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Juvenile Rheumatoid Arthritis Clinical Overview

Juvenile Rheumatoid Arthritis Clinical Overview. Daniel J. Lovell MD, MPH Levinson Professor of Pediatrics Division of Rheumatology Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio, USA. American College of Rheumatology Characteristics of JRA.

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Juvenile Rheumatoid Arthritis Clinical Overview

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  1. Juvenile Rheumatoid Arthritis Clinical Overview Daniel J. Lovell MD, MPH Levinson Professor of Pediatrics Division of Rheumatology Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio, USA

  2. American College of Rheumatology Characteristics of JRA Cassidy and Petty. Textbook of Pediatric Rheumatology, 2005

  3. Pain is Commonly Reported in JRA Self report of pain from 462 children with JRA Cincinnati Juvenile Arthritis Database Lovell and Walco. Pediatr Clin North Am 1989; 36:1015-27

  4. Functional Impact of Pain in Children with JRA • Parent’s assessment of activities affected by child’s pain • 22% pauciarticular course • 48% polyarticular course • 26% systemic onset Varni/Thompson Pediatric Pain Questionnaire Varni et al. Pain 1987; 28:27-38.

  5. Articular Erosions in JRA Patients Articular erosions by disease onset subtype from 132 children with 5 years follow-up Cassidy et al. Arthritis Rheum 1986; 29:274-81.

  6. Outcome Following Onset of JRA • Systematic review of published outcome data in JIA, JCA, JRA • 21 studies published over 10-year period • 19 retrospective studies; 2 prospective • Follow up varied • <5 years in 4 studies • >10 years in 14 studies • Study sizes varied: 44 – 1082 patients • 10 studies >200 patients • Total n = 5342 patients Adib N et al. Rheumatology 2005;44:995-1001

  7. Steinbrocker III/IV 7-27% Steinbrocker III/IV <1- 7% Steinbrocker III/IV 10% Remission Rates and Function in Studies Using ACR JRA Classification Criteria Function Percent of patients in remission Adib N et al. Rheumatology 2005;44:995-1001

  8. CV Thrombotic Adverse Events: CARRA Survey • Childhood Arthritis and Rheumatology Research Alliance (CARRA) • 98% pediatric rheumatologists in North America • Survey (sponsored by CARRA) • Conducted post Vioxx withdrawal • Distributed to 130 pediatric rheumatologists • Request for information regarding frequency of vascular complications in JRA patients • In association with NSAIDs and COX-2 inhibitors • Request for number of years of practice • Results • 73% responded (95/130) • 1546 years of practice in pediatric rheumatology • 0 vascular events in JRA population • 1 pulmonary embolism event reported for possible psoriatic arthritis patient

  9. NSAID Trials in JRA: Predating 1998 Approval of Celecoxib for Adults

  10. NSAID Trials in JRA: Subsequent to 1998 Approval of Celecoxib for Adults

  11. American College of Rheumatology (ACR) Pediatric 30 Response • ACR Pediatric 30 Response Criterion: ≥ 30% improvement in any 3 of 6 core set measures with no more than 1 of the remaining measures worsening by > 30%. Giannini E et al. Arthritis Rheum 1997;40(7):1202-1209

  12. Meloxicam vs Naproxen in JRA Percent change from Baseline in ACR Pediatric 30 Core Measures at 12 Weeks Ruperto N et al. Arthritis Rheum 2005;52 (2): 563-572

  13. Meloxicam vs Naproxen in JRA ACR Pediatric 30 Response Rate over 12 Months % Responders Ruperto N et al. Arthritis Rheum 2005;52 (2): 563-572

  14. Comparison of ACR Pediatric 30 Response Rates with Naproxen Reiff A et al. J Rheum 2006;33: 985-995 Ruperto N et al. Arthritis Rheum 2005;52 (2): 563-572 Gedalia A et al. Arthritis Rheum 2004;50(suppl)S95 Foeldvari et al. 2006. Arthritis Rheum 2006;54(suppl)

  15. Among patients with abdominal pain who underwent GI evaluation, gastroduodenal injury was reported in: 34% of patients taking NSAIDs 7.1% of patients not taking NSAIDs No complicated events NSAID-induced GI Pain and Injury Retrospective review of records from 570 patients seen in a pediatric rheumatology clinic over 3-year period Percent of Patients Reporting Abdominal Pain No NSAIDs N = 226 NSAIDs N = 344 Dowd et al. Arthritis Rheum 1995; 38:1225-31.

  16. Intolerability of NSAIDs in Children with JRA 101 Patients > 1 NSAID Mean age onset 6.7 years 21% Systemic Onset 23% Polyarticular Course 57% Pauciarticular Course 22% No toxicity 78% Discontinued NSAID due to toxicity 49% No Toxicity 51% Repeat toxicity with NSAID 38% Different toxicity 62% Same toxicity NSAIDs: Aspirin 34%; Tolmetin 21%; Naproxen 12%; Fenoprofen 11%; Ibuprofen 8%, Other 14% Toxicity = Laboratory abnormality or signs/ symptoms requiring NSAID discontinuation Barron KS et al. Journal of Rheumatology 1982; 9:149-55.

  17. Conclusion: JRA and Current Treatments • JRA comprises a group of heterogeneous yet related disorders in children • Chronic inflammatory arthritis with significant impact on function and health-related quality of life • Treatment effects include disease modification and symptom control • NSAIDs are used by most patients at some point in their disease • NSAIDs are generally well tolerated • GI adverse symptoms commonly reported • Serious GI complications uncommon

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