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23-02-2018 | Rheumatology | News | Article

Longer time in clinically inactive JIA may reduce flare risk after stopping methotrexate

medwireNews: A longer time spent in clinically inactive disease (CID) is associated with reduced flare risk following methotrexate discontinuation among patients with juvenile idiopathic arthritis (JIA), researchers report.

Methotrexate is the most widely used treatment for JIA, but adverse events (AEs) including abdominal discomfort and vomiting contribute to methotrexate intolerance, which “may impact on the treatment goal of inducing early disease remission in JIA by treatment discontinuation and non-compliance,” explain Jens Klotsche, from the German Rheumatism Research Centre in Berlin, and study co-authors.

“Therefore, it is important to develop strategies for discontinuing [methotrexate] that minimise the risk of disease flare after attaining clinical inactive disease,” they add.

As reported in the Annals of the Rheumatic Diseases, the team used a German national JIA register to assess predictors of flare in 1514 methotrexate-treated patients, 64.9% of whom discontinued the drug after a median of 2.3 years. The main reason for stopping methotrexate was ineffectiveness.

A total of 316 (20.8%) participants discontinued methotrexate due to achieving CID, defined as a clinical Juvenile Arthritis Disease Activity Score of 1 or lower, and of these patients, over half (58.2%) experienced a disease flare after a mean of 7.4 months.

In a multivariable analysis taking factors including sex, disease type and duration, and antinuclear antibody positivity into account, the team identified time spent in CID prior to methotrexate discontinuation as a significant predictor of flare risk.

Compared with patients who were in CID for less than 6 months before methotrexate withdrawal, those with CID lasting 6–12 months had a 39% reduced risk for flare, while those who were in CID for more than a year had a 50% lower risk.

Although these findings indicate that flares are likely to be less common in patients who spend at least 12 months in CID before stopping methotrexate, the researchers note that there was “a high flare rate” overall.

They stress that “[w]ithdrawing treatment in JIA is complex, and currently no guidelines or consented recommendations have been published.”

And Klotsche and colleagues conclude: “The clinician must balance the high risk for disease flares that may prevent the clinician from withdrawing treatment against the risk for AEs and [methotrexate] intolerance under continuing treatment.”

By Claire Barnard

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