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Gieling J, van den Bemt B, Hoppenreijs E, Schatorjé E. Discontinuation of biologic DMARDs in non-systemic JIA patients: a scoping review of relapse rates and associated factors. Pediatr Rheumatol Online J 2022; 20:109. [PMID: 36471348 PMCID: PMC9721079 DOI: 10.1186/s12969-022-00769-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 11/08/2022] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND Biologic disease-modifying antirheumatic drugs (bDMARDs) have changed the treatment of juvenile idiopathic arthritis (JIA) patients notably, as bDMARDs enable substantially more patients to achieve remission. When sustained remission is achieved, tapering or even discontinuation of the bDMARD is advocated, to reduce side effects and costs. However, when and how to discontinue bDMARD therapy and what happens afterwards, is less known. OBJECTIVES With this scoping review we aim to collect available data in current literature on relapse rate, time to relapse (TTR) and possible flare associated variables (such as time spent in remission and method of discontinuation) after discontinuing bDMARDs in non-systemic JIA patients. METHODS We performed a literature search until July 2022 using the Pubmed database. All original studies reporting on bDMARD discontinuation in non-systemic JIA patients were eligible. Data on patient- and study characteristics, the applied discontinuation strategy, relapse rates and time to relapse were extracted in a standardized template. RESULTS Of the 680 records screened, 28 articles were included in this review with 456 non-systemic JIA patients who tapered and/or stopped bDMARD therapy. Relapse rate after discontinuation of bDMARDs, either abruptly or following tapering, were 40-48%, 36.8-45.0% and 60-78% at 6, 8 and 12 months respectively. Total relapse rate ranged from 26.3% to 100%, with mean time to relapse (TTR) of 2 to 8.4 months, median TTR 3 to 10 months. All studies stated a good response after restart of therapy after flare. JIA subtype, type of bDMARD, concomitant methotrexate use, treatment duration, tapering method, age, sex, and time in remission could not conclusively be related to relapse rate or TTR. However, some studies reported a positive correlation between flare and antinuclear antibodies positivity, younger age at disease onset, male sex, disease duration and delayed remission, which were not confirmed in other studies. CONCLUSION Flares seem to be common after bDMARD discontinuation, but little is known about which factors influence these flares in JIA patients. Follow up after discontinuation with careful registration of patient variables, information about tapering methods and flare rates are required to better guide tapering and/or stopping of bDMARDs in JIA patients in the future.
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Affiliation(s)
- Job Gieling
- Department of Pediatric Rheumatology, Pediatrics, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Bart van den Bemt
- grid.10417.330000 0004 0444 9382Departments of Pharmacy, Sint Maartenskliniek / Radboud University Medical Center, Nijmegen, the Netherlands
| | - Esther Hoppenreijs
- grid.10417.330000 0004 0444 9382Department of Pediatric Rheumatology, Pediatrics, Sint Maartenskliniek / Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ellen Schatorjé
- grid.10417.330000 0004 0444 9382Department of Pediatric Rheumatology, Pediatrics, Sint Maartenskliniek / Radboud University Medical Center, Nijmegen, the Netherlands
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Foeldvari I, Constantin T, Vojinović J, Horneff G, Chasnyk V, Dehoorne J, Panaviene V, Sušić G, Stanevicha V, Kobusinska K, Zuber Z, Dobrzyniecka B, Nikishina I, Bader-Meunier B, Breda L, Doležalová P, Job-Deslandre C, Rumba-Rozenfelde I, Wulffraat N, Pedersen RD, Bukowski JF, Vlahos B, Martini A, Ruperto N. Etanercept treatment for extended oligoarticular juvenile idiopathic arthritis, enthesitis-related arthritis, or psoriatic arthritis: 6-year efficacy and safety data from an open-label trial. Arthritis Res Ther 2019; 21:125. [PMID: 31122296 PMCID: PMC6533709 DOI: 10.1186/s13075-019-1916-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 05/09/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To describe the 6-year safety and efficacy of etanercept (ETN) in children with extended oligoarticular juvenile idiopathic arthritis (eoJIA), enthesitis-related arthritis (ERA), and psoriatic arthritis (PsA) METHODS: Patients who completed the 2-year, open-label, phase III CLinical Study In Pediatric Patients of Etanercept for Treatment of ERA, PsA, and Extended Oligoarthritis (CLIPPER) were allowed to enroll in its 8-year long-term extension (CLIPPER2). Children received ETN at a once-weekly dose of 0.8 mg/kg, up to a maximum dose of 50 mg/week. Efficacy assessments included the JIA core set of outcomes, the JIA American College of Rheumatology response criteria (JIA-ACR), and the Juvenile Arthritis Disease Activity Score (JADAS). Efficacy data are reported as responder analyses using a hybrid method for missing data imputation and as observed cases. Safety assessments included treatment-emergent adverse events (TEAEs). RESULTS Out of 127 patients originally enrolled in CLIPPER, 109 (86%) entered CLIPPER2. After 6 years of trial participation (2 years in CLIPPER and 4 years in CLIPPER2), 41 (32%) patients were still taking ETN, 13 (11%) entered the treatment withdrawal phase after achieving low/inactive disease (of whom 7 had to restart ETN), 36 (28%) discontinued treatment for other reasons but are still being observed, and 37 (29%) discontinued treatment permanently. According to the hybrid imputation analysis, proportions of patients achieving JIA ACR90, JIA ACR100, and JADAS inactive disease after the initial 2 years of treatment were 58%, 48%, and 32%, respectively. After the additional 4 years, those proportions in patients who remained in the trial were 46%, 35%, and 24%. Most frequently reported TEAEs [n (%), events per 100 patient-years] were headache [28 (22%), 5.3], arthralgia [24 (19%), 4.6], and pyrexia [20 (16%), 3.8]. Number and frequency of TEAEs, excluding infections and injection site reactions, decreased over the 6-year period from 193 and 173.8, respectively, during year 1 to 37 and 61.3 during year 6. A single case of malignancy (Hodgkin's lymphoma) and no cases of active tuberculosis, demyelinating disorders, or deaths were reported. CONCLUSIONS Open-label etanercept treatment for up to 6 years was safe, well tolerated, and effective in patients with eoJIA, ERA, and PsA. TRIAL REGISTRATION ClinicalTrials.gov: CLIPPER, NCT00962741 , registered 20 August, 2009, CLIPPER2, NCT01421069 , registered 22 August, 2011.
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Affiliation(s)
- Ivan Foeldvari
- Hamburg Centre for Pediatric and Adolescent Rheumatology, Hamburg, Germany
| | - Tamàs Constantin
- Unit of Pediatric Rheumatology-Immunology, Second Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Jelena Vojinović
- Clinic of Pediatrics, Clinical Center Niš, Faculty of Medicine, University of Niš, Niš, Serbia
| | - Gerd Horneff
- Department of General Paediatrics, Asklepios Clinic Sankt Augustin, Sankt Augustin, Germany.,Department of Paediatric and Adolescents Medicine, Medical Faculty, University Hospital of Cologne, Cologne, Germany
| | - Vyacheslav Chasnyk
- Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russian Federation
| | - Joke Dehoorne
- Department of Pediatric Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Violeta Panaviene
- Children's Hospital, Affiliate of Vilnius University Hospital Santaros Clinic, Vilnius, Lithuania.,Clinic of Children's Diseases, Vilnius University, Vilnius, Lithuania
| | - Gordana Sušić
- Division of Pediatric Rheumatology, Institute of Rheumatology, Belgrade, Serbia
| | - Valda Stanevicha
- Department of Pediatrics, Riga Stradins University, Children University Hospital, Riga, Latvia
| | | | - Zbigniew Zuber
- Andrzej Frycz Modrzewski Krakow University, Krakow, Poland
| | - Bogna Dobrzyniecka
- Szpital Specjalistyczny im. A. Falkiewicza, Szpital Specjalistyczny, Wroclaw, Poland
| | - Irina Nikishina
- Pediatric Department, V.A. Nasonova Research Institute of Rheumatology, Moscow, Russian Federation
| | - Brigitte Bader-Meunier
- IMAGINE Institute, Hôpital Necker-Enfants Malades, Centre de Référence National pour les Rhumatismes Inflammatoires et les Maladies Auto-Immunes Sytémiques rares de l'enfant (RAISE), Unité d'Immunologie, Hématologie et Rhumatologie Pediatrique, Paris, France
| | - Luciana Breda
- Dipartimento di Pediatria, Ospedale Policlinico - Università degli Studi di Chieti, Chieti, Italy
| | - Pavla Doležalová
- Department of Pediatrics and Adolescent Medicine, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Chantal Job-Deslandre
- Hôpital Universitaire Cochin, Centre de Reference National pour les Arthrites Juveniles, Site Patients Adultes - Service Rhumatologie A, Paris, France
| | - Ingrida Rumba-Rozenfelde
- Faculty of Medicine, University of Latvia, Riga, Latvia.,University Children Hospital, Riga, Latvia
| | - Nico Wulffraat
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | | | | | | | - Alberto Martini
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DiNOGMI), Università degli Studi di Genova, Genoa, Italy
| | - Nicolino Ruperto
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, EULAR Centre of Excellence in Rheumatology 2008-2023, Paediatric Rheumatology International Trials Organisation (PRINTO), Via Gaslini, 5, 16147, Genoa, Italy.
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