Advances In Biologic Therapy Research Articles

Advances in biologic therapy for the treatment of moderate to severe psoriasis: a systematic review

Advances in biologic therapy for the treatment of moderate to severe psoriasis: a systematic review

Advances in biologic therapy of psoriasis.

Advances in biologic therapy of psoriasis.

Advances in biologic therapies for chronic rhinosinusitis with nasal polyps

Chronic rhinosinusitis (CRS) is a complex multifactorial inflammatory disease that affects more than ten percent of the adult population globally. CRS represents a large healthcare burden and is associated with significant morbidity. Despite conventional medical and surgical treatments, a subset of patients continue to have poor symptom control due to substantial inflammatory disease persistence. These difficult-to-treat patients represent ideal candidates for biologic therapeutics, which target key inflammatory processes implicated in CRS disease. Biologic agents targeting type 2 inflammation have been shown to reduce disease burden. Phase 3 clinical trials studying the effects of anti-IgE, anti-IL-5/anti-IL-5Rα, and anti-IL-4/IL-13 humanized monoclonal antibodies have shown the efficacy of these therapies to reduce polyp size, the need for revision surgeries, improve daily symptoms, and downregulate inflammatory markers while maintaining an acceptable safety profile. The reductions seen in inflammatory mediators are largely transient following treatment termination and additional investigations are required to discern the long-term effects of biologic use on disease modulation. Specifically, the evidence suggests that these biologics are beneficial for patients with CRSwNPs with comorbid asthma and aspirin exacerbated respiratory disease (AERDBiologics should be used sparingly because of significant cost and accessibility of the treatment. Current guidelines recommend that biologics be reserved for patients with CRSwNP with moderate to severe disease who have failed conventional medical and surgical therapy. Further studies are needed to better endotype patients to optimize biologic use, evaluate long-term effectiveness and compare the relative effectiveness of biologic therapies in these difficult-to-treat patients.

A Multi-Center Study of the Prevalence and Characteristics of Eosinophilic Phenotype and High IgE Levels Among Chinese Patients with Severe Asthma.

Patients with severe asthma have higher total- and asthma-related health burden than those whose disease is not severe. Recent medical advances in biologic therapies allow better control of asthma characterized by type 2 inflammation. To study the prevalence of eosinophilic phenotype and IgE levels in Chinese with severe asthma, and the relationship of these type 2 characteristics with asthma control, exacerbations and lung function. This was a multicenter cross-sectional observational study in Hong Kong, in Chinese adults with asthma on Step 4 or 5 of GINA treatment. Their blood eosinophil counts and total IgE levels were measured, and the relationship of these phenotypic parameters to the number of exacerbations in the past 12 months, and to symptom control in the past 4 weeks, were investigated. A total of 232 subjects were recruited from 6 centers. The mean age was 53.9±12.9 years, with 86 (37.1%) male, and the duration of diagnosed asthma was 26.2±15.7 years. A T-helper 2 (Th2) phenotype indicated by elevated eosinophils and/or IgE was present in 169 (72.8%) of patients. Of 232 patients, 43% had an eosinophilic phenotype (blood eosinophil count ≥300 cell/mm3), while 59% had high total IgE levels of >100 IU/mL (overlap with eosinophilic phenotype in 30%) and 44% had IgE levels of >150 IU/mL (overlap with eosinophilic phenotype in 22%). Subjects with eosinophilic phenotype and IgE >150 IU/mL had a higher rate (1.8 times) of uncontrolled asthma compared with those without such a combination. In Chinese adults with severe asthma defined by the use of conventional maintenance medication regimens, the prevalence of Th2 inflammation is comparable to that reported from other ethnic populations. Those with both eosinophil count ≥300 cell/mm3 and high IgE levels >150 IU/mL had a higher rate of uncontrolled asthma compared with those without a combination of these features.

β-Arrestin-biased proteinase-activated receptor-2 antagonist C781 limits allergen-induced airway hyperresponsiveness and inflammation.

Asthma is a heterogenous disease strongly associated with inflammation that has many different causes and triggers. Current asthma treatments target symptoms such as bronchoconstriction and airway inflammation. Despite recent advances in biological therapies, there remains a need for new classes of therapeutic agents with novel, upstream targets. The proteinase-activated receptor-2 (PAR2) has long been implicated in allergic airway inflammation and asthma and it remains an intriguing target for novel therapies. Here, we describe the actions of C781, a newly developed low MW PAR2 biased antagonist, in vitro and in vivo in the context of acute allergen exposure. A human bronchial epithelial cell line expressing PAR2 (16HBE14o- cells) was used to evaluate the modulation in vitro, by C781, of physiological responses to PAR2 activation and downstream β-arrestin/MAPK and Gq/Ca2+ signalling. Acute Alternaria alternata sensitized and challenged mice were used to evaluate C781 as a prophylactically administered modulator of airway hyperresponsiveness, inflammation and mucus overproduction in vivo. C781 reduced in vitro physiological signalling in response to ligand and proteinase activation. C781 effectively antagonized β-arrestin/MAPK signalling without significant effect on Gq/Ca2+ signalling in vitro. Given prophylactically, C781 modulated airway hyperresponsiveness, airway inflammation and mucus overproduction of the small airways in an acute allergen-challenged mouse model. Our work demonstrates the first biased PAR2 antagonist for β-arrestin/MAPK signalling. C781 is efficacious as a prophylactic treatment for allergen-induced airway hyperresponsiveness and inflammation in mice. It exemplifies a key pharmacophore for PAR2 that can be optimized for clinical development.

33765 Phase 1b randomized, double-blind, placebo-controlled study evaluating the safety, tolerability, and efficacy of GLPG3667 in patients with moderate-to-severe plaque psoriasis

Despite advances in biologic therapies for psoriasis, there remains a need for efficacious oral treatments with favorable safety profiles. Recently, small molecules targeting the JAK-STAT pathway, particularly TYK2 inhibitors, have emerged as promising new therapies. GLPG3667 is an oral potent and selective small-molecule TYK2 inhibitor in development for the treatment of inflammatory diseases. This Phase 1b randomized, double-blind, placebo-controlled study evaluated the safety, tolerability, and efficacy of GLPG3667 (NCT04594928).

Current advances in biological therapy of psoriasis: efficacy of guselkumab in real clinical practice

Psoriasis is an immune-mediated, chronic inflammatory skin disease, which is currently regarded as a systemic process given its association with multiple comorbid conditions. In psoriasis, there is a complex interaction between T cells and keratinocytes. The pathogenesis of psoriasis is not fully understood, but the IL-23/Th17 pathway is known to play the key role in the developmentof the disease. With the advent of genetically engineered biological drugs (GEBD), the treatment of psoriasis has undergone significant changes due to their high efficacy through targeted effects. Guselkumab is the first drug for the treatment of moderate to severe psoriasis to target the p19 subunit of interleukin (IL) 23. The efficacy of guselkumab has been demonstrated in a number of clinical trials. To date, only a few case studies from actual clinical practice have been published in the literature reflecting the use of guselkumab in severe psoriasis, including long-term drug survival and continued efficacy in patients with comorbidities. The article reviews the results of key efficacy studies of guselkumab and presents its own clinical case studies of successful use of the drug. It is noted that guselkumab is able to replicate the results obtained in studies in real clinical prachttps tice. However, the cases presented are also of interest in view of their concomitant metabolic syndrome, obesity, which often makes it difficult to respond to therapy. This group of patients is usually characterised by a particularly torpid course of psoriasis and a certain refractoriness to the ongoing treatment. Thus, guselkumab has an effective and safe profile, in addition it is convenient to use, and the improvement in the quality of life of patients during therapy makes it promising as a first-line GEBD therapy in the treatment of psoriasis.

26163 Risankizumab to treat psoriasis in a patient with hepatitis B and hepatitis C

Recent advances in biologic therapy have revolutionized the treatment of psoriasis. Risankizumab, a humanized monoclonal antibody targeting interleukin 23A, is the newest Food and Drug Administration (FDA)-approved biologic agent for the treatment of moderate-to-severe plaque psoriasis. Due to its potential immunomodulating effect, considerations for serious infections such as hepatitis B (HBV) and hepatitis C (HCV) are important when initiating biologic therapy; in particular, the serious complications of HBV and HCV reactivation.

Functional gastrointestinal disorders in inflammatory bowel disease: Time for a paradigm shift?

Recent advances in biological therapies have revolutionalised and redefined treatment targets in inflammatory bowel disease (IBD). There is now a stronger emphasis on achieving the more stringent therapeutic goals of mucosal and histological healing, rather than clinical remission alone. Consequently, the treatment of refractory “functional” gastrointestinal symptoms, often attributed as the aftermath of previous inflammation, has recently become more prominent in quiescent disease. With further expected advances in anti-inflammatory treatments on the horizon, the burden of such symptoms in quiescent disease, which have been relatively neglected, is set to become an even bigger problem. In this article, we highlight the current state of research and understanding in this field, including recent developments and clinical practice guidelines on the diagnosis and management of functional gastrointestinal symptoms, such as irritable bowel syndrome and functional anorectal and pelvic floor disorders, in patients with quiescent IBD. These disorders are not only highly prevalent in these patients, they are often misdiagnosed, and are difficult to treat, with very few evidence-based therapies. Moreover, they are associated with substantial impairment in quality-of-life, considerable morbidity, and psychological distress. There is therefore an urgent need for a change in emphasis towards earlier recognition, positive diagnosis, and targeted treatment for patients with ongoing functional gastrointestinal symptoms in the absence of active IBD. This article also highlights the need for further research to develop much needed evidence-based therapies.

Emergent colectomy rates decreased while elective ileal pouch rates were stable over time: a nationwide inpatient sample study.

Despite advances in biologic therapy, approximately 10-15% of ulcerative colitis (UC) patients require surgery. We aimed to (1) examine the rates of emergent colectomy and elective ileal pouch anal anastomosis (IPAA) over time among UC patients in the USA and (2) investigate disparities in surgery rates by patient demographics. Data from the Nationwide Inpatient Sample (NIS) from 2000 to 2014 were analyzed. Inclusion criteria were admissions with a primary UC ICD-9-CM diagnosis code and age > 18. Emergent cases were defined as those admitted through the emergency room with an outcome ICD-9-CM code for subtotal colectomy. Elective IPAA cases were defined with an outcome ICD-9-CM code for IPAA, used as a surrogate measure of colectomy. Patient and hospital-level demographics were analyzed. Temporal trends of colectomy were analyzed utilizing joinpoint-regression analysis with calculation of annual percentage change (APC). A total of 470,708 admissions were included over the 14-year period. Emergent colectomy rate significantly declined (APC - 7.35%, p= 0.0002), while the rate of elective IPAA remained stable (APC - 0.21%, p= 0.8). Emergent colectomy rates declined similarly across all demographics, though not as marked among patients age 50 and older and Medicare patients. Elective IPAA rates were significantly lower among blacks and patients with public insurance. There has been a significant decline in emergent UC colectomy rates in the USA; however, the overall need for surgery appears unchanged given stable IPAA rates. This suggests a limited impact on overall surgery rates with a shift from emergent to elective procedures.

Recent advances in biologic therapy of asthma and the role in therapy of chronic rhinosinusitis.

Great strides have been made in the last five years in understanding the pathology of chronic rhinosinusitis (CRS). CRS is now accepted to be the end-stage manifestation of inflammation resultant from various pathogenetic mechanisms. This has resulted in increasing recognition of distinct CRS endotypes. Such endotypes encompass a cluster of patients with similar pathogenic mechanisms that may have common therapeutic targets and responsiveness to interventions. The elucidation of mechanisms leading to the development of chronic upper (sino-nasal) airway inflammation has to some extent paralleled investigations of aberrant pathways operant in asthma. In this review, we focus on recent developments in understanding the innate immune pathways as well as adaptive (late) immune responses in CRS and asthma and their implication as potentially modifiable targets in CRS. Specific biologic therapy (that is, monoclonal antibodies targeting cytokines, cytokine receptors, or specific key molecules targeting inflammation) is an exciting proposition for the future of medical management of CRS. As of the writing of this article, the agents described are not approved for use in CRS; many have partial approval for use in asthma or are considered experimental.

Abstract B37: Value of penetrated NIR spectroscopy in the diagnostic process of lung cancer

Abstract Background: Recently due to advances in biological therapy and immunotherapy there is an increased need for precise morphological and mutational verification of lung cancer. We have been testing the possibilities of NIR (near infrared) n spectroscopy in the process lung cancer detection. Methods: For the analyses, we used a custom-made endoscopic lensed microprobe consisting of one excitation and one collection optical fibers that were coupled to a NIR spectrometer. In 55 patients with lung cancer diagnosis undergoing bronchoscopy we carried on 110 measurements of NIR penetrated spectra from both normal and malignant lung tissues. Detected spectral curves of absolute transmittance for normal tissue and pathological tissue were further analyzed utilizing two chosen parameters which are corresponding to important characteristics of the curves. First parameter was statical moment of area under spectral curve referenced to vertical axis of maximal wavelength whose value reflected average intensity of detected signal as well as rate of shifting higher intensities to shorter wavelengths of spectral band (that means how much is investigated tissue permeable on shortest possible wavelengths). As the second parameter serve horizontal coordinates of the centrum of gravity of the area under spectral curve referenced to vertical axis of maximal wavelength whose value reflected just the rate of shifting signal to shorter wavelengths of spectral band regardless absolute intensity (this parameter compared shifting to shorter wavelengths for spectral curves as if were normalized to its maximal intensity value). Finally ratio of pathological to normal value for both parameters was calculated. Results: Resulting values of these ratios for both above mentioned parameters were higher than 1 for all types of pathologies. Moreover ratio for second parameter is significantly higher for adenocarcinoma than for any type of pathologies. Conclusion: NIR spectroscopy showed a potential for a reliable discrimination between normal and pathological lung tissue. We observed spectral differences between adenocarcinoma and all other types of lung pathologies. Acknowledgement: PROGRAM MPO-TRIO PROJECT: FV 10657, OPROX, a.s. Research and development of technologies and methods for optical penetrating spectroscopy of atypical lung tissue nodules. Note: This abstract was not presented at the conference. Citation Format: Tomas Bruha, Jiri Votruba, Vladimír Cech, Josef Skvarek. Value of penetrated NIR spectroscopy in the diagnostic process of lung cancer [abstract]. In: Proceedings of the AACR International Conference: New Frontiers in Cancer Research; 2017 Jan 18-22; Cape Town, South Africa. Philadelphia (PA): AACR; Cancer Res 2017;77(22 Suppl):Abstract nr B37.

Apremilast: A Novel Oral Treatment for Psoriasis and Psoriatic Arthritis.

Psoriasis is a chronic immune-mediated disease associated with several co-morbidities and negative impacts on a patient's quality of life. Despite the advances in biologic therapy, there are still unmet needs in the treatment of psoriasis, as current treatments are limited in terms of long-term efficacy, tolerability, safety, route of administration, and cost. Apremilast is an oral, small-molecule phosphodiesterase 4 inhibitor that works intracellularly by blocking the degradation of cyclic adenosine 3',5'-monophosphate, resulting in increased intracellular cyclic adenosine 3',5'-monophosphate levels in phosphodiesterase 4-expressing cells. This inhibition results in the reduced expression of proinflammatory mediators, and an increased expression of anti-inflammatory mediators, providing apremilast with an anti-inflammatory rather than immunosuppressive mode of action. Apremilast offers a novel therapeutic option for patients with psoriasis and psoriatic arthritis and may fulfill some of the unmet needs in patients with psoriasis. Potential advantages of apremilast include moderate activity for both psoriasis and psoriatic arthritis and efficacy in difficult-to-treat forms of psoriasis, a good safety profile, no need of laboratory prescreening or ongoing monitoring for laboratory parameters, owing to the absence of organ toxicity, a potentially advantageous weight loss effect, and a convenient oral administration and dosing. Cost effectiveness and health economics considerations will be decisive in determining the ultimate place of apremilast in the therapeutic armamentarium for psoriasis.

Pathogenesis of Inflammatory Bowel Disease and Recent Advances in Biologic Therapies.

Inflammatory bowel disease (IBD) is a chronic intestinal inflammatory disorder with an unknown etiology. IBD is composed of two different disease entities: Crohn's disease (CD) and ulcerative colitis (UC). IBD has been thought to be idiopathic but has two main attributable causes that include genetic and environmental factors. The gastrointestinal tract in which this disease occurs is central to the immune system, and the innate and the adaptive immune systems are balanced in complex interactions with intestinal microbes under homeostatic conditions. However, in IBD, this homeostasis is disrupted and uncontrolled intestinal inflammation is perpetuated. Recently, the pathogenesis of IBD has become better understood owing to advances in genetic and immunologic technology. Moreover, new therapeutic strategies are now being implemented that accurately target the pathogenesis of IBD. Beyond conventional immunesuppressive therapy, the development of biological agents that target specific disease mechanisms has resulted in more frequent and deeper remission in IBD patients, with mucosal healing as a treatment goal of therapy. Future novel biologics should overcome the limitations of current therapies and ensure that individual patients can be treated with optimal drugs that are safe and precisely target IBD.

Biological therapy for Rheumatoid Arthritis – an update

Disease-Modifying Antirheumatic Drugs (DMARDs) play a vital role in the management of Rheumatoid Arthritis (RA). This update aims at focusing some important and novel aspects of biological DMARDs. Recent advances in biological therapy have opened a new window of opportunity for this potentially crippling disorder particularly patients refractory to conventional DMARDs. Close association of cytokine network in the pathophysiology of rheumatoid arthritis has facilitated the development of new biological agents and revolutionized the treatment. Novel drugs such as anti-tumor necrosis factor-alpha (anti-TNF-?) (eg, certolizumab), anti-interleukin-1 (anti-IL-1) (eg, anakinra), anti-interleukin-6 (anti–IL-6) (eg, tocilizumab), T-cell depletor (eg, abatacept), anti-cluster differentiation 20 (anti-CD-20) (eg, rituximab) have recently joined with the existing biological therapy in the arena of RA. Emerging agents like adhesion molecule inhibitors, anti-interleukin-15 (anti-IL-15), fusion protein-cytotoxic T-lymphocyte-associated antigen 4-immunoglobulin G1 (CTLA4Ig) are also under investigations. Higher potency, quicker onset of action, less frequency of administration are the main advantages as opposed to potential serious side effects such as infection susceptibility, injection site reaction, Systemic Lupus Erythematosus-like (SLE-like) and Multiple Sclerosis-like (MS-like) symptoms and higher price. Combination of biologicals is not recommended because of higher rate of adverse events and lack of additive effects. But biological DMARDs in combination of Methotrexate (MTX) are now a preferred choice of many rheumatologists. The last but not the least option for aggressive and refractory patients of RA is biological DMARDs. DOI: http://dx.doi.org/10.3329/jafmc.v10i1.22933 Journal of Armed Forces Medical College Bangladesh Vol.10(1) 2014

The risk of herpes zoster during biological therapy for psoriasis and other inflammatory conditions.

Recent advances in biological therapies have proved highly effective in treating psoriasis and other inflammatory conditions, including psoriatic arthritis, rheumatoid arthritis, inflammatory bowel disease and ankylosing spondylitis. However, adverse effects related to their immunosuppression have been observed, including an increased propensity to viral infections. This review evaluates the evidence of herpes zoster (HZ) risk from biologics based on clinical reports, cohort studies and randomized controlled studies. The risk of HZ associated with these agents remains controversial, especially when comparing their risk with non-biological therapy used to treat the same inflammatory conditions. This review specifically assesses the risk of the TNF inhibitors etanercept, adalimumab and infliximab, as well as interleukin-12/23 inhibitor ustekinumab. We found multiple cohort studies, randomized controlled trials and case reports that suggest infliximab increases risk of HZ, whereas adalimumab, etanercept and ustekinumab HZ risk remain controversial. Nevertheless, HZ vaccination should be considered prior to initiation of biological therapy, particularly infliximab.

Biological Therapy for Ulcerative Colitis: What is after Anti-TNF

Ulcerative Colitis (UC) is an idiopathic chronic inflammation. Its etiology is still largely unknown. Environmental and genetic factors in combination with the microbial flora or specific microorganisms are thought to trigger the gut inflammation, leading to the activation of the intestinal immune response. Immune and non-immune cells create a cross talk via the secretion of soluble mediators and expression of cell adhesion molecules, resulting in further cell activation. Mediators such as cytokines and chemokines play a key role in cell recruitment and polarization, intercellular signal amplification or activation and differentiation. Lack of balance between pro-inflammatory and anti-inflammatory cytokines is crucial in the pathogenesis of IBD. Conventional therapy of UC quite commonly fails to avoid complications or colectomy and the therapeutic armamentarium remains still limited. New therapeutic options, such as, biological therapy, gene therapy, hematopoietic stem cell transplantation, and leucoapheresis, have been investigated recently. Biological therapy is focused on different targets involved in the inflammatory process. Several new biological drugs have been introduced in the last decade or are under investigation for the treatment of IBD. They include anti TNF-α agents, anti adhesion molecules, anti IL-12/23, anti IL-6R and more. We review the recent advances in biological therapy for UC treatment beyond the anti-TNFs.

M1032 Managing the Long Term Care of Inflammatory Bowel Disease Patients: the Cost to European Health Care Providers

Introduction Inflammatory Bowel Disease (IBD), which includes Crohn9s disease (CD) and Ulcerative Colitis (UC), is a chronic condition characterised by substantial morbidity. Patients with IBD are considered expensive to manage although their use of health care resources has not been sufficiently estimated. To date, few studies have quantified the total cost of caring for IBD patients, preferring to focus on the cost-effectiveness of specific treatments instead. Estimating the resources used and costs incurred when caring for IBD patients is crucial to help healthcare providers plan patient clinical management. This need intensifies with advances in biological therapies and genetic diagnostic tools such as microarrays. Our study developed a framework to estimate the total cost of caring for IBD patients. This framework allows both the estimation of the costs of current care pathways in various settings, and the economic analysis of proposed future interventions. We apply the framework to consider the cost of care for UC and CD patients in the UK and mainland Europe. Methods Decision models were built to simulate the natural disease history of UC and CD based on clinical pathways mapped in four European hospitals. A healthcare provider perspective was adopted and model inputs applied from published sources and expert opinion. Two hypothetical cohorts of 10 000 UC/CD patients presenting with symptoms of varying severity were modelled over a 10-year period. The average starting age ranged from 25 to 85 years and the models were adjusted to capture differences in clinical management across Europe. Healthcare cost data (test, treatment, surgery, consultation costs) were taken from UK sources and expressed in 2008 prices. Results The average cost of care over the entire 10-year period for a 45-year-old UC/CD patient was £8035/£7759 in the UK and £7657/£9546 in mainland Europe. These costs are comparable with previous estimates. The average cost per patient fell with patient age. Much of the clinical course for both patient groups was spent in remission, and most costs were incurred soon after diagnosis. The costs of surgery, azathioprine and hospital admission had the greatest effect on the results. Conclusion Our study confirms that IBD patients are expensive to manage and illustrates the importance of differentiating between alternative clinical management scenarios. The framework we develop is an informative analytical tool which allows healthcare providers to predict the resources required and costs incurred from treating both current and future IBD patients. We acknowledge EC financial support and assistance received from members of the IBDchip consortium.

Value of biologic therapy: A forecasting model in three disease areas

Objective:Forecast the return on investment (ROI) for advances in biologic therapies in years 2015 and 2030, based upon impact on disease prevalence, morbidity, and mortality for asthma, diabetes, and colorectal cancer.Methods:A deterministic, spreadsheet-based, forecasting model was developed based on trends in demographics and disease epidemiology. ‘Return’ was defined as reductions in disease burden (prevalence, morbidity, mortality) translated into monetary terms; ‘investment’ was defined as the incremental costs of biologic therapy advances. Data on disease prevalence, morbidity, mortality, and associated costs were obtained from government survey statistics or published literature. Expected impact of advances in biologic therapies was based on expert opinion. Gains in quality-adjusted life years (QALYs) were valued at $100,000 per QALY.Results:The base case analysis, in which reductions in disease prevalence and mortality predicted by the expert panel are not considered, shows the resulting ROIs remain positive for asthma and diabetes but fall below $1 for colorectal cancer. Analysis involving expert panel predictions indicated positive ROI results for all three diseases at both time points, ranging from $207 for each incremental dollar spent on biologic therapies to treat asthma in 2030, to $4 for each incremental dollar spent on biologic therapies to treat colorectal cancer in 2015. If QALYs are not considered, the resulting ROIs remain positive for all three diseases at both time points.Conclusions:Society may expect substantial returns from investments in innovative biologic therapies. These benefits are most likely to be realized in an environment of appropriate use of new molecules.Limitations:The potential variance between forecasted (from expert opinion) and actual future health outcomes could be significant. Similarly, the forecasted growth in use of biologic therapies relied upon unvalidated market forecasts.

New advances in the management of juvenile idiopathic arthritis—2: The era of biologicals

Juvenile idiopathic arthritis (JIA) is the most common paediatric rheumatic disease with significant long-term morbidity and mortality. Major advances have taken place in recent years in our understanding and the...