Background/Purpose: Biological treatment (BT) has changed the perspectives of Juvenile Idiopathic Arthritis (JIA) patients, but it remains unclear when and how to taper or to withdraw treatment, neither the effect of treatment withdrawal after remission is achieved. 

Our aim is to assess the course of the disease after tapering or stopping BT in a cohort of JIA patients. Tapering strategies and median time to flare were analyzed.

Methods: A retrospective, descriptive study was conducted in a cohort of JIA patients followed up in a Pediatric and Transition Unit of a referral hospital and who had received BT between 2000 and 2019. All JIA patients with at least one attempt of tapering were included. Remission was defined according to Wallace criteria.

Results: 131 JIA patients and 219 BT were reviewed. 198 deescalations in 108 (49,3%) BT in 95 (72,5%) JIA patients were included. 67,7% were female. The median age at diagnosis was 5 years [IQR (2-12)] and the median age at the beginning of tapering was 17 years [IQR (11,8-26)]. Patients were in remission a median of 9 months [IQR (6-17)]. Main BT tapered were: TNF inhibitors (76,3%), IL6 inhibitors (15,2%) and IL1 inhibitors (6,5%).Conventional DMARDs were administrated in combination with BT in 40,4% of the deescalations. Regarding JIA categories: 44 (22,2%) were Oligoarticular Persistent, 36 (18,2%) were Oligoarticular Extended, 32 (16,2%) were Systemic, 31 (15,7%) were Enthesitis related Arthritis, 19 (16,2%) were Psoriatic Arthritis, 16 (8,1%) were Polyarticular RF+, 16 (8,1%) were Polyarticular RF- and 5 (2,5%) were Undifferentiated. 8 (6,3%) patients were lost in follow-up.

171/198 (86,3%) cases started a deescalation. The most frequent tapering strategy was prolonged interval between applications (90,6%), combined strategy (5,8%) and lower dosage (3,5%). The median remaining dose administrated was 50% [IQR (50, 75)].

Twenty-seven (13,6%) cases withdrawn BT abruptly. The main causes of abrupt BT withdrawal were: remission (33,3%), pregnancy (29,6%).

Forty-five (26,3%) cases stopped BT after tapering. Median time to withdrawal was 11 months [IQR (6-22)]. The main causes of withdrawal after tapering were remission (66,7%), pregnancy (11,1%). There was no difference in remission rates after withdrawal among cases with previous tapering (PT) or abrupt discontinuation(AD) [Median PT 5 +-(1,1), median AD 7 +- (2,6), Log rank=0,946]. After 6 months of withdrawal 48,1% of AD cases and 56,1% of  PT cases  had presented a flare. 10/72 (13,8%) cases are currently on remission without BT during follow-up, 9,7% without any treatment and 4,1% with cDMARDs.

BT was tapered without withdrawal in 126 (63,6%) cases. Remission rates during tapering are specified in table 1. 40 (20%) cases continue tapered without a flare after a median of 77 months [IQR (36,3-111,3)] of follow-up.

Conclusion: – There was no difference in remission rates among patients that discontinuated BT after tapering or after abrupt discontinuation. After 6 months of withdrawal 48,1% of cases that stopped abruptly and 56,1% of cases that stopped after tapering had presented a flare.

– Tapering without withdrawal is safe: 79,8% of cases at 6 months and 47,4% of cases at 24 months that tapered without withdrawal remained on sustained remission.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/evaluation-of-flare-rate-and-tapering-strategies-in-juvenile-idiopathic-arthritis/