NSAID Monotherapy for Systemic Juvenile Idiopathic Arthritis: Not One Size Fits All

Keypoints
• NSAID monotherapy can lead to clinically inactive disease in some children with systemic juvenile idiopathic arthritis (sJIA).

• However, NSAID monotherapy is not recommended for children with sJIA who are aged older than 8 years, have more than 5 joints involved, or present with a C-reactive protein level greater than 13 mg/dL.

Background
Great strides have been made in the treatment of sJIA. Classic treatment with a pyramid approach begins with NSAIDs and/or steroids, then disease-modifying antirheumatic drugs (DMARDs) or biologic agents.

Sura and fellow researchers¹ at the University of Michigan point out that while the Childhood Arthritis and Rheumatology Research Alliance protocols do not include NSAID monotherapy as an option, the 2011 American College of Rheumatology recommendations allow for initial treatment regimens with NSAIDs, steroids, or DMARDs.

The researchers note, "The absence of comparative trials limits the ability to make evidence-based suggestions about the treatment of specific children, so recommendations to date have primarily relied on expert consensus."

The current study sought to review and analyze the treatment and outcomes of children with sJIA and to determine the role of NSAID monotherapy. The researchers recently presented their findings in Pediatric Rheumatology.

Thestudy
The authors conducted a cohort study looking at children ages 0 to 18 with a diagnosis of sJIA. Cases were analyzed based on initial therapy, and children were identified who received NSAIDs alone. Ultimately, 87 children with sJIA were included in the study.

Theresults
• 51 subjects received NSAID monotherapy: 69% received naproxen; 24% indomethacin; 6% sulindac; and 2% ibuprofen.

• Children with serositis were unlikely to receive NSAIDs (P = .003).

• Initial joint count at diagnosis was the only independent predictor of achieving clinically inactive disease (P = .01).

• Age at presentation, initial joint count, and C-reactive protein level predicted a strong response to NSAID monotherapy (P = .002).

• In subjects who failed NSAID monotherapy, 81% achieved clinically inactive disease compared with 82% of those who did not receive NSAID monotherapy (P = .89).

• Subjects who succeeded in the NSAID monotherapy group achieved clinically inactive disease much faster than those who failed NSAID monotherapy (P = .004).

Implications for clinicians
• Non-steroidal anti-inflammatory medication as monotherapy for systemic juvenile arthritis is appropriate in select patients.

• NSAID monotherapy is suitable only for children who are younger than age 8 years, have fewer than 5 joints involved, and have C-reactive protein levels that are lower than 13 mg/dL.

• Follow up with children with sJIA who are receiving monotherapy within 2 to 4 weeks to assess for the need to escalate therapy to include steroids, DMARDs, and/or biologic medications.

References:

1. Sura A, Failing C, Sturza J, et al. Patient characteristics associated with response to NSAID monotherapy in children with systemic juvenile idiopathic arthritis. Pediatr Rheumatol Online J. 2018;16:2. doi: 10.1186/s12969-017-0219-4.