what is spondyloarthritis? what is psoriatic arthritis?
DESCRIPTION
TRANSCRIPT
2011 Juvenile Arthritis 2011 Juvenile Arthritis ConferenceConference
Bob Colbert MD, PhDSenior Investigator
Chief, Pediatric Translational Research Branch
NIAMS/NIH
Juvenile Spondyloarthritis and
Psoriatic Arthritis
Disclosures:
• No financial relationships to disclose
Objectives:• Provide overview of symptoms,
diagnosis, current treatment options and disease-management for Juvenile Spondyloarthritis and Psoriatic Arthritis
What is Spondyloarthritis?What is Psoriatic
Arthritis?• Spondyloarthritis (SpA)
• Usually involves the back or spine, but does not always cause back pain
• Tender and painful ‘entheses’
• Patients may have eye and bowel inflammation
• Major long-term problem is excessive bone formation and fusion of the spine
• Psoriatic Arthritis (PsA)
• Psoriasis – rash due to inflammation of the skin
• Sausage digits (dactylitis), nail pitting, arthritis
What is Spondyloarthritis?
Sacroiliac Joints
Dactylitis
Psoriatic Skin Rash
Psoriatic Nail Changes
Eye Inflammation(Acute Anterior Uveitis)
• Pain• Redness• One eye or both
eyes• Photophobia• Blurred vision
How are JSpA and JPsA diagnosed ?
• Medical history
• Physical examination
• Laboratory tests of blood
Autoantibodies - Anti-nuclear antibody (ANA); Rheumatoid factor (RF)
Markers of inflammation – erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)
Genetic marker - HLA-B27
• There are several forms of JIA distinguished by number of joints involved, presence of fever, rash, lab tests
JIA Subtypes
Few Joints(less than 5) =Oligoarticular
Many Joints(5 or more) = Polyarticular
Fever/rash= Systemic
SpA (spine)= ERA
WithPsoriasis
= PsA
?
Juvenile Spondyloarthritis(Enthesitis-Related Arthritis)
• Arthritis and Enthesitis OR Arthritis or Enthesitis
• With two or more of following:
• Sacroiliac tenderness or inflammatory lumbosacral pain
• HLA-B27
• Family history of HLA-B27-associated disease
• Acute anterior uveitis
• Male, age >7 years
• Exclusions: psoriasis in patient or family, RF, systemic JIA
Juvenile Psoriatic Arthritis
• Arthritis and Psoriasis OR….
• Arthritis two features:
• Dactylitis
• Nail changes (pitting or onycholysis)
• Psoriasis in first degree relative
• Exclusions: RF, systemic JIA, classification as another form of JIA
Two Subgroups of JPsA
Younger age at onset
• Peak 2-3 years
• More girls, ANA+
• More like early onset oligo/poly JIA
• More small joint and wrist arthritis
Older age at onset
• Peak 10-12 years
• Girls = boys
• More enthesitis and axial involvement
• More like SpA
How common is juvenile arthritis ?
• Occurs in 1 child in every 1,000 each year
• Close to 294,000 children in the US have arthritis or another rheumatic disease
• One of the most common chronic inflammatory diseases of childhood
Lawrence RA, et al., Arth Rheum 1998; 41:778-799Sacks J et al., Arth Rheum 2007; 57:1439-1455
How do we treat JIA ?
Management of JIA
Goals
• Control/eliminate disease activity – pain and inflammation
• Preserve joint function
• Prevent long-term consequences of disease and therapy
Treatment Pyramid
NSAIDS,
PT/OT
NSAIDS,
PT/OT
GLU
CO
CO
RTIC
OID
S
Methotrexate, Corticosteroid
injections
Methotrexate, Corticosteroid
injections
Biologics(anti-TNF,
anti-IL-1, anti-IL-6)
Biologics(anti-TNF,
anti-IL-1, anti-IL-6)
EXPEXP
NSAIDs• Used frequently but no longer mainstay of therapy
• Naproxen, ibuprofen, tolectin, indomethacin, celebrex, oxaprozin approved for use in children
• Generally well tolerated in children, but not effective enough for majority of patients
Methotrexate• Important ‘anchor’ drug known to improve symptoms and
modify underlying course of disease; well tolerated
• Most effective when given as a shot - subcutaneously
Oral steroids• Low doses may help control disease – should not be used long-
term
Joint Injections• Long-lasting benefit in significant proportion (triamcinolone
hexacetamide)
• Multiple joints often done to quickly squelch disease; often done asleep
Management of JIA
Biologics Frequently Used in Juvenile Biologics Frequently Used in Juvenile ArthritisArthritis
Anti-TNF
• Etanercept* (Enbrel)
• Infliximab (Remicade)- also effective for JIA uveitis
• Adalimumab* (Humira) – also effective for JIA uveitis
Anti-IL-1
• Anakinra (Kineret; IL-1RA) (approved for CAPS)
• Rilonacept (Arcalyst, IL-1 TRAP) (approved for CAPS)
• Canakinumab (Ilaris; anti-IL-1) (approved for CAPS)
*FDA approved for poly, extended oligo and systemic JIA with poly course disease.
Biologics Frequently Used in Juvenile Biologics Frequently Used in Juvenile ArthritisArthritis
Anti-IL-6 (blocks soluble IL-6 receptor)
• Tocilizumab (Actemra, RoActemra) (recently approved for sJIA)
CTLA4 Ig (blocks T cell activation)
• Abatacept (Orencia) (approved for poly JIA)
Anti-CD20 (depletes B cells)
• Rituximab (Rituxan) (case reports effective in poly and systemic JIA)
Anti-Others
• Anti-IL-17, anti-IL-23/12, anti-IL-22
Why is it important to do Why is it important to do research in children ?research in children ?
To practice evidence-based To practice evidence-based medicinemedicine
If we don’t do research, every If we don’t do research, every treatment becomes a poorly treatment becomes a poorly controlled experimentcontrolled experiment
Observational Studies
•Retrospective chart review
–Often missing data; potential for bias
–Not rigorous; ?quality of data
•Prospective – “registry” – collect specific information on large numbers of patients
–Can be used to collect information on patients treated a specific way, but not randomized
Translational Studies
•Patient gives one or more samples
–Blood, urine, tissue
–Analysis for biomarkers: RNA, DNA, inflammatory proteins
•Information about the patient is collected at the same time
–Disease characteristics/Medications
•Long-term goal of personalized medicine
Spondyloarthritis
Thank you for your attention!
National Institute of Arthritis and
Musculoskeletal and Skin Diseases