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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

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
American College of Rheumatology Characteristics of JRA

Cassidy and Petty. Textbook of Pediatric Rheumatology, 2005

pain is commonly reported in jra
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

functional impact of pain in children with jra
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.

articular erosions in jra patients
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.

outcome following onset of jra
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

remission rates and function in studies using acr jra classification criteria

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

cv thrombotic adverse events carra survey
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
american college of rheumatology acr pediatric 30 response
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

meloxicam vs naproxen in jra
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

meloxicam vs naproxen in jra13
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

comparison of acr pediatric 30 response rates with naproxen
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)

nsaid induced gi pain and injury
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.

intolerability of nsaids in children with jra
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.

conclusion jra and current treatments
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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