Biologics and Juvenile Idiopathic Arthritis are an Evolving Revolution

Issue: November 2016

I would like to add some brief perspective to this issue’s exciting Cover Story on the impact of biologics on pediatric patients with rheumatic diseases, especially juvenile idiopathic arthritis in all its forms.

Let me emphasize that I am an adult rheumatologist who has long been in awe of my pediatric rheumatology colleagues who do amazing work with our most precious patients. I have been blessed to be surrounded by some of the best practicioner during the years. Having said that, we must remind ourselves children are not miniature versions of adults. Their unique physiology during the developmental years warrants perhaps a different, if not deeper, scrutinization of how our treatments might affect them.

Outcomes

I have been fortunate to play an integral part in the evolution of biologic therapies in immune-mediated inflammatory disease in adults. However, at the beginning of my training, I would never have dreamed that I would one day be using one class of drugs, other than steroids, that so effectively treat conditions as diverse as rheumatoid arthritis, Crohn’s disease, spondyloarthritis and uveitis — just to name a few. Yet here we are. We have left the Oslerian maxim of wanting to “leave by the back door” when a patient with inflammatory arthritis comes in the front. Indeed, we now hold it wide open and welcome these patients — and the earlier the better. As a result, patient outcomes are better than would have hoped a short generation ago.

Similarly, outcomes now in juvenile idiopathic arthritis (JIA) and related diseases have exceeded the expectations for those of us whose training and practice have spanned the pre-biologic era. Children are benefiting from these medications big time. However, just as Banquo and Hamlet couldn’t see for themselves the future the witches promised them, those of us practicing rheumatology cannot see the futures we are creating for our pediatric patients. As an investigator interested in safety, primarily regarding serious and opportunistic infections, and as a clinical immunologist who treats patients with primary immunodeficiencies, I cannot help but have concern about the future of children who are exposed to biologics from such a young age, especially knowing they may need treatments for decades.

Organized Strategy

However, if one of my (now grown) children had developed JIA and I needed to decide on whether biologics would be used, I would have unhesitatingly sought such therapy for them if indicated. At the same time, not knowing how this decision would have affected their future would have been terrifying. Who can say what the effects of long-term biologics will ultimately be on everything — from the rate of future malignancies to the potential of untoward effects on aging of the immune system. For these reasons and more, I am comforted by the organized strategy of safety surveillance underway in the pediatric rheumatology world.

We know pharmaceutical companies are obliged to continuously monitor their exposed populations. In addition, there is a robust network of pediatric rheumatology registries throughout the world. For example, the CARRA Registry alone has a goal of monitoring 10,000 patients. Other registries, including the CAPS Registry, CAPRI Registry, BiKer and JuMBO Registries, will continue to inform us for years to come. We don’t know what the future will hold, but we will have a more trustworthy source than Hamlet’s witches to try to find our way.

Thank you for reading this issue of Healio Rheumatology. I look forward to receiving your comments at calabrl@ccf.org or on Twitter @LCalabreseDO.

For more information:
Leonard H. Calabrese, DO, is the Chief Medical Editor, Healio Rheumatology, and Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and RJ Fasenmyer Chair of Clinical Immunology at the Cleveland Clinic.

Disclosure: Calabrese reports he is a consultant for Genentech, Pfizer, Bristol-Myers Squibb, GlaxoSmithKline, Sanofi, Jansen and AbbVie; and is on the speakers bureau for Genentech, AbbVie and Bristol-Myers Squibb and Crescendo Bioscience.