Persistence, Effectiveness of TNF vs Non-TNF Inhibitors in JIA

A doctor prepares to examine a child.
Researchers assessed the persistence and effectiveness of TNF vs non-TNF inhibitors among patients with juvenile idiopathic arthritis after initiation with biologic DMARDs.

In patients with juvenile idiopathic arthritis (JIA), persistence is significantly longer among those initiating a tumor necrosis factor inhibitor (TNFi) as their first biologic agent compared with those initiating a non-TNFi, according to study results published in Rheumatology (Oxford).

Researchers sought to assess the effectiveness and persistence of TNFi vs non-TNFi among patients with newly diagnosed JIA after the initiation of a biologic disease-modifying antirheumatic drug (bDMARD).

A cohort study was conducted between January 1, 2009, and December 31, 2018, using longitudinal patient-level data from a large Midwestern US pediatric rheumatology hospital. Data were obtained from patients’ electronic medical records (EMRs), including demographics, medical history, laboratory results, prescription drugs, and disease outcomes.  

Over the 10-year period, the EMRs included a total of 2082 patients diagnosed with JIA. All eligible study participants were aged less than 19 years, had a diagnosis of nonsystemic JIA, received at least 1 dose of a bDMARD, and had 1 or more follow-up visits. Overall, the researchers identified 6 disease subcategories of nonsystemic JIA, including oligoarthritis, polyarthritis rheumatoid factor (RF)-positive, polyarthritis RF-negative, enthesitis-related arthritis, psoriatic arthritis, and undifferentiated JIA.

In the current study, persistence was defined by the duration from initiation to discontinuation of treatment. Treatment initiation — also known as the index date — was defined as the date on which a patient first was prescribed (ie, their first-ever or second-ever) a biologic agent. Treatment response was assessed using the clinical Juvenile Disease Activity Score with active joint counts truncated at 10 (cJADAS-10).

Of 667 patients with nonsystemic JIA, 614 (92.0%) received a TNFi as their first biologic treatment. Of the bDMARDs, etanercept was the most frequently prescribed (n=412; 67.1%), followed by adalimumab (n=169; 27.5%). Approximately 5% of participants received off-label bDMARDs as their first-course therapy and more than 20% received off-label bDMARDs as their second-course therapy. Overall, 7.3% of participants received at least 4 bDMARDs.

Study results showed that the median persistence of the first-course bDMARD was

320 days, with the persistence of the TNFi being significantly longer than that of the non-TNFi (395 vs 320 days, respectively; P =.010). At the 6-month follow-up visit, the cJADAS reduction was significantly greater among TNFi users compared with non-TNFi users (6.6 reduction; 95% CI, 5.7-7.5 reduction vs 3.0 reduction; 95% CI, 1.5-4.6 reduction, respectively; P <.0001). Further, at the 12-month follow-up, no significant differences were observed between treatment with a TNFi vs non-TNFi.

Study limitations included the existence of unmeasured confounding factors, such as comorbidities, that could have affected treatment and disease outcomes; the limited number of patients receiving non-TNFi as a first-line biologic; and the inability to determine medication adherence.

Researchers concluded, “Further studies should focus on real-world effectiveness and safety to more precisely evaluate the various benefits and detriments of newly approved biologic therapy, especially in a large population, so that first-line therapy can be more appropriately prescribed and switching between medications can be reduced.”


Yue X, Huang B, Hincapie AL, et al. Comparative effectiveness and persistence of TNFi and non-TNFi in juvenile idiopathic arthritis: a large pediatric rheumatology center in US. Rheumatology (Oxford). Published online December 28, 2020. doi:10.1093/rheumatology/keaa877