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Licciardi F, Covizzi C, Dellepiane M, Olivini N, Mastrolia MV, Lo Vecchio A, Monno V, Tardi M, Mauro A, Alessio M, Filocamo G, Cattalini M, Taddio A, Caorsi R, Marseglia GL, La Torre F, Campana A, Simonini G, Ravelli A, Montin D. Outcomes of MIS-C patients treated with anakinra: a retrospective multicenter national study. Front Pediatr 2023; 11:1137051. [PMID: 37675397 PMCID: PMC10478576 DOI: 10.3389/fped.2023.1137051] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 07/27/2023] [Indexed: 09/08/2023] Open
Abstract
Background The treatment of multisystem inflammatory syndrome in children unresponsive to first-line therapies (IVIG and/or steroids) is challenging. The effectiveness of IL-1 receptor antagonist, anakinra, is debated. Patients and methods We conducted an anonymous retrospective multicenter study on MIS-C patients treated with anakinra in Italy from January 2020 to February 2021. Our study outcomes included the percentage of patients who required further therapeutic step-up, the percentage of patients who experienced fever resolution within 24 h and a reduction of CRP by half within 48 h, and the percentage of patients who developed Coronary Artery Anomalies (CAA) during follow-up. Results 35 cases of MIS-C were treated in 10 hospitals. Of these, 13 patients started anakinra while in the ICU, and 22 patients started anakinra in other wards. 25 patients (71.4%) were treated with corticosteroids at a starting dose 2-30 mg/Kg/day plus IVIG (2 g/Kg), 10 patients (28.6%) received only corticosteroids without IVIG. Anakinra was administered intravenously to all patients in Group A (mean dose 8 mg/Kg/day), and subcutaneously in Group B (mean dose 4 mg/Kg/day). Only two patients required further treatment step-up and no patients developed CAA after receiving anakinra. The most commonly observed side effect was an increase in ALT, occurring in 17.1% of patients. Conclusions In this retrospective cohort of severe MIS-C patients treated with anakinra we report favorable clinical outcomes with a low incidence of side effects. The simultaneous use of steroids ± IVIG in these patients hinders definitive conclusions regarding the need of IL-1 inhibition in MIS-C treatment.
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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
| | - Carlotta Covizzi
- Division of Pediatric Immunology and Rheumatology, Department of Public Health and Pediatrics, “Regina Margherita” Children Hospital, University of Turin, Turin, Italy
| | - Marta Dellepiane
- Division of Pediatric Immunology and Rheumatology, Department of Public Health and Pediatrics, “Regina Margherita” Children Hospital, University of Turin, Turin, Italy
| | - Nicole Olivini
- Pediatrics Unit, University Department of Pediatrics (DEAPG), Bambino Gesù Children’s Hospital—IRCCS, Rome, Italy
| | - Maria Vincenza Mastrolia
- Rheumatology Unit, Department of Paediatrics, Meyer Children’s Hospital, University of Florence, Florence, Italy
| | - Andrea Lo Vecchio
- Section of Paediatrics, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Viviana Monno
- Pediatric Rheumatology Section, Department of Pediatrics, Giovanni XXIII Pediatric Hospital, Bari, Italy
| | - Maria Tardi
- Rheumatology Unit, Department of Pediatrics, Santobono Pausilipon Children Hospital, Naples, Italy
| | - Angela Mauro
- COVID Unit, Emergency Department, Santobono-Pausilipon Children Hospital, Naples, Italy
| | - Maria Alessio
- Section of Paediatrics, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Giovanni Filocamo
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Marco Cattalini
- Spedali Civili, Unità di Immunologia e Reumatologia Pediatrica, Clinica Pediatrica dell’Università di Brescia, Brescia, Italy
| | - Andrea Taddio
- Institute for Maternal and Child Health “IRCCS Burlo Garofolo”, Trieste and University of Trieste, Trieste, Italy
| | - Roberta Caorsi
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Gian Luigi Marseglia
- Pediatric Clinic Foundation IRCCS Policlinico S. Matteo, University of Pavia, Pavia, Italy
| | - Francesco La Torre
- Pediatric Rheumatology Section, Department of Pediatrics, Giovanni XXIII Pediatric Hospital, Bari, Italy
| | - Andrea Campana
- Pediatrics Unit, University Department of Pediatrics (DEAPG), Bambino Gesù Children’s Hospital—IRCCS, Rome, Italy
| | - Gabriele Simonini
- Rheumatology Unit, Department of Paediatrics, Meyer Children’s Hospital, University of Florence, Florence, Italy
| | - Angelo Ravelli
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Davide Montin
- Division of Pediatric Immunology and Rheumatology, Department of Public Health and Pediatrics, “Regina Margherita” Children Hospital, University of Turin, Turin, Italy
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Baldini L, Di Sabatino F, Bodrero E, Dellepiane M, Covizzi C, La Selva R, Montin D, Licciardi F. NeMO mutations: a rare cause of monogenic Behçet-like disease. Rheumatology (Oxford) 2021; 60:e92-e94. [PMID: 32954429 DOI: 10.1093/rheumatology/keaa505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Letizia Baldini
- Department of Pediatrics and Public Health, University of Turin, Turin, Italy
| | - Fabiana Di Sabatino
- Department of Pediatrics and Public Health, University of Turin, Turin, Italy
| | - Enrico Bodrero
- Department of Pediatrics and Public Health, University of Turin, Turin, Italy
| | - Marta Dellepiane
- Department of Pediatrics and Public Health, University of Turin, Turin, Italy
| | - Carlotta Covizzi
- Department of Pediatrics and Public Health, University of Turin, Turin, Italy
| | - Roberta La Selva
- Unit of Pediatric Plastic Surgery, Pediatric Dermatology, Città della Salute e della Scienza di Torino, Regina Margherita Children Hospital, Turin, Italy
| | - Davide Montin
- Department of Pediatrics and Public Health, University of Turin, Turin, Italy
| | - Francesco Licciardi
- Department of Pediatrics and Public Health, University of Turin, Turin, Italy
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Licciardi F, Baldini L, Denina M, Ricotti E, Covizzi C, Dellepiane M, Mignone F, Zoppo M, Felici E, Montin D. Peculiar immunophenotypic signature in MIS-C-affected children. Pediatr Allergy Immunol 2021; 32:801-804. [PMID: 33332663 DOI: 10.1111/pai.13434] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 01/19/2023]
Affiliation(s)
- Francesco Licciardi
- Regina Margherita Children's Hospital, AOU Città della Salute e della Scienza di Torino, Turin, Italy.,Department of Pediatric and Public Health Sciences, University of Torino, Turin, Italy
| | - Letizia Baldini
- Department of Public Health and Pediatrics, Postgraduate School of Pediatrics, University of Turin, Turin, Italy
| | - Marco Denina
- Regina Margherita Children's Hospital, AOU Città della Salute e della Scienza di Torino, Turin, Italy.,Department of Pediatric and Public Health Sciences, University of Torino, Turin, Italy
| | - Emanuela Ricotti
- Regina Margherita Children's Hospital, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Carlotta Covizzi
- Department of Public Health and Pediatrics, Postgraduate School of Pediatrics, University of Turin, Turin, Italy
| | - Marta Dellepiane
- Regina Margherita Children's Hospital, AOU Città della Salute e della Scienza di Torino, Turin, Italy.,Department of Pediatric and Public Health Sciences, University of Torino, Turin, Italy
| | - Federica Mignone
- Regina Margherita Children's Hospital, AOU Città della Salute e della Scienza di Torino, Turin, Italy.,Department of Pediatric and Public Health Sciences, University of Torino, Turin, Italy
| | - Marisa Zoppo
- Regina Margherita Children's Hospital, AOU Città della Salute e della Scienza di Torino, Turin, Italy.,Department of Pediatric and Public Health Sciences, University of Torino, Turin, Italy
| | - Enrico Felici
- Pediatric and Pediatric Emergency Unit, Children Hospital, AO SS Antonio e Biagio e C. Arrigo, Alessandria, Italy
| | - Davide Montin
- Regina Margherita Children's Hospital, AOU Città della Salute e della Scienza di Torino, Turin, Italy.,Department of Pediatric and Public Health Sciences, University of Torino, Turin, Italy
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Licciardi F, Baldini L, Dellepiane M, Covizzi C, Mogni R, Pruccoli G, Orsi C, Rabbone I, Parodi E, Mignone F, Montin D. MIS-C Treatment: Is IVIG Always Necessary? Front Pediatr 2021; 9:753123. [PMID: 34805048 PMCID: PMC8595395 DOI: 10.3389/fped.2021.753123] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 08/04/2021] [Accepted: 10/04/2021] [Indexed: 12/19/2022] Open
Abstract
Background: MIS-C is a potentially severe inflammatory syndrome associated with SARS-CoV-2 exposure. Intravenous immunoglobulin (IVIG) is considered the first-tier therapy, but it implies infusion of large fluid volumes that may worsen cardiac function. Patients and Methods: Since April 2020, we have developed a treatment protocol that avoids the infusion of IVIG as first-line therapy in the early phase of MIS-C. In this study, we retrospectively analyzed a cohort of consecutive patients treated according to this protocol between 01/04/2020 and 01/04/2021. Results: In the last year, 31 patients have been treated according to the protocol: 25 with high-dose pulse MP (10 mg/kg) and 6 with 2 mg/kg. 67.7% of the patients responded to the initial treatment, while the others needed a step-up, either with Anakinra (25.8%) or with MP dose increase (6.5%). IVIG was administered in four patients. Overall, only one patient (3.2%) needed ICU admission and inotropic support; one patient developed a small coronary artery aneurysm. Conclusions: Timely start of MP therapy and careful fluid management might improve the outcomes of MIS-C patients.
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Affiliation(s)
- Francesco Licciardi
- Department of Pediatrics and Public Health, Università degli Studi di Torino, Turin, Italy.,Ospedale Infantile Regina Margherita, Città della Salute e della Scienza, Turin, Italy
| | - Letizia Baldini
- Postgraduate School of Pediatrics, Università degli Studi di Torino, Turin, Italy
| | - Marta Dellepiane
- Department of Pediatrics and Public Health, Università degli Studi di Torino, Turin, Italy
| | - Carlotta Covizzi
- Postgraduate School of Pediatrics, Università degli Studi di Torino, Turin, Italy
| | - Roberta Mogni
- Postgraduate School of Pediatrics, Università degli Studi di Torino, Turin, Italy
| | - Giulia Pruccoli
- Department of Pediatrics and Public Health, Università degli Studi di Torino, Turin, Italy
| | - Cecilia Orsi
- Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Ivana Rabbone
- Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Emilia Parodi
- Department of Pediatrics and Public Health, Università degli Studi di Torino, Turin, Italy.,Ospedale Infantile Regina Margherita, Città della Salute e della Scienza, Turin, Italy
| | - Federica Mignone
- Department of Pediatrics and Public Health, Università degli Studi di Torino, Turin, Italy.,Ospedale Infantile Regina Margherita, Città della Salute e della Scienza, Turin, Italy
| | - Davide Montin
- Department of Pediatrics and Public Health, Università degli Studi di Torino, Turin, Italy.,Ospedale Infantile Regina Margherita, Città della Salute e della Scienza, Turin, Italy
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Licciardi F, Baldini L, Dellepiane M, Covizzi C, Mogni R, Pruccoli G, Orsi C, Rabbone I, Parodi E, Mignone F, Montin D. Corrigendum: MIS-C Treatment: Is IVIG Always Necessary? Front Pediatr 2021; 9:826518. [PMID: 35237545 PMCID: PMC8883580 DOI: 10.3389/fped.2021.826518] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 11/13/2022] Open
Abstract
[This corrects the article DOI: 10.3389/fped.2021.753123.].
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Affiliation(s)
- Francesco Licciardi
- Department of Pediatrics and Public Health, Università degli Studi di Torino, Turin, Italy.,Ospedale Infantile Regina Margherita, Città della Salute e della Scienza, Turin, Italy
| | - Letizia Baldini
- Postgraduate School of Pediatrics, Università degli Studi di Torino, Turin, Italy
| | - Marta Dellepiane
- Department of Pediatrics and Public Health, Università degli Studi di Torino, Turin, Italy
| | - Carlotta Covizzi
- Postgraduate School of Pediatrics, Università degli Studi di Torino, Turin, Italy
| | - Roberta Mogni
- Postgraduate School of Pediatrics, Università degli Studi di Torino, Turin, Italy
| | - Giulia Pruccoli
- Department of Pediatrics and Public Health, Università degli Studi di Torino, Turin, Italy
| | - Cecilia Orsi
- Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Ivana Rabbone
- Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Emilia Parodi
- Department of Pediatrics and Public Health, Università degli Studi di Torino, Turin, Italy.,Ospedale Infantile Regina Margherita, Città della Salute e della Scienza, Turin, Italy
| | - Federica Mignone
- Department of Pediatrics and Public Health, Università degli Studi di Torino, Turin, Italy.,Ospedale Infantile Regina Margherita, Città della Salute e della Scienza, Turin, Italy
| | - Davide Montin
- Department of Pediatrics and Public Health, Università degli Studi di Torino, Turin, Italy.,Ospedale Infantile Regina Margherita, Città della Salute e della Scienza, Turin, Italy
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Licciardi F, Dellepiane M, Covizzi C, Figus F, Azzolin I, Montin D, Iagnocco A. THU0505 MUSCULOSKELETAL ULTRASOUND MONITORING DURING MTX TAPERING IN JIA: A PROSPECTIVE BLINDED COHORT STUDY. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.4151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background:Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in children. Musculoskeletal ultrasound (MSUS) is a reliable tool in the assessment of chronic inflammatory arthropathies. MSUS in JIA has demonstrated a higher sensitivity for detecting synovitis and tenosynovitis as compared to physical examination. The occurrence of subclinical synovitis (Sub-S: MSUS+/ physical examination -) seems more frequent in wrist and foot joints; the clinical significance of Sub-S in real-life practice is still debated. Methotrexate (MTX) is the most widely used first-line DMARD in JIA therapy. Weekly treatment with MTX leads to clinical remission (CR) in 50-70% of patients. After a variable period of CR (usually 6-18 months), MTX is discontinued. Relapse rate after MTX suspension ranges between 40-50%; no predictors of disease flare have been identified so far.Objectives:We designed a cohort study in order to explore if MSUS monitoring during MTX tapering was able to predict disease flare.Methods:JIA patients in CR (as defined by the JADAS score) for at least 12 months were enrolled in the study. Patients at first attempt of suspension (G1) were tapered as follows: 1 week of suspension every 3 weeks for 3 months + 1 dose every 2 weeks for 3 months; if CR persisted, MTX was stopped. Patients who had a previous flare during/after MTX tapering (G2) had a similar tapering schedule but the step with 1 MTX dose every 2 weeks lasted 6 months. All patients underwent a complete MSUS of 48 joints every 3 months; clinicians who performed physical examinations and follow-up were blinded to US findings for the entire study period.Results:18 consecutive patients were enrolled between April 2018 and September 2019; patients had prevalently oligoJIA (55.5%) and RF- polyJIA (22.2%). Patients had been treated with MTX for 24.7 months (17.7–48.3), CR had been achieved 4.2 months after MTX start; 61.1% were at their first attempt of MTX tapering (G1).Baseline MSUS:at T0 MSUS detected 9/18 patients (50.0%) with Sub-S (MSUS+). Affected sites at T0 were distributed as follows: 4 MCP joints, 9 MTP joints, 1 f-IP joints, 11 knees. No significant differences resulted in comparing demographic and baseline disease features between MSUS- and MSUS+ patients at T0.Follow-up MSUS: 14 patients (77.8%) completed the entire study protocol, 4 patients are still ongoing. 7 patients relapsed: 42.9% during tapering, 1 of them relapsed during a VZV infection and was excluded from further analysis. We considered as Tlast-MSUS the last available MSUS before relapse or final MSUS (i.e. three months after MTX withdrawal) for not-relapsed subjects.At Tlast8 patients had at least 1 Sub-S. Sub-S per patient at Tlastwere more than Sub-S at T0 (2.85 vs 0.53 p=0.03) but the presence of Sub-S was not related with disease flare (50.0 vs 44.4% p=1). MSUS found 27 Sub-S of the small joints (sMSUS): 88.9% were in the feet, they had an OMERACT grading of 1. sMSUS+ patients were older (8.7 vs 3.9, p=0.002) therefore a weight-induced sub-S not related with JIA could be presumed.Kaplan-Meier curves were analyzed comparing MSUS results at T0 and Tlast, both considering all Sub-S and excluding small feet joints (pMSUS). The best performance was achieved with MSUS at Tlastand pMSUS (figure below, p=0.11).Conclusion:•Sub-S are present in 50% of patients in clinical remission >12 months.•Sub-S in older patients interest often feet small joints; these Sub-S may be of mechanical origin and are not associated with disease flare.•Sub-S increase during MTX tapering.Further patients must be enrolled to understand if Sub-S excluding feet small joints may predict disease flare.References:[1]Amendment of the OMERACT US definitions of joints’ features in healthy children using the DOPPLER technique. Collado P et al, Pediatr Rheumatol Online J. 2018.[2]Preliminary Definitions for the Sonographic Features of Synovitis in Children. Roth J, et al; Arthritis Care Res. 2017.Disclosure of Interests:Francesco Licciardi: None declared, Marta Dellepiane: None declared, Carlotta Covizzi: None declared, Fabiana Figus: None declared, Irene Azzolin: None declared, Davide Montin Speakers bureau: Not relevant for the topic, Annamaria Iagnocco Grant/research support from: Abbvie, MSD and Alfasigma, Consultant of: AbbVie, Abiogen, Alfasigma, Biogen, BMS, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Sanofi and Sanofi Genzyme, Speakers bureau: AbbVie, Alfasigma, BMS, Eli-Lilly, Janssen, MSD, Novartis, Sanofi
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