Disease modifying anti-rheumatic drug treatment cycles and rates of flare in juvenile idiopathic arthritis-a tale of Sisyphean endeavour?

Abstract

Withdrawal of DMARD therapy to determine need for ongoing medication is common in JIA management. Little is known about how often patients undergo trials of medication discontinuation or the outcomes of successive trials. This study examined DMARD treatment cycles in a JIA cohort to determine how frequently medication withdrawal trials occur over follow-up and if relapse rates change over consecutive cycles. This was a retrospective review of longitudinal cohort data of children with DMARD-treated JIA diagnosed between 2010 and 2014. Extracted data included demographics, DMARD therapy details and clinical assessments including active joint count, date of last follow-up and disease status at that time. Data were collected to January 2024. Ninety-one children were studied. Median age was 10.1 years (range 1.5-16.8), 59% were female and median follow-up was 7.0 years (range 0.7-13). A maximum of four cycles of DMARD treatment were undertaken. Forty-four percent of children underwent more than one cycle; 63.5% relapsed after their first cycle and 53.3% after their second; and 25.3% remained off treatment to last follow-up following cycle 1, and over two subsequent cycles of therapy this increased to just 35.2%. In JIA patients requiring DMARD therapy, recurrent treatment withdrawal trials are common over follow-up, but relapse risk is high and remains so over successive trials. Permanent treatment withdrawal is therefore not a realistic goal for most patients with therapies currently available. Until biomarkers of permanent remission are developed, strategies to minimize both drug toxicity and the risk of disease flares in patients with recurrently active disease after medication withdrawal are required.