vspВопросы современной педиатрииCurrent Pediatrics1682-55271682-5535Издательство «ПедиатрЪ»10.15690/vsp.v22i6.2649vsp-3356Research ArticleКЛИНИЧЕСКОЕ НАБЛЮДЕНИЕCLINICAL OBSERVATIONSПрименение белимумаба у пациентки с системной красной волчанкой с ювенильным дебютом и стероидным диабетом: клинический случайBelimumab in a Patient with Systemic Lupus Erythematosus with Juvenile Onset and Steroid-induced Diabetes: Clinical Casehttps://orcid.org/0000-0002-0513-6826КаледаМ. И.KaledaMaria I.

Каледа Мария Игоревна - кандидат медицинских наук, старший научный сотрудник лаборатории ревматических заболеваний детского возраста НИИ ревматологии им. В.А. Насоновой.

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kaleda-mi@yandex.ruhttps://orcid.org/0000-0003-1842-0348НикишинаИ. П.NikishinaIrina P.

Москва

Moscow

https://orcid.org/0009-0002-0402-3640ФирсаА. В.FirsaAlesya V.

Москва

Moscow

ФГБНУ «Научно-исследовательский институт ревматологии им. В.А. Насоновой»РоссияResearch Institute of Rheumatology named after V.A. NasonovaRussian Federation202312012024226546553Copyright © Каледа М.И., Никишина И.П., Фирса А.В., 20232023Каледа М.И., Никишина И.П., Фирса А.В.Kaleda M.I., Nikishina I.P., Firsa A.V.This work is licensed under a Creative Commons Attribution 4.0 License.https://vsp.spr-journal.ru/jour/article/view/3356

Обоснование. Лечение детей с системной красной волчанкой (СКВ), как правило, сопряжено с пожизненным приемом системных глюкокортикоидов и, как следствие, высоким риском серьезных побочных эффектов, в том числе развития стероидного диабета. Применение белимумаба, ингибитора активности стимулятора В-лимфоцитов, позволяет существенно снизить дозу глюкокортикоидов, риск и тяжесть осложнений стероидной терапии. Описание клинического случая. Диагноз СКВ у пациентки установлен в возрасте 16 лет. Начата терапия гидроксихлорохином и пероральным глюкокортикоидом в высокой дозе (56 мг метилпреднизолона в сутки). Через 1 мес от начала терапии диагностирован стероидный диабет, через 2 мес обнаружены участки аваскулярного некроза. На фоне терапии микофенолата мофетилом удалось добиться купирования активности заболевания. Однако в связи с сохранением потребности в инсулине и прогрессированием аваскулярного некроза через 5 мес после верификации диагноза назначен белимумаб. Заключение. Белимумаб — единственный генно-инженерный биологический препарат, зарегистрированный для лечения детей с СКВ. В результате его назначения удалось быстро (в течение 3 мес) стабилизировать состояние пациентки, существенно снизить дозу перорального глюкокортикоида метилпреднизолона (с 24 до 8 мг/сут), добиться ремиссии стероидного диабета с отменой инсулина, а также купировать клинические симптомы аваскулярного некроза.

Background. The management of children with systemic lupus erythematosus (SLE) is usually associated with lifelong systemic glucocorticoids administration and, thereby, high risk of serious side effects, including steroid-induced diabetes. The belimumab (B-lymphocyte stimulator inhibitor) administration significantly reduces the glucocorticoids dose, the risk and severity of steroid therapy complications. Clinical case description. The patient was diagnosed with SLE at the age of 16 years. Therapy with hydroxychloroquine and oral glucocorticoid at a high dose (methylprednisolone 56 mg per day) was initiated. Steroid-induced diabetes was diagnosed 1 month after the therapy start; avascular necrosis sites were revealed in 2 months. Mycophenolate mofetil made it possible to achieve the disease activity control. However, the belimumab was prescribed 5 months after diagnosis verification due to continuous insulin requirement and avascular necrosis progression. Conclusion. Belimumab is the only genetically engineered biologic drug approved for the treatment of children with SLE. As a result of its use, it was possible to stabilize the patient's condition quickly (within 3 months), to reduce significantly the dose of oral glucocorticoid, methylprednisolone (from 24 to 8 mg/day), to achieve remission of steroidinduced diabetes with further insulin withdrawal, and also to relieve avascular necrosis clinical symptoms.

системная красная волчанка с ювенильным началомпероральные глюкокортикоидыстероидный диабетаваскулярный некрозбелимумабsystemic lupus erythematosus with juvenile onsetoral glucocorticoidssteroid-induced diabetesavascular necrosisbelimumabПодготовка рукописи выполнена в рамках фундаментальной научной темы (исследования, выполняемого в рамках государственного задания) № 1021051302580-4 в НИИ ревматологии им. В.А. Насоновой. Авторы выражают благодарность за помощь в обследовании и лечении пациентки сотрудникам Национального медицинского исследовательского центра эндокринологии — заместителю главного врача к.м.н. Г.Н. Светловой, заведующему детским отделением сахарного диабета д.м.н. Д.Н. Лаптеву, сотрудникам отделения лучевой диагностики НИИ ревматологии им. В.А. Насоновой.The manuscript was prepared within the fundamental research topic (research within the state assignment) No. 1021051302580-4 at the Research Institute of Rheumatology named after V.A. Nasonova. The authors express gratitude to the employees of the National Medical Research Center of Endocrinology — deputy head physician, candidate of medicine, G.N. Svetlova, head of pediatric department of diabetes mellitus, doctor of medicine, D.N. Laptev, and diagnostic radiology department of Research Institute of Rheumatology named after V.A. Nasonova.Referencesdas Chagas Medeiros MM, Bezerra MC, Braga FN, et al. Clinical and immunological aspects and outcome of a Brazilian cohort of 414 patients with systemic lupus erythematosus (SLE): comparison between childhood-onset, adult-onset, and late-onset SLE. Lupus. 2016;25(4):355–363. doi: https://doi.org/10.1177/0961203315606983das Chagas Medeiros MM, Bezerra MC, Braga FN, et al. Clinical and immunological aspects and outcome of a Brazilian cohort of 414 patients with systemic lupus erythematosus (SLE): comparison between childhood-onset, adult-onset, and late-onset SLE. Lupus. 2016;25(4):355–363. doi: https://doi.org/10.1177/0961203315606983Асеева Е.А., Лила А.М., Соловьев С.К. и др. Клинико-иммунологические фенотипы системной красной волчанки, выделенные на основании кластерного анализа данных 400 пациентов ФГБНУ «Научно-исследовательский институт ревматологии им. В.А. Насоновой» // Современная ревматология. — 2022. — Т. 16. — № 5. — С. 13–21. — doi: https://doi.org/10.14412/1996-7012-2022-5-13-21Aseeva EA, Lila AM, Soloviev SK, et al. Clinical and immunological phenotypes of systemic lupus erythematosus, identified based on cluster analysis of data from 400 patients from V.A. Nasonova Research Institute of Rheumatology. Sovremennaya Revmatologiya = Modern Rheumatology Journal. 2022;16(5):13–21. (In Russ). doi: https://doi.org/10.14412/1996-7012-2022-5-13-21Hoffman IE, Lauwerys BR, De Keyser F, et al. Juvenile-onset systemic lupus erythematosus: different clinical and serological pattern than adult-onset systemic lupus erythematosus. Ann Rheum Dis. 2009;68(3):412–415. doi: https://doi.org/10.1136/ard.2008.094813Hoffman IE, Lauwerys BR, De Keyser F, et al. Juvenile-onset systemic lupus erythematosus: different clinical and serological pattern than adult-onset systemic lupus erythematosus. Ann Rheum Dis. 2009;68(3):412–415. doi: https://doi.org/10.1136/ard.2008.094813Guzman M, Hui-Yuen JS. Management of Pediatric Systemic Lupus Erythematosus: Focus on Belimumab. Drug Des Devel Ther. 2020;14:2503–2513. doi: https://doi.org/10.2147/DDDT.S216193Guzman M, Hui-Yuen JS. Management of Pediatric Systemic Lupus Erythematosus: Focus on Belimumab. Drug Des Devel Ther. 2020;14:2503–2513. doi: https://doi.org/10.2147/DDDT.S216193Hedrich CM, Smith EMD, Beresford MW. Juvenile-onset systemic lupus erythematosus (jSLE) — Pathophysiological concepts and treatment options. Best Pract Res Clin Rheumatol. 2017;31(4):488–504. doi: https://doi.org/10.1016/j.berh.2018.02.001Hedrich CM, Smith EMD, Beresford MW. Juvenile-onset systemic lupus erythematosus (jSLE) — Pathophysiological concepts and treatment options. Best Pract Res Clin Rheumatol. 2017;31(4):488–504. doi: https://doi.org/10.1016/j.berh.2018.02.001Насонов Е.Л., Попкова Т.В., Лила А.М. Белимумаб в лечении системной красной волчанки: 20 лет фундаментальных исследований, 10 лет клинической практики // Научно-практическая ревматология. — 2021. — Т. 59. — № 4. — С. 367–383. — doi: https://doi.org/10.47360/1995-4484-2021-367-383Nasonov EL, Popkova TV, Lila AM. Belimumab in the treatment of systemic lupus erythematosus: 20 years of basic research, 10 years of clinical practice. Nauchcno-Prakticheskaya Revmatologia = Rheumatology Science and Practice. 2021;59(4):367–383. (In Russ). doi: https://doi.org/10.47360/1995-4484-2021-367-383Watson L, Beresford MW, Maynes C, et al. The indications, efficacy and adverse events of rituximab in a large cohort of patients with juvenile-onset SLE. Lupus. 2015;24(1):10–17. doi: https://doi.org/10.1177/0961203314547793Watson L, Beresford MW, Maynes C, et al. The indications, efficacy and adverse events of rituximab in a large cohort of patients with juvenile-onset SLE. Lupus. 2015;24(1):10–17. doi: https://doi.org/10.1177/0961203314547793Trindade VC, Carneiro-Sampaio M, Bonfa E, Silva CA. An Update on the Management of Childhood-Onset Systemic Lupus Erythematosus. Paediatr Drugs. 2021;23(4):331–347. doi: https://doi.org/10.1007/s40272-021-00457-zTrindade VC, Carneiro-Sampaio M, Bonfa E, Silva CA. An Update on the Management of Childhood-Onset Systemic Lupus Erythematosus. Paediatr Drugs. 2021;23(4):331–347. doi: https://doi.org/10.1007/s40272-021-00457-zКаледа М.И., Никишина И.П., Николаева Е.В. и др. Ритуксимаб при ревматических заболеваниях у детей: результаты ретроспективного исследования безопасности терапии // Научно-практическая ревматология. — 2021. — Т. 59. — № 2. — С. 208– 214. — doi: https://doi.org/10.47360/1995-4484-2021-208-214Kaleda MI, Nikishina IP, Nikolaeva EV, et al. Rituximab for rheumatic diseases in children: Results of a retrospective study of the safety of therapy. Nauchcno-Practicheskaya Revmatologia = Rheumatology Science and Practice. 2021;59(2):208–214. (In Russ). doi: https://doi.org/10.47360/1995-4484-2021-208-214Chen F, Zheng Y, Chen X, et al. Belimumab in childhood systemic lupus erythematosus: A review of available data. Front Immunol. 2022; 13:940416. doi: https://doi.org/10.3389/fimmu.2022.940416Chen F, Zheng Y, Chen X, et al. Belimumab in childhood systemic lupus erythematosus: A review of available data. Front Immunol. 2022; 13:940416. doi: https://doi.org/10.3389/fimmu.2022.940416Brunner HI, Abud-Mendoza C, Viola DO, et al. Paediatric Rheumatology International Trials Organisation (PRINTO) and the Pediatric Rheumatology Collaborative Study Group (PRCSG). Safety and efficacy of intravenous belimumab in children with systemic lupus erythematosus: results from a randomised, placebo-controlled trial. Ann Rheum Dis. 2020;79(10):1340–1348. doi: https://doi.org/10.1136/annrheumdis-2020-217101Brunner HI, Abud-Mendoza C, Viola DO, et al. Paediatric Rheumatology International Trials Organisation (PRINTO) and the Pediatric Rheumatology Collaborative Study Group (PRCSG). Safety and efficacy of intravenous belimumab in children with systemic lupus erythematosus: results from a randomised, placebo-controlled trial. Ann Rheum Dis. 2020;79(10):1340–1348. doi: https://doi.org/10.1136/annrheumdis-2020-217101Fontana F, Alfano G, Leonelli M, et al. Efficacy of Belimumab for active lupus nephritis in a young Hispanic woman intolerant to standard treatment: a case report. BMC Nephrol. 2018;19(1):276. doi: https://doi.org/10.1186/s12882-018-1066-3Fontana F, Alfano G, Leonelli M, et al. Efficacy of Belimumab for active lupus nephritis in a young Hispanic woman intolerant to standard treatment: a case report. BMC Nephrol. 2018;19(1):276. doi: https://doi.org/10.1186/s12882-018-1066-3Zeng HQ, Lu XP, Yan ZB, Ye ZZ. First case presentation of refractory pediatric bullous lupus erythematosus (BSLE) treatment with belimumab. Eur Rev Med Pharmacol Sci. 2022;26(21):7980– 7985. doi: https://doi.org/10.26355/eurrev_202211_30151Zeng HQ, Lu XP, Yan ZB, Ye ZZ. First case presentation of refractory pediatric bullous lupus erythematosus (BSLE) treatment with belimumab. Eur Rev Med Pharmacol Sci. 2022;26(21):7980– 7985. doi: https://doi.org/10.26355/eurrev_202211_30151Wang D, Shan C, Liu J, et al. Efficacy and safety of belimumab for the treatment of refractory childhood-onset systemic lupus erythematosus: A single-center, real-world, retrospective study. Front Immunol. 2022;13:1067721. doi: https://doi.org/10.3389/fimmu.2022.1067721Wang D, Shan C, Liu J, et al. Efficacy and safety of belimumab for the treatment of refractory childhood-onset systemic lupus erythematosus: A single-center, real-world, retrospective study. Front Immunol. 2022;13:1067721. doi: https://doi.org/10.3389/fimmu.2022.1067721Suh S, Park MK. Glucocorticoid-Induced Diabetes Mellitus: An Important but Overlooked Problem. Endocrinol Metab (Seoul). 2017;32(2):180–189. doi: https://doi.org/10.3803/EnM.2017.32.2.180Suh S, Park MK. Glucocorticoid-Induced Diabetes Mellitus: An Important but Overlooked Problem. Endocrinol Metab (Seoul). 2017;32(2):180–189. doi: https://doi.org/10.3803/EnM.2017.32.2.180Bao S, Huang H, Jin Y, et al. Autoantibody-based subgroups and longitudinal seroconversion in juvenile-onset systemic lupus erythematosus. Lupus Sci Med. 2023;10(1):e000834. doi: https://doi.org/10.1136/lupus-2022-000834Bao S, Huang H, Jin Y, et al. Autoantibody-based subgroups and longitudinal seroconversion in juvenile-onset systemic lupus erythematosus. Lupus Sci Med. 2023;10(1):e000834. doi: https://doi.org/10.1136/lupus-2022-000834Gladman DD, Urowitz MB, Goldsmith CH, et al. The reliability of the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index in patients with systemic lupus erythematosus. Arthritis Rheum. 1997;40(5):809–813. doi: https://doi.org/10.1002/art.1780400506Gladman DD, Urowitz MB, Goldsmith CH, et al. The reliability of the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index in patients with systemic lupus erythematosus. Arthritis Rheum. 1997;40(5):809–813. doi: https://doi.org/10.1002/art.1780400506Rella V, Rotondo C, Altomare A, et al. Bone Involvement in Systemic Lupus Erythematosus. Int J Mol Sci. 2022;23(10):5804. doi: https://doi.org/10.3390/ijms23105804Rella V, Rotondo C, Altomare A, et al. Bone Involvement in Systemic Lupus Erythematosus. Int J Mol Sci. 2022;23(10):5804. doi: https://doi.org/10.3390/ijms23105804Yang Y, Kumar S, Lim LS, et al. Risk Factors for Symptomatic Avascular Necrosis in Childhood-onset Systemic Lupus Erythematosus. J Rheumatol. 2015;42(12):2304–2349. doi: https://doi.org/10.3899/jrheum.150464Yang Y, Kumar S, Lim LS, et al. Risk Factors for Symptomatic Avascular Necrosis in Childhood-onset Systemic Lupus Erythematosus. J Rheumatol. 2015;42(12):2304–2349. doi: https://doi.org/10.3899/jrheum.150464Groot N, de Graeff N, Avcin T, et al. European evidence-based recommendations for diagnosis and treatment of childhood-onset systemic lupus erythematosus: the SHARE initiative. Ann Rheum Dis. 2017;76(11):1788–1796. doi: https://doi.org/10.1136/annrheumdis-2016-210960Groot N, de Graeff N, Avcin T, et al. European evidence-based recommendations for diagnosis and treatment of childhood-onset systemic lupus erythematosus: the SHARE initiative. Ann Rheum Dis. 2017;76(11):1788–1796. doi: https://doi.org/10.1136/annrheumdis-2016-210960Алексеева Е.И., Дворяковская Т.М., Никишина И.П. и др. Системная красная волчанка: клинические рекомендации. Часть 2 // Вопросы современной педиатрии. — 2018. — Т. 17. — № 2. — С. 110–125. — doi: https://doi.org/10.15690/vsp.v17i2.1877Alexeeva EI, Dvoryakovskaya TM, Nikishina IP, et al. Systemic Lupus Erythematosus: Clinical Recommendations. Part 2. Voprosy sovremennoi pediatrii — Current Pediatrics. 2018;17(2): 110–125. (In Russ). doi: https://doi.org/10.15690/vsp.v17i2.1877Fanouriakis A, Kostopoulou M, Alunno A, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745. doi: https://doi.org/10.1136/annrheumdis-2019-215089Fanouriakis A, Kostopoulou M, Alunno A, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745. doi: https://doi.org/10.1136/annrheumdis-2019-215089Hammam N, Evans M, Bell CF, et al. Evaluating the Use of Glucocorticoids Among Belimumab-Treated Patients With Systemic Lupus Erythematosus in Real-World Settings Using the Rheumatology Informatics System for Effectiveness Registry. ACR Open Rheumatol. 2022;4(10):883–889. doi: https://doi.org/10.1002/acr2.11482Hammam N, Evans M, Bell CF, et al. Evaluating the Use of Glucocorticoids Among Belimumab-Treated Patients With Systemic Lupus Erythematosus in Real-World Settings Using the Rheumatology Informatics System for Effectiveness Registry. ACR Open Rheumatol. 2022;4(10):883–889. doi: https://doi.org/10.1002/acr2.11482Massias JS, Smith EM, Al-Abadi E, et al. Clinical and laboratory phenotypes in juvenile-onset Systemic Lupus Erythematosus across ethnicities in the UK. Lupus. 2021;30(4):597–607. doi: https://doi.org/10.1177/0961203320984251Massias JS, Smith EM, Al-Abadi E, et al. Clinical and laboratory phenotypes in juvenile-onset Systemic Lupus Erythematosus across ethnicities in the UK. Lupus. 2021;30(4):597–607. doi: https://doi.org/10.1177/0961203320984251Lim LSH, Pullenayegum E, Lim L, et al. From childhood to adulthood: the trajectory of damage in patients with juvenile-onset systemic lupus erythematosus. Arthritis Care Res (Hoboken). 2017;69(11):1627–1635. doi: https://doi.org/10.1002/acr.23199Lim LSH, Pullenayegum E, Lim L, et al. From childhood to adulthood: the trajectory of damage in patients with juvenile-onset systemic lupus erythematosus. Arthritis Care Res (Hoboken). 2017;69(11):1627–1635. doi: https://doi.org/10.1002/acr.23199Malagón C, Gomez MDP, Mosquera C, et al. Juvenile polyauto-immunity in a rheumatology setting. Autoimmun Rev. 2019;18(4): 369–381. doi: https://doi.org/10.1016/j.autrev.2018.11.006Malagón C, Gomez MDP, Mosquera C, et al. Juvenile polyauto-immunity in a rheumatology setting. Autoimmun Rev. 2019;18(4): 369–381. doi: https://doi.org/10.1016/j.autrev.2018.11.006Setoue DN, Pitta AC, Fiorot FJ, et al. Brazilian Childhood-onset Systemic Lupus Erythematosus Group. Symptomatic polyautoimmunity at diagnosis of 1463 childhood-onset lupus: A Brazilian multicenter study. Autoimmun Rev. 2018;17(8): 836–839. doi: https://doi.org/10.1016/j.autrev.2018.03.009Setoue DN, Pitta AC, Fiorot FJ, et al. Brazilian Childhood-onset Systemic Lupus Erythematosus Group. Symptomatic polyautoimmunity at diagnosis of 1463 childhood-onset lupus: A Brazilian multicenter study. Autoimmun Rev. 2018;17(8): 836–839. doi: https://doi.org/10.1016/j.autrev.2018.03.009Heshin-Bekenstein M, Trupin L, Yelin E, et al. Longitudinal disease- and steroid-related damage among adults with childhood-onset systemic lupus erythematosus. Semin Arthritis Rheum. 2019;49(2):267–272. doi: https://doi.org/10.1016/j.semarthrit.2019.05.010Heshin-Bekenstein M, Trupin L, Yelin E, et al. Longitudinal disease- and steroid-related damage among adults with childhood-onset systemic lupus erythematosus. Semin Arthritis Rheum. 2019;49(2):267–272. doi: https://doi.org/10.1016/j.semarthrit.2019.05.010Nakamura J, Saisu T, Yamashita K, et al. Age at time of corticosteroid administration is a risk factor for osteonecrosis in pediatric patients with systemic lupus erythematosus: a prospective magnetic resonance imaging study. Arthritis Rheum. 2010;62(2):609–615. doi: https://doi.org/10.1002/art.27236Nakamura J, Saisu T, Yamashita K, et al. Age at time of corticosteroid administration is a risk factor for osteonecrosis in pediatric patients with systemic lupus erythematosus: a prospective magnetic resonance imaging study. Arthritis Rheum. 2010;62(2):609–615. doi: https://doi.org/10.1002/art.27236Tsai HL, Chang JW, Lu JH, Liu CS. Epidemiology and risk factors for avascular necrosis in childhood systemic lupus erythematosus in a Taiwanese population. Sci Rep. 2020;10(1):15563. doi: https://doi.org/10.1038/s41598-020-71923-wTsai HL, Chang JW, Lu JH, Liu CS. Epidemiology and risk factors for avascular necrosis in childhood systemic lupus erythematosus in a Taiwanese population. Sci Rep. 2020;10(1):15563. doi: https://doi.org/10.1038/s41598-020-71923-wKallas R, Li J, Petri M. Predictors of Osteonecrosis in Systemic Lupus Erythematosus: A Prospective Cohort Study. Arthritis Care Res (Hoboken). 2022;74(7):1122–1132. doi: https://doi.org/10.1002/acr.24541Kallas R, Li J, Petri M. Predictors of Osteonecrosis in Systemic Lupus Erythematosus: A Prospective Cohort Study. Arthritis Care Res (Hoboken). 2022;74(7):1122–1132. doi: https://doi.org/10.1002/acr.24541Kunyakham W, Foocharoen C, Mahakkanukrauh A, et al. Prevalence and risk factor for symptomatic avascular necrosis development in Thai systemic lupus erythematosus patients. Asian Pac J Allergy Immunol. 2012;30(2):152–157.Kunyakham W, Foocharoen C, Mahakkanukrauh A, et al. Prevalence and risk factor for symptomatic avascular necrosis development in Thai systemic lupus erythematosus patients. Asian Pac J Allergy Immunol. 2012;30(2):152–157.Nevskaya T, Gamble MP, Pope JE. A meta-analysis of avascular necrosis in systemic lupus erythematosus: prevalence and risk factors. Clin Exp Rheumatol. 2017;35(4):700–710.Nevskaya T, Gamble MP, Pope JE. A meta-analysis of avascular necrosis in systemic lupus erythematosus: prevalence and risk factors. Clin Exp Rheumatol. 2017;35(4):700–710.Sakamoto M, Shimizu K, Iida S, et al. Osteonecrosis of the femoral head: a prospective study with MRI. J Bone Joint Surg Br. 1997;79(2): 213–219. doi: https://doi.org/10.1302/0301-620x.79b2.7179Sakamoto M, Shimizu K, Iida S, et al. Osteonecrosis of the femoral head: a prospective study with MRI. J Bone Joint Surg Br. 1997;79(2): 213–219. doi: https://doi.org/10.1302/0301-620x.79b2.7179Gurion R, Tangpricha V, Yow E, et al. Atherosclerosis Prevention in Pediatric Lupus Erythematosus Investigators. Avascular necrosis in pediatric systemic lupus erythematosus: a brief report and review of the literature. Pediatr Rheumatol Online J. 2015;13:13. doi: https://doi.org/10.1186/s12969-015-0008-x36.Gurion R, Tangpricha V, Yow E, et al. Atherosclerosis Prevention in Pediatric Lupus Erythematosus Investigators. Avascular necrosis in pediatric systemic lupus erythematosus: a brief report and review of the literature. Pediatr Rheumatol Online J. 2015;13:13. doi: https://doi.org/10.1186/s12969-015-0008-x36.Hui-Yuen JS, Reddy A, Taylor J, et al. Safety and Efficacy of Belimumab to Treat Systemic Lupus Erythematosus in Academic Clinical Practices. J Rheumatol. 2015;42(12):2288–2295. doi: https://doi.org/10.3899/jrheum.150470Hui-Yuen JS, Reddy A, Taylor J, et al. Safety and Efficacy of Belimumab to Treat Systemic Lupus Erythematosus in Academic Clinical Practices. J Rheumatol. 2015;42(12):2288–2295. doi: https://doi.org/10.3899/jrheum.150470

The authors declare that there are no conflicts of interest present.