A111-b: Evaluation of an NHS Juvenile Idiopathic Arthritis (JIA) Treatment Pathway Compared to Published International Recommendations
Authors: Katherine Green, Marinka Twilt, Taunton R. Southwood
Journal: Arthritis & Rheumatology (2014)

Background/Purpose:

The ACR recommendations for the treatment of Juvenile Idiopathic Arthritis (ACR-JIA) were published in 2011 with the aim of providing an evidencebased, consensus-approved therapeutic pathway for safe and effective JIA treatment. Our aim was to determine the feasibility of applying ACR-JIA to a real-life paediatric JIA cohort to evaluate their treatment pathway.



Methods:

We conducted a retrospective analysis of a single-centre paediatric JIA cohort. This included a review of the patient case notes, radiology and drug monitoring data of all children newly diagnosed with JIA and polyarticular involvement (5 or more joints) in the 2 years since ACR-JIA were published.



In total, 35 patients fulfilled ILAR criteria for the diagnosis of JIA since 2011: systemic arthritis (n=5), polyarthritis (n=25) and extended Oligoarthritis (n=5). ACR-JIA does not distinguish between polyarthritis and extended oligoarthritis, and consequently these groups were analysed together. Patients with JIA: systemic arthritis were reviewed separately. To assess feasibility of the treatment pathways in real clinical practice, disease duration from diagnosis to starting Methotrexate and Etanercept treatments was calculated, and the frequency of drug monitoring noted.



Results:

25 females and 10 males (median age at onset 13, range 1.5–15 years) were included in the evaluation. Median age at disease onset for poly/extended oligoarthritis was 10 years (1.5–16), with a median of 12 joints (12–38) active at presentation, and for the systemic group median age at onset was 6 years (2–7), with a median number of 6 active joints (2–10). 3 polyarthritis patients were rheumatoid factor positive. The prognostic features and disease activity levels of the cohort are displayed in the 1 below.



22/30 patients with polyarthritis/extended oligoarthritis followed the ACR recommendations for treatment according to their disease severity, commencing methotrexate therapy within a median of 6 weeks (3–37) of diagnosis and etanercept (where relevant) within a median of 7 months (3–24) of diagnosis. 7 patients did not follow ACR-JIA guidelines due to excessive length of time between diagnosis and commencing methotrexate or etanercept treatment, in some cases due to delays in administrative and funding approval. One patient did not have sufficient regular drug monitoring tests.



All patients with systemic arthritis followed the ACR-JIA recommendations for treatment and drug monitoring.


Table 1. 	JIA Subtype	Disease Severity	N=	Poor Prognostic Factors	RhF positive	Median Duration to MTX (weeks)	Median Duration to Etanercept (weeks)
Systemic N=5	Low	1	0	0	N/A	N/A	
 	Moderate	2	0	0	 	 	
 	High	2	0	0	 	 	
Polyarthritis & Extended Oligoarthritis N=30	Low	0	0	0	6 (3–37)	7 (3–24)	
 	Moderate	23	9	2	 	 	
 	High	6	2	1	 	 	
 	Unknown	1	0	0	 	 	



Conclusion:

Overall, 27/35 patients followed the ACR-JIA recommendations. This evaluation highlights the potential influence of the local health economy in achieving rapid commencement of new JIA therapies and the challenges of ensuring regular drug monitoring in all patients.