Background/Purpose: The use of biologic DMARDs (bDMARDs) has vastly changed the treatment of autoimmune arthritis, both Rheumatoid Arthritis (RA) and polyarticular and oligoarticular Juvenile Idiopathic Arthritis (JIA). At this time 5 bDMARDs are approved by the FDA for JIA, however, many patients fail these medications, due to adverse effects or inefficacy. Studies looking at retention rate for these medications have found varying reasons for discontinuation of first line treatments between adults and children, however attention has not been paid to those patients who fail multiple rounds of bDMARDs, and have come to be considered refractory.  As childhood-onset rheumatic disease is often more severe than adult-onset, we hypothesize that JIA patients will have an increased rate of refractoriness when compared to RA patients. This study aims to characterize and compare refractory patients with JIA and RA.

Methods: This is a retrospective chart review of adult patients diagnosed with polyarticular or oligoarticular JIA as children and adult-onset RA seen in the Los Angeles County + University Southern California Medical Center (LAC+USC) and Keck University Hospital from January 2010 to December 2017. All JIA patients were diagnosed and treated by pediatric rheumatologists as children and all RA patients were diagnosed based on the 1987 ACR classification criteria. Patients were deemed refractory if they failed ≥ 3 DMARDs, one of which is a bDMARD.  Refractory patients were included in the study as cases and controls were selected from non-refractory patients.  Descriptive statistics were reported for demographic and clinic data. Logistic regression models were used to evaluate the association between arthritis type (JIA vs. RA) and refractoriness while controlling for disease duration.

Results: A total of 100 patients were reviewed, 53 adults with polyarticular or oligoarticular JIA and 47 RA patients.  Ninety-three percent were women and 76% were Hispanic. The JIA group was younger (mean age 27.7 years, SD of 10.3) than the RA group (mean age 55.9 years, SD of 11.8).  However, average disease durations were comparable (mean of 15.5 years in the JIA group, 14.3 in the RA group).  There was no difference in number of refractory cases between JIA and RA patients, 50.9% and 53.2%, respectively. Comparison of the refractory cases and their controls, however, showed an increase in disease duration (mean 17.8 years vs. 11.8 years) as well as a higher prevalence of sero-positivity for both RF and anti-CCP status (82.70% and 78.57% as compared with 58.33% and 66.67%) and erosive disease (55.77% as opposed to 20.83%).

Conclusion: This study failed to find an association between adult JIA patients and refractory disease when compared with RA patients.  Although JIA patients are equally refractory to DMARDs when adjusted for disease duration, this still presents a formidable problem when it comes to the future of these patients, as they likely have at least double the number of years with disease ahead of them when compared to RA patients. Future studies evaluating the continued bDMARD use in young, refractory patients are necessary to better understand how best to treat these patients. 

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/a-retrospective-study-comparing-refractoriness-to-biologic-disease-modifying-anti-rheumatic-drugs-in-adults-with-juvenile-idiopathic-arthritis-as-compared-to-those-with-rheumatoid-arthritis/