Most Juvenile Arthritis Can Be Tamed With Current Treatments

Janis C. Kelly

May 27, 2014

Most kids with juvenile idiopathic arthritis (JIA) who begin currently recommended treatment within 6 months of diagnosis have a good chance of attaining inactive disease within 2 years, and approximately half of them will achieve remission within 5 years, according to a new study.

Jaime Guzman, MD, from the Division of Pediatric Rheumatology, BC Children's Hospital, Vancouver, British Columbia, Canada, and colleagues report their findings in an article published online May 19 in the Annals of the Rheumatic Diseases.

"We believe the main implications for clinicians are that early treatment of JIA along current recommendations works well and should be encouraged, as it produces good outcomes," Dr. Guzman told Medscape Medical News. "[T]reatment needs to be tailored to the subtype of arthritis the child has — one size does not fit all; and that more effective lines of therapy are needed for children with polyarthritis."

This analysis, part of the Research in Arthritis in Canadian Children emphasizing Outcomes study (ReACCh-Out), included 1104 children newly diagnosed with JIA at 16 Canadian pediatric rheumatology centers from 2005 to 2010. Although other pediatric cohorts have been studied, Dr. Guzman said, this is the largest prospective longitudinal cohort reported to date.

The patients underwent comprehensive study visits 0, 6, 12, 18, 24, 36, 48, and 60 months after enrollment (which occurred a median of 0.3 months after diagnosis). At each visit, researchers collected data on demographic and clinical information, juvenile arthritis core variables, information on medications used, and quality-of-life measures.

Treatment was at the discretion of the pediatric rheumatologist and the family and followed current International League of Associations for rheumatology JIA practice recommendations: initial treatment with intraarticular corticosteroids and nonsteroidal anti-inflammatory drugs for JIA affecting a few joints, or disease-modifying antirheumatic drugs (DMARDs) followed by biological agents if DMARDs failed to bring the disease under control for polyarthritis and for children with poor prognostic factors.

At enrolment, 88% of children received nonsteroidal anti-inflammatory drugs. During the study, 608 children started DMARDs, including 93% of those with rheumatoid factor–positive (RF-positive) polyarthritis and 83% of those with RF-negative polyarthritis. During the study, 129 patients started biological therapies, including 11.1% in children with RF-positive polyarthritis and 5.3% in children with systemic JIA. Only 6.6% of children with oligoarthritis used biological agents.

Most (79%) of children with systemic JIA started systemic corticosteroids within 6 months of diagnosis, as did 61% of children with RF-positive polyarthritis. Intraarticular corticosteroids (nearly always triamcinolone hexacetonide) were used most often in oligoarthritis and least often in systemic JIA.

The researchers used Kaplan-Meier survival curves for each JIA category to estimate the probability of attaining an active joint count of 0, inactive disease, disease remission, and receiving specific treatments. They defined inactive disease as no active joints, no extraarticular manifestations, and a physician global assessment of disease activity lower than 10 mm. They defined remission as inactive disease more than 12 months after discontinuing treatment.

The investigators found that children had a better than 78% chance of attaining an active joint count of 0 at least once within 2 years after beginning treatment, regardless of their JIA category and differences in treatment

For patients with RF-positive polyarthritis, the probability of attaining inactive disease within 2 years was 48% compared with 91% for those with psoriatic arthritis.

Sixty-seven percent of patients were able to discontinue therapy at least once over the course of 5 years. The first attempt to discontinue treatment occurred, on average, after 3 years. The chance of remission within 5 years was 46% to 57% for all patients except those with polyarthritis. Patients were followed-up for a median of 16.6 months after treatment discontinuation.

Most patients with JIA received intraarticular corticosteroids, and patients with systemic JIA or RF-positive polyarthritis usually received systemic corticosteroids. Patients had a less than 20% chance of receiving biological agents within 5 years of diagnosis unless they had RF-positive polyarthritis or systemic JIA.

Patients with oligoarthritis had about a 40% chance of receiving DMARDs, about a 40% chance of experiencing remission, and a 20% chance that their disease would extend to more joints within 4 years of diagnosis. Most children with RF-positive polyarthritis eventually attained inactive disease and were likely to receive DMARDs and biological agents but were unlikely to discontinue treatment within 5 years of diagnosis.

"The overall good results were expected, but children with psoriatic arthritis did better than expected," Dr. Guzman said. "Children with RF-positive polyarthritis were clearly different and, in the long run, had the most severe kind of JIA. Children with systemic JIA did not do as badly as feared. They may present 'with a bang,' but most of them eventually respond and settle nicely with treatment. Future research needs to be devoted to further understand the different mechanism of disease in different children so that treatment can be truly personalized." Dr. Guzman said.

This study was supported by the Canadian Institutes of Health Research. The authors have disclosed no relevant financial relationships.

Ann Rheum Dis. Published online May 19, 2014. Abstract


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