Elsevier

Joint Bone Spine

Volume 76, Issue 1, January 2009, Pages 24-27
Joint Bone Spine

Original article
Efficacy and safety of TNFα antagonist therapy in patients with juvenile spondyloarthropathies

https://doi.org/10.1016/j.jbspin.2008.03.008Get rights and content

Abstract

Objectives

To evaluate the efficacy and safety of TNFα antagonist therapy in patients with juvenile spondyloarthropathies refractory to nonsteroidal anti-inflammatory drugs (NSAIDs).

Methods

Retrospective review of the medical charts of 20 patients (16 males and 4 females) with a mean age of 11.6 years at diagnosis. Median time from diagnosis to initiation of TNFα antagonist therapy was 41 months. Escape phenomenon developed in 3 patients, who were switched to another TNFα antagonist. Etanercept was used for 19/23 treatments, infliximab for 3/23 treatments, and adalimumab for 1 treatment. The efficacy criteria were morning stiffness duration; nocturnal awakenings; tender and swollen joint counts; entheseal count; back, buttock, and hip pain; percentage of patients on NSAIDs and/or glucocorticoid therapy; and mean and median values of the erythrocyte sedimentation rate, C-reactive protein level, and hemoglobin level. A remission was defined as resolution of the axial and peripheral pain, joint swelling, and laboratory evidence of inflammation, with or without continued NSAID therapy.

Results

TNFα antagonist therapy was associated with clinical and laboratory improvements after 3 months, and the benefits were sustained after 1 year. Axial pain required 6 months to improve. A remission was achieved in 59% of patients after 3 months and 70% after 6 and 12 months. Median time to remission under treatment was 3 months. The interval between the TNFα antagonist injections was increased for 12/18 treatments and the treatment was stopped in 7 cases. However, treatment discontinuation was consistently followed by a relapse, after a median time of 2.5 months. Two serious adverse events occurred, namely, acute bacterial pneumonia and recurrent impetigo; in both cases the outcome was promptly favorable after a brief interruption of the TNFα antagonist.

Conclusion

TNFα antagonist therapy seems safe and rapidly effective in patients with juvenile spondyloarthropathies refractory to NSAIDs, in keeping with data from adults. However, prospective studies in larger patient populations are needed.

Section snippets

Patients

We identified 20 patients who were given TNFα antagonists for at least 3 months to treat juvenile spondyloarthropathies meeting ILAR criteria as revised in Edmonton [5]. Before TNFα antagonist initiation, 18 of the 20 patients received one or more disease-modifying antirheumatic drugs (DMARDs), usually sulfasalazine, azathioprine, and/or methotrexate. All 20 patients had active disease (nocturnal pain, morning stiffness, and peripheral arthritis and/or enthesopathy) despite regular NSAID

Methods

The patients were identified by reviewing the medical records of patients, with juvenile spondyloarthropathy seen by either of two pediatric rheumatologists (CJD et PQDM) between December 1999 and January 2007. The first patient was started on TNFα antagonist therapy in September 2001 and the last patient in October 2006.

For each patient, the following data were abstracted from the medical chart: clinical presentation during the first year, treatments used before TNFα antagonist therapy,

Results

There were 16 males and 4 females with a mean age of 11.6 ± 2.3 years at diagnosis (range, 8–16.5 years). Mean time from symptom onset to diagnosis was 10.9 ± 19 months (range, 0–72 months). Mean disease duration at TNFα antagonist initiation was 10.0 ± 6.5 years. Of the 14 patients tested for the HLA B27 antigen, 13 were positive. A family history of spondyloarthropathy was noted in 8 patients. Extraarticular symptoms were present in 4 patients before TNFα antagonist initiation; they consisted of

Discussion

Juvenile spondyloarthropathies (enthesitis-related arthritis in the Edmonton revision of the ILAR criteria [5]) carry a fairly severe prognosis, with greater long-term alterations in function and quality of life compared to other forms of juvenile idiopathic arthritis [7]. Early effective treatment is therefore crucial. Studies have established that TNFα antagonist therapy is effective in adults with spondyloarthropathies [3], [4], [8], in juvenile idiopathic arthritis overall [9], and in

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