Although most pediatric rheumatologists agree with published consensus treatment plans; and with each other regarding tapering steroids for systemic juvenile idiopathic arthritis, there is considerable disagreement related to tapering decisions for other drugs; according to survey data published in Pediatric Rheumatology.
“[Systemic] JIA can follow a monophasic (one episode of disease followed by remission); polyphasic (multiple flares of either systemic or arthritic features), or persistent course,” Susan Shenoi, MBBS, MS, RhMSUS,of the University of Washington School of Medicine; and colleagues wrote. “Currently there are no genetic or immunologic clues that allow treating physicians to determine which of these three courses patients will follow over time.”
“Hence, clinical decisions on when to continue, taper; or withdraw medications are often subjective and vary from physician to physician,” they added. “Clinicians need to balance the risk of medication withdrawal; causing disease flare versus the risk of continued medication exposure and related side effects.” To evaluate physician views on tapering medications in systemic JIA; Shenoi and colleagues partnered with REDCap to distribute the online survey to 100 randomly selected physician-voting members of the Childhood Arthritis and Rheumatology Research Alliance (CARRA) JIA workgroup.
Inactive disease in systemic JIA
The survey included three broad sections detailing participants’ demographic information; their opinions on clinical inactive disease in systemic JIA and existing practices for tapering medications. In addition, the survey featured multiple-choice questions with branching logic to facilitate; and tailor responses. Certain questions allowed participants to write in text; for example, if they did not agree with Wallace definitions for clinical inactive disease. A total of 86 participants completed the survey.
According to the researchers, 88% agreed with the current criteria for clinical inactive disease; with 93% falling in line with the criteria for clinical remission on medications. In addition, 78% said it was necessary to meet clinical remission on medications criteria; before tapering any drugs other than steroids. Among the participants; 76% reported using the CARRA consensus for systemic JIA treatment either always or in most cases.
All participants agreed that steroids should be tapered first in patients on combination therapy; with 47% advocating waiting more than 6 months before tapering additional medications. However, answers varied regarding other treatments; with 35% agreeing to tapered methotrexate over a period of more than 6 months, and another 35% advocating a period of 2 to 6 months.
Amongst pediatric rheumatologists
About 39% encouraged tapering anakinra (Kineret, Sobi Inc); canakinumab (Ilaris, Novartis) and tocilizumab (Actemra, Genentech) more quickly, during a period of 2 to 6months; and spaced out the dosing interval for canakinumab and tocilizumab. In cases of patients treated with a combination of methotrexate and biologics; 58% of participants agreed with tapering methotrexate first while others based their decision on patient or family preferences, as well as adverse effects.
“A first key finding of this survey is the demonstrated agreement and consensus amongst; providers in using the existing Wallace criteria for determining inactive disease and remission states in children with systemic JIA,” Shenoi and colleagues wrote. “With the exception of steroids and non-steroidal anti-inflammatory medication withdrawal; most providers wait for clinical remission on medications to start tapering or withdrawing other medications.”
“The second key finding of this study is the considerable variability amongst pediatric rheumatologists in decisions on which medication to taper next when patients are on combination therapy, how long to wait before tapering of other medications after discontinuing prednisone, and over what duration to taper medications,” they added. “This likely is due to the paucity of current evidence or biomarkers to guide physicians on best strategies for withdrawal of medications.”