With data indicating that it is the most common pediatric rheumatologic disease, juvenile idiopathic arthritis (JIA) can impact quality of life and cause disability starting in childhood. Despite hope that the growing use of disease modifying antirheumatic drugs (DMARDs) could help stop disease progression in patients with polyarticular JIA (pcJIA), studies indicate that less than one-half of this patient population has achieved this goal with DMARD treatment. However, there may be an under-utilized window of opportunity for DMARD treatment, according to Bin Huang, PhD, and Esi Morgan, MD. “By treating patients with pcJIA early in the disease course, and effectively, we could achieve inactive disease earlier, avoiding joint damage and leading to better long-term outcomes,” They conclude.
Window of Treatment
For a study published in RMD Open, Drs. Huang, Morgan, and colleagues sought to determine whether the implementation of an early aggressive treatment plan could be more effective in stopping pcJIA progression, as well as whether early administration of a biologic DMARD (bDMARD) could benefit patients more than waiting until conventional synthetic DMARD (csDMARD) therapy fails and then adding a bDMARD. The team gathered and analyzed EHR data from DMARD-naïve patients aged 1-19 with newly diagnosed pcJIA, including subtypes of polyarthritis, extended oligoarthritis, psoriatic arthritis, enteritis-related arthritis, and undifferentiated arthritis. “EHR data analysis not only allowed us to find answers quickly, it, more importantly, helps tell the story of what actually happens in a real-world setting,” notes Dr. Huang.
Early aggressive treatment consisted of both bDMARD and csDMARD prescriptions within 2 months of diagnosis. Patients on the conservative track received only csDMARDs for at least the first 3 months. Follow-up visits were tracked at 3, 6, and 12 months after initial prescription, following prescription changes and routine clinical visits. At 0, 6, and 12 months, clinical Juvenile Arthritis Disease Activity Score (cJADAS) was analyzed on a 0-30 scale among participants, while Pediatric Quality of Life Inventory (PedsQL) scores were analyzed, on a 0-100 scale, annually via questionnaire.
“Patients on the early aggressive treatment had significantly more active disease, as measured by cJADAS, at baseline than those on conservative treatment, but the two groups’ scores were similar by 6 and 12 months,” highlights Dr. Huang (Figure). Average baseline cJADAS for patients prescribed aggressive treatment was 16.08, compared with 12.39 for those on conservative treatment. These scores were 6.47 and 6.91, respectively, at 6-months follow-up, and 5.45 and 5.25, respectively, at 12-months follow-up.
“Causal inference analyses suggested that if all patients had gone through early aggressive treatment, average cJADAS would have been reduced a significant 2.17 points at 6 months, compared with if they had gone through conservative treatment and had delayed biologic treatment introduced at 6 months, which showed little effect,” adds Dr. Huang. The PedsQL scores continued to improve for aggressive treatment at 12-months follow-up (conservative, 76.26 vs. aggressive, 82.61).
Drs. Huang and Morgan emphasize that timing matters in the treatment of pcJIA. . “Treating patients with pcJIA early with more effective cs+bDMARD can make a difference 6 months after starting initiating treatment, when compared with waiting to determine the effects of conservative csDMARD treatment alone,” they add. “This approach fits with the ‘treat-to-target’ approach to JIA, which has been recommended by an international task force to promptly escalate treatment if a good response is not achieved. Also, treatment should result from a shared decision-making process that includes informing patients of treatment options and data.”
Timing matters: real-world effectiveness of early combination of biologic and conventional synthetic disease-modifying antirheumatic drugs for treating newly diagnosed polyarticular course juvenile idiopathic arthritis