological distress. Also, strategies need to address regarding primary nonresponse/secondary loss of response to anti-TNF treatment, biological switching, and monitoring regimens for these drugs. Optimal management of pediatric uveitis involves a multidisciplinary team, including specialist pediatric uveitis and rheumatology nurses, pediatric rheumatologists, psychological support, orthoptic and optometry support, and play specialists.
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Affiliation(s)
- Inês Leal
- Ophthalmology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal; Visual Sciences Study Centre, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.
| | - Laura R Steeples
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK; Academic Health Science Centre, Manchester, UK
| | - Shiao Wei Wong
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Chiara Giuffrè
- Centro Europeo di Oftalmologia, Palermo, Italy; Ophthalmology Department, San Raffaele Scientific Institute, University Vita-Salute, Milan, Italy
| | - Sasa Pockar
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Vinod Sharma
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Elspeth K Y Green
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Janine Payne
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Nicholas P Jones
- School of Biological Sciences, University of Manchester, Manchester, UK
| | | | - Jane Ashworth
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK; Division of Evolution & Genomic Sciences, University of Manchester, Manchester, UK
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3
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Lima LDM, Aurilio RB, Fonseca AR, Parente AAAI, Sant’Anna MDFBP, Sant’Anna CC. Tuberculosis in children and adolescents with rheumatic diseases using biologic agents: an integrative review. Rev Paul Pediatr 2023; 42:e2022084. [PMID: 37436237 PMCID: PMC10332438 DOI: 10.1590/1984-0462/2024/42/2022084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 02/05/2023] [Indexed: 07/13/2023]
Abstract
OBJECTIVE To conduct a bibliographic review on tuberculosis (TB) disease in children and adolescents with rheumatic diseases, being managed with biologic therapy. DATA SOURCE An integrative review with a search in the U.S. National Library of Medicine and the National Institutes of Health (PubMed) using the following descriptors and Boolean operators: (["tuberculosis"] AND (["children"] OR ["adolescent"]) AND ["rheumatic diseases"] AND (["tumor necrosis factor-alpha"] OR ["etanercept"] OR ["adalimumab"] OR ["infliximab"] OR ["biological drugs"] OR ["rituximab"] OR ["belimumab"] OR ["tocilizumab"] OR ["canakinumab"] OR ["golimumab"] OR ["secukinumab"] OR ["ustekinumab"] OR ["tofacitinib"] OR ["baricitinib"] OR ["anakinra"] OR ["rilonacept"] OR ["abatacept"]), between January 2010 and October 2021. DATA SYNTHESIS Thirty-seven articles were included, with the total number of 36,198 patients. There were 81 cases of latent tuberculosis infection (LTBI), 80 cases of pulmonary tuberculosis (PTB), and four of extrapulmonary tuberculosis (EPTB). The main rheumatic disease was juvenile idiopathic arthritis. Among LTBI cases, most were diagnosed at screening and none progressed to TB disease during follow-up. Of the TB cases using biologics, most used tumor necrosis factor-alpha inhibitors (anti-TNFα) drugs. There was only one death. CONCLUSIONS The study revealed a low rate of active TB in pediatric patients using biologic therapy. Screening for LTBI before initiating biologics should be done in all patients, and treatment, in cases of positive screening, plays a critical role in preventing progression to TB disease.
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Affiliation(s)
- Lenita de Melo Lima
- Instituto de Puericultura e Pediatria Martagão Gesteira, Rio de Janeiro, RJ, Brazil
| | | | - Adriana Rodrigues Fonseca
- Instituto de Puericultura e Pediatria Martagão Gesteira, Rio de Janeiro, RJ, Brazil
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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4
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Leone GM, Mangano K, Petralia MC, Nicoletti F, Fagone P. Past, Present and (Foreseeable) Future of Biological Anti-TNF Alpha Therapy. J Clin Med 2023; 12:jcm12041630. [PMID: 36836166 PMCID: PMC9963154 DOI: 10.3390/jcm12041630] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/09/2023] [Accepted: 02/14/2023] [Indexed: 02/22/2023] Open
Abstract
Due to the key role of tumor necrosis factor-alpha (TNF-α) in the pathogenesis of immunoinflammatory diseases, TNF-α inhibitors have been successfully developed and used in the clinical treatment of autoimmune disorders. Currently, five anti-TNF-α drugs have been approved: infliximab, adalimumab, golimumab, certolizumab pegol and etanercept. Anti-TNF-α biosimilars are also available for clinical use. Here, we will review the historical development as well as the present and potential future applications of anti-TNF-α therapies, which have led to major improvements for patients with several autoimmune diseases, such as rheumatoid arthritis (RA), ankylosing spondylitis (AS), Crohn's disease (CD), ulcerative colitis (UC), psoriasis (PS) and chronic endogenous uveitis. Other therapeutic areas are under evaluation, including viral infections, e.g., COVID-19, as well as chronic neuropsychiatric disorders and certain forms of cancer. The search for biomarkers able to predict responsiveness to anti-TNF-α drugs is also discussed.
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Affiliation(s)
- Gian Marco Leone
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via S. Sofia 97, 95123 Catania, Italy
| | - Katia Mangano
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via S. Sofia 97, 95123 Catania, Italy
| | - Maria Cristina Petralia
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy
| | - Ferdinando Nicoletti
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via S. Sofia 97, 95123 Catania, Italy
- Correspondence:
| | - Paolo Fagone
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via S. Sofia 97, 95123 Catania, Italy
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5
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Udaondo C, Núñez Cuadros E, Murias S, Remesal A, Alcobendas R, Guerrero C, Guillen-Martin S, Escuredo M, Aleo E, Alonso D, Tagarro A, De Santiago E, Camacho-Lovillo M, Diaz F, Arenas D, Camacho P, Lirola MJ, Díaz Almirón M, Calvo C. Are infections in children with juvenile idiopathic arthritis more frequent than in healthy children? A prospective multicenter observational study. Front Pediatr 2022; 10:917731. [PMID: 36034561 PMCID: PMC9403004 DOI: 10.3389/fped.2022.917731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/26/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Children with juvenile idiopathic arthritis (JIA) might be at a higher risk of infection. Our objectives are to describe and compare infection rates in patients with JIA vs. healthy patients. METHODS A prospective, multicenter observational study was performed in Spain from January 2017 to June 2019. Patients with JIA from 7 participating hospitals and children without JIA (siblings of patients with JIA, and non-JIA children from primary health centers) were followed up with quarterly questionnaires to record infection episodes. Tuberculosis, herpes zoster, and infections requiring hospital admission were considered severe infections. Rates of infection (episodes/patient/year) were compared using a generalized estimating equations model. RESULTS A total of 371 children (181 with and 190 without JIA) were included. The median age was 8.8 years (IQR 5.5-11.3); 75% of the patients with JIA received immunosuppressive treatment (24% methotrexate, 22% biologic, 26% both). A total of 667 infections were recorded; 15 (2.2%) were considered severe. The infection rate was 1.31 (95%CI 1.1-1.5) in JIA and 1.12 (95%CI 0.9-1.3) in non-JIA participants (p = 0.19). Age <4 years increased the infection rate by 2.5 times (2.72 vs. 1.12, p < 0.001) in both groups. The most frequent infection sites were upper respiratory (62.6% vs. 74.5%) and gastrointestinal (18.8% vs. 11.4%). There were no differences in severe infections (2.5% vs. 2%, p = 0.65) between the groups. In children with JIA, younger age and higher disease activity (JADAS71) were associated with a higher infection rate. CONCLUSION We found no differences in the infection rate or infection severity between patients with and without JIA. Most infections were mild. An age younger than 4 years increased the infection risk in both groups. Higher disease activity was associated with a higher infection rate.
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Affiliation(s)
- Clara Udaondo
- Pediatric Rheumatology Unit, University Hospital La Paz, Madrid, Spain.,La Paz Research Institute (IDIPaz), Madrid, Spain.,CIBERINFEC ISCIII, Madrid, Spain
| | - Esmeralda Núñez Cuadros
- Pediatric Rheumatology Unit, UCG Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Sara Murias
- Pediatric Rheumatology Unit, University Hospital La Paz, Madrid, Spain
| | - Agustin Remesal
- Pediatric Rheumatology Unit, University Hospital La Paz, Madrid, Spain
| | - Rosa Alcobendas
- Pediatric Rheumatology Unit, University Hospital La Paz, Madrid, Spain
| | | | - Sara Guillen-Martin
- Pediatric Rheumatology Unit, UCG Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain.,Pediatrics, Hospital de Getafe, Madrid, Spain
| | | | - Esther Aleo
- Pediatrics, Fundación para la Investigación del Hospital Clínico San Carlos, Hospital Clinico San Carlos, Madrid, Spain
| | | | - Alfredo Tagarro
- Fundación de Investigación Biomédica Hospital 12 de Octubre. Instituto de Investigación 12 de Octubre (imas12), Madrid, Spain.,Department of Pediatrics, Infanta Sofía University Hospital, Madrid, Spain.,Infanta Sofia University Hospital and Henares University Hospital Foundation for Biomedical Research and Innovation (FIIB HUIS HHEN), Madrid, Spain.,Facultad de Medicina, Universidad Europea de Madrid, Madrid, Spain
| | | | - Marisol Camacho-Lovillo
- Pediatric Immunology, Rheumatology and Infectious Diseases Department, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | | | - Pilar Camacho
- Pediatrics, Centro Alcala de Guadaira, Seville, Spain
| | - Maria Jose Lirola
- Pediatric Rheumatology, Grupo IHP - Instituto Hispalense de Pediatría, Seville, Spain
| | - Mariana Díaz Almirón
- CIBERINFEC ISCIII, Madrid, Spain.,Biostatistics, Investigation department, IDIPaz, University Hospital La Paz, Madrid, Spain
| | - Cristina Calvo
- CIBERINFEC ISCIII, Madrid, Spain.,Pediatric Rheumatology Unit, UCG Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain.,Pediatric Infectious Diseases Department, University Hospital La Paz, Madrid, Spain
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6
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Ogstrup AK, Spannow AH, Holm M, Rubak S, Veirum JE, Glerup M, Herlin T. Serious Opportunistic Lower Respiratory Tract Infections in Pediatric Rheumatic Diseases During Treatment With Biologics. J Clin Rheumatol 2021; 27:S387-S391. [PMID: 32694355 DOI: 10.1097/rhu.0000000000001480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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7
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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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8
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Axelrod H, Adams M. Biologic Agents and Secondary Immune Deficiency. Immunol Allergy Clin North Am 2021; 41:639-652. [PMID: 34602234 DOI: 10.1016/j.iac.2021.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Biologics are protein-based pharmaceuticals derived from living organisms or their proteins. We discuss the mechanism of action for currently approved biologics and a give summary of the studies on immune suppression from biologics. Most of these studies have been conducted with rheumatology patients, and many in adults. Their relevance for children is explored and existing gaps in data for children are highlighted.
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Affiliation(s)
- Heather Axelrod
- Department of Pediatrics (PGY3), Children's Hospital of Michigan, Detroit, MI, USA
| | - Matthew Adams
- Division of Pediatric Rheumatology, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, 3950 Beaubien Boulevard, Detroit, MI 48201, USA.
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9
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10
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Blanchard-Rohner G. Vaccination in Children With Autoimmune Disorders and Treated With Various Immunosuppressive Regimens: A Comprehensive Review and Practical Guide. Front Immunol 2021; 12:711637. [PMID: 34408752 PMCID: PMC8365419 DOI: 10.3389/fimmu.2021.711637] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/12/2021] [Indexed: 01/04/2023] Open
Abstract
Children with autoimmune disorders are especially at risk of vaccine-preventable diseases due to their underlying disease and the immunosuppressive treatment often required for a long period. In addition, vaccine coverage remains too low in this vulnerable population. This can be explained by a fear of possible adverse effects of vaccines under immunosuppression, but also a lack of data and clear recommendations, particularly with regard to vaccination with live vaccines. In this review, the latest literature and recommendations on vaccination in immunosuppressed children are discussed in detail, with the aim to provide a set of practical guidelines on vaccination for specialists caring for children suffering from different autoimmune disorders and treated with various immunosuppressive regimens.
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Affiliation(s)
- Geraldine Blanchard-Rohner
- Paediatric Immunology and Vaccinology Unit, Division of General Paediatrics, Department of Paediatrics, Gynaecology and Obstetrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland.,Centre for Vaccinology and Neonatal Immunology, Department of Paediatrics and Pathology-Immunology, Medical Faculty and University Hospitals of Geneva, Geneva, Switzerland
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11
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Licciardi F, Giani T, Baldini L, Favalli EG, Caporali R, Cimaz R. COVID-19 and what pediatric rheumatologists should know: a review from a highly affected country. Pediatr Rheumatol Online J 2020; 18:35. [PMID: 32321540 PMCID: PMC7175817 DOI: 10.1186/s12969-020-00422-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/03/2020] [Indexed: 01/08/2023] Open
Abstract
On March 11th, 2020 the World Health Organization declared COVID-19 a global pandemic. The infection, transmitted by 2019 novel coronavirus (2019-nCov), was first discovered in December 2019, in Wuhan, Hubei Province, and then rapidly spread worldwide. Italy was early and severely involved, with a critical spread of the infection and a very high number of victims. Person-to-person spread mainly occurs via respiratory droplets and contact. The median incubation period is 5 days. The spectrum of respiratory symptoms may range from mild to severe, strictly depending on the age of the patient and the underlying comorbidities.In children COVID-19 related disease is less frequent and less aggressive. In Italy 1% of positive cases are under 18 years of age, and no deaths have been recorded before 29 years of age. For patients affected by rheumatic disease, despite the concerns related to the imbalance of their immune response and the effect of immunosuppressive treatments, there are still few data to understand the real consequences of this infection. Major scientific societies have issued recommendations to help rheumatologists in caring their patients. Interestingly, some of the drugs mostly used by rheumatologists appear to be promising in critical COVID-19 infected patients, where the hyperinflammation and cytokine storm seem to drive to the multiorgan failure.Pediatric rheumatologists are expected to play a supporting role in this new front of COVID-19 pandemic, both as general pediatricians treating infected children, and as rheumatologists taking care of their rheumatic patients, as well as offering their experience in the possible alternative use of immunomodulatory drugs.
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Affiliation(s)
- Francesco Licciardi
- Division of Pediatric Immunology and Rheumatology, Department of Public Health and Pediatrics, Regina Margherita Children Hospital, University of Turin, Turin, Italy
| | - Teresa Giani
- AOU Meyer, V.le Pieraccini 24, 50139, Florence, Italy.
- Department of Medical Biotechnology, University of Siena, Siena, Italy.
| | - Letizia Baldini
- Division of Pediatric Immunology and Rheumatology, Department of Public Health and Pediatrics, Regina Margherita Children Hospital, University of Turin, Turin, Italy
| | - Ennio Giulio Favalli
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO Institute, Milan, Italy
| | - Roberto Caporali
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO Institute, Milan, Italy
- Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Università degli Studi di Milano, Milan, Italy
| | - Rolando Cimaz
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO Institute, Milan, Italy
- Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Università degli Studi di Milano, Milan, Italy
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12
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Salonen PH, Salonen JH, Säilä H, Helminen M, Linna M, Kauppi MJ. Decreasing trend in the incidence of serious pneumonias in Finnish children with juvenile idiopathic arthritis. Clin Rheumatol 2019; 39:853-860. [PMID: 31732822 DOI: 10.1007/s10067-019-04804-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 09/25/2019] [Accepted: 10/02/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Children with juvenile idiopathic arthritis (JIA) may be predisposed to serious pneumonia due to modern disease-modifying anti-rheumatic treatment. In this nationwide retrospective study with clinical data, we describe the pneumonia episodes among children with JIA. METHODS Patients under 18 years of age with JIA and pneumonia during 1998-2014 were identified in the National Hospital Discharge Register in Finland. Each individual patient record was reviewed, and detailed data on patients with JIA and pneumonia were retrieved, recorded, and analyzed. If the patient was hospitalized or received intravenous antibiotics, the pneumonia was considered serious. RESULTS There were 157 episodes of pneumonia among 140 children with JIA; 111 episodes (71%) were serious (80% in 1998-2006 and 66% in 2007-2014). The mean age of the patients was 9 years. Forty-eight percent had active JIA and 46% had comorbidities. Disease-modifying anti-rheumatic drugs (DMARD) were used at the time of 135 episodes (86%): methotrexate (MTX) by 62% and biologic DMARDs (bDMARD) by 30%. There was no significant difference in the use of bDMARDs, MTX and glucocorticoids between the patient groups with serious and non-serious pneumonia episodes. During six of the episodes, intensive care was needed. Two patients (1.3%) died, the remaining ones recovered fully. CONCLUSIONS Although the incidence of pneumonia and the use of immunosuppressive treatment among children with JIA increased from 1998 to 2014, the proportion of serious pneumonias in these patients decreased. There was no significant difference in the use of anti-rheumatic medication between patients with serious and non-serious pneumonia.Key Points• The incidence of serious pneumonias decreased from 1998 to 2014 among children with juvenile idiopathic arthritis (JIA).• There was no significant difference in the use of the disease-modifying anti-rheumatic medication between JIA patients with serious and non-serious pneumonias.• Active JIA, comorbidities, and combination medication were associated with nearly half of the pneumonias.
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Affiliation(s)
- Päivi H Salonen
- Faculty of Medicine and Life Science, Tampere University, Tampere, Finland. .,Päijät-Häme Joint Authority for Health and Wellbeing, Terveystie 4, 15870, Lahti, Hollola, Finland.
| | - Juha H Salonen
- Department of Infectious Diseases, Vaasa Central Hospital, Vaasa, Finland
| | - Hanna Säilä
- Orton Research Institute, Orton Foundation, Helsinki, Finland
| | - Mika Helminen
- Research, Development and Innovation Centre, Tampere University Hospital, Tampere, Finland.,Faculty of Social Sciences, Health Sciences, Tampere University, Tampere, Finland
| | | | - Markku J Kauppi
- Faculty of Medicine and Life Science, Tampere University, Tampere, Finland.,Department of Rheumatology, Päijät-Häme Central Hospital, Lahti, Finland
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13
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Abstract
Biologics are protein-based pharmaceuticals derived from living organisms or their proteins. We discuss the mechanism of action for currently approved biologics and a give summary of the studies on immune suppression from biologics. Most of these studies have been conducted with rheumatology patients, and many in adults. Their relevance for children is explored and existing gaps in data for children are highlighted.
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Affiliation(s)
- Heather Axelrod
- Department of Pediatrics (PGY3), Children's Hospital of Michigan, Detroit, MI, USA
| | - Matthew Adams
- Division of Pediatric Rheumatology, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, 3950 Beaubien Boulevard, Detroit, MI 48201, USA.
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14
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Lai JH, Ling XC, Ho LJ. Useful message in choosing optimal biological agents for patients with autoimmune arthritis. Biochem Pharmacol 2019; 165:99-111. [PMID: 30876919 DOI: 10.1016/j.bcp.2019.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 03/07/2019] [Indexed: 02/07/2023]
Abstract
The introduction of biological disease-modifying antirheumatic drug (bDMARD) treatments for various types of autoimmune arthritis, such as rheumatoid arthritis, psoriatic arthropathy and ankylosing spondylitis, represents a new era of treatment for patients with a refractory response to conventional synthetic DMARDs (csDMARDs). Many new bDMARDs with different modalities or that target different pro-inflammatory molecules, likely cytokines, are rapidly emerging. Hence, physicians in the field may be confused about choosing appropriate bDMARDs for their patients. Considering the high cost of bDMARDs and the rapid destructive process of autoimmune arthritis in patients, the choice of optimal bDMARDs for patients who fail to respond or show an inadequate therapeutic response to csDMARDs designed to control the disease is very critical. Here, we summarize the strengths and weaknesses of bDMARDs and specifically focus on their uses in patients with comorbid conditions or with specific medical conditions, such as pregnancy. This commentary provides a solid up-to-date review on commercially available bDMARDs and very useful information for physicians to facilitate the choice of more appropriate bDMARDs to treat patients with autoimmune arthritis and for basic researchers to understand the current strategies of bDMARD usage and hopefully to develop more powerful bDMARDs with fewer safety concerns.
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Affiliation(s)
- Jenn-Haung Lai
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, Tao-Yuan, Taiwan, ROC; Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan, ROC.
| | - Xiao Chun Ling
- Department of Ophthalmology, Chang Gung Memorial Hospital, Chang Gung University, Tao-Yuan, Taiwan, ROC
| | - Ling-Jun Ho
- Institute of Cellular and System Medicine, National Health Research Institute, Zhunan, Taiwan, ROC.
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15
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Aeschlimann FA, Chong SL, Lyons TW, Beinvogl BC, Góez-Mogollón LM, Tan S, Laxer RM. Risk of Serious Infections Associated with Biologic Agents in Juvenile Idiopathic Arthritis: A Systematic Review and Meta-Analyses. J Pediatr 2019; 204:162-171.e3. [PMID: 30318371 DOI: 10.1016/j.jpeds.2018.08.065] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/20/2018] [Accepted: 08/24/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess whether treatment with biologic response modifying agents during clinical trial study periods increases the risk of serious infections in children with juvenile idiopathic arthritis (JIA). STUDY DESIGN A systematic literature review using Medline, Embase, Cochrane library, and the clinical trial registry was performed up to July 2017. Random effects meta-analyses were used to compare rates of serious infections in children with JIA given biologic agents compared with controls, and the pooled relative risk calculated. Subanalyses were performed for different biologic agent classes. RESULTS In total, 19 trials accounting for 21 individual studies were included (11 for tumor necrosis factor-alpha inhibitors [n = 814 patients], 3 for interleukin-6 inhibitors [n = 318], 6 for interleukin-1 inhibitors [n = 353], and 1 for selective T-lymphocyte costimulation modulators [n = 122]). Patients (68% female) had a mean age of 10.8 years. Seventeen serious infections were reported among 810 children receiving biologic agents and 15 among 797 controls. The most frequent infections were bronchopulmonary and varicella. No statistically significant difference in risk of serious infections was found between children receiving biologic agents compared with control groups (pooled relative risk = 1.13; 95% CI [0.63, 2.03]) during the trial study periods. The risk remained nonsignificant when evaluating the different classes of biologic agents separately. However, the analyses were underpowered to detect differences in the risk of serious infections overall or differences between classes of biologic agents. CONCLUSIONS In this systematic review and meta-analyses, serious infections were uncommon and not significantly increased among patients with JIA receiving biologic agents compared with controls. However, the analyses were underpowered and study periods were relatively short. Ongoing careful monitoring for serious infections remains necessary for all patients with JIA, and particularly those receiving biologic agents.
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Affiliation(s)
- Florence A Aeschlimann
- Pediatric Immunology-Hematology and Rheumatology Unit, University Hospital Necker-Enfants Malades, Paris, France.
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital and Duke-NUS Medical School, Singapore, Singapore
| | - Todd W Lyons
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Beate C Beinvogl
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA
| | | | - Sally Tan
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Ronald M Laxer
- Division of Rheumatology, The Hospital for Sick Children, Department of Pediatrics and Medicine, University of Toronto, Toronto, Ontario, Canada
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16
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Abstract
Introduction: Tumor necrosis factor alpha (TNF-α) is a pro-inflammatory cytokine involved in the pathogenesis of many inflammatory diseases. Several drugs blocking TNF-α are employed in clinical practice in pediatrics. Given their action on the immune system, TNF-α inhibitors have raised concerns on their safety profile since their introduction. A broad spectrum of side effects related to TNF inhibition has been reported: immunogenicity, infectious diseases, malignancies, and others. Areas covered: In order to assess the risk related to the use of anti-TNF-α agents in children with rheumatic diseases we analyzed data obtained from retrospective and prospective safety studies, case reports and case series, and controlled trials. Expert commentary: Anti-TNF-α agents have shown a remarkably good safety profile in the pediatric population so far. However, there are lots of questions to be answered and maintaining active surveillance on these drugs is necessary in order to not overlook any possible unexpected adverse effects.
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Affiliation(s)
- Achille Marino
- a Department of Pediatrics, Desio Hospital , ASST Monza , Desio (MB) , Italy.,b PhD student in Biomedical Sciences , University of Florence , Florence , Italy
| | - Teresa Giani
- c Department of Medical Biotechnology , University of Siena , Siena , Italy.,d Rheumatology Unit, Meyer Children's Hospital , University of Florence , Florence , Italy
| | - Rolando Cimaz
- e Department of Neurosciences, Psychology, Drug Research and Child Health, Rheumatology Unit, Meyer Children's Hospital , University of Florence , Florence , Italy
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