Biologic therapies for systemic lupus erythematosus: where are we now?

Advances in molecular biology have led to the development of biologic therapies. This is particularly relevant in systemic lupus erythematosus (SLE), which is a multisystem autoimmune rheumatic disease (ARD) associated with potentially life-threatening complications if not adequately treated. The availability of new biologic drugs has improved the prognosis of SLE in selected cases associated with unsatisfactory response to conventional therapies. Over the last decade, there have been developments in the availability of biologic agents for SLE treatment based upon the advances in the understanding of the disease pathogenesis. Even if the evidence of biologic treatment efficacy in SLE is weaker than in other autoimmune rheumatic diseases, such as rheumatoid arthritis (RA), significant progress was made, as the first biologic treatment for use in SLE patients received approval in 2011. These new biologic therapies for SLE range from anti-CD20/CD22 (clusters of differentiation characteristic to B cells), to anti-B cell activating factors and anti-interferon alpha (IFNα). This chapter reviews the various biologic agents used in SLE, their mechanism of action and safety profile. The most common side effects to biologic treatments include infection, tuberculosis (TB) reactivation and allergic reactions. Less common side effects include development of lymphoma and anti-drug or autoimmune antibody formation. Despite their toxicity profile, biologic agents are gaining ground in clinical practice due to the limited efficacy or increased toxicity of conventional disease modifying agents (DMARD’s). Biologic therapies targeting B cells, such as rituximab, and B cell activation factors, such as belimumab, are currently used in the treatment of refractory SLE. Furthermore, aggressive treatment, including the use of biologic agents, reduces long-term complications associated with prolonged use of steroids in SLE, such as cardiovascular disease and osteoporosis. In the short term, the biologic agents are expensive when compared to traditional DMARDs; however there is evidence that their use is associated with long term benefits for patients with SLE, such as reduced hospital admission and disease complications, and improved patient outcomes. This chapter provides a summary of most biologic agents tested in SLE patients, considering their efficacy and safety profile, as well as the health implications associated with their use. We also take a brief look at newer agents currently investigated in clinical trials

Similarities and Differences Between Juvenile and Adult Spondyloarthropathies

Spondyloarthritis (SpA) encompasses a broad spectrum of conditions occurring from childhood to middle age. Key features of SpA include axial and peripheral arthritis, enthesitis, extra-articular manifestations, and a strong association with HLA-B27. These features are common across the ages but there are important differences between juvenile and adult onset disease. Juvenile SpA predominantly affects the peripheral joints and the incidence of axial arthritis increases with age. Enthesitis is important in early disease. This review article highlights the similarities and differences between juvenile and adult SpA including classification, pathogenesis, clinical features, imaging, therapeutic strategies, and disease outcomes. In addition, the impact of the biological transition from childhood to adulthood is explored including the importance of musculoskeletal and immunological maturation. We discuss how the changes associated with adolescence may be important in explaining age-related differences in the clinical phenotype between juvenile and adult SpA and their implications for the treatment of juvenile SpA

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The role of whole-body MRI in musculoskeletal inflammation detection and treatment response evaluation in inflammatory arthritis across age: A systematic review

OBJECTIVE: To evaluate the relation between whole-body MRI (WBMRI) outcomes and disease activity measures, including clinical examination, composite scores, and other imaging outcomes, and the ability of WBMRI to detect treatment response in patients with inflammatory arthritis (IA) across age. METHODS: Human studies published as full text or abstract in the PubMed and MEDLINE and Cochrane databases from inception to 11th April 2021 were systematically and independently searched by two reviewers. Studies including patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), spondyloarthritis (SpA), juvenile idiopathic arthritis (JIA) or unclassified inflammatory arthritis (UA) who underwent WBMRI and which reported on disease outcomes were included. RESULTS: Nineteen full-text studies were eligible for inclusion: 2 interventional, 7 retrospective and 10 prospective observational studies, comprising 540 participants (SpA 38.7%, RA 24.8%, JIA 17.8%, PsA 11.5%, healthy controls 5.9%, UA 1.3%). Abstracts of 6 conference papers were reported separately. Five studies in PsA and SpA and 4 in RA measured the frequency of WBMRI-detected and clinically-detected synovitis, and all found the former to be more frequent. Less enthesitis was detected by WBMRI than clinical examination in 5/8 studies. After biologic treatment, the WBMRI inflammation scores declined in 3 studies in SpA and 2 in RA, whilst in 3 studies the results were equivocal. CONCLUSION: The ability of WBMRI to assess disease activity and treatment response in IA was adequate overall. Further studies are needed to corroborate WBMRI findings with IA outcomes and investigate the clinical value of subclinical inflammation