medwireNews: The clinical Juvenile Arthritis Disease Activity Score (cJADAS) may help to identify patients with juvenile idiopathic arthritis (JIA) who require anti-tumor necrosis factor (TNF) therapy, researchers report.
The current ACR clinical practice guideline (CPG) that includes criteria for escalation of therapy in JIA patients “is hard to memorise and probably too complicated for implementation in daily clinical practice,” meaning that alternative guidance or tools are required, say Joost Swart (University Medical Center Utrecht, the Netherlands) and study co-authors.
They explain that the JADAS score – constructed from the active joint count, physician global assessment, wellbeing score, and erythrocyte sedimentation rate (ESR) – gives a simpler single-score result, and that the shortened cJADAS version does not require waiting for ESR results before a treatment decision can be made.
The team analyzed medical records from JIA patients who initiated treatment with methotrexate between 2011 and 2015, and found that physicians did not follow the current ACR-CPG for treatment escalation in many cases.
For example, among the 39 patients with oligoarticular JIA, following the ACR-CPG criteria would have resulted in 18% of patients commencing anti-TNF treatment 3 months after initiating methotrexate, but only 8% were escalated to an anti-TNF.
And for the 74 patients with polyarticular JIA, 59% would have been given a TNF inhibitor at month 3 if the ACR-CPG had been followed, but just 18% were treated as such.
After 1 year of follow-up, 75.0% of patients with oligoarticular JIA and 71.9% of those with polyarticular disease who were not given TNF inhibitors had responded to methotrexate treatment, meaning that “[t]he physician’s decision not to escalate […] appeared to be right” in these patients, write Swart and colleagues in the Annals of the Rheumatic Diseases.
The team then compared the prognostic ability of the ACR-CPG criteria with that of the cJADAS, finding that the latter was better able to predict which patients were likely to fail methotrexate treatment, defined as not reaching the criteria for inactive disease at the 1-year follow-up, when optimal cutoff values were used to avoid overtreatment at the 3-month mark and undertreatment at 6 months.
For example, when the two scores were applied to oligoarticular patients 3 months after starting methotrexate, the ACR-CPG correctly identified those in need of TNF inhibitor therapy on 10.0% of occasions. By comparison, using the best-performing cutoff value of 5 points, the cJADAS identified patients who required treatment escalation on 71.4% of occasions. Conversely, the correct recommendation not to escalate was made in 86.4% of patients when applying the ACR-CPG at 3 months, compared with 70.6% when using the cJADAS.
And for patients with polyarticular disease, 86.7% of patients in need of escalation were identified using the ACR-CPG criteria at 3 months, compared with 81.3% when using the cJADAS at the best-performing cutoff value of 7 points. Physicians made the correct decision not to escalate treatment in just 44.4% of patients when the ACR criteria were used, compared with 72.0% of patients when using the cJADAS with a cutoff value of 4 points.
“The cJADAS identifies patients in need of anti-TNF and is a user-friendly tool ready to be used for treat to target in JIA,” summarize the researchers.
They acknowledge, however, that the study was limited by its small sample size and single-center experience, and that “larger multicentre studies are needed to validate our findings, as well as to optimise the cut-off values for the cJADAS.”
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