Background/Purpose: Juvenile idiopathic arthritis associated uveitis (JIAU) is the most common extra-articular manifestation of JIA, and occurs in approximately 10% of affected children.  Although there are effective medications to treat JIAU, guidelines and large studies that inform of tapering treatment after disease remission are lacking.

Methods: We surveyed vie email international pediatric rheumatologists: 1. Multinational Interdisciplinary Working Group for Uveitis in Childhood (MIWGUC), 2. Pediatric Rheumatologic Email-Listserve, 3. CARRA uveitis workgroup, and international ophthalmologic specialized in children with JIAU.  Survey questions focused on the definition of remission, duration of remission prior to initiation of medication tapering, and method of tapering. Specific medications included methotrexate (MTX), adalimumab (ADA), infliximab (IFX), abatacept (ABA), and tocilizumab (TOC).

Results: Of 45 responses, 88% were from pediatric rheumatologists with a mean work experience of 18 years. The regional distribution was 31 form Europa, 9 from North-America, 3 from South-America and 2 from Asia. The responding colleagues managed a mean number of 43 JIAU patients.  Remission on medication was defined as no cells in the anterior chamber (78%), followed by no need for eye drops (36%), and no uveitis flares (32%).  Tapering practices were described for MTX monotherapy (100%) ADA (100%), IFX (80%), TOC (56% [25% s.c.]) and ABA (46% [30% s.c.]).

Standardized protocol for tapering exists in 32% of centers for MTX, in 26% for ADA, and 20% for IFX. The timepoint for tapering was after 6 months of remission on medication by  14% of respondents, 12 months for 38%, 24 months for 56% and 36 months for 12%.

MTX was tapered by dose in 42%, dose and interval in 40%, and interval in 15%. The lowest dose of MTX was 6mg/m2/week at the time of tapering and the longest mean interval 2.5 weeks (1 to 4 weeks).  ADA was first tapered to every 3 weeks by 76% of the responders and then to every 4 weeks by 49% before discontinuing. Fewer respondents used or tapered IFX, TOC or ABA. Around 65% tapered the interval and 20% tapered the dose and interval for ABA, 26% for TOC and 37% IFX

There were differences in the duration of tapering prior to discontinuation of specific medications.  For ADA it was 6 months in 62%, 12 months in 36% ,and 24 months in 10%.   For IFX it was 6 months in 27%, 12 months in 45%, and 24 months in 33%. For TOC it was 40% after 4 weeks, 87% after 6 weeks and 53% after 24 weeks. For ABA i.v.  it was 30% after 8 weeks, and 90% after 12 weeks.

If combination therapy was used, 36% tapered the bDMARD first, 62% csDMARD first, and 12% both simultaneously.

Conclusion: This is the first survey to describe “real world” medication tapering and discontinuation practices of pediatric rheumatologists and ophthalmologists globally. Most physicians start to taper medication after 24 months of remission on medication and discontinue after the 6 to 12 months of tapering.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/practice-patterns-for-tapering-medications-in-the-treatment-of-jia-associated-uveitis/