Effectiveness of Common Treatment Strategies for Juvenile Arthritis in Usual Practice: Results from the Research in Arthritis in Canadian Children Emphasizing Outcomes Cohort

Amieleena Chhabra¹, Adam Huber^2,3, Natalie J. Shiff⁴, Gilles Boire⁵, Kiem Oen⁶ and Jaime Guzman¹, ¹BC Children's Hospital, Vancouver, BC, Canada, ²IWK Health Centre, Halifax, NS, Canada, ³Dalhousie University, Halifax, NS, Canada, ⁴University of Florida, Gainesville, FL, ⁵Rheumatology Division, Centre Hospitalier Universitaire de Sherbrooke and Universite de Sherbrooke, Sherbrooke, QC, Canada, ⁶Department of Pediatrics and Child Health University of Manitoba, Winnipeg, MB, Canada

Meeting: 2017 ACR/ARHP Annual Meeting

Date of first publication: September 18, 2017

Keywords: treatment

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.

Disclosure: A. Chhabra, None; A. Huber, None; N. J. Shiff, None; G. Boire, None; K. Oen, None; J. Guzman, None.

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/