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Why 2013 Was an Important Year for Juvenile Arthritis

Rheumatologists weigh in on the important news regarding JA medications, treatments and genetic discoveries and explain what they could mean for your child.

By Kelli Miller, ELS

During 2013, there was a lot of news regarding the treatment of juvenile idiopathic arthritis (JIA). But navigating the news – and understanding the research – can be complicated and time-consuming, particularly when you’re caring for a child with arthritis. We asked pediatric rheumatology experts how new drug approvals, advances in drug delivery and other treatment-related news could impact your child’s outcome and care.

“There is a great deal of excitement regarding a wide spectrum of juvenile arthritis treatments that are helping more and more children with JA have improvement and experience remission of their disease,” says Ann Reed, MD, chair of the department of pediatrics and adolescent medicine at the Mayo Clinic, Rochester, Minn.

Here’s what you need to know.

A Boom for Biologics
Biologics continue to have a meaningful impact for many kids with juvenile arthritis. In 2013, the U.S. Food and Drug Administration approved two biologics for children with JIA and studies involving a third have shown promise. 

• Canakinumab (Ilaris) is the first biologic to be approved specifically for kids with active systemic JIA (sJIA), an uncommon but especially severe form of childhood arthritis. Canakinumab blocks interleukin-1 (IL-1), a protein that helps trigger inflammation. The drug’s May 2013 approval came after studies involving sJIA patients aged 2 to 19 showed significant symptom improvement in most of those who took the drug. "To have effective therapies that control systemic features is a huge breakthrough,” says Daniel Lovell, MD, associate director of the division of rheumatology at Cincinnati Children's Hospital Medical Center and professor of pediatrics at the University of Cincinnati in Ohio. “Despite advances [in treatment] for other types of JIA, we really don't have good treatments for sJIA, the form that is most severe and associated with the highest mortality."

• Tocilizumab (Actemra) received FDA approval in 2013 for kids with polyarticular JIA. (It was already approved for kids with sJIA and adults with rheumatoid arthritis [RA].) It blocks an inflammation-provoking protein called interleukin-6 (IL-6). How will this new drug fit into your child’s treatment regimen? Some pediatric rheumatologists say the verdict is still out. “Most pediatric rheumatologists will continue to use tumor necrosis factor (TNF) inhibitors as the first-line biologic treatment for JIA, because of their years of experience and comfort with them. But tocilizumab is definitely an option for a child whose arthritis does not improve enough with TNF inhibitors. “The overall impact of tocilizumab on the treatment of polyarticular JIA, in general, may not be huge, but for the individual child who is not doing well with the other biologics, it could be life changing,” says Timothy Beukelman, MD, a pediatric rheumatologist and associate professor of pediatrics in the division of rheumatology at the University of Alabama at Birmingham School of Medicine. 

• Rilonacept (Arcalyst) is another drug that blocks IL-1. Research presented in 2013 showed that, for kids with sJIA, it works and it is relatively safe. But, it is experimental and not approved by the FDA as of January 2014. Dr. Beukelman says “despite being effective and safe, rilonacept is unlikely to have a huge impact on the overall treatment of sJIA in the near future, because it does not appear to be significantly different from the currently available IL-1 inhibitors,” which include canakinumab (Ilaris). A potential drawback for this drug: Rilonacept is a weekly injection, instead of a monthly one like canakinumab. That means more frequent shots for your child.

 

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Why 2013 Was an Important Year for Juvenile Arthritis

Rheumatologists weigh in on the important news regarding JA medications, treatments and genetic discoveries and explain what they could mean for your child.

By Kelli Miller, ELS


During 2013, there was a lot of news regarding the treatment of juvenile idiopathic arthritis (JIA). But navigating the news – and understanding the research – can be complicated and time-consuming, particularly when you’re caring for a child with arthritis. We asked pediatric rheumatology experts how new drug approvals, advances in drug delivery and other treatment-related news could impact your child’s outcome and care.

“There is a great deal of excitement regarding a wide spectrum of juvenile arthritis treatments that are helping more and more children with JA have improvement and experience remission of their disease,” says Ann Reed, MD, chair of the department of pediatrics and adolescent medicine at the Mayo Clinic, Rochester, Minn.

Here’s what you need to know.

A Boom for Biologics
Biologics continue to have a meaningful impact for many kids with juvenile arthritis. In 2013, the U.S. Food and Drug Administration approved two biologics for children with JIA and studies involving a third have shown promise. 

• Canakinumab (Ilaris) is the first biologic to be approved specifically for kids with active systemic JIA (sJIA), an uncommon but especially severe form of childhood arthritis. Canakinumab blocks interleukin-1 (IL-1), a protein that helps trigger inflammation. The drug’s May 2013 approval came after studies involving sJIA patients aged 2 to 19 showed significant symptom improvement in most of those who took the drug. "To have effective therapies that control systemic features is a huge breakthrough,” says Daniel Lovell, MD, associate director of the division of rheumatology at Cincinnati Children's Hospital Medical Center and professor of pediatrics at the University of Cincinnati in Ohio. “Despite advances [in treatment] for other types of JIA, we really don't have good treatments for sJIA, the form that is most severe and associated with the highest mortality."

• Tocilizumab (Actemra) received FDA approval in 2013 for kids with polyarticular JIA. (It was already approved for kids with sJIA and adults with rheumatoid arthritis [RA].) It blocks an inflammation-provoking protein called interleukin-6 (IL-6). How will this new drug fit into your child’s treatment regimen? Some pediatric rheumatologists say the verdict is still out. “Most pediatric rheumatologists will continue to use tumor necrosis factor (TNF) inhibitors as the first-line biologic treatment for JIA, because of their years of experience and comfort with them. But tocilizumab is definitely an option for a child whose arthritis does not improve enough with TNF inhibitors. “The overall impact of tocilizumab on the treatment of polyarticular JIA, in general, may not be huge, but for the individual child who is not doing well with the other biologics, it could be life changing,” says Timothy Beukelman, MD, a pediatric rheumatologist and associate professor of pediatrics in the division of rheumatology at the University of Alabama at Birmingham School of Medicine. 

• Rilonacept (Arcalyst) is another drug that blocks IL-1. Research presented in 2013 showed that, for kids with sJIA, it works and it is relatively safe. But, it is experimental and not approved by the FDA as of January 2014. Dr. Beukelman says “despite being effective and safe, rilonacept is unlikely to have a huge impact on the overall treatment of sJIA in the near future, because it does not appear to be significantly different from the currently available IL-1 inhibitors,” which include canakinumab (Ilaris). A potential drawback for this drug: Rilonacept is a weekly injection, instead of a monthly one like canakinumab. That means more frequent shots for your child.

Less Painful Methotrexate Shots
A new delivery method for methotrexate may give kids with arthritis a less painful way to take the medicine. The FDA approved a single-dose auto-injector form of methotrexate (Otrexup) in late 2013 for adults with RA and kids with active polyarticular JIA a who cannot tolerate or do not get better with first-line therapies, including nonsteroidal anti-inflammatory drugs (NSAIDs). “[The auto-injector] provides a quicker shot. That should be less painful and scary for kids,” says Donald Miller, PharmD, professor and chair of the pharmacy practice department at North Dakota State University in Fargo, N.D. Another thing that makes Otrexup different than existing methotrexate injections: It’s pre-filled. That means parents no longer have to draw up a syringe and fill it from a multi-dose vial.

Aggressive Treatment Is Best
Children with JIA who are aggressively treated with multiple medications soon after the disease appears spend more time without symptoms than kids treated with a single drug or who start aggressive treatment later, according to research presented at the American College of Rheumatology 2013 Annual Meeting. This finding upholds an earlier study showing that early, aggressive JIA treatment works better than regimens that start slowly and step up to stronger therapies over time. In the studies, the aggressive therapy involved the combination of methotrexate, entanercept (Enbrel) and prednisolone.

New Guidelines for Treating sJIA
The American College of Rheumatology (ACR) released updated treatment recommendations in 2013 for kids with sJIA. The changes add information on canakinumab (Ilaris), tocilizumab (Actemra) and rilonacept (Arcalyst), which were not included in the 2011 guidelines. The new guidelines also recommend anakinra (Kineret) as a first-line treatment option for children with active systemic features, such as fever and rash, along with inflammation of the joint lining (synovitis) or macrophage activation syndrome (MAS). The update also helps guide the treatment for kids with sJIA and synovitis who are at risk for MAS. “If your child has JIA and has changes in blood counts or liver tests, ask his or her doctor about the possibility of MAS, which is common in sJIA,” advises Dr. Reed. Ask your doctor how the new recommendations affect your child’s treatment plan.

Knee Implants For Kids
Knee implants in young people with JIA are durable – but they don’t last quite as long as implants used in older patients with arthritis, according to results from a multicenter study. About 90 percent of knee replacements last 15 to 20 years in adults – but in kids, only about 75 percent of knee implants last that long.

JIA Genetic Link Breakthrough
The largest study-to-date of genetics and JIA has linked 14 new genes with the disease. The international study team also confirmed the link between three other genes and JIA. The breakthrough discovery will help researchers better understand what causes JIA and how the disease progresses, which could open new areas of research and treatment. The research appeared online in Nature Genetics in April 2013.

“The power of these studies is to take this information and merge this with other new biological data. Taken together, this data is extremely powerful in helping us improve diagnosis and treatment options,” says Dr. Reed.