Reports From National Arthritis Meeting

Dr. Shiel Gives Perspectives Of Interest On Arthritis in Children From 2001 Annual Scientific Meeting Of The American College Of Rheumatology

Below are perspectives on key reports presented at the recent national meeting of the American College of Rheumatology:

• Introduction
• New Treatments

Introduction

Arthritis in children is referred to as juvenile arthritis. Arthritis affects approximately 1 child in every 1,000 in a given year. Fortunately, most of these cases are mild. However, approximately 1 child in every 10,000 will have more severe arthritis that doesn't just go away. Many children have what is called an acute reactive arthritis following a viral or bacterial infection. This arthritis is often quite severe for a brief period, but usually disappears within a few weeks or months. Juvenile rheumatoid arthritis (JRA) is the most common type of arthritis that persists for months or years at a time.

There are three main forms of JRA, which are distinguished by how the disease begins; pauciarticular, polyarticular, and systemic onset (also called Still's Disease). Pauciarticular JRA is defined by the involvement of fewer than four joints at the beginning of the disease. Polyarticular JRA is the form in which four or more joints are involved from the onset. Systemic Onset (Still's Disease) begins with high fevers and a rash.

JRA can be associated with a severe inflammation of the eye, called uveitis. Uveitis is the most common cause of blindness in these children.

With proper treatment, most children with arthritis usually get better over time.

New Treatments

REMICADE

Remicade (infliximab) is an antibody that blocks the effects of tumor necrosis factor alpha (TNF-alpha). TNF-alpha is a substance made by cells of the body that has an important role in promoting inflammation. By blocking the action of TNF-alpha, infliximab reduces the signs and symptoms of inflammation. Remicade, an approved treatment for adult rheumatoid arthritis, is given by intravenous infusion every 2 months.

Remicade was reported in this meeting as effective for treating JRA, thereby resulting in a significant and prompt reduction in disease activity and improved quality of life. Another paper presented data demonstrating that doses of Remicade that are higher than currently recommended doses could be effective and necessary in JRA.

Dr. Shiel's Perspective: This does not surprise me, since it is the same situation for adults with rheumatoid arthritis who are being treated in my practice.

Remicade was reported as a successful treatment for a child with dermatomyositis, a severe disease with inflamed muscles.

Dr. Shiel's Perspective: This was only a single case report, but it was an impressive one. The patient, an 18 year old boy, had had dermatomyositis since age 11 years. He was becoming more and more seriously ill despite powerful treatments with cyclophosphamide (Cytoxan), methotrexate, intravenous immunoglobulin, plasmapheresis, and steroids. He was unable to move out of bed. After starting Remicade intravenous infusions, he gradually became stronger, his muscle enzyme tests normalized after being elevated in the thousands, and he eventually walked again. Remicade's action in blocking TNF-alpha is probably the reason he improved. Dermatomyositis has been associated with elevated levels of TNF alpha in the blood.

ENBREL

Enbrel is an injectable anti-tumor necrosis factor for treating rheumatoid arthritis. Tumor necrosis factor (TNF) is a protein that the body produces during the inflammatory response, which is the body's reaction to injury. TNF promotes the inflammation and its associated fever and signs (pain, tenderness, and swelling) in several inflammatory conditions, including psoriatic arthritis and ankylosing spondylitis. Enbrel is a synthetic (man-made) protein that binds to TNF. Enbrel thereby acts like a sponge to remove most of the TNF molecules from the joints and blood. This prevents TNF from promoting inflammation and the fever, pain, and tenderness and swelling of joints in patients with psoriatic arthritis and ankylosing spondylitis. Enbrel is indicated for severely active, polyarticular-course JRA in patients who have had an inadequate response to one or more disease-modifying medicine(s). Enbrel is also used for adults with rheumatoid arthritis. Enbrel is injected into the skin twice weekly.

Enbrel was documented to be effective and safe in treating JRA in children under the age of 4 years.

Dr. Shiel's Perspective: Enbrel is already approved for use in children. This verifies its potential in the very young.

Two papers documented the effectiveness and safety of Enbrel in the treatment of ankylosing spondylitis in children (juvenile ankylosing spondylitis).

Dr. Shiel's Perspective: These are important papers that will open up options of treatment for this rare disease of children and even children under the age of 4 years, according to one of the studies.

SLIDESHOW

What Is Rheumatoid Arthritis (RA)? Symptoms, Treatment, Diagnosis See Slideshow

Uveitis (Eye Inflammation)

Remicade was reported by a number of groups of researchers as a beneficial treatment of uveitis.

Dr. Shiel's Perspective: This interesting use of Remicade will likely slip into the arsenal of doctors treating uveitis, which is a horrible, painful cause of blindness. I have recently had the occasion to witness this result first hand in my practice. I had a man come to me with a history of uveitis due to Behcet's syndrome. This patient nearly went blind while undergoing a litany of traditional therapies for his eye until a university professor started him on Remicade infusions. He was able to discontinue all other medications and he remarkably stabilized.

Exercise

Aerobic exercise was reported to be associated with an increase in laboratory markers of inflammation in children with arthritis.

Dr. Shiel's Perspective: A graded bicycle method was used for the exercise technique. Why was this report interesting? Because these same researchers from New York had previously reported that gentle resistance exercises may have an effect against inflammation. Rheumatologist are big advocates of exercise, but in the stages of the arthritis when it is active, we tend to recommend rest. This study demonstrates chemical reasons why that is probably wise.

Education

A study evaluating the value of video vs. computer for the education of children with arthritis suggested that both we welcome forms of educating methods, but that they may have different roles. The video may have more value as a tool for introducing younger patients to the disease, whereas the computer was very valuable as a resource for the disease in the later stages.

Dr. Shiel's Perspective: Welcome to MedicineNet.com !!