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:
The efficacy of medications in randomized trials may differ substantially from their effectiveness (degree of beneficial effect under “real world” clinical settings). Reliable estimates of actual observed effectiveness of medications in usual medical practice will help parents and physicians make better-informed treatment decisions. Therefore we sought to estimate the effectiveness of common treatment strategies observed in usual practice in JIA patients followed in a large prospective inception cohort.
Methods:
Data from the Research in Arthritis in Canadian Children emphasizing Outcomes (ReACCh-Out) cohort were used to describe the observed success rate of common JIA treatment strategies. Treatment changes in each child were conceptualized as a series of n-of-1 treatment trials and systematically analyzed. A treatment trial starts with a change in treatment and concludes with the next change in treatment. The start could also be the initial treatment. Success was defined as attainment of inactive disease, or as maintenance of inactive disease when tapering treatment. Inactive disease was defined as no active joints, no extra-articular manifestation and PGA <10mm according to criteria by Wallace et al. Success rates and 95% confidence intervals (CI) were calculated for trials observed in at least 25 patients.
Results:
2962 treatment trials were observed in 1275 children; 2151 (72.6%) were step-up trials. NSAID monotherapy (usually naproxen) was trialed in 606 children, mostly as first line treatment for oligoarthritis, at a mean of 1.1 years after disease onset and had a success rate of 62%. NSAID plus joint injection (JI) had a success rate of 74% (see Table). Adding a DMARD to NSAID ±JI was trialed in 445 children. Methotrexate plus NSAID was trialed in 385 children, many with polyarticular involvement, at a mean of 1.2 years since onset and had a success rate of 67%. In logistic regression analyses, the odds of success for NSAID ±JI were reduced by each additional active joint at the start of a trial (odds ratio OR 0.90, 95%CI 0.87-0.94) and by each additional year since onset (OR 0.90, 0.81-0.99). RF negative polyarthritis, ERA and undifferentiated JIA had decrease chances of DMARD success relative to oligoarticular JIA. After adjustment for time since disease onset, number of active joints and JIA category, ankle or wrist involvement were associated with a reduced NSAID success rate (OR for ankle 0.53, 0.38-0.74; for wrist 0.66, 0.42-1.0). Similar trends were observed for response to adding a DMARD to NSAID ±JI.
Conclusion:
These estimates of effectiveness of medications in usual medical practice from a prospective nation-wide cohort can help answer parents’ questions regarding how effective NSAID monotherapy or combinations of DMARD and NSAID may be for their child and help inform treatment decisions.
Table: Success rate of various treatment strategies:
|
Treatment |
Subgroup |
Number of patients/trials |
Success rate (95% CI) |
|
NSAID Monotherapy |
All |
606 |
62(58-66) |
|
Naproxen |
514 |
62(58-66) |
|
|
Indomethacin |
66 |
56(42-66) |
|
|
Ibuprofen |
21 |
–* |
|
|
<5 active joints |
501 |
67(63-71) |
|
|
5 or more |
105 |
36(26-46) |
|
|
NSAID+JI |
All |
298 |
74(69-79) |
|
Naproxen+JI |
260 |
76(71-82) |
|
|
Indomethacin+JI |
21 |
–* |
|
|
Ibuprofen+JI |
16 |
–* |
|
|
<5 active joints |
271 |
75(70-80) |
|
|
5 or more |
27 |
66(47-86) |
|
|
Adding DMARD to NSAID ±JI |
Methotrexate |
385 |
67(62-72) |
|
<5 active joints |
182 |
75(69-82) |
|
|
5 or more |
203 |
60(53-66) |
|
|
Sulfasalazine |
60 |
62(49-74) |
|
*not estimated as number was <25.
To cite this abstract in AMA style:
Chhabra A, Huber A, Shiff NJ, Boire G, Oen K, Guzman J. Effectiveness of Common Treatment Strategies for Juvenile Arthritis in Usual Practice: Results from the Research in Arthritis in Canadian Children Emphasizing Outcomes Cohort [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10). https://acrabstracts.org/abstract/effectiveness-of-common-treatment-strategies-for-juvenile-arthritis-in-usual-practice-results-from-the-research-in-arthritis-in-canadian-children-emphasizing-outcomes-cohort/. Accessed .« Back to 2017 ACR/ARHP Annual Meeting
ACR Meeting Abstracts - https://acrabstracts.org/abstract/effectiveness-of-common-treatment-strategies-for-juvenile-arthritis-in-usual-practice-results-from-the-research-in-arthritis-in-canadian-children-emphasizing-outcomes-cohort/