Welcome to the Remission Edition of my perusal of the JIA abstracts at ACR 2014.
With a combination of Enbrel (generic name: etanercept) and dietary changes, our daughter has been arthritis-free for the past 10 months. But we never know when and if arthritis will rear its ugly head again. How long will the effects of Enbrel last? And what does it mean if she has occasional morning stiffness or fatigue but is well otherwise? The abstracts below help address these questions:
Abstract #293: Long-Term Functional Outcome and Quality of Life of Patients with Refractory Juvenile Idiopathic Arthritis Treated with Etanercept; Results of the Dutch Arthritis and Biologicals in Children Register. Anink et al. (Netherlands)
Initiation of etanercept in children with JIA who are refractory to methotrexate has been shown to improve both disability and health related quality of life shortly after treatment begins. This study used a Dutch registry to identify 43 children (median range 18-24 years old) with JIA on long-term etanercept treatment. They questioned them on education and employment, disability and quality of life, and the registry was used to obtain data on recent disease status, co-morbidities and structural damage. This study was good news for those on long-standing biologics (specifically, etanercept) as the effect on quality of life was sustained. Patients in the study had low disability, and functioned comparable to or better than the general population. 14% of patients in this study required surgery, but it appears this was from damage done prior to etanercept, stressing the importance of early treatment of JIA.
Abstract #351: Doctor, Will My Fatigue be Better If I’m In Remission? An Exploratory Analysis of 1284 Rheumatoid Arthritis Patients Indicates Fatigue Is the Only Aspect of Patient-Perceived Impact to Remain Significant in ACR/EULAR Boolean Remission. Gossec et al. Paris, France.
This is an RA study but brings out interesting data on arthritis and its relationship to fatigue. The ACR/EULAR definition of remission includes assessment of joints, CRP and patient global assessment, but fatigue is not specifically assessed. The authors of this study investigated fatigue levels in patients in remission compared to those near-remission and not in remission. Using the RAID database (an international, multi-center study of RA patients from 12 European countries) and the baseline data in COMEDRA (a French national study in stable RA patients), the authors investigated patient-reported assessment of fatigue as well as pain, function, sleep, coping and well-being. 1284 patients were included, with mean age 57 +/- 11 years old, disease duration 13 +/- 10 years, 78% female. For all patients, mean fatigue was 4.1 (+/- 2.7). For patients in remission, all of the components of RAID were very low (mean value below 1) except fatigue (mean value 1.2 +/- 1.8). Fatigue was above 1/10 in a quarter of the remission patients. Patients in near-remission, fatigue was at the general level. For patients in remission, fatigue was the only aspect to remain at significant levels. The authors conclude that more work is needed to understand the link between fatigue and disease activity.
Abstract #278: Is It Worth Allowing the Presence of Morning Stiffness in the Definition of Inactive Disease in Juvenile Idiopathic Arthritis? Alessandro Consolaro et al. Istituto Giannina Gaslini, Genova, Italy.
Morning stiffness is a major symptom of active JIA, but even in remission children may have some degree of residual morning stiffness. The 2011 criteria for inactive disease (ID) allows for the presence of morning stiffness lasting less than or equal to 15 minutes. The authors investigated a database of 785 patients to identify patients with inactive disease with or without morning stiffness < 15 minutes. 85% of those with inactive disease had no morning stiffness while 9% had morning stiffness < 15 minutes and 6% > 15 minutes. For patient who met the 2011 criteria for ID but still had < 15 minutes of morning stiffness, parents reported worse outcomes, suggesting that parents do not perceive their child’s disease state as a true remission when morning stiffness is present. The authors suggest that changing the criterion for inactive disease to “absense of morning stiffness” should be considered. This study did not go on to assess what happens to those children – do they go on to flare? Do they go on to have more joint damage?
Abstract #292: Flares in Children with Juvenile Idiopathic Arthritis: Results from Reacch-Out Cohort. Tucker et al. BC Children’s Hospital and University of British Columbia, Vancouver, BC.
This study set out to describe flares in children with JIA and determine differences in flare characteristics among JIA subtypes. Patients were diagnosed with JIA between 2005 and 2010 and had at least one visit with ID (defined as no active joints, no extra-articular manifestation, and a physician global assessment < 10mm). Of the 1492 children recruited in ReACCh-Out, 1146 had at least one visit with ID. The majority of flares occurred while patients were still on treatment for their JIA and overall 45% were not associated with treatment changes. Although disease flares occurred in approximately half that children with JIA managed with usual care, many are mild and required no treatment change.