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Group formulates treatment plans for NSAID-resistant chronic nonbacterial osteomyelitis
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Members of the Childhood Arthritis and Rheumatology Research Alliance have developed three consensus treatment plans for patients with chronic nonbacterial osteomyelitis resistant to NSAIDs and/or those with active spinal lesions, according to report published by the group.
The treatment plans, which are the first for patients with chronic nonbacterial osteomyelitis (CNO), were developed through monthly conference calls, a planning meeting, surveys sent to of the Childhood Arthritis and Rheumatology Research Alliance’s Scleroderma, Vasculitis, Autoinflammatory and Rare Diseases (SVARD) subcommittee, and consensus meetings.
A work group conducted a literature search, but as there were no randomized, controlled studies or case-control studies on CNO, the researchers reviewed case series, historical cohorts and observational studies with a minimum 3-months follow-up in the pediatric population. They identified 21 eligible articles and later included 11 additional articles. The group then devised clinical scenarios, evaluated survey responses from CNO workgroup members and finalized treatment plans.
Of physicians who responded to the surveys, 95% reported using NSAIDs as first-line treatment in children newly diagnosed with CNO. In patients with CNO recalcitrant to NSAIDs, the most frequently used treatments included methotrexate (67%); tumor necrosis factor inhibitors (65%); and bisphosphonates (46%). These responses informed the development of the consensus treatment plans.
Researchers determined that patients with pediatric CNO refractory to NSAID monotherapy and/or active spinal lesion should have the following characteristics: age equal to or younger than 21 years; presence of bone edema on short-tau inversion recovery sequence within the past 12 weeks; a whole-body imaging examination with either MRIs or bone scintigraphy; active disease after failing a minimum of 4 weeks of NSAIDs and/or presence of active spinal lesions; and bone biopsy to rule out infection or malignancy except bone lesions.
In the literature review, non-biological disease-modifying antirheumatic drugs, TNFi and bisphosphonates were identified as medications with reported efficacy in treating NSAID-resistant CNO. Although no head-to-head comparisons of these treatments were found, current data suggested higher rates of remission were achieved by children treated with DMARDs vs. TNFi and bisphosphonates.
The group reached a consensus that the three most frequently used combinations of medications should be used in the final consensus treatment plans; these included MTX, TNFi and bisphosphonates. The group deliberated whether concomitant “bursts” of NSAIDS and/or oral glucocorticoids should be permitted. They decided both treatments could be used optimally, with restrictions on the duration of glucocorticoid use due to side effects. In addition, the group determined that in patients on a TNFi regimen, concomitant methotrexate should be permitted to impede the production of human anti-chimeric, anti-TNF antibodies, particularly with infliximab. The three final CTPs were identified as methotrexate or sulfasalazine; TNFi with optimal use of concomitant methotrexate; and bisphosphonates.
“Three standardized consensus treatment plans were developed for patients with CNO with insufficient response to NSAIDs and/or the presence of active spinal lesions,” the researchers wrote. “Use of these treatment plans will provide the opportunity to generate meaningful data for future prospective observational studies to evaluate their effectiveness in children with CNO.” -by Jennifer Byrne
Disclosure: Please see the full study for a list of relevant disclosures.
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Zhao Y, et al. Arthritis Care Res. 2017;doi:10.1002/acr.23462.
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