Tuberculosis miliar en pacientes en tratamiento con adalimumab, una asociación no tan frecuente en pediatría / Miliary tuberculosis in patients treated with adalimumab, an association not so frequent in pediatrics

Los antagonistas del Factor de Necrosis Tumoral-α, son medicamentos que en los últimos años han tenido un incremento de su uso en pacientes con condiciones inflamatorias inmunomediadas en pediatría, como la Artritis Idiopática Juvenil y la Enfermedad Inflamatoria Intestinal. El uso de estos medicamentos en adultos tiene una fuerte asociación con la primoinfección o reactivación por Mycobacterium tuberculosis, pero en niños la evidencia es limitada. Se presentan 2 casos de pacientes tratados con adalimumab, quienes, a pesar de un buen control de su enfermedad y una prueba de tuberculina negativa al inicio de la terapia, desarrollaron tuberculosis miliar en el seguimiento, con importantes implicaciones para su salud. El tamizaje de tuberculosis latente con tuberculina/IGRAS (Interferón-γ release assays, por sus siglas en inglés) y un alto índice de sospecha de tuberculosis, son las herramientas disponibles para una adecuada identificación de la tuberculosis en pacientes que reciben crónicamente estas terapias.

Tumor Necrosis Factor-α antagonists are drugs that in recent years have seen an increase in their use in patients with immune-mediated inflammatory conditions in pediatrics such as Juvenile Idiopathic Arthritis and Inflammatory Bowel Disease. The use of these drugs in adults has a strong association with primary infection or reactivation by mycobacterium tuberculosis, but in children the evidence is limited. We present 2 cases of patients treated with adalimumab who, despite good control of their disease and a negative tuberculin test at the beginning of therapy, developed miliary tuberculosis during follow-up with important implications for their health. Screening for latent tuberculosis with tuberculin / IGRAS (Interferón-γ release assays) and a high index of suspicion for tuberculosis are the tools available for an adequate identification of tuberculosis in patients who receive these therapies chronically.

Clinical analysis of 5 cases of systemic juvenile idiopathic arthritis with coronary artery dilatation / 中华儿科杂志

Objective: To investigate the clinical characteristics of systemic juvenile idiopathic arthritis combined with coronary artery dilatation. Methods: A retrospective analysis was performed on the clinical data, including clinical manifestations, blood routine, inflammatory factors, echocardiography, vascular ultrasound and CT angiography, treatment and outcomes, etc, of 5 cases with systemic juvenile idiopathic arthritis combined with coronary artery dilation admitted to Department of Rheumatology in the affiliated Children's Hospital of Capital Institute of Pediatrics from May 2019 to June 2021. Results: There were 2 males and 3 females among 5 cases. The onset age ranged from 7 months to 4 years 7 months.The diagnostic time ranged from 1.5 months to 3.0 months.Four cases were diagnosed as atypical Kawasaki disease. Three cases showed unilateral coronary artery dilation.Two cases showed bilateral coronary artery dilation.Four cases developed multiple organ injuries.Three cases developed macrophage activation syndrome.Three cases developed lung injury.Two cases developed pericardial effusion.One case developed pulmonary hypertension.As for treatment, 3 cases treated with methylprednisolone pulse therapy and methotrexate combined with cyclosporine, improved after the final application of biological agents, and have stopped prednisone. The other 2 cases were treated with adequate oral prednisone and gradually reduced, and methotrexate was added at the same time, 1 case relapsed in the process of reduction. No other vascular involvement was found in 5 cases. Coronary artery dilation recovered completely after 1 to 3 months of treatment. Conclusions: Systemic juvenile idiopathic arthritis combined with coronary artery dilatation has the clinical characteristics of small onset age, long diagnostic time, prone to multiple organ injuries. Corticosteroids and conventional immunosuppressive agents are not sensitive, and biological agents should be used as soon as possible.The prognosis of coronary artery dilation is good after timely treatment.

Treatment of 11 cases of juvenile idiopathic arthritis by intra-articular injection of adalimumab / 中华儿科杂志

Objective: To evaluate the efficacy and safety of intra-articular injection of adalimumab (ADA) in the treatment of refractory oligoarticular juvenile idiopathic arthritis (JIA). Methods: This was a retrospective study. Clinical data on age, gender, and symptoms of joint swelling and pain were collected from 11 children with refractory oligoarticular JIA involving only knee joints admitted to Department of Rheumatism and Immunology of Children's Hospital, Capital Institute of Pediatrics from November 2019 to October 2020. The physician and parent-child evaluation of disease activity, the number of active joints, and the level of erythrocyte sedimentation rate (ESR) at different treatment time points were analyzed at every 4-week observation point after drug administration, and the non-parametric Kruskal-Wallis test was used to compare the differences in clinical evaluation indicators and changes in laboratory tests at different treatment times. The follow-up period was 6 months. Results: Among the 11 children, 5 were boys and 6 were girls. The age was 3.0 (2.8) years. All 11 children had symptoms of joint swelling and pain as well as limitation of movement. After 3 intra-articular injections of ADA, the joint symptoms of 11 children were better than before treatment; the joint symptoms of 7 children disappeared completely, and no recurrence occurred during the 6-month follow-up period. At different treatment times, physician and parent-child evaluation of disease activity, a gradual decrease in the number of active joints in the children, ESR, and juvenile arthritis disease activity score with 27 joints were all statistically significant (χ2=53.99, 59.37, 32.87, 40.07, 54.00, all P<0.001).No significant adverse drug reactions were observed in any of the 11 children during treatment and follow-up. Conclusion: Intra-articular injection of ADA in the treatment of refractory oligoarticular JIA has a significant effect in controlling joint symptoms and is relatively safe.

Trastorno de la alineación de articulaciones metacarpofalángicas en una adolescente con artritis idiopática juvenil / Metacarpophalangeal joint alignment disorder in a teenager diagnosed with juvenile idiopathic arthritis

La artritis idiopática juvenil es una enfermedad inflamatoria, sistémica y crónica que afecta a personas menores de 18 años de edad. Tiene diversas formas clínicas de presentación, pero todas y cada una de ellas pueden causar un elevado número de complicaciones articulares y extraarticulares que pueden desencadenar discapacidad funcional y disminución de la percepción de la calidad de vida relacionada con la salud. Se presenta la imagen poco frecuente de alteraciones de la alineación en las articulaciones metacarpofalángicas de ambas manos en una paciente de 14 años de edad con antecedentes de 3 años de evolución de artritis idiopática juvenil. Se administró tratamiento con esteroides y medicamentos modificadores de la enfermedad. A los 3 meses se encontraba estable, con una escala visual análoga de dolor ocasional de 2 puntos y con esquema terapéutico adecuado para el control de su enfermedad de base(AU)

Juvenile idiopathic arthritis is an inflammatory, systemic and chronic disease that affects people under 18 years of age. It presents various clinical forms of presentation but each and every one of them can generate a high number of joint and extra-articular complications that can trigger functional disability and decrease in the perception of health-related quality of life. There is a rare image of alterations in the alignment at the level of metacarpophalangeal joints of both hands in a 14-year-old patient with a history of three years of evolution of juvenile idiopathic arthritis(AU)

Artritis Idiopática Juvenil: manifestaciones clínicas y tratamiento / Juvenile Idiopathic Arthritis: clinical manifestation and treatment

Resumen La Artritis Idiopática Juvenil es la enfermedad reumática más frecuente en niños. Es una enfermedad crónica, degenerativa y de etiología desconocida; que puede dejar múltiples secuelas en la población pediátrica. Consta de siete afecciones definidas por la International League of Associations for Rheumatology del 2001: Artritis Sistémica, Oligoartritis, Artritis con Factor Reumatoide positivo o Factor Reumatoide negativo, Artritis relacionada a entesitis, Artritis psoriasica y Artritis indiferenciada; distintas tanto en el aspecto clínico, patogénico como evolutivo. Esta enfermedad se caracteriza por una alteración de la regulación del sistema inmunitario innato con una falta de linfocitos T autorreactivos y autoanticuerpos. La inflamación continua estimula el cierre rápido y prematuro del cartílago de crecimiento provocando un acortamiento óseo. Para llegar a su diagnóstico no se requiere más que una buena historia clínica y examen físico, ya que no hay laboratorios o gabinete lo bastante sensible que nos puedan ayudar. Fármacos como el metrotexate y los inhibidores del factor de necrosis tumoral han venido a modificar la evolución de la enfermedad y mejorar la calidad de vida de estos pacientes.

Abstract Juvenile idiopathic arthritis is the most common rheumatic disease in children. It is a chronic and degenerative disease, with an unknown etiology; that can leave multiple sequels in the pediatric population. There are seven conditions defined by 2001 International League of Associations for Rheumatology: Systemic Arthritis, Oligoarthritis, Arthritis with positive rheumatoid factor or negative rheumatoid factor, enthesitis-related arthritis and undifferentiated arthritis; distinct in clinical, pathogenetic and evolutionary aspects. This disease is characterized by an alteration on the regulation of the innate immune system with a lack of autoreactive lymphocytes T and autoantibodies. Continuous inflammation stimulates the rapid and premature closure of the growth cartilage causing bone shortening. To arrive at the diagnosis, it is only necessary to have a good medical history and physical exam, since there are no laboratory test sensitive enough to help us. Drugs such as methotrexate and tumor necrosis factor inhibitors have come to modify the evolution of the disease and improve the quality of life of these patients.

Clinical characteristics and biological treatment of adult patient with juvenile idiopathic arthritis / 北京大学学报(医学版)

OBJECTIVE@#To explore the clinical characteristics and biological treatment of juvenile Idiopathic arthritis (JIA) after adulthood.@*METHODS@#Selected 358 patients with previous medical history diagnosed by JIA who were hospitalized in the Department of Rheumatology and Immunology, West China Hospital of Sichuan University from January 1, 2009 to January 1, 2019. Perform retrospective analysis of basic information, clinical symptoms, diagnostic indicators, treatment plans, outpatient follow-up (inpatients require outpatient follow-up treatment) and diagnosis and treatment process of 90 eligible cases included, and observe different ages and different courses of disease. The clinical characteristics of young and middle-aged idiopathic arthritis in adults and the outpatient situation of using biological agents for 6 months.@*RESULTS@#According to age, they were divided into ≤26 years old group (42 cases) and >26 years old group (48 cases). Under examination [rheumatoid factor (RF), anti-nuclear antibody (ANA), anti-neutrophil antibody (ANCA), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), interleukin-1β (IL-1β), interleukin 6 (IL-6), hemoglobin (HGB), white blood cell count (WBC), human leukocyte antigen-B27 (HLA-B27), complement 3 (C3), etc.], concurrent in terms of symptoms, treatment and prognosis, the ≤26-year-old group was generally lighter than the >26-year-old group; that was, the older the age, the heavier the onset of inflammation and other symptoms, the more complications, the worse the treatment effect, and the worse the prognosis, and there were statistical differences academic significance (P < 0.05). According to the course of disease, they were divided into ≤19 years group (46 cases) and >19 years group (44 cases). In terms of examination (RF, ANA, ANCA, ESR, CRP, IL-1β, IL-6, HGB, HLA-B27, C3, etc.), complications, treatment and prognosis, the course of disease ≤19 years group was compared with the disease course> 19 years group Overall mild; that was, the longer the course of the disease, the more severe the onset of symptoms such as inflammation, the more complications, the worse the treatment effect, and the worse the prognosis, P < 0.05, the difference was statistically significant. After 6 months of outpatient treatment with biological agents, it was found that biological agents could improve some of the patients' clinical symptoms and delay the further development of the disease. Compared with the non-biological agent treatment group (48 cases), the biological agent group (42 cases) benefited, and the difference was statistically significant (P < 0.05).@*CONCLUSION@#Through retrospective analysis, this article believes that although adult JIA is diagnosed as connective tissue disease, it has special clinical characteristics with the course of the disease and age. Therefore, it should be recommended to give special attention to JIA patients after adulthood, require regular medical treatment in the adult rheumatology department, according to the corresponding connective tissue disease or JIA diagnosis, and standard treatment; at the same time, pay attention to the history of JIA. In the comparison of biological and non-biological treatment, it is proved that biological treatment can effectively improve some of the clinical symptoms of JIA patients after adulthood. Therefore, it is recommended that biological treatment be used as soon as possible if economic conditions permit to delay the development of the disease.

Adverse drug reactions associated with treatment in patients with chronic rheumatic diseases in childhood: a retrospective real life review of a single center cohort

Abstract Background: Adverse drug reactions (ADRs) are the sixth leading causes of death worldwide; monitoring them is fundamental, especially in patients with disorders like chronic rheumatic diseases (CRDs). The study aimed to describe the ADRs investigating their severity and associated factors and resulting interventions in pediatric patients with CRDs. Methods: A retrospective, descriptive and analytical study was conducted on a cohort of children and adolescents with juvenile idiopathic arthritis (JIA), juvenile systemic lupus erythematosus (JSLE) and juvenile dermatomyositis (JDM). The study evaluated medical records of the patients to determine the causality and the management of ADRs. In order to investigate the risk factors that would increase the risk of ADRs, a logistic regression model was carried out on a group of patients treated with the main used drug. Results: We observed 949 ADRs in 547 patients studied. Methotrexate (MTX) was the most frequently used medication and also the cause of the most ADRs, which occurred in 63.3% of patients, followed by glucocorticoids (GCs). Comparing synthetic disease-modifying anti-rheumatic drugs (sDMARDs) vs biologic disease-modifying antirheumatic drugs (bDMARDs), the ADRs attributed to the former were by far higher than the latter. In general, the severity of ADRs was moderate and manageable. Drug withdrawal occurred in almost a quarter of the cases. In terms of risk factors, most patients who experienced ADRs due to MTX, were 16 years old or younger and received MTX in doses equal or higher than 0.6 mg/kg/week. Patients with JIA and JDM had a lower risk of ADRs than patients with JSLE. In the multiple regression model, the use of GCs for over 6 months led to an increase of 0.5% in the number of ADRs. Conclusions: Although the ADRs highly likely affect a wide range of children and adolescents with CRDs they were considered moderate and manageable cases mostly. However, triggers of ADRs need further investigations.(AU)

Tocilizumab for juvenile idiopathic arthritis: a single-center case series

ABSTRACT BACKGROUND: Juvenile idiopathic arthritis (JIA) is the commonest chronic rheumatic disease among children. When not treated effectively, JIA can lead to functional disability, due to joint damage, along with long-term morbidities. OBJECTIVES: To describe the use of tocilizumab therapy for 11 patients with polyarticular JIA (pJIA) and systemic JIA (sJIA) who presented inadequate response or were refractory to disease-modifying anti-rheumatic drugs (DMARDs) and/or other biological therapies; and to evaluate its benefits, safety and tolerability. DESIGN AND SETTING: Observational retrospective case series at a tertiary-level training and research hospital. METHODS: We reviewed the medical records of 11 consecutive patients with JIA who received tocilizumab (anti-IL-6) therapy in our pediatric nephrology and rheumatology outpatient clinic. We analyzed their demographic data, clinical and laboratory findings, treatment response and adverse reactions. We determined the efficacy of tocilizumab treatment using the American College of Rheumatology (ACR) pediatric (Pedi) response criteria, including ACR Pedi 30, 50, 70 and 90 scores. We used the Wilcoxon test to compare measurements before and after treatment. RESULTS: Tocilizumab was given to seven patients with sJIA and four with pJIA (one of the pJIA patients was rheumatoid factor-positive). In most patients, we observed improvement of symptoms, absence of articular and extra-articular inflammation and continued inactive disease. ACR Pedi 30, 50 and 70 scores were achieved by 90.9% of the patients. Five patients showed minor side effects, possibly due to use of tocilizumab. CONCLUSIONS: Tocilizumab therapy should be considered for treating patients with diagnoses of pJIA or sJIA who are resistant to non-biological DMARDs and/or other biological therapies.

Correlation of ultrasonography synovitis with disease activity and clinical response to etanercept treatment in juvenile idiopathic arthritis patients

This study aimed to investigate the correlation of ultrasonography (US) of synovitis with disease activity and clinical response to etanercept (ETN) in juvenile idiopathic arthritis (JIA) patients. Eighty-two JIA patients who underwent ETN treatment for 24 weeks were consecutively enrolled. US evaluations of 28 joints (shoulder, elbow, wrist, metacarpophalangeal, and proximal interphalangeal of hands and knee) at baseline were performed using grey-scale US and power doppler (PD) US, and US synovitis was defined as grey-scale abnormalities or PD abnormalities. Clinical response was assessed according to the ACRpedi 50 response criteria. In total, 2296 joints were scanned and 608 (26.5%) joints presented US synovitis, which was numerically higher than clinical synovitis (513 (22.3%)). The mean number of joints showing synovitis on US was 7.42±3.35, which was also numerically higher than that of clinical synovitis (6.26±2.70). The number of joints showing synovitis on US was positively correlated with C-reactive protein, erythrocyte sedimentation rate, number of joints with active disease, number of joints with limited range of motion, physician's global assessment of disease activity, parent/patient global assessment of overall well-being, and childhood health assessment questionnaire score. Most interestingly, the baseline number of joints showing synovitis on US was increased in ACRpedi 50 response JIA patients compared to non-response JIA patients, and it serves as an independent predictive factor for higher clinical response to ETN treatment. In conclusion, US is a more sensitive test to evaluate subclinical synovitis and disease activity in JIA patients, and US synovitis might serve as a marker for predicting increased clinical response rate to ETN treatment.

Latent tuberculosis infection screening in juvenile idiopathic arthritis patients preceding anti-TNF therapy in a tuberculosis high-risk country / Rastreamento da infecção latente por tuberculose em pacientes com artrite idiopática juvenil previamente à terapia anti-TNF em um país de alto risco para tuberculose

Abstract Objectives: To evaluate, in an endemic country, the long-term efficacy of latent tuberculosis infection (LTBI) screening and primary prophylaxis in patients with JIA receiving TNF blockers. Methods: This was a retrospective cohort that included JIA patients eligible to anti-TNF therapy. Patients were screened for LTBI prior to anti-TNF using tuberculin skin test (TST), chest X-ray and history of exposure to TB. Subjects were regularly followed at 2-month intervals. Results: Sixty-nine JIA patients with current age of 17.4 ± 5.8 years, mean disease duration of 5.0 ± 4.9 years were included. Forty-seven patients received a single anti-TNF, while 22 patients switched to another anti-TNF once or twice: 57 were treated with etanercepte, 33 patients with adalimumab and 3 infliximab. LTBI screening was positive in three patients: one had TST-positive and history of TB exposure and two had solely TST-positive. No active TB was diagnosed during the study period (median of follow-up was 3.8 years). Conclusion: Long-term evaluation revealed that LTBI screening and primary prophylaxis before anti-TNF treatment was effective in a high-risk country and TST was the most sensitive parameter to identify these patients.

Resumo Objetivo: Avaliar, em um país endêmico, a eficácia em longo prazo do rastreamento à procura de infecção latente por tuberculose (ILTB) e profilaxia primária em pacientes com AIJ em uso de bloqueadores do TNF. Métodos: Trata-se de uma coorte retrospectiva que incluiu pacientes com AIJ elegíveis para a terapia anti-TNF. Os pacientes foram rastreados à procura de ILTB previamente ao uso de anti-TNF por meio do teste tuberculínico (TT), radiografia de tórax e história de exposição à TB. Os indivíduos foram acompanhados regularmente em intervalos de dois meses. Resultados: Incluíram-se 69 pacientes com AIJ com idade atual de 17,4 ± 5,8 anos, com média de duração da doença de 5 ± 4,9 anos; 47 pacientes receberam um único anti-TNF, enquanto 22 foram transferidos para outro anti-TNF uma ou duas vezes: 57 foram tratados com etanercepte, 33 com adalimumabe e três com infliximabe. O rastreamento à procura de ILTB foi positivo em três pacientes: um era TT positivo e tinha história de exposição à TB e dois apenas eram TT positivo. Não foi diagnosticado caso de TB ativa durante o período de estudo (mediana de seguimento de 3,8 anos). Conclusão: A avaliação em longo prazo revelou que o rastreamento à procura de ILTB e a profilaxia primária antes do tratamento com anti-TNF foram eficazes em um país de alto risco para TB e o TT foi o parâmetro mais sensível para identificar esses pacientes.

A fatal case of tuberculous meningitis in a child with juvenile idiopathic arthritis: a diagnostic challenge

Abstract The prognosis of tuberculous meningitis, a rare form of extrapulmonary tuberculosis, depends on the stage of treatment initiation. We report a fatal case of tuberculous meningitis. The patient had received successive tumor necrosis factor (TNF) antagonists and abatacept to treat juvenile idiopathic arthritis, with negative results for polymerase chain reaction and acid-fast bacilli on smear, had normal cerebrospinal fluid (CSF) adenosine deaminase and glucose levels. Six weeks post-admission, the CSF culture demonstrated Mycobacterium tuberculosis. The altered immunological responses caused by anti-TNF treatment made the diagnosis challenging. Clinicians should bear this in mind and, if suspected, treatment should be initiated immediately.

Evolución de pacientes con artritis idiopática juvenil en terapia biológica que cursan infección por virus varicela zoster: a propósito de 4 casos / Outcomes of patients with juvenile idiopathic arthritis on biological therapy and have a varicella-zoster virus infection

En niños inmunocomprometidos, la infección por virus varicela puede producir una enfermedad grave. Existen pocos casos publicados de varicela en pacientes con artritis idiopática juvenil (AIJ) y terapia biológica. OBJETIVO: Describir la evolución de pacientes con AIJ con terapia biológica que adquirieron el virus varicela. CASOS CLÍNICOS: Se describe la historia clínica de 4 pacientes con AIJ, de entre 3 y 12 años de edad, que presentaron infección por virus varicela zoster estando con distintas terapias biológicas: 2 con anti TNF, uno con anti IL-6 y uno con bloqueador de la coestimulación del linfocito T. Dos de ellos habían recibido la vacuna contra la varicela. Todos recibieron diferentes terapias y evolucionaron sin complicaciones, no encontrando diferencias importantes en relación con el tipo de terapia biológica ni con el antecedente de haber sido vacunados. En todos los pacientes se suspendió el tratamiento biológico por al menos 2 semanas y se reinició sin reactivación de la artritis. CONCLUSIONES: En esta serie de pacientes con AIJ tratados con terapia biológica que cursaron con infección por VVZ no se observaron complicaciones graves.

Varicella virus infection may develop into severe disease in immunocompromised children. There are few studies that describe the clinical presentation of varicella infection in patients with Juvenile Idiopathic Arthritis when on biological therapy. OBJECTIVE: Describe the outcomes of patients with a diagnosis of Juvenile Idiopathic Arthritis, who acquired a varicella virus infection during treatment with biological therapy. CLINICAL CASES: A description is presented on 4 cases of Juvenile Idiopathic Arthritis in children between 3 and 12 years old, who developed a varicella-zoster infection during treatment with different biological therapies. Two patients were taking anti-TNF agents, one an Anti IL-6 agent, and one patient a T cell costimulatory blockade agent. Two of them received varicella vaccination prior to the start of biological therapy. All of them received different therapies and had favourable outcome without developing complications. No significant differences were found as regards the type of biological therapy or history of previous vaccination. Biological therapy was suspended for at least 2 weeks in all patients, and was restarted without reactivation of arthritis. CONCLUSIONS: No serious complications were observed in this patient series of children with JIA treated with biological therapy associated with VZV infection.

Effects of the use of growth hormone in children and adolescents with juvenile idiopathic arthritis: a systematic review / Efeitos do uso do hormônio de crescimento em crianças e adolescentes com artrite idiopática juvenil: revisão sistemática

Abstract Introduction: Children with juvenile idiopathic arthritis (JIA) often have impaired growth and short stature. There is evidence that the therapeutic use of growth hormone (GH) is useful and safe in these patients. Objective: To analyze the effects of GH use in patients with JIA. Method: A systematic review of the literature over the last 18 years in Medline and Embase databases. The criteria were analyzed independently by the researchers. We used the following keywords: "growth hormone", "arthritis, juvenile", "arthritis, rheumatoid", "child" and "adolescent". Results: Among the 192 identified articles, 20 corresponded to the inclusion criteria. Seventeen longitudinal studies and 3 case reports were found. Most studies analyzed observed increased growth, muscle mass and bone mass using GH. Adverse effects observed were glucose intolerance, diabetes, bone deformities, osteonecrosis, reactivation of the disease and low final height. Conclusion: The majority of studies reported positive effects after the therapeutic use of GH, but some variability in response to treatment was observed. The combination of growth hormone with other drugs seems to be a good option.

Resumo Introdução: Crianças com artrite idiopática juvenil (AIJ) frequentemente apresentam prejuízo no crescimento e baixa estatura. Existem evidências de que o uso terapêutico do hormônio de crescimento (GH) é útil e seguro nesses pacientes. Objetivo: Analisar os efeitos do uso de GH em pacientes com AIJ. Método: Fez-se revisão sistemática da literatura nos últimos 18 anos, nas bases de dados Medline e Embase. Os critérios foram analisados pelos pesquisadores de forma independente. Usaram-se os seguintes descritores: growth hormone, arthritis, juvenile, arthritis, rheumatoid, child e adolescent. Resultados: Entre os 192 artigos identificados, 20 corresponderam aos critérios de inclusão. Foram encontrados 17 estudos longitudinais e três relatos de casos. A maioria dos estudos analisados observou um aumento de crescimento, massa muscular e massa óssea com o uso do GH. Os efeitos adversos observados foram intolerância à glicose, diabetes, deformidades ósseas, osteonecrose, reativação da doença e altura final baixa. Conclusão: A maioria dos estudos relatou efeitos positivos após uso terapêutico do GH, porém certa variabilidade na resposta ao tratamento foi observada. A combinação do hormônio de crescimento com outros medicamentos parece ser uma boa opção.

Medication adherence in patients with juvenile idiopathic arthritis / Adesão ao tratamento farmacológico em pacientes com artrite idiopática juvenil por meio de questionários

ABSTRACT Objective: The aim of this study was to investigate pharmacological treatment adherence of patients with juvenile idiopathic arthritis, attended in an outpatient pharmacy at a tertiary hospital in northeastern Brazil. Methods: The analysis of adherence was performed along with caregivers, through a structured questionnaire based on Morisky, Green and Levine, which enabled the categorization of adherence in “highest”, “moderate” or “low” grades, and through evaluating medication dispensing registers, which classified the act of getting medications at the pharmacy as “regular” or “irregular”. Drug Related Problems (DRP) were identified through the narrative of caregivers and classified according to the Second Granada Consensus. Then, a pharmaceutical orientation chart with information about the therapeutic regimen was applied, in order to function as a guide for issues that influenced adherence. Results: A total of 43 patients was included, with a mean age of 11.12 years, and 65.1% (n = 28) were female. Applying the questionnaire, it was found “highest” adherence in 46.5% (n = 20) patients, “moderate” adherence in 48.8% (n = 21), and “low” adherence in 4.7% (n = 2). Through an analysis of the medication dispensing registers, a lower level of adherence was observed: only 25.6% (n = 11) of the participants received “regularly” the medications. Twenty-six DRP was identified, and 84.6% (n = 22) were classified as real. There were no significant associations between socio-demographic variables and adherence, although some caregivers have reported difficulty in accessing the medicines and in understanding the treatment. Conclusion: Our findings showed problems in the adherence process related to inattention, forgetfulness and irregularity in getting medicines, reinforcing the need for the development of strategies to facilitate a better understanding of treatment and to ensure adherence.

RESUMO Objetivo: Investigar a adesão ao tratamento farmacológico de pacientes com artrite idiopática juvenil, atendidos na farmácia ambulatorial de hospital terciário do Nordeste do Brasil. Métodos: A análise da adesão foi feita junto aos cuidadores, por meio de questionário estruturado com base no teste de Morisky, Green e Levine, que viabilizou a categorização da adesão em “máxima”, “moderada” ou “baixa”, e da avaliação dos registros de dispensação dos medicamentos, que classificou a retirada de medicamentos na farmácia como “regular” ou “irregular”. Os problemas relacionados com medicamentos (PRM) foram identificados por meio da narrativa dos cuidadores e classificados conforme o Segundo Consenso de Granada. Em seguida, aplicou-se uma tabela de orientação farmacêutica, que contém informações sobre o esquema terapêutico, de forma a esclarecer questões que influenciavam a adesão. Resultados: Participaram 43 pacientes, com média de 11,12 anos, 65,1%, (n = 28) do sexo feminino. Por meio do questionário, verificou-se adesão “máxima” em 46,5% (n = 20) dos pacientes, “moderada” em 48,8% (n = 21) e “baixa” em 4,7% (n = 2). Pelo registro de dispensação, observou-se um nível de adesão menor: apenas 25,6% (n = 11) dos participantes receberam os medicamentos “regularmente”. Identificaram-se 26 PRM, 84,6% (n = 22) classificados como “reais”. Não foram observadas associações significativas entre as variáveis sociodemográficas e a adesão, embora alguns cuidadores tenham relatado dificuldade de acesso ao medicamento e de compreensão do tratamento. Conclusão: Nossos achados demonstraram falhas no processo de adesão, relacionadas ao descuido, esquecimento e à irregularidade para receber os medicamentos, o que reforça a necessidade de estratégias para facilitar a compreensão do tratamento e garantir a adesão

Intra-articular injection in patients with juvenile idiopathic arthritis: factors associated with a good response / Infiltração intra-articular em pacientes com artrite idiopática juvenil: fatores associados à boa resposta

ABSTRACT Introduction: Intra-articular injection of corticosteroids (IIC) for treatment of patients with juvenile idiopathic arthritis (JIA) is increasingly used in Pediatric Rheumatology. Objectives: To describe the clinical course of patients undergoing IIC in our Pediatric Rheumatology Unit. Methods: Retrospective study of patients with JIA undergoing IIC from January 2008 to December 2012, with a minimum follow-up of six months after the injection. Good response to IIC was set as the presence of inactivity on the infiltrated joint by at least six months. Results: Eighty-eight patients underwent a total of 165 IICs. Of these, 75% were girls and 35.2% had persistent oligoarticular JIA. The mean age at diagnosis was 6.8 years, and when IIC was carried out, 12.2 years. Regarding patients, younger age at diagnosis (p = 0.037) and the occurrence of uveitis in the course of the disease (p = 0.015) were associated with good response to IIC. From 165 IICs, 63% had a good response and joints remained inactive for a median of 18.1 months. The type of joint injection (p = 0.001), lesser values stated in the overall visual analog scale by the physician (p = 0.015) and by parents/patient (p = 0.01) have been associated with a good response to IIC. Nine adverse events (5.4%) were observed. Conclusion: In our study, more than half of the joints showed a good response to IIC. Younger patients at diagnosis and uveitis during the course of the disease had good response to IIC. Knees, wrists and elbows were the joints that best responded to IIC. IIC proved to be a safe procedure.

RESUMO Introdução: A infiltração intra-articular de corticosteroides (IIC) para tratamento de pacientes com artrite idiopática juvenil (AIJ) é cada vez mais usada em reumatologia pediátrica. Objetivos: Descrever a evolução clínica dos pacientes submetidos à IIC em nosso setor de reumatologia pediátrica. Métodos: Estudo retrospectivo de pacientes com AIJ submetidos à IIC de janeiro/2008 a dezembro/2012, com seguimento mínimo de seis meses após a infiltração. Boa resposta à IIC foi definida como inatividade na articulação infiltrada por, no mínimo, seis meses. Resultados: Foram submetidos a 88 pacientes a 165 IICs. Desses, 75% eram meninas e 35,2% apresentavam AIJ oligoarticular persistente. A média de idade ao diagnóstico foi de 6,8 anos e à IIC de 12,2 anos. Em relação aos pacientes, a menor idade ao diagnóstico (p = 0,037) e a ocorrência de uveíte no curso da doença (p = 0,015) foram associados à boa resposta à IIC. Das 165 IICs, 63% apresentaram boa resposta e as articulações permaneceram inativas por um tempo médio de 18,1 meses. O tipo de articulação infiltrada (p = 0,001), menores valores na escala visual analógica global do médico (p = 0,015) e dos pais/paciente (p = 0,01) foram associados a uma boa resposta à IIC. Nove efeitos adversos (5,4%) foram observados. Conclusão: Em nosso estudo, mais da metade das articulações mostrou boa resposta à IIC. Os pacientes com menor idade ao diagnóstico e uveíte durante o curso da doença tiveram boa resposta à IIC. Os joelhos, punhos e cotovelos foram as articulações que mais bem responderam à IIC. A IIC mostrou ser um procedimento seguro.

Eficacia y seguridad del uso de tocilizumab para el tratamiento de artritis idiopatica juvenil en pacientes con falla alt ratamiento con aines, glucocorticoides y farmes / Efficacy and safety of the use of tocilizumab for the treatment of juvenile idiopathic arthritis in patients with failure to treat with aines, glucocorticoids and pharmacies

INTRODUCCIÓN: Antecedentes: El presente dictamen responde a la solicitud de evaluación del uso fuera del petitorio de tocilizumab para el tratamiento de pacientes con Artritis Idiopática Juvenil refractarios a tratamiento con FARMES. La Artritis Idiopática Juvenil (AIJ) engloba varios tipos de artritis crónica cuyo inicio se da antes de los 16 años, y está dada de manera general por un mal funcionamiento del sistema inmune que resulta en producción excesiva de moléculas pro-inflamatorias dirigidas principalmente a la membrana (revestimiento de las articulaciones). Tecnologia Sanitaria de Interés: Tocilizumab, con nombre comercial Actemra, es un anticuerpo monoclonal recombinante humanizado contra el receptor de interleucina-6 (IL-6). Este anticuerpo se une a los receptores de IL-6 que se encuentran en las membranas celulares o disueltos en el plasma, interrupiendo la unión de la IL-6 con su receptor en los tejidos. La IL-6 es una citoquina pro-inflamatoria secretada por células del sistema inmune, y que participa en diversas patologias asociadas a procesos inflamatorios. Tocilizumab ejerce su acción bloqueando los receptos de IL-6 de tal manera que no pued ser activada la cascada de señalización intracelular que lleva a la inflamación de los tejidos. METODOLOGÍA: Estrategia de Busqueda: Se utilizó el motor de búsqueda Pubmed empleando el algoritmo mostrado en la subsección B y los filtros correspondientes a meta-análisis, revisiones sistemáticas y ensayos clínicos, en línea con los criterios de elegibilidad. Se llevó a cabo una búsqueda sistemática de la literatura con respecto a la eficacia y seguridad de tocilizumab para el tratamiento de Artritis Idiopática Juvenil de varidad sistémica. La búsqueda se inició revisando la información sobre el uso del medicamento de acuerdo con entidades reguladoras como la Food And Drug Administration (FDA), la European Medicines Agency (EMA) y la Dirección General de Medicamentos y Drogas (DIGEMID). Posteriormente, se revisaron las bases de datos de PubMed, TRIPDATABASE y www.clinicaltrials.gov. Adicionalmente, se realizó una búsqueda de evaluaciones de tecnologías y guías de práctica clínica en las páginas wev de grupos dedicados a la invstigación y educación en salud en general como The National Institute for Health and Care Excellence (NICE); y especializados en Enfermedades Reumatoides como el American College or Rheumatology (ACR). RESULTADOS: Sinopsos de la Evidencia: De acuerdo con la pregunta PICO, se llevó a cabo una búsqueda de evidencia científica relacionada al uso de tocilizumab como tratamiento de pacientes con Artritis Idiopática Juvenil varidad sistémica refractaria a tratamiento convencional con AINEs, corticoides y FARMEs. En la presente sinopsis se describe la evidencia disponible según el tipo de publicación, siguiendo lo indicado en los criterios de elegibilidad (GPC, ETS, RS, MA y ECA fase III). CONCLUSIONES: La GPC y la ETS recomiendan el uso de tocilizumab como una alternativa de tratamiento de AIJ sistémica en niños mayores de 2 años quienes han presentado una respuesta inadecuada a AINEs, corticosteroides sistémicos y metotrexato (FARME). Tocilizumab presenta una mayor frecuencia de eventos adversos moderados y severos en comparación con placebo. Sin embargo, estos son controlables. Tocilizumab no está recomendado para el tratamiento de pacientes mayores de 2 años con AIJ que responden al tratamiento con metotrexato o no han sido tratados con metotrexato previamente. El Instituto de Evaluaciones de Tecnologías en Salud e Investigación-IETSI, aprueba el uso de tocilizumab para el manejo de los pacientes con diagnóstico de AIJ variedad sistémica refractaria a AINEs corticosteroides y FARMEs.

La artritis reumatoidea juvenil y su influencia en la alteración de desarrollo de la mandíbula / Juvenile rheumatoid arthritis and its influence on the alteration of jaw development

La artritis reumatoidea juvenil (ARJ) es una enfermedad inflamatoria autoinmune que se presenta en niños menores de 16 años. Es de curso crónico, etiología desconocida, y afecta sobre todo las articulaciones, como la temporomandibular (ATM). El daño de la ATM puede ocasionar: alteraciones en el crecimiento facial (micrognatia), maloclusión clase II, mordida abierta anterior, desviaciones laterales, erosiones óseas, destrucción del cón-dilo, oclusión disfuncional y alteración de la estética facial, entre otras consecuencias. La posición oclusal neurofisiológica lograda por medio de elementos electrónicos, como el Transcutaneus Electrical Neural Stimulation (TENS), y mantenida por el Dispositivo Intaroral (DIO) podría posibilitar la remodelación de la cabeza del cóndilo, en pacientes en crecimiento, en los que la enfermedad se halla controlada, regulando así también la sintomatología dolorosa...

Coorte Sarar: atividade de doença, capacidade funcional e dano radiológico em pacientes com artrite reumatoide submetidos à artroplastia total de quadril e joelho / Sarar cohort: disease activity, functional capacity, and radiological damage in rheumatoid arthritis patients undergoing total hip and knee arthroplasty

RESUMOObjetivos:A coorte Sarar é composta por pacientes portadores de artrite reumatoide (AR) e artrite idiopática juvenil (AIJ) submetidos a artroplastias de quadril e joelho no hospital Sarah-Brasília. O objetivo deste estudo foi avaliar fatores clínicos e laboratoriais associados à atividade de doença, capacidade funcional e dano radiológico em pacientes com AR, participantes dessa coorte.Métodos:Estudo transversal, com coleta de dados em revisão de prontuário.Resultados:Foram incluídos 32 pacientes, com tempo médio de início da doença de 240 meses. Dezenove pacientes foram submetidos a ATJ e 17, a ATQ. Foi encontrada correlação positiva entre dose máxima de metotrexato (MTX) durante a evolução e Clinical Disease Activity Index (CDAI) (R = -0,46, p = 0,011) e negativa com Simplified Erosion and Narrowing Score (SENS) (R = -0,58, p = 0,004). Valores de SENS foram maiores nos pacientes com fator reumatoide (FR) (p = 0,005) e anticorpo antipeptídeo cíclico citrulinado 3 (anti-CCP3) positivo (p = 0,044), nos com maiores títulos de FR (p = 0,037) e anti-CCP3 (p = 0,025) e menores nos pacientes com história familiar de AR (p = 0,009). Valores de HAQ foram maiores em pacientes mais idosos (p = 0,031). Na regressão linear múltipla, somente “dose máxima de MTX” e “história familiar” permaneceram com associação significativa com SENS (r2= 0,73, p < 0,001 para ambas as variáveis). No modelo que avaliou CDAI, apenas “dose máxima de MTX” permaneceu com associação significativa (r2 = 0,35, p = 0,016).Conclusão:Na coorte Sarar, fatores clínicos e laboratoriais estiveram relacionados à atividade de doença, capacidade funcional e dano radiológico, semelhantemente a estudos que avaliaram pacientes com menor tempo de doença.

ABSTRACTObjectives:The Sarar cohort consists of patients with rheumatoid arthritis and juvenile idiopathic arthritis who underwent hip or knee arthroplasties at hospital SARAH-Brasília. The objective of this study was to evaluate clinical and laboratory factors associated with disease activity, functional capacity and radiological damage in rheumatoid arthritis patients, participants in this cohort.Methods:Cross-secal study, with data collection achieved from medical records review.Results:Thirty-two patients were included, with a mean time of disease onset of 240 months. Nineteen patients underwent total knee and 17 total hip arthroplasty. There was a positive correlation between maximum dose of methotrexate and Clinical Disease Activity Index (R = −0.46, p = 0.011), and a negative one with Simplified Erosion and Narrowing Score (R = −0.58, p= 0.004). Simplified Erosion and Narrowing Score values were higher in patients with rheumatoid factor (p = 0.005) and anti-cyclic citrullinated peptide antibody 3 positivity (p = 0.044), in those with higher rheumatoid factor (p = 0.037) and anti-cyclic citrullinated peptide antibody 3 (p = 0.025) titers, and lower in patients with family history of rheumatoid factor (p = 0.009). Health Assessment Questionnaire values were higher in older patients (p = 0.031). In multiple linear regression, only “maximum dose of methotrexate” and “family history” remained with significant association with Simplified Erosion and Narrowing Score (r2 = 0.73, p < 0.001 for both variables). In the model evaluating “Clinical Disease Activity Index” only “maximum dose of methotrexate” remained significantly associated (r2 = 0.35, p = 0.016).Conclusion:In the Sarar cohort, clinical and laboratory factors were related to disease activity, functional capacity and radiological damage, similar to studies evaluating patients with lower disease duration.