Methotrexate use varies significantly prior to etanercept in juvenile idiopathic arthritis
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There is significant variation in the patterns of methotrexate use prior to initiating etanercept in patients with juvenile idiopathic arthritis, according to registry data published in Pediatric Rheumatology.
“Although etanercept has been approved for the treatment of JIA for more than 20 years, there are knowledge gaps about its contemporary usage patterns that we sought to address using observational registry data from more than 60 clinical sites in the United States and Canada,” Timothy Beukelman, MD, MSCE, of the University of Alabama at Birmingham, told Healio Rheumatology.
To analyze and characterize the use of etanercept (Enbrel, Amgen) in patients with JIA, Beukelman and colleagues examined data from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry. According to the researchers, the CARRA registry is a large, multicenter convenience cohort of individuals with juvenile onset rheumatic diseases, including 5,641 patients with JIA. For their study, Beukelman and colleagues included all patients with JIA who had been treated with etanercept and had corresponding data describing the month and year of initiation.
In all, the study included 2,032 patients from the CARRA registry. The researchers grouped these patients based on their use of etanercept and methotrexate. The categories included “combination therapy,” or etanercept and methotrexate initiated concurrently; “step-up therapy,” or methotrexate started first followed by etanercept later; “switchers,” or methotrexate started but then ceased at or prior to etanercept initiation; “methotrexate add-on,” or etanercept started first followed by methotrexate later; and “etanercept only,” or no methotrexate use at all.
In their analysis, the researchers used parametric and non-parametric statistics, as appropriate, to describe their data.
According to the researchers, 66.9% of the included patients received a non-biologic disease-modifying antirheumatic drug — primarily methotrexate — before starting etanercept. There was “significant variability” in the use of methotrexate prior to etanercept initiation, the researchers wrote, with “step-up therapy” being the most common approach.
In addition, only 34% of patients with persistent oligoarticular JIA continued treatment with a non-biologic DMARD 3months or more following etanercept initiation. Etanercept persistence overall was 66.3% at 24 months, 49.4% at 36 months and 37.3% at 48months.
Among patients with spondyloarthritis, etanercept persistence varied by methotrexate pattern, with a rate of 68.9% reported in those who received combination therapy, and 73.3% reported in “switchers” and the “etanercept only” group. Meanwhile, patients in the “step-up” and “methotrexate add-on” groups had persistence rates of 65.4% and 51.1%, respectively.
“Physicians are quick to start treatment with etanercept,” Beukelman said. “Among patients who initiated etanercept since 2015, the median time to start etanercept was 4.3 months after JIA diagnosis. A ‘step-up’ approach with a brief trial of methotrexate prior to initiation of etanercept remains the most common treatment pattern overall, but several subgroups of patients were found to exhibit an increased frequency of other treatment patterns. Patients with a more severe initial presentation may initiate etanercept and methotrexate simultaneously.”
“Patients with enthesitis-related arthritis may start etanercept monotherapy,” he added. “Patients with oligoarthritis may switch from methotrexate to etanercept rather than continue both medications. Etanercept usage was largely consistent with existing JIA treatment recommendations. Patients and their families may be comforted to know that quick initiation of etanercept has become a standard approach to treatment.”
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