Reducing steroid use with sJIA

Treatment for systemic juvenile idiopathic arthritis (sJIA) has long included steroids, but biologics now offer new ways to treat. Does early initiation of biologic therapy lead to a lessening in steroid use?

For children with systemic juvenile idiopathic arthritis, steroids have long been one of the only available treatments, despite the fact that they can increase the risk of infection and impede growth. The introduction of biologic therapies over the past few years has offered a new way to treat the condition without those adverse effects. A report in Pediatric Rheumatology Online Journal examined how early initiation of biologic therapy impacted the use of glucocorticoids.1

The investigators performed an emulated pragmatic trial that used observational data from children who had been hospitalized with new-onset systemic juvenile idiopathic arthritis. The Pediatric Health Information System was used to determine diagnostic and billing records. Glucocorticoid exposure during the index hospitalization was found through an inpatient billing code for oral or intravenous dexamethasone, hydrocortisone, methylprednisolone, prednisolone, or prednisone. Biologic therapy included anakinra, rilonacept, canakinumab, or tocilizumab.

A total of 468 children met the eligibility criteria for the study. Among this cohort, 19% of the patients had a billing code for biologic therapy without either preceding or concurrent initiation of immunomodulatory medications. The proportion saw significant increase over the study period from 2008 to 2019, reaching 40% of all patients discharged between 2017 and 2019. Median time to initiate a biologic therapy from admission was 4 days. For glucocorticoids, it was 5 days. Overall 51.3% of patients were given glucocorticoids, including 22.5% who were administered at least 1 dose of pulse dose glucocorticoids. Once glucocorticoids were started in patients, nearly all of them continued receiving them until they were discharged. Additionally, exposure to methotrexate was more common in patients who did not initiate biologics versus those who initiated them (8.6% vs 2.8%, p = 0.09). The most common biologic therapy used was anakinra, which was initiated in 69 patients. Canakinumab was used in 1 patient and tocilizumab was used another patient.

The investigators concluded that not only has the use of biologic therapy with new-onset systemic juvenile idiopathic arthritis increased meaningfully over the past decade, but this shift in treatment appeared to be linked to less exposure to glucocorticoids. They believe that this increase in biologics could lead to clinically relevant reductions in adverse effects tied to the use of glucocorticoids.

Reference

1. Peterson R, Xiao R, Katcoff H, Fisher B, Weiss P. Effect of first-line biologic initiation on glucocorticoid exposure in children hospitalized with new-onset systemic juvenile idiopathic arthritis: emulation of a pragmatic trial using observational data. Pediatric Rheumatology. 2021;19(1)109. doi:10.1186/s12969-021-00597-z