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Abstract Number: 67

Relapse and Remission in Children with Chronic Non-Infectious Uveitis Treated with Methotrexate and Tumor Necrosis Factor-α Inhibitors

Courtney McCracken1, Curtis Travers1, Kirsten Jenkins2, Carolyn Drews-Botsch3, Steven Yeh4, Sampath Prahalad1,5 and Sheila Angeles-Han6,7, 1Pediatrics, Emory University School of Medicine, Atlanta, GA, 2Children's Healthcare of Atlanta, Atlanta, GA, 3Epidemiology, Emory University School of Public Health, Atlanta, GA, 4Ophthalmology, Emory University School of Medicine, Atlanta, GA, 5Pediatrics, Emory Children's Center, Atlanta, GA, 6Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 7Pediatrics, University of Cincinnati, Cincinnati, OH

Meeting: 2017 Pediatric Rheumatology Symposium

Keywords: juvenile idiopathic arthritis (JIA), remission, treatment and uveitis

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Session Information

Date: Thursday, May 18, 2017

Title: Clinical and Therapeutic Poster Session

Session Type: Abstract Submissions

Session Time: 5:30PM-7:00PM

Background/Purpose: Methotrexate (MTX) and tumor necrosis factor-α inhibitors (TNFi) are common treatments for children with chronic non-infectious uveitis (NIU). Optimal duration of treatment prior to taper and discontinuation is understudied. Our aim is to identify factors that predict successful medication discontinuation and sustained remission in children with NIU.

Methods: We reviewed records of 120 children with NIU and identified children who tapered and/or discontinued MTX or TNFi (infliximab or adalimumab). We recorded date of medication start, taper, and discontinuation, and time to relapse or remission. Comparisons between children with and without remission were made using Mann-Whitney tests or Chi-square tests.

Results: There were 28 children in whom we attempted to discontinue medication (MTX in 16 and TNFi in 12 (10 infliximab, 2 adalimumab)). They were mostly Caucasian (43%) females (79%), with JIA-associated uveitis (57%) (Table 1). Most common reason for drug discontinuation was remission/inactive disease (61%).

In 16 children, MTX was given for a median of 1.6 years (25th– 75th: 1.1 – 3.0) prior to taper. Four (25%) discontinued MTX without taper, and 12 (75%) tapered over a median of 8 months. Only 5 (31%) successfully discontinued medication and sustained remission for a median of 6 months as of last follow-up. The remaining 11 (69%) relapsed in approximately 8 months. Successful discontinuation of MTX was associated with longer duration of therapy (3.3 vs. 1.4 years; p =0.02) and fewer ocular complications (2/5, 40% vs.11/11, 100%, p= 0.02). Gender, race, NIU type, age at MTX start, duration of NIU before MTX, MTX route and dosing, and eye disease at taper/discontinuation were not associated with successful MTX discontinuation. 

In 12 children, TNFi was given for a median of 1.8 years (25th– 75th: 1.4 – 2.9) prior to taper or discontinuation. Eight (67%) discontinued TNFi without taper.  All 8 relapsed and needed to restart or switch therapy at a median of 3 months.  Four (33%) attempted to taper medication, but only 1 discontinued but later relapsed after 1.3 years. The remaining 3 children restarted/switched therapy at a median of 10 months after starting taper.

In the 23 patients that relapsed, 9 (39%) relapsed within 3 months, 11 (48%) within 6 months, 17 (74%) within 1 year and 22 (96%) within 1.5 years of medication discontinuation/taper.

Conclusion: Most children were unable to discontinue MTX and TNFi. Our results suggest that longer duration of MTX treatment and fewer ocular complications may be associated with sustained remission. Patients requiring TNFi appear to require medication throughout their disease course.  Factors leading to successful medication discontinuation and remission in children on TNFi need further study.

 

Table 1. Characteristics of Children with Uveitis Treated with  Methotrexate and Tumor Necrosis Factor-α Inhibitor Medications

Characteristics, N (%) or median (25th – 75th)

MTX

N = 16

TNFi

N = 12

Demographics

 

 

Gender, female

13 (81.3%)

9 (75.0%)

Race

 

 

  Caucasian

5 (31.3%)

7 (58.3%)

  African American

6 (37.5%)

4 (33.3%)

  Other

6 (31.3%)

1 (8.3%)

Uveitis Diagnosis

 

 

     JIA-Associated Uveitis

8 (50.0%)

8 (66.7%)

     Other Types of Uveitis

8 (50.0%)

4 (33.3%)

   Chronic Anterior Uveitis

2 (12.5%)

1 (8.3%)

   HLA-B27 Uveitis

0 (0%)

2 (16.7%)

   Idiopathic Uveitis

2 (12.5%)

1 (8.3%)

   ACE+/Sarcoidosis

2 (12.5%)

0 (0%)

   Pars Planitis

1 (6.3%)

0 (0%)

   Unknown

1 (6.3%)

0 (0%)

Age at Uveitis Diagnosis¸ years

9.3 (4.6, 12.8)

4.8 (3.5, 6.0)

Duration of Disease To Date, years

6.5 (5.6, 7.1)

6.9 (5.5, 10.4)

Uveitis Characteristics

 

 

Location

 

 

     Anterior

12 (75.0%)

11 (91.7%)

     Intermediate

0 (0.0%)

0

     Posterior/Panuveitis

3 (18.8%)

1 (8.3%)

     Unknown

1 (6.3%)

0

Bilateral Disease

11 (68.8%)

11 (91.7%)

Complications

 

 

Cataracts

9 (56.3%)

7 (58.3%)

Glaucoma

3 (18.8%)

3 (25.0%)

Synechiae

8 (50.0%)

8 (66.7%)

Keratopathy

4 (25.0%)

5 (41.7%)

Macular Edema

5 (31.3%)

4 (33.3%)

Medication Administration

 

 

Taper/Discontinued Medication

 

 

MTX Subcutaneous

11 (68.8%)

—

MTX Oral

5 (31.3%)

—

Infliximab

—

10 (83.3%)

Adalimumab

—

2 (16.7%)

Age at Start of Therapy, years

10.6 (5.0, 13.3)

8.0 (6.7, 12.7)

Duration of Uveitis Before Starting Therapy, years

0.47 (0.27, 1.66)

2.4 (2.1, 5.6)

Duration on Therapy until discontinuation or relapse, years

2.3 (1.3 , 3.1)

1.8 (1.4, 2.9)

Age at Start of Taper, years

11.9 (7.3, 15.4)

10.4 (7.6, 14.9)

Age at Discontinuation or Relapse During Taper, years

12.8 (8.8, 15.2)

10.4 (7.6, 14.9)

Reason for Discontinuation (>1 may apply)

 

 

Remission/Inactive Disease

12 (75.0%)

5 (41.7%)

Patient/Parent Preference

4 (25.0%)

1 (8.3%)

Insurance

4 (25.0%)

3 (25.0%)

Allergic Reaction

0 (0%)

2 (16.7%)

Infections

0 (0%)

1 (8.3%)

Quick Taper/Discontinuation

4 (25.0%)

8 (66.7%)

Sustained Remission

5 (31.3%)

0 (0%)

Duration of Remission, years

0.5 (0.4, 0.8)

—

Relapsed/Restarted Medication

11 (68.8%)

12 (100%)

Time to Relapse/ Restarted Medication

0.7 (0.59, 1.53)

0.4 (0.20, 0.93)

 


Disclosure: C. McCracken, None; C. Travers, None; K. Jenkins, None; C. Drews-Botsch, None; S. Yeh, None; S. Prahalad, None; S. Angeles-Han, None.

To cite this abstract in AMA style:

McCracken C, Travers C, Jenkins K, Drews-Botsch C, Yeh S, Prahalad S, Angeles-Han S. Relapse and Remission in Children with Chronic Non-Infectious Uveitis Treated with Methotrexate and Tumor Necrosis Factor-α Inhibitors [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 4). https://acrabstracts.org/abstract/relapse-and-remission-in-children-with-chronic-non-infectious-uveitis-treated-with-methotrexate-and-tumor-necrosis-factor-%ce%b1-inhibitors/. Accessed .
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