Early vs delayed treatment with biologic disease-modifying antirheumatic drugs (bDMARDs) is more effective in reducing disease activity at 6 and 12 months in newly diagnosed polyarticular course juvenile idiopathic arthritis (JIA), according to study results published in RMD Open.1
Previous guidelines for JIA treatment2 recommend a more conservative approach, with conventional synthetic DMARDs (csDMARDs) as the first method of treatment followed by the introduction of bDMARDs based on patient response. However, other clinical trials have suggested that a combination of csDMARDs and bDMARDs vs only bDMARDs is more effective.
To compare the effectiveness and timing of treatment with DMARDs in JIA, the researchers of this study extracted data of 2082 patients with newly diagnosed JIA aged between 1 and 19 years who were DMARD-naive. Demographic information on age, race, sex, and insurance type were collected, along with data on symptoms. The primary end point of the study was clinical Juvenile Arthritis Disease Activity Score (cJADAS) at 6 and 12 months after the first DMARD prescription; the secondary end point included the Pediatric Quality of Life Inventory (PedsQL) module, which scored patients on a scale of 0 to 100, with higher scores indicating a better quality of life.
Of 545 eligible patients, 330 received treatment by the conservative strategy (only csDMARDs), and 135 received treatment with the early aggressive strategy (csDMARDs + bDMARDs). At the 3-month follow-up, of the 315 patients, 285 (90.5%) remained on the same treatment course and 24 (7.6%) stopped treatment with DMARDs. At the 6-month follow-up, of the 300 patients, 149 (50%) remained on their initial prescription, 44% started treatment with bDMARDs, and 6% stopped DMARD treatment.
Results indicated that disease activity was not statistically different between the 2 groups, though patients receiving early aggressive treatment had higher disease activity (mean cJADAS, baseline: 16.08±7.14 and 12.39±5.91; 6 months: 6.47±5.68 and 6.91±5.68; and 12 months: 5.45±5.64 and 5.25±5.32, respectively). Compared with patients in the conservative treatment group, patients in the early aggressive treatment group showed worse quality of life at the baseline, but similar scores at the 6- and 12-month follow-ups (mean PedsQL score, 67.58±17.53 vs 61.35±19.24; 74.34±19.38 vs 73.40±17.42; and 78.52±18.63 vs 76.32±16.47, respectively).
To evaluate the effectiveness for the 12-month outcome, patients completed the PedQL generic module, annually. Findings from this analysis showed PedQL scores of 76.26±4.80 and 82.61±6.09 after 12 months with csDMARDs and csDMARDs + bDMARDs, respectively, indicating a 6.35-point (95% CI, -5.89 to 18.58 points) improvement with csDMARDs + bDMARDs.
Study limitations included the collection of data from only 1 clinic and the relatively small sample size.
Researchers concluded, “… compared with csDMARD only, early aggressive use of bDMARD in treating patients with [polyarticular course] JIA soon after diagnosis achieves more than  points of additional reduction in disease activity at 6 months. Adding bDMARD after 6 months to the initial treatment provides very little added benefit. Future studies are needed to investigate the long-term clinical and health-related quality-of-life outcomes.”
1. Huang B, Qiu T, Chen C, et al. Timing matters: real-world effectiveness of early combination of biologic and conventional synthetic disease-modifying antirheumatic drugs for treating newly diagnosed polyarticular course juvenile idiopathic arthritis. RMD Open. 2020;6:e001091.
2. Ringold S, Weiss PF, Colbert RA, et al. Childhood arthritis and rheumatology research alliance consensus treatment plans for new-onset polyarticular juvenile idiopathic arthritis. Arthritis Care Res (Hoboken). 2014;66:1063-1072.