Earlier bDMARD Initiation Can Prevent Long-Term Adverse Events in Juvenile Arthritis


A study on juvenile idiopathic arthritis emphasizes early initiation of biologic treatment for better long-term outcomes, as delayed treatment is linked to greater physical disability and worse quality of life in adulthood.

João Eurico Fonseca, MD, PhD | Credit: University of Lisbon

João Eurico Fonseca, MD, PhD
Credit: University of Lisbon

A recent study from investigators in Portugal is underlining the importance of early action in the management of juvenile idiopathic arthritis (JIA).

An analysis of more than 350 adult patients with JIA, results of the study suggests later initiation of biologic disease-modifying antirheumatic drug (bDMARD) initiation was associated with greater physical disability, worse health-related quality of life, and lower chance of drug-free remission in adulthood.

“This study’s strength lies in the large dimension of the adult JIA patient cohort, in its long follow-up, and in the fact that it reflects real-world evidence and clinical practice. This is one of the first studies to address the influence of the timing of biological treatment initiation on JIA long-term health-related outcomes,” wrote investigators.1

Since the approval of etanercept in 1999, biologic treatments have become a cornerstone in the management of JIA.2 With an interest in exploring the influence of timing of treatment initiation on long-term outcomes in patients with JIA, a team led by João Eurico Fonseca, MD, PhD, head of the Rheumatology Research Unit in the Institute of Molecular Medicine at the University of Lisbon, designed the current study as a cross-section analysis of data from adult patients with JIA registered in the Rheumatic Diseases Portuguese Register.1

Launched in June 2008 by the Portuguese Society of Rheumatology, the Rheumatic Diseases Portuguese Register contains data from patients with rheumatic disease residing in mainland Portugal, Brazil, and the Madeira and Azores islands. For inclusion in the investigators’ analyses, patients were required to be 18 years of age or older, have received treatment with a bDMARD, have available data in adulthood, and have JIA according to the 2001 revised International League of Associations for Rheumatology criteria.1

A total of 361 adult patients with JIA and a history of bDMARD use were identified for inclusion. This cohort had a median age at last registered visit of 29.1 (Interquartile range [IQR], 21.8 to 40.2) years, a median disease duration of 20.3 (IQR, 12.1 to 30.2) years, and 79% of patients had a disease duration of more than 10 years. Compared to those with earlier initiation, those who started bDMARD after 5 years of disease onset were older at the last visit than the patients from the other groups and had longer disease duration. Investigators 72% of those who initiated 5 years or more after disease onset had the disease onset before the year 2000.1

Upon analysis, results suggested those starting a bDMARD more than 5 years after disease onset was associated with a significant reduction in the likelihood of achieving remission off medication (Odds Ratio [OR], 0.24; 95% Confidence Interval [CI], 0.06 to 0.92; P = .038). Analysis of Health Assessment Questionnaire scores demonstrated those initiating treatment with a bDMARD after 5 or more years after onset (Median, 0.05; IQR, 0 to 1.25; P = .001) had a greater median HAQ than their counterparts who initiated less than 2 years after onset (median, 0; IQR, 0 to 0.25) and those initiating 2 to 5 years after onset (median, 0; IQR, 0 to 0.09).1

Additionally, worse scores were observed for those initiating 5 years or more after disease onset for the physical component, vitality, and social function domains of SF-36. Investigators also pointed out there were more joint surgeries in those with later bDMARD treatment initiation when compared to an earlier start.1

“Our results document that in JIA patients, the late start of bDMARDs increases the likelihood of having more physical disability and worse [health-related quality of life] and decreases the chances of achieving remission off medication in adulthood,” investigators wrote.1


  1. Oliveira Ramos F, Rodrigues AM, Melo AT, et al. Influence of the timing of biological treatment initiation on Juvenile Idiopathic Arthritis long-term outcomes. Arthritis Res Ther. 2023;25(1):177. Published 2023 Sep 21. doi:10.1186/s13075-023-03166-9
  2. Pan A, Wu EY, Cannon L. Biologics to the Rescue: Changing the treatment paradigm in juvenile idiopathic arthritis. Contemporary Pediatrics. April 14, 2023. Accessed September 25, 2023. https://www.contemporarypediatrics.com/view/biologics-to-the-rescue-changing-the-treatment-paradigm-in-juvenile-idiopathic-arthritis.
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