Professor Yukiko Kimura
Early combination therapy – csDMARD and bDMARD started together – appears the best treatment strategy for children with polyarticular JIA.
Professor of Paediatrics Yukiko Kimura, from the Hackensack Meridian School of Medicine in New Jersey, presented 3-year results from the STOP-JIA study at ACR Convergence.
The observational study compared outcomes in 300 American and Canadian children from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) registry.
Most children (196) were treated with a step-up protocol – starting on csDMARDs then adding bDMARD if needed after ≥ 3 months – 76 were treated with early combination therapy and 31 started biologic monotherapy first.
Professor Kimura told the meeting that while each was a consensus treatment plan for untreated polyarticular JIA, it was not clear when was the optimal time to start the very effective biologics.
“We don’t know whether waiting months for methotrexate to work and then starting a biologic might potentially lessen their effectiveness. We don’t know if a window of opportunity is lost by waiting to see if methotrexate will work.”
Professor Kimura said a previously published 12-month follow-up on STOP-JIA [link here] found no significant differences in outcomes between the three groups.
However the 3-year follow-up found the proportions of patients who achieved clinical remission at any time in the study were significantly different – 67% in the early combination group, 47% in the traditional step-up group, and 49% in the biologic first group.
The percentage of patients in clinically inactive disease off glucocorticoids (CID) and clinical Juvenile Arthritis Disease Activity Score based on 10 joints (cJADAS10) inactive disease (score ≤2.5) did not differ between the groups at 3-years.
However, the percentage of time spent in CID was significantly higher in the early combination group compared to the step-up group (39.2% v 27.3%; p=0.006).
Similarly, the percentage of time spent in cJADAS10 inactive disease was significantly higher in the early combination group compared to the step-up group (50.6% v 37.5%; p=0.005).
“This study shows that the treatment that poly-JIA patients receive initially very early on in their disease matters, even three years after that treatment was started,” Professor Kimura said.
“[However] … we still have a lot of work to do. Despite effective biologic treatments, we found 40-60% of patients with poly-JIA do not achieve inactive disease, so we need better and more treatments,” she said.
“We also need to better understand in the future how to adapt these findings to the individual patient because what we really need to know is which specific treatment or combination of treatments is best for the individual patient who is standing in front of us.”
Acknowledging that funding for biologics often required previous treatment with methotrexate, Professor Kimura said she hoped the results from STOP-JIA would provide evidence for providers and payers to ensure patients can get earlier access to biologics.
Professor Kimura is a coauthor on the 2021 ACR guideline on JIA. [link here]