Juvenile idiopathic arthritis: how do clinicians define remission and withdraw etanercept?

Abstract

Preliminary criteria for defining juvenile idiopathic arthritis (JIA) remission were proposed in 2004. There is no evidence base to inform method of etanercept withdrawal in remission. Aims To determine how clinicians define disease remission in JIA, how long is required in remission prior to disease-modifying antirheumatic drug (DMARD) withdrawal and what strategies are used for etanercept withdrawal. Methods A 10-part, piloted questionnaire was sent to 86 consultant members of British Society for Paediatric and Adolescent Rheumatology. A link to SurveyMonkey software1 was sent by email between September 2009 and November 2009, with one reminder. Results 31 clinicians (36% response rate) completed the questionnaire. 90% had experience of stopping DMARD therapy because of disease remission in JIA. To define remission, all clinicians required an active joint count of 0 and rated this “extremely” important. 96% required no extra-articular features and 93% required no active uveitis. More than 75% rated these criteria as “very” or “extremely” important. There was less consensus about erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), with more than 75% rating these as “slightly”, “moderately” or “very” important as these values were too non-specific. There was no consensus on other criteria. The duration of remission before withdrawing DMARD treatment varied from 6 months to 2 years with 41% responders stating 1 year and 41% 2 years. The duration required was most significantly affected by a previous failed trial off DMARDs, although only 45% rated this as “very” or “extremely” important. The method of etanercept withdrawal varied, half weaning to once weekly injections before stopping and 39% stopping from full dose twice weekly. Two thirds of clinicians had to restart etanercept, irrespective of the withdrawal method. Conclusions An active joint count of 0, no extra-articular features and no active uveitis were the key factors clinicians used to define remission in JIA. ESR and CRP values were deemed too non-specific. Most clinicians required at least 1 year in remission before DMARD withdrawal, although many required 2 years. Several methods of etanercept withdrawal were used, with two thirds reporting the need to restart etanercept because of disease relapse.