@article {10555, title = {Intra-articular corticosteroids versus intra-articular corticosteroids plus methotrexate in oligoarticular juvenile idiopathic arthritis: a multicentre, prospective, randomised, open-label trial.}, journal = {Lancet}, volume = {389}, year = {2017}, month = {2017 03 04}, pages = {909-916}, abstract = {

BACKGROUND: Little evidence-based information is available to guide the treatment of oligoarticular juvenile idiopathic arthritis. We aimed to investigate whether oral methotrexate increases the efficacy of intra-articular corticosteroid therapy.

METHODS: We did this prospective, open-label, randomised trial at ten hospitals in Italy. Using a concealed computer-generated list, children younger than 18 years with oligoarticular-onset disease were randomly assigned (1:1) to intra-articular corticosteroids alone or in combination with oral methotrexate (15 mg/m; maximum 20 mg). Corticosteroids used were triamcinolone hexacetonide (shoulder, elbow, wrist, knee, and tibiotalar joints) or methylprednisolone acetate (ie, subtalar and tarsal joints). We did not mask patients or investigators to treatment assignments. Our primary outcome was the proportion of patients in the intention-to-treat population who had remission of arthritis in all injected joints at 12 months. This trial is registered with European Union Clinical Trials Register, EudraCT number 2008-006741-70.

FINDINGS: Between July 7, 2009, and March 31, 2013, we screened 226 participants and randomly assigned 102 to intra-articular corticosteroids alone and 105 to intra-articular corticosteroids plus methotrexate. 33 (32\%) patients assigned to intra-articular corticosteroids alone and 39 (37\%) assigned to intra-articular corticosteroids and methotrexate therapy had remission of arthritis in all injected joints (p=0{\textperiodcentered}48). Adverse events were recorded for 20 (17\%) patients who received methotrexate, which led to permanent treatment discontinuation in two patients (one due to increased liver transaminases and one due to gastrointestinal discomfort). No patient had a serious adverse event.

INTERPRETATION: Concomitant administration of methotrexate did not augment the effectiveness of intra-articular corticosteroid therapy. Future studies are needed to define the optimal therapeutic strategies for oligoarticular juvenile idiopathic arthritis.

FUNDING: Italian Agency of Drug Evaluation.

}, keywords = {Adrenal Cortex Hormones, Arthritis, Juvenile, Humans, Injections, Intra-Articular, Italy, Methotrexate, Prospective Studies, Treatment Outcome}, issn = {1474-547X}, doi = {10.1016/S0140-6736(17)30065-X}, author = {Ravelli, Angelo and Dav{\`\i}, Sergio and Bracciolini, Giulia and Pistorio, Angela and Consolaro, Alessandro and van Dijkhuizen, Evert Hendrik Pieter and Lattanzi, Bianca and Filocamo, Giovanni and Verazza, Sara and Gerloni, Valeria and Gattinara, Maurizio and Pontikaki, Irene and Insalaco, Antonella and De Benedetti, Fabrizio and Civino, Adele and Presta, Giuseppe and Breda, Luciana and Marzetti, Valentina and Pastore, Serena and Magni-Manzoni, Silvia and Maggio, Maria Cristina and Garofalo, Franco and Rigante, Donato and Gattorno, Marco and Malattia, Clara and Picco, Paolo and Viola, Stefania and Lanni, Stefano and Ruperto, Nicolino and Martini, Alberto} } @article {1838, title = {Therapeutic approaches in the treatment of juvenile dermatomyositis in patients with recent-onset disease and in those experiencing disease flare: an international multicenter PRINTO study.}, journal = {Arthritis Rheum}, volume = {63}, year = {2011}, month = {2011 Oct}, pages = {3142-52}, abstract = {

OBJECTIVE: To evaluate response to therapy over a 24-month period in a large prospective international cohort of patients with juvenile dermatomyositis (DM).

METHODS: The study included 145 patients with recent-onset juvenile DM and 130 juvenile DM patients experiencing disease flare, all of whom were <18 years old. Disease activity parameters and therapeutic approaches in 4 geographic areas were analyzed at baseline and at 6, 12, and 24 months. Response was assessed according to the Pediatric Rheumatology International Trials Organization (PRINTO) juvenile DM response criteria, and data were reported "as observed" and in the intent-to-treat (ITT) population.

RESULTS: Patients with recent-onset juvenile DM at baseline had higher baseline disease activity and greater improvement over 24 months when compared to juvenile DM patients experiencing disease flare at baseline. Methotrexate (MTX) or high-dose corticosteroids were administered more frequently to patients with recent-onset juvenile DM, compared to juvenile DM patients experiencing disease flare, who were more likely to receive cyclosporine. Compared to patients from Western and Eastern Europe, a higher proportion of patients from South and Central America and North America received pulse steroids, and the average steroid dosage was higher in the North American and South and Central American patients. The use of MTX was similar in all 4 regions, while cyclosporin A was more frequently used in Western Europe. In the "as observed" analysis, 57.9\% of the patients with recent-onset juvenile DM and 36.4\% of the patients experiencing disease flare (P<0.001) reached at least a 70\% response by PRINTO criteria at 6 months; these proportions had increased at month 24 to 78.4\% and 51.2\%, respectively (P<0.001). Corresponding results of the ITT analysis were much lower, with only one-third of the patients able to maintain the initial assigned therapy over 24 months.

CONCLUSION: Patients with recent-onset juvenile DM are more likely to achieve significant clinical improvement over 24 months, when compared to patients experiencing flares of juvenile DM. Internationally, various therapeutic approaches are used to treat this disease.

}, keywords = {Adolescent, Adrenal Cortex Hormones, Child, Dermatologic Agents, Dermatomyositis, Female, Humans, Longitudinal Studies, Male, Methotrexate, Prospective Studies, Treatment Outcome}, issn = {1529-0131}, doi = {10.1002/art.30475}, author = {Hasija, Rachana and Pistorio, Angela and Ravelli, Angelo and Demirkaya, Erkan and Khubchandani, Raju and Guseinova, Dinara and Malattia, Clara and Canhao, Helena and Harel, Liora and Foell, Dirk and Wouters, Carine and De Cunto, Carmen and Huemer, Christian and Kimura, Yukiko and Mangge, Harald and Minetti, Carlo and Nordal, Ellen Berit and Philippet, Pierre and Garozzo, Rosaria and Martini, Alberto and Ruperto, Nicolino} } @article {1695, title = {EULAR/PRINTO/PRES criteria for Henoch-Sch{\"o}nlein purpura, childhood polyarteritis nodosa, childhood Wegener granulomatosis and childhood Takayasu arteritis: Ankara 2008. Part I: Overall methodology and clinical characterisation.}, journal = {Ann Rheum Dis}, volume = {69}, year = {2010}, month = {2010 May}, pages = {790-7}, abstract = {

OBJECTIVES: To report methodology and overall clinical, laboratory and radiographic characteristics for Henoch-Sch{\"o}nlein purpura (HSP), childhood polyarteritis nodosa (c-PAN), c-Wegener granulomatosis (c-WG) and c-Takayasu arteritis (c-TA) classification criteria.

METHODS: The preliminary Vienna 2005 consensus conference, which proposed preliminary criteria for paediatric vasculitides, was followed by a EULAR/PRINTO/PRES - supported validation project divided into three main steps. Step 1: retrospective/prospective web-data collection for HSP, c-PAN, c-WG and c-TA, with age at diagnosis

RESULTS: A total of 1183/1398 (85\%) samples collected were available for analysis: 827 HSP, 150 c-PAN, 60 c-WG, 87 c-TA and 59 c-other. Prevalence, signs/symptoms, laboratory, biopsy and imaging reports were consistent with the clinical picture of the four c-vasculitides. A representative subgroup of 280 patients was blinded to the treating physician diagnosis and classified by a consensus panel, with a kappa-agreement of 0.96 for HSP (95\% CI 0.84 to 1), 0.88 for c-WG (95\% CI 0.76 to 0.99), 0.84 for c-TA (95\% CI 0.73 to 0.96) and 0.73 for c-PAN (95\% CI 0.62 to 0.84), with an overall kappa of 0.79 (95\% CI 0.73 to 0.84).

CONCLUSION: EULAR/PRINTO/PRES propose validated classification criteria for HSP, c-PAN, c-WG and c-TA, with substantial/almost perfect agreement with the final consensus classification or original treating physician diagnosis.

}, keywords = {Adolescent, Biopsy, Child, Delphi Technique, Granulomatosis with Polyangiitis, Humans, International Cooperation, Internet, Polyarteritis Nodosa, Purpura, Schoenlein-Henoch, Reproducibility of Results, Takayasu Arteritis}, issn = {1468-2060}, doi = {10.1136/ard.2009.116624}, author = {Ruperto, Nicolino and Ozen, Seza and Pistorio, Angela and Dolezalova, Pavla and Brogan, Paul and Cabral, David A and Cuttica, Ruben and Khubchandani, Raju and Lovell, Daniel J and O{\textquoteright}Neil, Kathleen M and Quartier, Pierre and Ravelli, Angelo and Iusan, Silvia M and Filocamo, Giovanni and Magalh{\~a}es, Claudia Saad and Unsal, Erbil and Oliveira, Sheila and Bracaglia, Claudia and Bagga, Arvind and Stanevicha, Valda and Manzoni, Silvia Magni and Pratsidou, Polyxeni and Lepore, Loredana and Espada, Graciela and Kone-Paut, Isabella and Paut, Isabelle Kone and Zulian, Francesco and Barone, Patrizia and Bircan, Zelal and Maldonado, Maria del Rocio and Russo, Ricardo and Vilca, Iris and Tullus, Kjell and Cimaz, Rolando and Horneff, Gerd and Anton, Jordi and Garay, Stella and Nielsen, Susan and Barbano, Giancarlo and Martini, Alberto} } @article {1664, title = {Methotrexate withdrawal at 6 vs 12 months in juvenile idiopathic arthritis in remission: a randomized clinical trial.}, journal = {JAMA}, volume = {303}, year = {2010}, month = {2010 Apr 7}, pages = {1266-73}, abstract = {

CONTEXT: Novel therapies have improved the remission rate in chronic inflammatory disorders including juvenile idiopathic arthritis (JIA). Therefore, strategies of tapering therapy and reliable parameters for detecting subclinical inflammation have now become challenging questions.

OBJECTIVES: To analyze whether longer methotrexate treatment during remission of JIA prevents flares after withdrawal of medication and whether specific biomarkers identify patients at risk for flares.

DESIGN, SETTING, AND PATIENTS: Prospective, open, multicenter, medication-withdrawal randomized clinical trial including 364 patients (median age, 11.0 years) with JIA recruited in 61 centers from 29 countries between February 2005 and June 2006. Patients were included at first confirmation of clinical remission while continuing medication. At the time of therapy withdrawal, levels of the phagocyte activation marker myeloid-related proteins 8 and 14 heterocomplex (MRP8/14) were determined.

INTERVENTION: Patients were randomly assigned to continue with methotrexate therapy for either 6 months (group 1 [n = 183]) or 12 months (group 2 [n = 181]) after induction of disease remission.

MAIN OUTCOME MEASURES: Primary outcome was relapse rate in the 2 treatment groups; secondary outcome was time to relapse. In a prespecified cohort analysis, the prognostic accuracy of MRP8/14 concentrations for the risk of flares was assessed.

RESULTS: Intention-to-treat analysis of the primary outcome revealed relapse within 24 months after the inclusion into the study in 98 of 183 patients (relapse rate, 56.7\%) in group 1 and 94 of 181 (55.6\%) in group 2. The odds ratio for group 1 vs group 2 was 1.02 (95\% CI, 0.82-1.27; P = .86). The median relapse-free interval after inclusion was 21.0 months in group 1 and 23.0 months in group 2. The hazard ratio for group 1 vs group 2 was 1.07 (95\% CI, 0.82-1.41; P = .61). Median follow-up duration after inclusion was 34.2 and 34.3 months in groups 1 and 2, respectively. Levels of MRP8/14 during remission were significantly higher in patients who subsequently developed flares (median, 715 [IQR, 320-1 110] ng/mL) compared with patients maintaining stable remission (400 [IQR, 220-800] ng/mL; P = .003). Low MRP8/14 levels indicated a low risk of flares within the next 3 months following the biomarker test (area under the receiver operating characteristic curve, 0.76; 95\% CI, 0.62-0.90).

CONCLUSIONS: In patients with JIA in remission, a 12-month vs 6-month withdrawal of methotrexate did not reduce the relapse rate. Higher MRP8/14 concentrations were associated with risk of relapse after discontinuing methotrexate.

TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN18186313.

}, keywords = {Adolescent, Antirheumatic Agents, Arthritis, Juvenile, ATP-Binding Cassette Transporters, Calgranulin B, Child, Child, Preschool, Female, Humans, Infant, Male, Methotrexate, Predictive Value of Tests, Prospective Studies, Recurrence, Remission Induction}, issn = {1538-3598}, doi = {10.1001/jama.2010.375}, author = {Foell, Dirk and Wulffraat, Nico and Wedderburn, Lucy R and Wittkowski, Helmut and Frosch, Michael and Gerss, Joachim and Stanevicha, Valda and Mihaylova, Dimitrina and Ferriani, Virginia and Tsakalidou, Florence Kanakoudi and Foeldvari, Ivan and Cuttica, Ruben and Gonzalez, Benito and Ravelli, Angelo and Khubchandani, Raju and Oliveira, Sheila and Armbrust, Wineke and Garay, Stella and Vojinovic, Jelena and Norambuena, Ximena and Gamir, Mar{\'\i}a Luz and Garc{\'\i}a-Consuegra, Julia and Lepore, Loredana and Susic, Gordana and Corona, Fabrizia and Dolezalova, Pavla and Pistorio, Angela and Martini, Alberto and Ruperto, Nicolino and Roth, Johannes} } @article {1714, title = {Predictors of poor response to methotrexate in polyarticular-course juvenile idiopathic arthritis: analysis of the PRINTO methotrexate trial.}, journal = {Ann Rheum Dis}, volume = {69}, year = {2010}, month = {2010 Aug}, pages = {1479-83}, abstract = {

OBJECTIVES: To determine whether baseline demographic, clinical, articular and laboratory variables predict methotrexate (MTX) poor response in polyarticular-course juvenile idiopathic arthritis.

METHODS: Patients newly treated for 6 months with MTX enrolled in the Paediatric Rheumatology International Trials Organization (PRINTO) MTX trial. Bivariate and logistic regression analyses were used to identify baseline predictors of poor response according to the American College of Rheumatology pediatric (ACR-ped) 30 and 70 criteria.

RESULTS: In all, 405/563 (71.9\%) of patients were women; median age at onset and disease duration were 4.3 and 1.4 years, respectively, with anti-nuclear antibody (ANA) detected in 259/537 (48.2\%) patients. With multivariate logistic regression analysis, the most important determinants of ACR-ped 70 non-responders were: disease duration > 1.3 years (OR 1.93), ANA negativity (OR 1.77), Childhood Health Assessment Questionnaire (CHAQ) disability index > 1.125 (OR 1.65) and the presence of right and left wrist activity (OR 1.55). Predictors of ACR-ped 30 non-responders were: ANA negativity (OR 1.92), CHAQ disability index > 1.14 (OR 2.18) and a parent{\textquoteright}s evaluation of child{\textquoteright}s overall well-being < or = 4.69 (OR 2.2).

CONCLUSION: The subgroup of patients with longer disease duration, ANA negativity, higher disability and presence of wrist activity were significantly associated with a poorer response to a 6-month MTX course.

}, keywords = {Adolescent, Antibodies, Antinuclear, Antirheumatic Agents, Arthritis, Juvenile, Child, Child, Preschool, Disability Evaluation, Female, Follow-Up Studies, Humans, Immunosuppressive Agents, Male, Methotrexate, Prognosis, Treatment Outcome}, issn = {1468-2060}, doi = {10.1136/ard.2009.120840}, author = {Vilca, Iris and Munitis, Pablo Garcia and Pistorio, Angela and Ravelli, Angelo and Buoncompagni, Antonella and Bica, Blanca and Campos, Lucia and H{\"a}fner, Renate and Hofer, Michael and Ozen, Seza and Huemer, Christian and Bae, Sang Cheol and Sztajnbok, Flavio and Arguedas, Olga and Foeldvari, Ivan and Huppertz, Hans Iko and Gamir, Mar{\'\i}a Luz and Magnusson, Bo and Dressler, Frank and Uziel, Yosef and van Rossum, Marion A J and Hollingworth, Peter and Cawkwell, Gail and Martini, Alberto and Ruperto, Nicolino} }