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Pediatric rheumatologists were most likely to postpone the decision to withdraw biologic therapy when the patient and/or parents expressed a preference for continuation.
In pediatric patients with clinically inactive non-systemic juvenile idiopathic arthritis (JIA), the preferences of the patient and parents were the strongest motivating factor regarding the decision to postpone biologic therapy withdrawal, according to a study published in Pediatric Rheumatology.1
Evidence and guidelines on when and how to withdraw biologic therapy from patients with JIA with inactive disease and/or those who are in clinical remission is lacking. However, timely withdrawal of therapy is necessary to avoid prolonged exposure and an increased risk of severe adverse events, in addition to cost savings.2
“Decisions to withdraw treatment are inherently complex, with 3 in 4 patients flaring within 12 months after stopping biologic therapy, and the risk of not being able to recapture inactive disease with the same medication,” wrote Janine A van Til, PhD, associate professor in health preference research at the department of Health Technology and Services Research at the University of Twente, Netherlands, and colleagues. “However, multiple studies have failed to yield conclusive evidence on clinical and biologic predictors for successful medication withdrawal in JIA, which further complicates these decisions.”
A survey collected information on background characteristics, minimum treatment time with biologics, treatment patterns, and 16 different patient vignettes from 83 pediatric rheumatologists residing in Canada and the Netherlands. For each of the vignettes, participants were asked whether they would withdraw biologic medication at their minimum treatment time. If they opted to remain on therapy, they were asked how long they would continue treatment. The statistical analysis included descriptive statistics, logistic analysis, and interval regression analysis.
A total of 33 pediatric rheumatologists participated in the survey with an overall 40% response rate (60.0% in the Netherlands and 35.3% in Canada). No differences in age, sex, and clinical experience were observed between countries.
According to the survey, the most common time to biologic therapy withdrawal in a patient without complications was 12 months after achieving clinically inactive disease. The main reason rheumatologists surveyed were most likely to postpone the decision to withdraw biologic therapy was when the patient and/or parents expressed a preference for continuation (odds ratio [OR] 6.3; P <.001). Other reasons included in case of a flare (OR 3.9; P = .001) and in case of uveitis (OR 3.9; P <.001). The average biologic therapy withdrawal initiation was 6.7 months later when the patient or parent preferred to continue biologic therapy.
Investigators noted the vignette design as a strength of the study, as different characteristics were presented in a single patient as opposed to individual characteristics, which better reflected actual clinical practice. However, not all disease and treatment characteristics of JIA were included, as it would have increased the information in the vignette and the number of clinical vignettes. An additional limitation was the lack of distinction between patients on biologic monotherapy or those receiving a combination of biologic therapy and methotrexate. Some rheumatologists noted combination therapy would have influenced their decision to withdrawal treatment. Lastly, the relatively small sample size of rheumatologists in the Netherlands due to the limited number of pediatric rheumatologists made it impossible to test for differences between countries.
“There is a large variation in minimum treatment time between pediatric rheumatologists, which is partly explained by the country of residence which may reflect different underlying medication access issues,” investigators concluded. “These findings emphasize the need, and inform the design of, a tool to support pediatric rheumatologists, patients and parents in decision making.”