Background. To assign genetically engineered biologic drugs, we need data on the predictors for response to therapy. Prognostic factors for the response to tocilizumab in patients with juvenile idiopathic arthritis (JIA) without systemic symptoms are poorly studied.Objective. Our aim was to reveal early predictors for the response to tocilizumab therapy in patients with JIA without systemic symptoms.Methods. A retrospective cohort study enrolled patients with JIA without systemic symptoms who received tocilizumab therapy between July 2009 and August 2017. We assessed the association between the initial demographic, clinical, and laboratory parameters in patients and the best response (according to the ACR90 criteria) to treatment after a year.Results. The study included 95 (girls 85%) patients; the mean age was 10.3 (6.0; 13.6). During the first year of therapy, 71 (75%), 55 (58%), 38 (40%), and 22 (23%) patients achieved the improvement according to ACR30/50/70/90 criteria, respectively; 22 (23%) patients reached disease inactive stage according to the Wallace criteria. When performing multivariate analysis, the following improvement predictors were revealed based on the ACR90 criteria after a year of treatment: decrease in serum C-reactive protein level during the first month of therapy [odds ratio (OR) 1.024; 95% confidence interval (CI) 1.007–1.051], decrease in disease activity score on the visual analogue scale according to the parent/patient assessment (OR 1.048; 95% CI 1.005–1.105), early onset of the disease (OR 0.38; 95% CI 0.16–0.72), persistent oligoarthritis according to the ILAR (OR 9.9; 95% CI 1.5–109.3). During the first year of tocilizumab administration, neutropenia was registered in one patient, leukopenia — in three cases, and urticaria — in one case.Conclusion. The variant of JIA, the age at the disease onset, and the disease course pattern in the first month of tocilizumab therapy are the predictors of treatment efficacy throughout the year.

BackgroundA significant number of systemic juvenile idiopathic arthritis (sJIA) patients discontinue biologic disease-modifying antirheumatic drugs (bDMARDs) due to lack of efficacy or safety concerns. Studies of biologic therapy switch regimens in sJIA are required.MethodsPatients with sJIA who switched from tocilizumab (due to lack of efficacy or safety) to canakinumab (4 mg/kg every 4 weeks) and were hospitalized at the rheumatology department from August 2012 to July 2020 were included. Primary efficacy outcomes were 30% or greater improvement based on the paediatric criteria of the American College of Rheumatology (ACR30), achievement of inactive disease (JADAS-71 = 0) and clinical remission (ACR sJIA clinical inactive disease criteria). Follow-up from time first canakinumab dose administered was 12 months or the closest time point (not less than 6 and not more than 18 months). Data were extracted from electronic outpatient medical records.ResultsDuring the study period, 46 patients with sJIA switched from tocilizumab to canakinumab. Median age at baseline was 8.2 [interquartile range (IQR) 4.0–12.9] years, with the median sJIA duration being 1.8 (IQR 0.8–5.8) years; 37 (80%) patients received at least one conventional DMARD (cDMARD; oral corticosteroids, methotrexate and/or cyclosporine A). Study outcomes were followed up in 45 patients (one patient did not attend the follow-up for an unknown reason); median follow-up was 359 (IQR 282–404) days. During the follow-up, 1 patient discontinued canakinumab due to tuberculosis detection and the dose was reduced or the injection interval increased in 4 (9%) patients. In total, 27 (60%) patients continued to receive at least one cDMARD. Improvement according to the ACR30 criteria was achieved in 43 patients [96%; 95% confidence interval (CI) 85–99], inactive disease in 42 (93%; 95%CI 82–98), and remission in 37 (82%; 95% CI 69-91); after adjustment for actual time-at-risk, the rates were 83, 85 and 73 events per 100 person-years, respectively. During follow-up, 23 AEs (most frequently infections) were reported in 19/45 (42%) patients; 5/45 (11%) patients developed macrophage activation syndrome, with a favorable outcome in all cases.ConclusionsOne-year canakinumab therapy was found to be potentially effective as second-line biologic therapy after discontinuation of tocilizumab in patients with sJIA.

Background. Immunological potency of 13-valent pneumococcal vaccine (PCV-13) in children with systemic juvenile idiopathic arthritis (SJIA) is still unstudied. Estimates of the genetically engineered biologic drugs (GEBD) effects on pneumococcal vaccination results also remain controversial.Objective. The aim of the study was to explore the PCV-13 efficacy in patients with SJIA and who is on treatment with monoclonal antibodies against interleukin 6 receptor (tocilizumab) and interleukin 8 receptor beta (canakinumab).Methods. The study included patients under the age of 18 with SJIA in remission or active form of disease vaccinated with PCV-13. The vaccine was administered in single dose of 0.5 ml intramuscularly in patients on treatment with GEBD or 3 weeks before GEBD administration for the first time (for patients with active disease). Vaccination was considered effective at achievement of the minimum protective level of antibodies to capsular polysaccharide of pneumococcus (anti-SPP IgG; ≥ 7 U/ml) or increase of anti-SPP IgG level ≥ 2 times in 4 weeks after vaccination. The anti-SPP IgG levels were measured with enzyme immunoassay.Results. The study included 53 patients (27 girls) in remission of SJIA and 25 (16 girls) in active disease. Median age was 13.3 and 10.8 years respectively. Tocilizumab/canakinumab was administrated in 43/10 and 18/7 patients respectively. Minimum significant anti-SPP IgG level and two-fold increase in anti-SPP IgG level were recorded in 49/53 (92%) and 32/53 (60%) patients with SJIA in remission, as well as in 22/25 (88%) and 18/25 (72%) patients in active disease respectively. PCV-13 immunological potency in patients with SJIA in remission and in active disease (in those who were initially administrated and who did not receive GEBD) did not differ.Conclusion. PCV-13 vaccination allows to achieve protective antibodies level in most of the patients with SJIA in children population regardless of the disease stage and the history of GEBD administration.

BackgroundDevelopment of biologics and their launching into clinical practice has yielded significant progress in pediatric rheumatology. Nevertheless, treatment of severe disorders, and systemic JIA in particular, still remains a challenge. JIA often has the early-onset form. If its course is aggressive and persistent, patients exhibit poor response to treatment with first-line biologics. Effectiveness of the second-line and subsequent biologics, as well as the optimal sequence of prescribing drugs belonging to different classes to children younger than 4 years, remains an open questionObjectivesTo compare the efficacy of canakinumab (CAN) in children with sJIA younger than 4 years (in biologic-naïve patients and when prescribed as a second-line biologic).MethodsThe study was conducted as a subanalysis of the prospective cohort study to evaluate the efficacy of biologics in children with sJIA. Comparative analysis involved 17 patients who had initiated CAN treatment at the National Medical Research Center of Children’s Health (Moscow, Russia) when aged < 4 years (9 biologic-naïve patients (the naïve group) and 8 patients switched from tocilizumab therapy (the switched group)). Treatment efficacy was evaluated according to the dynamics of clinical and laboratory signs using the ACRPedi criteria. The Wallace criteria were used to evaluate whether or not remission had been achieved. Treatment safety was evaluated according to the data presented in the Adverse Event ReportsResultsAt baseline, patients had comparable duration and severity of the disease. The biologic proved efficacious already after 4 weeks of treatment. Five (55.6%) patients in the naïve group and 4 (50%) patients in the switched group achieved ACR90 (p>0.999) within one year of treatment. A state of inactive disease according to the Wallace criteria was achieved in one patient in each group, (12.5% and 11.1%, respectively (p>0.999). JADAS-71 decreased significantly from 12.8 (IQR 10.4-16.2) to 4.4 (IQR 2-6.8) in the naïve group (p=0.012) and from 11.6 (IQR 8-13.88) to 2.35 (IQR 1-3.03) in the switched group (p=0.017).ConclusionCAN was found to be highly efficacious and have a good safety profile in children younger than 4 years regardless of prior biologic treatment.Disclosure of InterestsNone declared

Background:The need for continuous use of immunosuppressive drugs leads to increased risk of developing infectious diseases in children with juvenile idiopathic arthritis with systemic manifestation (sJIA). Questions about choosing the optimal vaccination time and the effect of different classes of therapy on vaccination effectiveness are still open.Objectives:To study clinical and laboratory effectiveness of PCV13-vaccination in children with sJIA on tocilizumab (TOC) and canakinumab (CAN) treatment depending on disease activity stage.Methods:Prospective cohort study included 2 groups of sJIA patients: in stable remission (Remission group, n=53) receiving CAN (n=10) or TOC (n=43) treatment, and in acute stage of disease (Acute group, n=25) which started to received CAN (n=7) or TOC (n=18) either before vaccination (Acute Treated Before subgroup, n=17) or after vaccination (Acute Treated After subgroup, n=8). 0.5 ml of the 13-valent PCV was administered once subcutaneously. Efficacy was evaluated by achieving of protection level of anti-pneumococcal antibodies after 4 weeks and by clinical indicators after 6 month follow-up: frequency of acute respiratory infections, frequency of antibiotics treatment courses, frequency of temporary withdrawal of biologics treatment due to severe infections. Frequency of events were counted per patients-years.Results:Four weeks after vaccination, protection level of anti-pneumococcal antibodies was achieved by for 36 (67.9%) patients in Remission group, 16 (64%) patients in Acute group (intergroup p=0.932), and in 8 (47.06%) patients in Acute Treated Before subgroup and in 8 (100%) patients in Acute Treated After subgroup (intersubgroup p=0.022). PCV13 have shown high clinical effectiveness in both Remission group and Acute group. Reducing of acute respiratory infections frequency was as follows: from 4.57 to 2.15 episodes per patient-year in Remission group (p<0.001) and from 4.32 to 1.28 per patient-year in Acute group (p<0.001).Duration of antibiotics treatment reduced from 2.31 to 0.81 weeks per 1 patient-year in Remission group (p<0.001) from 1.97 to 0.74 in Acute group (p<0.001). Among patients who were previously treated with biologics, frequency of therapy withdrawal reduced from 4.34 to 2.42 per patient-year in Remission group (p<0.001) and from 3.53 to 1.18 in Acute Treated Before subgroup (p=0.002). The incidence of reactions to vaccination of PCV13 (local hyperemia, pain, subfebrile temperature) was similar in groups (22 (41.5%) for Remission group and 7 (28%) for Acute group, p= 0.319).Conclusion:Vaccination with the 13-valent PCV has demonstrated high clinical efficacy and safety in children with sJIA both in the acute stage of the disease and during remission. Vaccination of patients in acute stage of sJIA before treatment has advantages over vaccination during remission or after prolonged immunosuppressive therapy in terms of achieving an adequate vaccine response.Disclosure of Interests:Dariya Vankova: None declared, Ekaterina Alexeeva Grant/research support from: Roche, Pfizer, Centocor, Novartis, Speakers bureau: Roche, Novartis, Pfizer., Tatyana Dvoryakovskaya: None declared, Ksenia Isaeva: None declared, Aleksandra Chomakhidze: None declared, Rina Denisova: None declared, Anna Mamutova: None declared, Anna Fetisova: None declared, Marina Gautier: None declared, Elizaveta Krekhova: None declared, Meyri Shingarova: None declared, Ivan Kriulin: None declared, Anastasiya Kontorovich: None declared, Olga Galkina: None declared, Tatyana Radygina: None declared, Irina Zubkova: None declared, Natalia Tkachenko: None declared, Yanina Orlova: None declared, Mariya Kurdup: None declared, Anna Ismailova: None declared, Alina Alshevskaya: None declared, Andrey Moskalev: None declared, Olga Lomakina: None declared

BackgroundMacrophage activation syndrome (MAS) is a rare and severe complication of juvenile idiopathic arthritis (JIA) that most typically develops in patients with its systemic form (sJIA). Tocilizumab proved to be efficacious for treatment of both systemic JIA and polyarthritis. Nevertheless, the question regarding the effect of MAS on efficacy of TOC therapy in patients with sJIA is still to be solved.ObjectivesTo evaluate the efficacy of tocilizumab therapy in patients having sJIA and MAS versus the patients without MAS.MethodsThroughout the period between 2009 and 2018, 251 children with the acute phase of sJIA started to be treated with TOC at the Rheumatology Department of the National Medical Research Center of Children’s Health (Moscow, Russia). Of those, 69 patients had active MAS at initiation of TOC therapy. Patients were diagnosed with MAS according to the preliminary diagnostic guidelines for MAS complicating sJIA [1]. Treatment efficacy was evaluated according to the dynamics of clinical and laboratory signs using the ACRPedi criteria. The Wallace criteria were used to evaluate whether or not remission had been achieved.ResultsAt initiation of TOC therapy, patients with and without MAS were comparable in terms of their sex and age characteristics, as well as the overall severity of arthritis (the percentage of women, 56.6% (intergroup p=0.396); the median age, 7.83 (4.39-11.3) years (intergroup p=0.640); and JADAS-71, 17.4 (13.7-22.8) (intergroup p=0.055)). Nevertheless, patients differed in terms of intensity of certain clinical manifestations and prior history of the disease. The group with MAS was characterized by such parameters as shorter disease duration, shorter duration morning stiffness, and smaller number of affected joints but higher activity and severity score (Patient/Parent and Physician VAS score).After treatment initiation, TOC was discontinued after treatment for 4-12 weeks only in 2 out of 69 (2.9%) patients because of persistent MAS or MAS flare. The patients successfully achieved remission after therapy switching. No intergroup differences were observed for the rate of treatment discontinuation within the first year of therapy: the drug was discontinued in 5 (7.2%) patients in the MAS+sJIA group (2 MAS flares + 3 cases of poor efficacy) and in 25 (13.7%) patients in the sJIA group (4 SAEs + 21 cases of poor efficacy).Figure 1 One-year treatment with TOC proved that this drug is highly efficacious to treat sJIA regardless of whether or not patients had MAS at treatment initiation (Figure).No deaths were reported throughout the entire treatment period. We attributed this to early diagnosis and high efficacy of treatment of JIA patients.ConclusionTocilizumab therapy in patients with sJIA in the presence of MAS is as efficacious as in patients without MAS and does not aggravate the course of MAS.Reference[1] Ravelli A, Magni-Manzoni S, Pistorio A, Besana C, Foti T, Ruperto N, Viola S, Martini A. Preliminary diagnostic guidelines for macrophage activation syndrome complicating system...

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