ACR Meeting Abstracts

ACR Meeting Abstracts

Abstract Number: 2291

Three Treatment Strategies in Recent Onset DMARD Naive Juvenile Idiopathic Arthritis:  First Results of Clinical Outcome after 24 Months

Petra Hissink Muller1,2, Danielle Brinkman1,3, Dieneke Schonenberg-Meinema4, Yvonne Koopman-Keemink5, Wytse van den Bosch6, Isabel Brederije1, Peter Bekkering7, Taco Kuijpers4, Marion van Rossum8, Lisette van Suijlekom-Smit2, J Merlijn van den Berg4, CF Allaart9 and Rebecca ten Cate1, 1Pediatric Rheumatology, Leiden University Medical Center, Leiden, Netherlands, 2Pediatric Rheumatology, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands, 3Pediatrics, Alrijne Hospital, Leiderdorp, Netherlands, 4Department of Pediatric Hematology, Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital AMC, University of Amsterdam, Amsterdam, Netherlands, 5Department of Pediatrics, Hagaziekenhuis Juliana Children's Hospital, The Hague, Netherlands, 6Department of Pediatrics, Haaglanden Medical Center, The Hague, Netherlands, 7Department of Physiotherapy, Prinses Maxima Pediatric Oncology Center, Utrecht, Netherlands, 8Department of Pediatric Rheumatology, Amsterdam Rheumatology and Immunology Center location Reade Amsterdam, Amsterdam, Netherlands, 9Rheumatology, Leiden University Medical Center, Leiden, Netherlands

Meeting: 2017 ACR/ARHP Annual Meeting

Date of first publication: September 18, 2017

Keywords: ,

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 BeSt treatment strategy for children with juvenile idiopathic arthritis (JIA) has not been determined. The aim of the BeSt for Kids study was to investigate, which of three treatment strategies is most effective and safe, by direct comparison. The target was inactive disease in all arms was inactive disease by rapid reduction of disease activity and repeated monitoring and revision of therapy in case of insufficient response. We hypothesized that early treatment with etanercept and methotrexate (arm 3), compared to initial monotherapy (arm 1) or initial combination therapy with methotrexate and prednisone (arm 2), would lead to significantly earlier clinical inactive disease.

Methods:

We conducted a randomized, single blinded, multicenter, treatment strategy study with 24 months of follow up. Disease modifying anti rheumatic drug (DMARD)-naive JIA patients were randomized to 1. sequential DMARD-monotherapy (sulfasalazine (SSZ) or methotrexate (MTX), 2. combination therapy: MTX and prednisolone-bridging, 3. Combination-therapy MTX with etanercept. For all arms, the treatment protocol described a number of subsequent treatment steps in case medication failed. Missing data were imputed. Primary outcome was time to inactive disease and time to flare after tapering and stopping DMARD therapy calculated using Kaplan Meier plot with log rank test. Secondary outcomes are adjusted ACRPedi 30/50/70/90 scores and toxicity. Generalised Estimates Equations were used for longitudinal data analyses.

Results:

Ninety-four patients were randomised, 32 in arm 1, 32 in arm 2 and 30 in arm 3. Two patients received a different diagnosis during follow-up and were left out of all analysis. Two patient were lost to follow up but were analysed due to intention to treat principle. Overall baseline median (InterQuartileRange IQR) age was 9.1 (4.6-12.9) years. 37% were ANA positive, 11 patients had oligo-articular disease, 66 patients polyarticular JIA and 15 patients juvenile psoriatic (polyarticular) arthritis. Baseline median (IQR) ACRpedi-scores: VAS physician 50 (39-58) mm, VAS patient 54 (37-70) mm, ESR 6(2-14) mm/hr, active joint count 8 (5-12), limited joint count 2.5 (1-5), CHAQ score 0.9 (0.6-1.5). Inactive disease occurred overall after mean 9.8 months (8.5-11.1). Time to inactive disease was not significantly different in all three arms (log rank test p=0.23). Outcome measures after 24 months are summarised in the table.

Arm 1

n=31

Arm 2

n=32

Arm 3

n=29

3 vs 1

p OR (CI)

2 vs 1

p OR (CI)

3 vs 2

p OR (CI)

aACRPEdi30(%)(CI)

92.2

(82,1-102.4)

84.4

(71.2-97.5)

96.6

(89.8-103.3)

0.14

1.7 (0.8-3.4)

0.8

0.9(0.5-1.7)

0.09

1.8 (0.9-3.7)

aACRPedi50 (%)(CI)

85.5

(72.4-98.6)

83.8

(70.1-97.4)

93.1

(83.7-102.4)

0.3

1.4(0.7-2.8)

0.9

1.1(0.6-2.0)

0.4

1.3(0.7-2.7)

aACRPedi70 (%)(CI)

69.0

(52.1-85.9)

68.8

(51.6-85.9)

82.8

(68.8-96.8)

0.07

1.8(1.0-3.3)

0.7

0.9(0.4-1.7)

0.03

2.1(1.1-4.0)

aACRPedi90(%)(CI)

58.4

(40.6-76.1)

55.3

(37.3-73.3)

69.0

(51.8-86.1)

0.34

1.4 (0.7-2.6)

0.38

0.7(0.4-1.5)

0.06

1.9 (1.0-3.5)

Inactive disease (%)(CI)

61.0

(39.7-82.3)

63.1

(43.6-82.7)

61

(40.9-81.2)

0.9

1.0(0.7-1.7)

0.1

0.7(0.4-1.1)

0.09

1.5(0.9-2.5)

JADAS-10 (CI)

2.6(1.4-3.8)

4.0(2.2-5.8)

3.0(1.6-4.4)

0.6

0.6(0.1-3.5)

0.2

3.1(0.5-20.3)

0.09

0.2(0.03-1.3)

Conclusion:

Although our study did not meet its primary end point, treat-to-target treatment in this cohort of children with recent onset JIA resulted in high frequencies of clinical inactive disease and adjusted ACRpedi30/50/70 scores in all three arms. In clinical trials inactive disease seems a feasible goal in juvenile idiopathic arthritis patients. Tight control seems to be more important than the agent(s) inducing it.

Disclosure: P. Hissink Muller, None; D. Brinkman, None; D. Schonenberg-Meinema, None; Y. Koopman-Keemink, None; W. van den Bosch, None; I. Brederije, None; P. Bekkering, None; T. Kuijpers, None; M. van Rossum, None; L. van Suijlekom-Smit, None; J. M. van den Berg, None; C. Allaart, None; R. ten Cate, None.

To cite this abstract in AMA style:

Hissink Muller P, Brinkman D, Schonenberg-Meinema D, Koopman-Keemink Y, van den Bosch W, Brederije I, Bekkering P, Kuijpers T, van Rossum M, van Suijlekom-Smit L, van den Berg JM, Allaart C, ten Cate R. Three Treatment Strategies in Recent Onset DMARD Naive Juvenile Idiopathic Arthritis:  First Results of Clinical Outcome after 24 Months [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10). https://acrabstracts.org/abstract/three-treatment-strategies-in-recent-onset-dmard-naive-juvenile-idiopathic-arthritis-first-results-of-clinical-outcome-after-24-months/. Accessed .

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