From the Journals

Longer poly-JIA inactivity not necessarily better before stopping anti-TNF therapy



Recent data suggest the longer a patient with polyarticular forms of juvenile idiopathic arthritis stays on anti–tumor necrosis factor therapy to maintain a clinical inactive disease state, the higher the likelihood of experiencing disease flare after discontinuing anti-TNF therapy.

Daniel J. Lovell, MD, MPH, of the Cincinnati Children’s Hospital Medical Center, and his coauthors prospectively evaluated 137 patients with clinical inactive PF-JIA who were receiving anti-TNF therapy at 16 academic pediatric centers. Of these, 7 patients dropped from the study and 24 patients did not maintain clinical inactive disease (CID) for 6 months.

Dr. Daniel J. Lovell of Cincinnati Children’s Hospital Medical Center.

Dr. Daniel J. Lovell

“CID was an unstable state and 18.5% of the patients were unable to maintain CID for 6 continuous months of observation, even while continuing to receive the anti-TNF agent and stable doses of all background medications,” Dr. Lovell and his colleagues wrote in their study, published in Arthritis & Rheumatology.

Among the 106 patients who continued anti-TNF therapy for 6 months and maintained CID, the investigators then stopped anti-TNF therapy and examined patients for disease flare at 1-month, 2-month, 3-month, 4-month, 6-month, and 8-month follow-up. A total of 42% of these patients were also taking background medication such as methotrexate. Investigators found 39 patients (37%) who showed signs of disease flare within 8 months of discontinuing anti-TNF therapy. A number of factors proved to be significantly associated with disease flare, including age at disease onset (hazard ratio, 0.92; 95% confidence interval, 0.85-0.99; P = .03), age at disease diagnosis (HR, 0.91; 95% CI, 0.84-0.99; P = .02), disease duration at enrollment (HR, 1.12; 95% CI, 1.04-1.21; P less than .01) and time from onset until first CID (HR, 1.10; 95% CI, 1.01-1.20; P = .04). Flare occurred at a mean 7.01 months (standard error of the mean, 0.32) and median 8.26 months (95% CI, 7.80-8.66).

“These data certainly do not support the existence of a protective effect of longer duration of CID before considering stopping anti-TNF therapy,” the authors wrote in their study. “In fact, the data suggest that CID, even in those who did demonstrate CID consistently for the first 6 months of the study, continued to be an unstable clinical state and prolonged observation of CID resulted in a significantly greater risk for flare.”

Dr. Lovell and his colleagues noted their results suggest a “window of opportunity” where treating JIA early with “aggressive therapy” to reach CID sooner will help improve outcomes and long-term control of the disease.

The study was sponsored by a grant from the National Institutes of Health.

SOURCE: Lovell D et al. Arthritis Rheumatol. 2018 Mar 31. doi: 10.1002/art.40509.

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