Background/Purpose: Patients with juvenile spondyloarthropathy (JSpA) have lower clinical remission rates, report higher pain scores, worse functioning and lower quality of life compared to other juvenile arthritis subtypes. JSpA patients present with different clinical features, including enthesitis, lower back pain, and sacroiliitis. Biologics, such as anti-tumor necrosis factor drug (TNFi), are increasingly being used for the treatment of pediatric inflammatory arthritis. In JSpA, TNFi are typically a second or third line treatment. We sought to evaluate the reasons for TNFi initiation in JSpA, identify specific measures of disease activity and disease progression associated with the TNFi start, and assess the effect of TNFi on JSpA disease activity.

Methods: A retrospective cohort study of JSpA patients with first-time use of a TNFi followed by the Pediatric Rheumatology Department at Stanford Children’s Health from January 1, 2007, to December 31, 2014, was conducted. Patients were identified using Stanford STRIDE, a clinical data review tool. Reasons for TNFi initiation and change in JSpA disease activity index (JSpADA) components were assessed. JSpADA components changes were compared at diagnosis, TNFi initiation, 6 months post-TNFi initiation and 12 months post-TNFi initiation, as well as by disease duration at TNFi start.

Results: A total of 86 patients with clinical documentation at the time of JSpA diagnosis, TNFi initiation, and 6 months post-TNFi initiation were included in the analysis. The median age at JSpA diagnosis was 13.4y (IQR 9.9-15.5y) and the median time from JSpA diagnosis to TNFi initiation was 0.5y (IQR 0.2-2.4y). The most common reason for the physician to initiate a TNFi was for physical exam findings consistent with active disease (61%). Pain was included as a reason for initiation in 24% of patients, but never as the only reason. After six months of TNFi therapy, patients on average had three fewer active joints and one fewer active enthesitis point. Patient-reported pain also improved from moderate/severe to mild pain. At 12 months post-TNFi initiation, 54% of TNFi initiators were still considered to have active disease. Comparisons with the total JSpADA scores were unable to be performed due to missing data.

Conclusion: This study provides insight into the relationship between TNFi initiation and clinical disease activity in the JSpA population. Physical exam findings of active disease were enough to escalate therapy with a TNFi for most JSpA patients. TNFi initiation for pain alone without any definitive signs of active disease was not found to be a reason for escalation. Six months after initiating a TNFi, there was an improvement in active joint and enthesitis counts as well as patient-reported pain. However, more than half of the patients still had active disease one year after TNFi initiation. The physician’s reason for starting a TNFi and the timing of TNFi initiation did not influence the clinical disease status after one year of TNFi therapy.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/determinants-of-anti-tumor-necrosis-factor-drug-use-in-juvenile-spondyloarthropathy-and-impact-on-clinical-disease-outcomes/