Using a treat-to-target approach in children with polyarticular JIA

High rates of remission achieved after 12 months of treat-to-target.

Introduction
Juvenile idiopathic arthritis (JIA for short) is an umbrella term for arthritis of an unknown cause in children under the age of 16. JIA causes pain, swelling and stiffness in one or more joints, as well as other symptoms like extreme tiredness (fatigue). Polyarticular JIA is a subtype of JIA where the child has arthritis in five or more joints.

In recent years, doctors have started to use an approach called treat-to-target for people with rheumatic diseases. This means that targets or goals are set for treatment. These targets say how well a medicine should have worked over a certain period of time. If targets are not met then changes are made. This could include changing the dose of the medicine, adding in another medicine, or completely switching to a different drug. In JIA, it is known that children who have an early response to treatment do better overall. Treat-to-target approaches usually follow a flowchart of steps to help doctors make decisions at each point, together with children and their families.

What did the authors hope to find?
The authors wanted to show that treat-to-target would be better than an unguided treatment approach for children with polyarticular JIA. They did not want to compare different medicines, but just the idea of a following a pre-determined treat-to-target approach.

Who was studied?
The study looked at 63 children aged 2–16 with polyarticular JIA. All the children were being treated at one of six hospital clinics in Germany. All the children had at least four joints affected by the disease. Everyone began the study at the same time as they started taking their first disease-modifying antirheumatic drug (often shortened to DMARD). Everyone in the study was classed as having early disease, and had started treatment within 12 months of their symptoms starting.

How was the study conducted?
This was an open, single-arm study. This means that both the children and their doctors knew what medicine they were taking and that they were trialling a treat-to-target approach. All the children started taking methotrexate, which is the recommended first-line treatment for JIA. After 3, 6, 9 and 12 months the children were checked to see how well their JIA had responded to the treatment. Disease activity was measured using a tool called the JADAS10 (short for Juvenile Arthritis Disease Activity Score), which helps doctors to understand how active the JIA is. The target was to keep increasing the response over time. Children were said to have met their target if they had shown some improvement after 3 months, had acceptable disease at 6 months, minimal disease at 9 months, and then if they had achieved remission after 12 months.

At each time point, if children had reached their target, and had no side effects, they stayed on the same treatment. If they had not met their target, then a biologic medicine was added, or – if they were already taking a biologic – they were switched to a different one. The choice of biologic was a decision made between the doctor, the child and the parents or carers.

The results from the children in this treat-to-target group were compared with historical data from a database called the German BIKER registry. This was the unguided treatment group. In this group, all children also had early JIA and had started on methotrexate as their first treatment.

What were the main findings of the study?
The main finding was that the treat-to-target approach was better than unguided treatment, since more children reached remission or minimal disease activity after 1 year of treat-to-target management compared to unguided treatment. More children in the treat-to-target group received biologic medicines 1 year after starting treatment than those on unguided treatment. The treat-to target concept was easy to manage, and did not require any extra clinic visits or examinations for children with JIA.

Are these findings new?
Yes, and they add to a growing interest in treat-to-target approaches, here compared against unguided treatment in children with polyarticular JIA.

What are the limitations of the study?
The main limitation is that the study design was not a tight clinical trial, and both doctors and patients knew which medicine they were taking, which could mean there is bias in the results. In addition, the treat-to-target results were compared to data from the German BIKER registry, but these were patients starting treatment between 2005 and 2011, so may not be directly comparable to children being treated today as the willingness to prescribe biologics may have increased in recent years. Also, the study did not look at whether the children could stop taking their treatment if they reached remission. Finally, long-term data are not available.

What do the authors plan on doing with this information?
The treat-to-target approach is now recommended in the German Guideline for the treatment of JIA. The concept will also be studied in a national cohort study called PROKIND, which is looking at the treatment of JIA in Germany, and comparing different treatment approaches.

What does this mean for me?
If you have JIA, or if you are caring for a child with JIA, your doctor might recommend a treat-to-target approach. This is a treatment plan that aims to help your child to reach goals of remission or minimal disease activity. This is done with regular monitoring, and changing treatment when needed.

If you have any concerns about your disease or its treatment, please speak to your doctor.

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Date prepared: May 2020
Summary based on research article published on: 16 April 2020
From: Klein A, et al. Treat-to-target study for improved outcome in polyarticular juvenile idiopathic arthritis. Ann Rheum Dis 2020;79:969–974. doi:10.1136/annrheumdis-2019-216843

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