The risk and nature of flares in juvenile idiopathic arthritis: results from the ReACCh-Out cohort

Abstract

ObjectiveTo describe probabilities and characteristics of disease flares in children with juvenile idiopathic arthritis (JIA) and to identify clinical features associated with an increased risk of flare.MethodsWe studied children in the Research in Arthritis in Canadian Children emphasizing Outcomes (ReACCh-Out) prospective inception cohort. A flare was defined as a recurrence of disease manifestations after attaining inactive disease and was called significant if it required intensification of treatment. Probability of first flare was calculated with Kaplan–Meier methods, and associated features were identified using Cox regression.Results1146 children were followed up a median of 24 months after attaining inactive disease. We observed 627 first flares (54.7% of patients) with median active joint count of 1, physician global assessment (PGA) of 12 mm and duration of 27 weeks. Within a year after attaining inactive disease, the probability of flare was 42.5% (95% CI 39% to 46%) for any flare and 26.6% (24% to 30%) for a significant flare. Within a year after stopping treatment, it was 31.7% (28% to 36%) and 25.0% (21% to 29%), respectively. A maximum PGA >30 mm, maximum active joint count >4, rheumatoid factor (RF)-positive polyarthritis, antinuclear antibodies (ANA) and receiving disease-modifying antirheumatic drugs (DMARDs) or biological agents before attaining inactive disease were associated with increased risk of flare. Systemic JIA was associated with the lowest risk of flare.ConclusionsIn this real-practice JIA cohort, flares were frequent, usually involved a few swollen joints for an average of 6 months and 60% led to treatment intensification. Children with a severe disease course had an increased risk of flare.

Identification of enhanced IFN-γ signaling in polyarticular juvenile idiopathic arthritis with mass cytometry

“…Even with modern biologic therapies, a significant fraction of polyarticular JIA patients have persistent disease activity (9). RF + polyarticular JIA patients in particular have lower response rates to treatment and longer times to clinical remission, with higher rates of disease flare (8,10,11). Together, these observations suggest mechanistic differences in polyarticular JIA compared with other JIA subsets.…”

Correction: Prevalence, incidence and progression of hand osteoarthritis in the general population: the Framingham Osteoarthritis Study

“…10 The patients with US abnormality showed a higher percentage of flares compared with those without abnormalities. US abnormalities increased the risk of flare by almost four times after considering the therapy as a confounder.…”

“…34 In a previous large study, physician global assessment (PGA) >30, active joint count >4, positive rheumatoid factor polyarthritis, antinuclear antibody (ANA) positivity and DMARDs or biological therapy before attaining inactive disease were associated with increased risk of flare, but US examination was not available. 10 Considering only significant flares and the results of a multivariate analysis, active joint count >4 and joint injections were still associated with the risk of relapse, with the maximum value of HR equal to 1.29. Our study focuses on US and if confirmed could support US examination as a useful tool for clinical management.…”

“…1 2 Unfortunately, the risk of flare after discontinuation of methotrexate or biological therapy is high, [1][2][3][4][5][6][7][8][9] and tools predicting relapse are urgently needed. A recent paper by Guzman et al 10 showed that there are no clinical features reliably associated with the risk of flare except the JIA subtype.…”

Parental Perspectives about Research and Knowledge Translation in Juvenile Idiopathic Arthritis

“…The primary aim of the ReACCh-Out study was to describe clinical outcomes of juvenile idiopathic arthritis (JIA) in a prospective inception cohort of children in order to better counsel families of newly diagnosed patients (9,12). JIA, the most common chronic rheumatic disease of childhood, is characterized by joint swelling and stiffness, chronic pain, decreased quality of life, the need for long-term medications, and frequent flares (13,14).…”