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Biologikabehandlung bei der juvenilen idiopathischen Arthritis

Vergleich von Mono- und Kombinationstherapie mit synthetischen DMARDs

Biologics in the treatment of juvenile idiopathic arthritis

A comparison of mono- and combination therapy with synthetic DMARDs

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Zusammenfassung

Für die Behandlung der polyartikulären juvenilen idiopathischen Arthritis (JIA) wird in erster Linie Methotrexat (MTX) eingesetzt. Bei unzureichendem Ansprechen oder Unverträglichkeit steht mittlerweile eine Reihe von Biologika zu Verfügung. Dies stellt die Ärzte vor anspruchsvolle Entscheidungen. Häufig werden die Biologika mit MTX kombiniert, für die JIA gibt es dazu wenig Evidenz und uneinheitliche Ergebnisse aus verschiedenen Untersuchungen. Insbesondere bei der rheumatoiden Arthritis konnte unter der Kombinationstherapie mit Tumornekrosefaktor(TNF)-Inhibitoren eine bessere Effektivität beobachtet werden. Tocilizumab scheint auch als Monotherapie sehr effektiv zu sein. Möglicherweise hat MTX ebenso bei Kindern einen protektiven Effekt auf die Bildung von Anti-Drug-Antikörpern, was v. a. beim Einsatz von Anti-TNF-Antikörpern von Bedeutung ist. Bei Golimumab ist eine Kombination mit MTX durch die Zulassung vorgegeben, ebenso bei Abatacept. Hinsichtlich der Verträglichkeit gibt es bis auf die klassischen Nebenwirkungen von MTX keine weiteren signifikanten Auffälligkeiten bei der Kombination von MTX und Biologika. Bei Unverträglichkeit von MTX kann als (nicht zugelassene) Alternative Leflunomid erwogen werden.

Abstract

In polyarticular juvenile idiopathic arthritis, methotrexate (MTX) is still used as first-line treatment. In case of insufficient response or intolerance, a number of biologics are now available. This faces physicians with challenging choices. Biologics are often combined with MTX, although in JIA there is little evidence and inconsistent results from various studies. In rheumatoid arthritis, combination therapy with tumor necrosis factor (TNF) inhibitors has been associated with higher efficacy. Tocilizumab appears to be highly effective as a monotherapy. MTX has a protective effect on the formation of anti-drug antibodies, which is particularly important for the use of anti-TNF antibodies. This could also be observed in children. For golimumab, combination with MTX is mandatory according to its approval, as is the cause for abatacept. With regard to tolerability, apart from the classic side effects of MTX, there are no other significant differences concerning the combination of MTX and biologics. In case of MTX intolerance, leflunomide may be considered as an (unapproved) alternative.

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  1. Allgemeine Kinder- und Jugendmedizin, Asklepios Klinik Sankt Augustin GmbH, Arnold-Janssenstraße 29, 53757, Sankt Augustin, Deutschland

    Ariane Klein

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Klein, A. Biologikabehandlung bei der juvenilen idiopathischen Arthritis. Z Rheumatol 78, 599–609 (2019). https://doi.org/10.1007/s00393-019-0645-4

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