Immune response to influenza vaccination in children treated with methotrexate or/and tumor necrosis factor-alpha inhibitors.

In children treated with immunosuppressive medication such as methotrexate and tumor necrosis factor-alpha (TNF-α) inhibitors, additional immunizations are recommended because of increased susceptibility to infections. However, it is unclear if adequate antibody response to vaccinations can be established in children receiving methotrexate and/or TNF-α inhibitors. In a prospective open label study, we assessed seroprotection and seroconversion following influenza vaccination during 2 seasons (6 strains) in 36 children with autoimmune disease treated either with methotrexate (n=18), TNF-α inhibitors (n=10) or both (n=8) and a control group of 16 immunocompetent children. Influenza antibody titers were determined by hemagglutinin inhibition assay, before and 4-8 weeks after vaccination. Post-vaccination seroprotection (defined as a titer ≥1:40) did not significantly differ between immunosuppressed and immunocompetent subjects. Seroconversion, defined as the change from a nonprotective (< 1:40) to a protective titer (≥1:40) with at least a 4-fold titer increase, was less likely to occur in immunosuppressed patients, although no significant difference from the control group was established. Safety evaluation of vaccination showed no serious adverse events. Children receiving methotrexate and/or TNF-α inhibitors can be safely and effectively immunized against influenza, with a seroprotection after vaccination comparable to immunocompetent children.

Adrenal insufficiency after glucocorticoid withdrawal in children with rheumatic diseases.

AIM: Glucocorticoids (GCs) are often used for the treatment of rheumatic disorders. However, doses are prescribed, which may suppress the hypothalamic-pituitary-adrenal (HPA) axis. After GC withdrawal, recovery of the HPA axis may be delayed putting the patient at risk for adrenal insufficiency. We assessed adrenal function and factors influencing adrenal responsiveness after termination of GC therapy in paediatric patients with rheumatic diseases. METHODS: Nineteen patients aged 2-15 years were followed clinically, and adrenal function was tested by low-dose adrenocorticotropic hormone test 1 month after GC withdrawal. In case of adrenal insufficiency by test, re-assessment was performed after 6 and 18 months. RESULTS: No signs or symptoms of adrenal insufficiency occurred in any of the patients during and after GC withdrawal. Biochemical examination revealed adrenal insufficiency in 32% (6/19) at 4 weeks and in 11% (2/19) at 20 months after GC withdrawal. CONCLUSIONS: In conclusion, current strategies to withdraw GC from paediatric patients with rheumatic diseases are safe. Routine adrenal function testing after GC therapy and withdrawal may not be needed considering the low risk but high number of patients treated with GCs. Nevertheless, awareness of the potential risk and information of patients and their caregivers are crucial to avoid adrenal crisis.

The provisional Paediatric Rheumatology International Trials Organisation/American College of Rheumatology/European League Against Rheumatism Disease activity core set for the evaluation of response to therapy in juvenile dermatomyositis: a prospective validation study.

OBJECTIVE: To validate a core set of outcome measures for the evaluation of response to treatment in patients with juvenile dermatomyositis (DM). METHODS: In 2001, a preliminary consensus-derived core set for evaluating response to therapy in juvenile DM was established. In the present study, the core set was validated through an evidence-based, large-scale data collection that led to the enrollment of 294 patients from 36 countries. Consecutive patients with active disease were assessed at baseline and after 6 months. The validation procedures included assessment of feasibility, responsiveness, discriminant and construct ability, concordance in the evaluation of response to therapy between physicians and parents, redundancy, internal consistency, and ability to predict a therapeutic response. RESULTS: The following clinical measures were found to be feasible, and to have good construct validity, discriminative ability, and internal consistency; furthermore, they were not redundant, proved responsive to clinically important changes in disease activity, and were associated strongly with treatment outcome and thus were included in the final core set: 1) physician's global assessment of disease activity, 2) muscle strength, 3) global disease activity measure, 4) parent's global assessment of patient's well-being, 5) functional ability, and 6) health-related quality of life. CONCLUSION: The members of the Paediatric Rheumatology International Trials Organisation, with the endorsement of the American College of Rheumatology and the European League Against Rheumatism, propose a core set of criteria for the evaluation of response to therapy that is scientifically and clinically relevant and statistically validated. The core set will help standardize the conduct and reporting of clinical trials and assist practitioners in deciding whether a child with juvenile DM has responded adequately to therapy.

[Chronic arthroses in children: practical approach and epidemiological data]. / Arthrites chroniques de l'enfant: approche pratique et données épidémiologiques.

Osteo-articular symptoms are frequent in pediatrics, but chronic arthritis is rare in childhood. Arthritis may be difficult to recognize in children and there is a large differential diagnosis including infectious and neoplastic diseases. Even if juvenile arthritis has often a favourable course, significant functional damage may occur. The diagnosis and the follow-up of chronic arthritis should be performed in collaboration with a specialized consultation in pediatric rheumatology, in order to allow access to multidisciplinary medical care and help to increase the clinical and epidemiological knowledge in these rare diseases. A study is starting this fall aimed at collecting epidemiological datas on childhood arthritis in the french part of Switzerland.