‘Substantial’ proportion of patients left with active JIA before treat-to-target era
Key takeaways:
- Between 2007 and 2017, approximately 42% to 52% of patients with JIA treated with a ‘step-up approach’ achieved inactive disease at 5 years.
- The finding sets a baseline to compare later outcomes with treat-to-target.
A significant number of children with juvenile idiopathic arthritis treated prior to the treat-to-target era demonstrated persistently active disease up to 5 years later, according to data from an Italian pediatric hospital.
“In 2018, the paradigm of explicitly defining a treatment target and applying tight control and necessary therapeutic adjustments to reach the target has been incorporated into treat-to-target recommendations for JIA,” Ana Isabel Rebollo-Giménez, of the Giannina Gaslini Institute, in Genoa, Italy, and colleagues wrote in Pediatric Rheumatology. “It has been suggested that transferring this approach into clinical practice will significantly improve the outcomes for patients with JIA.
“To further evaluate the impact of the application of the [treat-to-target] strategy in the real world clinical practice, it is important to gain insights into the frequency of complete disease quiescence in children with JIA treated before this approach was proposed,” they added.
To gain that insight, and to established a “benchmark” for comparing outcomes in the treat-to-target era, RebolloGiménez and colleagues retrospectively analyzed the health records of 394 children with JIA who received care at the Giannina Gaslini Institute from 2007 through 2017, before the establishment of treat-to-target. All the patients were treated at the institute within 6 months of disease onset and followed for at least 6 months from their baseline visit. Analyzing patients who visited only this center, rather than those who were referred, helped ensure the therapeutic management of different patients “was uniform throughout the entire disease course,” the researchers wrote.
Most patients were received care based on a “step-up” approach, starting with intra-articular glucocorticoids and, depending on their specific disease phenotype and the number of joints affected, a conventional synthetic disease-modifying anti-rheumatic drug. If disease remained active several months later, they were given a TNF inhibitor or other biologic DMARD.
According to the researchers, the cohort’s rates of clinically inactive disease rose from 25.1% at 6 months, to 34.5% at 12 months, to 44.6% at 24 months and to 49.1% at 60 months. The highest rates of clinically inactive disease were seen among patients with systemic (6 months: 32.1%; 12 months: 40%) and oligoarticular (6 months: 29.5%; 12 months: 41.1%) phenotypes.
Among the 226 patients with data at 60 months, clinically inactive disease was attained by 42.9% of patients with systemic arthritis, 51.7% of patients with oligoarticular arthritis, 46.7% of patients with polyarticular arthritis, and 45.5% of patients with other arthritis phenotypes.
“It should be considered that the figures for [clinically inactive disease] at 5 years are likely underestimated, as 30% of the 323 patients who had a follow-up visit at 2 years did not have a 5-year evaluation,” RebolloGiménez and colleagues wrote.
Still, the share of children with active JIA, despite 5 years of treatment, remained “substantial” between 2007 and 2017, they added.
“This finding contrasts with our previous observation of remarkable improvement in terms of physical disability, disease damage and health-related quality of life among patients followed in the same epoch as compared to those seen before the 2000s,” RebolloGiménez and colleagues wrote. “Future experiences on the application of treat-to-target strategy will determine whether this approach increases the ability to achieve sustained disease quiescence in patients with who respond suboptimally to the conventional therapeutic protocols.”
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