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Earlier Use of Second-Line Agents in Juvenile Arthritis Associated With Marked Improvement: Presented at ACR

By Paula Moyer

San Diego, CA -- November 18, 2005 -- When second-line medications are initiated within 3 months of a diagnosis of juvenile rheumatoid arthritis (JRA), it improves the chances of improvement in functioning ability, investigators reported here at American College of Rheumatology Annual Scientific Meeting (ACR).

Principal investigator Beth Gottlieb, MD, assistant professor of pediatrics, division of pediatric rheumatology, Schneider Children's Hospital, New Hyde Park, New York, reported the findings of an ongoing prospective, observational, multicenter study on November 16^th.

Dr. Gottlieb presented 1-year data on 317 children who were followed from 1996 to 1999, and 177 children enrolled in 2001 and who continue to be followed.

Dr. Gottlieb said that the data for both cohorts are still being compiled.

At enrollment and at annual follow-up assessments, the investigators are documenting the subtype of JRA, laboratory and x-ray features, and joints with active arthritis. They also documented the patients' duration of morning stiffness and extra-articular symptoms, as well as the Physician's and Parents' Global Assessment; medications being used, including doses and adverse effects; the disease course; need for physical or occupational therapy; and responses on the Childhood Health Assessment Questionnaire (CHAQ).

At 1 year, 24% of the first cohort and 20% of the second cohort were taking methotrexate; 30% and 19%, respectively, were on other disease modifying antirheumatic drugs (DMARDs), such as sulfasalazine, leflunomide, gold, or azathioprine. Biologics were being used by 7% and 8%, respectively.

"The 2 groups were enrolled at very different times in terms of the therapeutic options available to them," Dr. Gottlieb said, referring to the introduction of biologic agents that were not available when the first cohort was enrolled.

The second cohort experienced a shorter wait time before going to all second-line agents. In the first cohort, methotrexate was initiated an average of 11 months after diagnosis, while the first cohort initiated it an average of 3 months after diagnosis.

Other DMARDs were initiated an average of 3 months after diagnosis in the second group, compared with an average of 9 months in the first cohort.

Dr. Gottlieb noted that the first group received biologic antirheumatic agents a median of 34.6 months after diagnosis, compared with a median of 4.3 months in the second cohort.

At the 1-year follow-up, those treated with methotrexate in the first cohort had an average of 6.2 swollen upper joints and 2.9 swollen lower joints, compared with an average of 2.0 and 0.8 swollen joints, respectively, in patients treated with methotrexate in the second cohort (P < .001 for upper joints; P < .00001 for lower joints).

Among those on other DMARDs, the first cohort averaged 5.7 swollen upper joints and 2.8 swollen lower joints. The second cohort averaged 2.0 swollen upper joints and 0.8 swollen lower joints (P < .00001 for each).

Among those treated with biologics, the first cohort had an average of 5.1 swollen upper joints and 2.3 swollen lower joints; the second cohort and an average of 2.4 swollen upper joints and 1.3 swollen lower joints (P < .02 for each).

"Both improved, but the improvements were far greater in the second cohort," she said. "Children with polyarticular disease, in particular, the type that is most similar to adult rheumatoid arthritis, were found --- to have greater improvement in the Physicians' Global Assessment in the new cohort. It is presumed to be due to the earlier introduction of second-line medications." She noted, for example, that 71% of children had improvement in CHAQ when methotrexate is started within 3 months of diagnosis, compared with 66% when methotrexate is started after that time.

The study was funded by the Arthritis Foundation.


[Presentation title: Outcomes of Juvenile Rheumatoid Arthritis (JRA): Changing Treatment Patterns and Outcomes. Abstract 126]

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