A recent study concluded that “timing matters” and that early, aggressive treatment trumps delayed, conservative treatment in children with newly diagnosed polyarticular course juvenile idiopathic arthritis (pcJIA).
Much remains unknown about the disease, according to the study authors, which is the most common pediatric rheumatological disease and causes significant childhood disability. The estimated worldwide prevalence of JIA is about 19.4 per 100,000 for girls and 11.0 per 100,000 for boys. Its cause is unknown.
“The advent of disease-modifying antirheumatic drugs (DMARDs), particularly biologic DMARDs (bDMARDs), in the past two decades have revolutionised the treatment approaches to JIA, making it possible to target for inactive disease as the treatment goal,” the authors wrote. “Despite the advanced DMARD treatment, still about 50% of the patients with JIA failed to achieve inactive disease during long-term follow-up, and most of them had detectable joint damage.”
To conduct the present study, which was published in RMD Open, the researchers queried the electronic medical record (EMR) system of a large U.S. Midwest pediatric rheumatology clinic. EMR data were obtained for 2,082 JIA patients who were aged between one and 19 years; were DMARD-naïve; and were newly diagnosed with pcJIA; including subtypes of polyarthritis, oligoarthritis, psoriatic arthritis, enteritis-related arthritis and undifferentiated arthritis. Eligible patients received a pcJIA diagnosis in at least two visits by pediatric rheumatologists and visited a rheumatology clinic within six months of their diagnosis. Patients were excluded if they had inflammatory bowel disease, celiac disease, or trisomy.
Study Methods, Results for JIA Treatment Strategies
Early aggressive treatment patients received bDMARD and conventional synthetic DMARD (csDMARD) prescriptions during a two-month period. Conservative treatment patients received initial csDMARDs and were not prescribed bDMARDs for at least three months. Baseline was the month patients received their first DMARD prescription; three-, six-, and 12-month follow-up visits were determined based on subsequent clinical visits and prescription updates, which were documented and compared against previous prescriptions. Prescription changes were used to stratify patients into the second-stage adaptive groups, determined by initiation or termination of bDMARDs at six months. The main outcome was six- and 12-month clinical Juvenile Arthritis Disease Activity Score (cJADAS); the secondary outcome was 12-month Pediatric Quality of Life Inventory (PedsQL) generic total score.
Final analysis included 465 patients: 330 in the conservative treatment group and 135 in the aggressive treatment group. Both groups presented improvements in cJADAS and PedsQL. The early aggressive approach was, compared to the conservative approach, superior in six-month cJADAS reduction (mean, −2.17; 95% confidence interval [CI], −3.77 to −0.56). The addition of bDMARD six months after baseline was not beneficial.
“Similarly to the cJADAS results, the early aggressive group presented worse quality of life at the baseline, but similar scores at the 6 and 12 months of follow-up, with PedsQL scores (mean±SD) 61.35±19.24 versus 67.58±17.53 at baseline, 73.40±17.42 versus 74.34±19.38 at 6 months and 76.32±16.47 versus 78.52±18.63 at 12 months,” the authors added.
The researchers concluded, “All treatment strategies show significant improvement from the baseline. The study results suggest that, compared with csDMARD only, early aggressive use of bDMARD in treating patients with pcJIA soon after diagnosis achieves more than two points of additional reduction in disease activity at 6 months.”