Early treatment: a key to improved outcomes in polyarticular JIA

Patients with polyarticular Juvenile Idiopathic Arthritis (pJIA) are more likely to achieve clinical remission with a combination of conventional and biological disease-modifying anti-rheumatic drugs (DMARDs) compared with the far more common approach of step-up therapy. Moreover, patients in the early combination group spent more time in clinically inactive disease (CID).

“We know that pJIA patients are at risk of poor outcomes, and we do not have much evidence to support the best time to start biologics,” said Prof. Yukiko Kimura (Hackensack Meridian School of Medicine, NJ, USA) [1]. The Childhood Arthritis and Rheumatology Research Alliance (CARRA) developed 3 consensus treatment plans that differ when biologics are started [2]. The goal of the ongoing prospective, observational study STOP-JIA (NCT02593006) was to identify the optimal timing for starting biologics in untreated pJIA using the CARRA treatment plans. At the ACR meeting, Prof. Kimura presented the 3-year outcomes.

The following 3 CARRA treatment arms were assessed [1]:

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  • Step-up: methotrexate monotherapy with a biologic added after 3 months if needed;
  • Early Combination: conventional DMARD and biological DMARD started together;
  • Biologic First: biologic monotherapy.

The study collected data from the CARRA Registry every 3 months for the first 12 months and every 6 months thereafter.

The study endpoints at 3 years were CID off glucocorticoids, the clinical Juvenile Arthritis Disease Activity Score based on 10 joints (cJADAS10) inactive disease (score <2.5), clinical remission (CID for more than 6 months), and percentage of time spent in CID and cJADAS10 inactive disease.

After 3 years of follow-up, of 297 patients, 190 had started the Step-up plan, 76 the Early Combination, and 31 the Biologic First. At this time, there were no significant differences between the 3 groups in achieving CID and cJADAS10 inactive disease. Nearly 40-60% of pJIA patients failed to achieve both endpoints. However, the proportion of patients who achieved clinical remission and the amount of time patients spent in CID and cJDAS10 inactive disease were significantly higher in the Early Combination group. Indeed, 67.1% of patients in the Early Combination group achieved clinical remission versus 47.3% in the Step-up group. Moreover, the percentage of time in CID for Early Combination patients compared with Step-up patients was 42.1% versus 30.0%. Time in cJADAS10 inactive disease for Early Combination patients compared with Step-up patients was 52.4% versus 40.0%.

“The STOP-JIA study shows that initial therapy and the timing of starting DMARDs is important, even 3 years after treatment initiation,” concluded Prof. Kimura. “Overall, the STOP-JIA study showed that pJIA patients are not doing as well as we thought they would. The majority of patients never achieved CID,” Prof. Kimura said. In her view, early disease treatment is key to improved outcomes in pJIA.

 

1. 
   
   1. Kimura Y. The Childhood Arthritis and Rheumatology Research Alliance Start Time Optimization of Biologic Therapy in Polyarticular JIA (STOP-JIA) Study: Three-Year Outcomes. 1679, ACR Convergence 2022, 10–14 November, Philadelphia, USA.
   2. Ringold S, et al. Arthritis Care Res (Hoboken). 2014;66:1063-72.

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Posted on 1 December 20221 February 2024