BSPAR/BSR Position Statement on prescribing of biological therapies in adults with JIA

  

This statement relates to the use of biological agents in adults with juvenile idiopathic arthritis (JIA) and has been jointly prepared by representatives from the BSR and BSPAR Executive. The purpose of this statement is to aid clinicians in dialogue with funding bodies to support the provision of biologic agents to young people and adults with JIA.

JIA by definition presents before the sixteenth birthday and many patients (up to 50%) will continue to have active disease or sequelae from previous active disease, well into adult life (1, 2). Although there are clinical similarities with other inflammatory conditions such as rheumatoid arthritis and ankylosing spondylitis, it is important to realise JIA is a distinct clinical entity and remains so throughout its clinical course and into adulthood. It is important to acknowledge that as well as continuity of disease activity into adult years, there are also patients who develop de novo active flares of disease in adult life after years of remission or adequate disease control with conventional disease modifying anti-rheumatic drugs (DMARDS).

To date the only NICE guidance available on the use of biological therapies specifically in JIA is for

etanercept (3) and although a review of the

guidance is planned, this guidance is currently limited to the use of etanercept between the ages of 4 and 17. The recently published NICE guidance on the commissioning of biologic drugs for the treatment of inflammatory disease in rheumatology, dermatology and

gastroenterology (4) notes this, but also points out that JIA can remain active beyond the age of seventeen and that commissioners need to be aware of this. In adult rheumatology there are several different biologic agents used in clinical practice and NICE and BSR guidance exists for their use (5-10). There is no equivalent guidance for JIA although in clinical practice, biologics other than etanercept are increasingly used both in paediatric practice and in older patients with JIA after transfer to adult services. As evidence for the use of etanercept and other biological agents in JIA accumulates, NICE will undoubtedly publish further guidance, and it is hoped that this will include guidance on the use of biologic agents in people with JIA of eighteen years and above.

In the absence of definitive guidelines and in order to facilitate optimal clinical care for patients with active JIA persisting into adult life the following recommendations should be taken into account:

  • People with JIA requiring biologic treatment at the age of 17 are likely to continue to need this treatment into adulthood. The NICE guideline for etanercept should not be inter-preted as suggesting that this drug (or other DMARDs) should be discontinued solely on the grounds of age once a patient reaches eighteen years of age. It is important that processes are in place to ensure ongoing funding and access to biologic therapy and other disease modifying agents at the time of transfer from adolescent to adult services.
  • Similarly, JIA may become active during adult life and patients may need treatment with a biologic agent for the first time. It is important that adults with JIA requiring a biologic, either for the first time or to have treatment reinstated (e.g. after a period of remission or pregnancy) should have access to this.

  • Adults with JIA must not be inappropriately re-categorised as having rheumatoid arthritis, ankylosing spondylitis or another condition.

  • When assessing disease activity in adults with JIA it is inappropriate to use tools designed for assessing activity of other inflammatory dis-eases (eg DAS 28, modified New York criteria). These tools have not been validated for JIA and due to the different clinical characteristics of the disease in many cases reliance on these tools would result in under ascertainment of cases requiring biologic therapies. Similarly the core outcome variables used to assess disease activity in childrenwith JIA are not validated for adults with JIA.

  • There is an urgent need for appropriate assessment tools for adults with JIA to be developed. In the meantime, it is recommended that adult JIA patients are assessed for their eligibility for biologics, using the existing NICE criteria for JIA.

  • The choice of biologic agent will depend on current evidence and individual patient circumstances. As in adult inflammatory arthritides, response to specific biologics cannot be accurately predicted, and a sequential trial of different biological agents may be necessary before the one most effective/suitable for the patient is found.

 References:

Packham JC, Hall MA Long-term follow-up of 246 adults with juvenile idiopathic arthritis: functional outcome. Rheumatology 2002 41(12):1428-35

Etanercept for the treatment of juvenile idio-pathic arthritis: www.nice.org.uk/TA035

Minden K. Adult Outcomes of Patients with Juve-nile Idiopathic Arthritis. Hormone Research 2009; 72 (Supp 1): 20-25

Commissioning biologic drugs for the treatment of inflammatory disease in rheumatology, der-matology and gastroenterology: http://www.nice.org.uk/usingguidance/commissioningguides/biologicaltherapies/CommissioningBiologic Drugs

Adalimumab, etanercept and infliximab for the treatment of rheumatoid arthritis http://www.guidance.nice.org.uk/TA126

Rituximab for the treatment of rheumatoid ar-thritis: http://www.guidance.nice.org.uk/TA126

Tocilizumab for the treatment of rheumatoid arthritis: http://www.guidance.nice.org.uk/TA186

Certolizumab pegol for the treatment of rheumatoid arthritis: http://www.guidance.nice.org.uk/TA186

Rheumatoid arthritis – drugs for treatment after failure of a TNF inhibitor: http://guidance.nice.org.uk/TA195

Etanercept, Infliximab and adalimumab for the treatment of psoriatic arthritis http://www.guidance.nice.org.uk/TA199

Ankylosing spondylitis – adalimumab, etanercept and infliximab: http://guidance.nice.org.uk/TA143

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