Disease modifying anti-rheumatic drug treatment cycles and rates of flare in juvenile idiopathic arthritis—a tale of Sisyphean endeavour?

Objectives Withdrawal of Disease Modifying Antirheumatic Drugs (DMARDs) to determine need for ongoing medication is common in JIA management. Little is known about how often patients undergo trials of medication discontinuation or the outcomes of successive trials. This study examined DMARD treatment cycles in a JIA cohort to determine how frequently medication withdrawal trials occur over follow-up and if relapse rates change over consecutive cycles. Methods Retrospective review of longitudinal cohort data of children with DMARD-treated JIA diagnosed between 2010–14. Extracted data included demographics, DMARD therapy details and clinical assessments including active joint count, date of last follow-up and disease status at that time. Data was collected to January 2024. Results Ninety-one children were studied. Median age 10.1 yr (range 1.5–16.8), 59% were female and median follow-up 7.0 yr (range 0.7–13). A maximum of 4 cycles of DMARD treatment were undertaken. 44.0% of children underwent more than one cycle. 63.5% relapsed after their first cycle and 53.3% after their second. 25.3% remained off treatment to last follow-up following cycle one and over two subsequent cycles of therapy this increased to just 35.2%. Conclusion In JIA patients requiring DMARD therapy recurrent treatment withdrawal trials are common over follow-up, but relapse risk is high and remains so over successive trials. Permanent treatment withdrawal is therefore not a realistic goal for most patients with therapies currently available. Until biomarkers of permanent remission are developed, strategies to minimize both drug toxicity and the risk of disease flares in patients with recurrently active disease after medication withdrawal are required.