Session Information
Date: Tuesday, November 7, 2017
Title: Pediatric Rheumatology – Clinical and Therapeutic Aspects Poster III: Juvenile Arthritis
Session Type: ACR Poster Session C
Session Time: 9:00AM-11:00AM
Background/Purpose: Stopping medications is a priority for many patients with well-controlled JIA, but few factors predict favorable outcomes after discontinuation. We examined factors associated with sustained discontinuation off disease-modifying drugs in a large pediatric registry.
Methods: We conducted a case-control study using the Childhood Arthritis & Rheumatology Research Alliance Registry of clinical data from >55 pediatric rheumatology clinics in the United States and Canada. The study included children with JIA who started at least 1 conventional or biologic DMARD and had at least 2 years of available subsequent data. Reasons for drug discontinuation were obtained from the medication log. Sustained discontinuers had at least 1 year of drug-free follow-up after discontinuation for well-controlled disease. Comparators included children who did not discontinue all DMARDs for well-controlled disease (never discontinuers) and those who stopped DMARDs for at least 30 days and restarted within 1 year (unsustained discontinuers). Children in each group may have stopped DMARDs for reasons besides well-controlled JIA. We compared characteristics of sustained discontinuers and comparators using descriptive statistics, excluding children with <1 year of follow-up off medicines without restarting DMARDs.
Results: There were 1194 children with JIA who started DMARDs, of whom 479 (40%) stopped all drugs due to well-controlled disease for at least 30 days after median 1.9 years of DMARD use (interquartile range [IQR] 1.1, 3.4). There were 175 sustained discontinuers (15%, group 1). Comparators included 268 unsustained discontinuers (22%, group 2) and 681 never discontinuers (57%, group 3) (Table). Only 24 children in group 2 subsequently stopped all DMARDs for at least 1 year. Compared with all children who started a DMARD (unsustained and never discontinuers), sustained discontinuers were younger at diagnosis and DMARD initiation, less likely to have polyarthritis, and less likely to have used a biologic DMARD. Compared with unsustained discontinuers, sustained discontinuers were less likely to have used biologics. No other factors were associated with sustained discontinuation among those who stopped DMARDs, including time to discontinuation and JIA category. A history of uveitis and radiographic joint damage were not associated with sustained discontinuation in either comparison.
Conclusion: In a large multicenter cohort of children with JIA who started DMARDs, only 1 in 6 children stopped DMARDs for well-controlled disease for at least 1 year. Younger age at DMARD initiation, oligoarticular disease course, and exclusive use of conventional DMARDs were independently associated with sustained discontinuation. The prognostic value of these factors should be considered when making decisions about stopping medicines for well-controlled JIA.
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Table. Characteristics of study subjects with JIA who started at least 1 DMARD |
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Characteristic (N, % unless otherwise noted) |
Group 1: off DMARDs ≥12 months1 (N=175) |
Group 2: off DMARDs <12 months1 (N=268) |
Group 3: not off DMARDs1 (N=681) |
P-value2 (1 vs 2+3) |
P-value2 (1 vs 2) |
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Demographic |
|
|
|
|
|
|
Age at diagnosis (years), median (IQR) |
4.0 (2.0, 8.0) |
4.0 (2.0, 8.0) |
6.0 (2.0, 11.0) |
0.002 |
0.95 |
|
Age at start of DMARD (years), median (IQR) |
5.5 (3.0, 8.9) |
6.1 (3.1, 9.9) |
8.3 (4.1, 12.3) |
<0.001 |
0.41 |
|
Time from start of DMARD to first DMARD discontinuation (years), median (IQR) |
1.9 (1.2, 3.4) |
1.9 (1.1, 3.4) |
– |
0.40 |
0.40 |
|
Time from start of first DMARD to end of follow-up (years), median (IQR) |
6.0 (4.5, 8.8) |
6.0 (4.0, 8.9) |
4.1 (2.8, 6.6) |
<0.001 |
0.37 |
|
Female sex |
126 (72%) |
208 (78%) |
522 (77%) |
0.16 |
0.18 |
|
White race |
141 (81%) |
224 (84%) |
550 (81%) |
0.76 |
0.42 |
|
Latino ethnicity |
22 (13%) |
22 (8%) |
83 (12%) |
0.14 |
0.20 |
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Residence in US |
171 (98%) |
259 (97%) |
659 (97%) |
0.95 |
0.72 |
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Clinical |
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|
|
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JIA category |
|
|
|
0.18 |
0.92 |
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Systemic |
29 (17%) |
33 (12%) |
93 (14%) |
|
|
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Oligoarticular, persistent |
14 (8%) |
26 (10%) |
27 (4%) |
|
|
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Oligoarticular, extended |
23 (13%) |
41 (15%) |
53 (8%) |
|
|
|
RF- polyarticular |
84 (48%) |
128 (48%) |
338 (50%) |
|
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|
RF+ polyarticular |
9 (5%) |
16 (6%) |
78 (12%) |
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Psoriatic |
7 (4%) |
11 (4%) |
40 (6%) |
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ERA |
6 (3%) |
7 (3%) |
38 (6%) |
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Undifferentiated |
3 (2%) |
6 (2%) |
14 (2%) |
|
|
|
≥5 total joints affected |
149 (85%) |
245 (91%) |
623 (91%) |
0.006 |
0.11 |
|
Radiographic evidence of joint damage |
33 (19%) |
61 (23%) |
136 (20%) |
0.77 |
0.49 |
|
ANA positive |
78 (45%) |
116 (43%) |
277 (41%) |
0.66 |
0.35 |
|
History of uveitis |
15 (9%) |
25 (9%) |
72 (11%) |
0.72 |
0.80 |
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Any biologic DMARD use |
69 (39%) |
140 (52%) |
599 (88%) |
<0.001 |
0.008 |
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ANA, antinuclear antibody; DMARD, disease-modifying antirheumatic drug; RF, rheumatoid factor, ERA, enthesitis-related arthritis; IQR, interquartile range. 1 Refers to discontinuation from all DMARDs for at least 30 days for well-controlled JIA 2 P-values calculated by Wilcoxon rank sum testing for continuous variables and chi-square for categorical variables |
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To cite this abstract in AMA style:
Horton DB, Xie F, Mannion ML, Ringold S, Correll CK, Dennos AC, Beukelman T. Factors Related to Sustained Discontinuation of Medications for Well-Controlled JIA in the Childhood Arthritis & Rheumatology Research Alliance Registry [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10). https://acrabstracts.org/abstract/factors-related-to-sustained-discontinuation-of-medications-for-well-controlled-jia-in-the-childhood-arthritis-rheumatology-research-alliance-registry/. Accessed .« Back to 2017 ACR/ARHP Annual Meeting
ACR Meeting Abstracts - https://acrabstracts.org/abstract/factors-related-to-sustained-discontinuation-of-medications-for-well-controlled-jia-in-the-childhood-arthritis-rheumatology-research-alliance-registry/