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Joseph E. Levinson Professor of Pediatrics
Division of Rheumatology
Department of Pediatrics
Cincinnati Children's Hospital Medical Center
Daniel Lovell, MD, MPH: consultant: Abbott, AstraZeneca, GlaxoSmithKline, NIH-NIAMS, Novartis, Pfizer, United Bioscience Corporation; advisor: Pfizer; researcher: AbbVie, Bristol-Myers Squibb, Janssen, NIH/NICHD, Novartis, Roche.
This commentary summarizes key takeaways from the recent program titled, “Giving Patients a Voice: Enhancing Patient-Centered Care in Psoriatic Arthritis.”
Therapeutic Approach for Juvenile PsA
When considering therapy initiation for psoriatic arthritis (PsA) in children, the clinical presentation is quite heterogeneous. Therefore, the treatment approach must be adjusted to the intensity of the arthritis and psoriasis―but often the two are discordant. In children with very mild and intermittent arthritis, with only 1 or 2 joints impacted, steroid injections are effective. If patients have more severe disease, then methotrexate and tumor necrosis factor (TNF) inhibitors are agents commonly used. I prefer to start with them because of their long-time safety record. When treating children, the potential for long-term safety implications is much higher than for adults, so safety is essential in choosing agents. Methotrexate and TNF agents have been used for several decades due to their safety record, and they are efficacious for many patients with PsA.
That said, it is a boon that newer treatment options with different mechanisms of action are available for PsA. If patients have not responded to methotrexate or TNF inhibitors, different treatment approaches are possible. Expert experience with the newer agents for PsA in children is limited, as they just have been recently approved; nevertheless, the efficacy and safety profiles seem similar to those seen in adults. Patients with severe articular disease, patients with peripheral arthritis, and patients who have predominantly axial arthritis―or a mixture of axial and peripheral disease―are candidates for new treatment approaches.
In many children, psoriasis is far more severe and problematic than arthritis. Newer agents have the potential of effectiveness for both psoriasis and arthritis symptoms when present. Collaboration with a dermatologist will allow for optimizing the topical treatment for the psoriasis, as well as shared decision-making on the systemic treatment of the arthritis and psoriasis. Many dermatologists are using these biologics for their patients with psoriasis, so collaboration can lead to maximal benefit in children with both skin and articular disorders.
Overcoming Barriers to Using Newer Therapies
Family Concerns With Newer Agents
Families sometimes have concerns because the use of these newer agents in children is both small and short term, so safety studies are limited compared with adults. Therefore, some families may hesitate to start with a newer agent early in therapy.
Usually, families prefer to use the TNF inhibitors first, as they have a longer history of use. If those are not efficacious for the child, other therapies can be considered. The newer agents are more specifically tailored to treat the known pathogenesis for PsA and more significantly benefit both the skin and the articular disease. Thus, they can help in the shared decision-making process.
Access and Insurance Coverage
Fortunately, several newer therapies have been approved by the FDA for the treatment of juvenile idiopathic arthritis. For this reason, getting insurance approval is not always a significant barrier. When prescribing these agents, healthcare professionals could emphasize this FDA approval.
What are your thoughts and questions on the use of novel therapies in the management of juvenile PsA? Please answer the polling question and join the conversation by posting a comment in the discussion section below.