Disease activity at two consecutive registry visits and subsequent medication escalation for patients with juvenile idiopathic arthritis in the CARRA registry

Objective: To account for the chronic time course of juvenile idiopathic arthritis (JIA), we assessed medication changes by disease activity patterns across 2 sequential timepoints. Methods: Patients with non-systemic JIA enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry with complete clinical Juvenile Arthritis Disease Activity Scores (cJADAS) at 6 and 12-month registry visits were included. Disease activity was classified by cJADAS categories (inactive/minimal, moderate/high). The primary outcome was disease modifying anti-rheumatic drug (DMARD) escalation at the 12-month visit. We examined the association between cJADAS patterns and DMARD escalation. Results: The cJADAS patterns across paired visits for 2,956 patients with JIA were: 71% persistent inactive/minimal, 25% persistent moderate/high, 2% “improving”, and 2% “flaring”. Only 10% of patients had DMARD escalation at the 12-month visit, including only 15% of patients with persistent moderate/high disease activity. In multivariable logistic regression adjusting for sociodemographic and clinical variables, DMARD escalation at the 12-month visit was associated with “flaring” disease activity (odds ratio [OR] 2.62, 95% confidence interval [CI] 1.33–5.18), DMARD escalation between the 6- and 12-month visits (OR 1.86, 95% CI 1.40–2.49) and morning stiffness (> 60 min 4.98, 95% CI 3.00–8.27), while age 15–19 years were less likely to escalate (OR 0.61, 95% CI 0.38–0.97). Conclusion: In a large multicenter registry of US patients with JIA, DMARD escalation at the 12-month visit was uncommon overall, even for those with persistent moderate/high disease activity. Our findings suggest that DMARD escalation in this cohort did not align well with a treat to target approach using cJADAS thresholds.