The Best Ways to Achieve Remission in JIA

There’s no cure for juvenile idiopathic arthritis, but early, aggressive treatment could lead to long-term remission.

The Best Ways to Achieve Remission in JIA
By Stephanie Watson 

Without a cure for juvenile idiopathic arthritis (JIA), doctors aim to put kids into remission — or periods of little or no disease activity and symptoms of disease (joint flares, fever, etc.). Research finds that treating the disease early and aggressively offers children the best odds of achieving long-term symptom relief.

Benefits of Early, Aggressive Treatment 
A few studies have shown that starting aggressive therapy early in the course of the disease provides the best results for kids with JIA. Doctors define aggressive therapy as a combination of a biologic drug and methotrexate, sometimes with an added steroid.

One such study was the TREAT trial, which included 85 children with polyarticular JIA. Researchers divided the kids into two groups: One group received methotrexate, a biologic drug and a steroid. The other group got methotrexate alone. Nine children in the first group achieved remission after 12 months, compared to just three in the second group. In a follow-up study on 48 of the children two years later, 54% had achieved clinical remission.

Other research has also shown that kids with polyarticular JIA who start a biologic early, such as etanercept (Enbrel), plus methotrexate do better than those who take methotrexate alone.

“I think there are strong data showing that early, aggressive therapy really helps these kids, and that it’s the way to go,” says Susan Shenoi, MBBS, MS, pediatric rheumatologist at Seattle Children’s Hospital and assistant professor of pediatric rheumatology at the University of Washington.

The Window of Opportunity
Some researchers who study JIA use the term “window of opportunity.” It refers to the idea that there is a period of time in which the disease responds best to treatment. Kids who take medication during this period are most likely to achieve long-term remission and avoid permanent joint damage.

“There seems to be a trend where, if you treat kids early on with an effective medication, they have better outcomes and achieve inactive disease,” Dr. Shenoi says. Often the term “window of opportunity” is used specifically for kids with systemic JIA—one of the most severe forms of the disease.

For these children, the most effective therapy is with interleukin-1 (IL-1) and interleukin-6 (IL-6) inhibitors. “The IL-1 and IL-6 inhibitors have revolutionized the way we treat systemic JIA,” says Dr. Shenoi. “Studies show that if you start kids on an IL-1 inhibitor like anakinra (Kineret) early on, there seems to be a dramatic change in their outcome, with several of them achieving inactive disease or remission.”

Treat to Target
Treat to target is another recent concept in JIA therapy. It’s been used for many years in adults with rheumatoid arthritis, but it’s just starting to catch on among pediatric rheumatologists.

“In treat to target, patients and physicians work together to come to a consensus on what the outcome or target (usually remission or low disease activity) needs to be, and they keep adapting the therapy to make sure that the target is achieved,” Dr. Shenoi says. At each visit, the parents, the doctor and patient evaluate outcome progress and then decide whether to stay with the same treatment or make a change. 

The ultimate goal is achieving remission off medications. Of course, the risk is that the disease will flare again. A study of 135 children with JIA in Arthritis Care & Research found that most kids—more than 75% — flared up within an average of six months after they stopped taking biologics.

Knowing when to take kids off their medication is an imprecise science. Doctors don’t know which kids will see a return of their symptoms—and when. “We don’t have enough data to predict when, and if, a flare might happen,” says Nancy Pan, MD, a pediatric rheumatologist at the Hospital for Special Surgery in New York. She adds that flares can happen shortly after kids stop treatment, or months or years later.

Finding the Right Treatment Strategy
Early intervention with effective medication is the most critical component to achieving remission in kids with JIA—but it’s not the only treatment strategy. Practicing healthy lifestyle habits, like eating a nutritious diet and getting regular exercise is essential for these kids.  “Physical therapy is also important for a lot of patients to maintain their range of motion,” Dr. Pan says.

Above all, treating JIA often involves a lot of trial and error. “We don’t know that patient X is going to respond to drug X or drug Y,” Dr. Shenoi says. “A lot of our therapy is trying a medication and seeing if it works, and that can be frustrating.”

But overall, the outlook for kids with JIA has improved dramatically in recent years. Biologic drugs and other new treatments are helping kids stay mobile and avoid permanent disability. 

“We’re in a very exciting era in treating arthritis,” Dr. Pan says. “I think the prognosis for patients now is better than ever.”
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