“These authors posited: Could there be a difference in the innate or inflammatory response in children who are Black compared to others?” she said.8
These studies clearly show that disparities exist in both the care and outcomes of children with rheumatic disease, Dr. Becker said, and we must seek out and address these disparities to improve our patients’ outcomes.
Optimizing Therapeutics
Dr. Becker then switched gears to discuss advances in therapeutic optimization, discussing three key papers.
In summer 2021, Kimura et al. published the first paper from the STOP-JIA (start time optimization of biologic therapy in polyarticular JIA) study. The STOP-JIA study is a multi-center, prospective, observational study using the Childhood Arthritis and Rheumatology Research Alliance (CARRA) registry that compared three consensus treatment plans (CTPs) developed for the treatment of polyarticular JIA.
The three CTPs are: 1) a step-up plan where patients were initiated on a non-biologic disease-modifying anti-rheumatic drug (DMARD) and then escalated to add a biologic DMARD if disease activity persisted; 2) an early combination treatment plan with early initiation of both biologic and non-biologic DMARDs up front; and 3) a biologic first CTP, in which patients were initiated on a biologic-only treatment plan.
Given that this is a real-world observational study, clinical differences and imbalances existed between groups, Dr. Becker explained, but the investigators found no significant differences in clinically inactive disease at 12 months. However, they did find that patients in the early combination CTP achieved a low-disease activity score by 12 months more frequently than patients treated with the other two CTPs. The patients on the early combination CTP also received less glucocorticoids during the first six months of treatment.9
Another study, an extension of the STOP-JIA trial, assessed the effect of biologic DMARDs on disease course. By using latent class trajectory modeling, Ong et al. found that patients could be separated into three classes of disease activity: slow, moderate and rapid improvement. These trajectories diverged by three months, and timing of biologic DMARD initiation was the most significant predictor for a favorable trajectory.
Dr. Becker also noted a subgroup within the rapid improvement group received only non-biologic DMARD therapy (rather than a biologic DMARD), but again, the most significant predictor for a rapid and favorable response was early initiation on DMARD therapy.
These results provide further evidence of the importance of early initiation of biologic DMARDs in children with polyarticular JIA and raise an additional question regarding how clinicians can identify patients who may still have favorable outcomes with non-biologic DMARD therapy.10
