Abstract Background/Aims Adalimumab is an effective therapy for the management of juvenile idiopathic arthritis (JIA), but evidence guiding discontinuation following prolonged remission remains limited. This service evaluation aimed to assess outcomes in children and young people discontinuing adalimumab after achieving disease control, to identify trends in those who maintained inactive disease off treatment and those who flared, and to determine the proportion restarting adalimumab. Methods Patients aged ≤ 18 years, with a diagnosis of JIA, who discontinued adalimumab for inactive disease between 01/09/2021 and 30/09/2022, with ≥ 3 months follow up, were included. Retrospective data were collected from electronic medical records, including demographics, JIA subtype, previous and concurrent medications, anti-adalimumab antibody testing, and outcome following cessation. Results Twenty-two patients (11 female; median age 14 years) were included. Eleven patients had rheumatoid factor-negative polyarticular JIA, 9 oligo-JIA, 1 enthesitis-related arthritis and 1 Down syndrome-associated arthritis. Nineteen discontinued adalimumab for the first time, with 10 (52%) experiencing a flare following cessation (8 with arthritis, 2 with uveitis). Median time to flare was 6 months. Seven patients (70%) restarted adalimumab: 4 achieved and maintained disease control; 2 did not achieve control on adalimumab alone and required an additional conventional synthetic disease-modifying anti-rheumatic drug (csDMARD) and 1 achieved disease control on adalimumab monotherapy but flared after 1 year 9 months, requiring the addition of sulfasalazine. Three of the 10 patients who flared after stopping adalimumab for the first time, were not restarted. One tested positive for anti-adalimumab antibodies and was switched to infliximab/ mycophenolate mofetil, and two were managed with intra-articular corticosteroid injections alone. Three of the 22 patients stopped adalimumab for a second time. All three patients flared off treatment (median time to flare: 3 months) and restarted. One achieved disease control, one required increased injection frequency and concurrent csDMARD, and one achieved inactive disease then experienced a uveitis flare which was managed with steroid eyes drops. Anti-adalimumab antibody testing was performed in 8/13 patients who flared. Antibodies were present in 1 patient, who was not on prior concurrent csDMARD. Of the 9/22 patients who did not flare, 6/9 (66%) were receiving methotrexate alongside adalimumab. Of the 22 patients who stopped adalimumab, 11 had concomitant csDMARD therapy and 11 had monotherapy. 5/11 (45%) treated with concurrent csDMARD flared after stopping compared with 8/11 (73%) on adalimumab monotherapy. Of the 22 patients, 6 (27%) had JIA-associated uveitis which flared in 5 (83%) after stopping adalimumab. Conclusion More than half of the patients flared after discontinuing adalimumab, with the majority requiring re-initiation of systemic therapy. Concurrent csDMARD use may be associated with decreased risk of flare. While limited by sample size, these findings highlight the need for clearer clinical guidance of biologic withdrawal in JIA. Disclosure F. Crompton: None. K. Hartley: None. S. Jandial: None. F. McErlane: None. S. Sampath: None. E.S. Sen: None.
Crompton et al. (Wed,) studied this question.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: