New Guidance for Rheumatologists who Treat JIA

When TNF-α inhibitor therapy (etanercept or adalimumab) is initiated, methotrexate should be continued for patients who have previously had a partial clinical response to methotrexate. Continuing methotrexate is appropriate when initiating infliximab because methotrexate can reduce the production of neutralizing antibodies to infliximab. That approach is also consistent with the labeling on infliximab.

Initiate TNF-α inhibitor therapy earlier

Most of the recommendations should be familiar to rheumatologists who frequently care for children with arthritis, according to Dr. Beukelman. Some of the recommendations, however, may be surprising to those who treat these children less frequently, such as the recommendation to use biologic agents relatively early in the disease course.

Concern about treating children with TNF-α inhibitors increased about two years ago when the U.S. Food and Drug Administration issued a black-box warning about the risk of malignancy in children being treated with the agents. Dr. Beukelman presented research at the ACR/ARHP Annual Scientific Meeting in November 2010 that found no increase in risk of malignancy in children treated with the therapy. Children with JIA, however, do have an increased risk of cancer, suggesting that the risk may be due to the disease itself rather than the therapy.

According to Dr. Beukelman, one of the notable recommendations, is that TNF-α inhibitors should be initiated for children with a history of arthritis of four or fewer joints if significant arthritis proves refractory to methotrexate. Among the recommendations for this treatment group is that these patients can be treated with TNF-α therapy if they have received glucocorticoid joint injections and three months of methotrexate at the maximum tolerated typical dose and have moderate or high disease activity and features of poor prognosis.