Early treatment with biologics is increasingly being given to children newly diagnosed with systemic juvenile idiopathic arthritis (sJIA) in the U.S., but their use varies widely among hospitals and a reliance on glucocorticoids remains high, according to a large, 12-year data study.
Hospitals admitting more patients were more likely to turn to biologics as a first-line treatment, in line with recent recommendations, while those with fewer admissions were more likely to favor glucocorticoids.
The study, “Variation in treatment of children hospitalized with new‐onset systemic juvenile idiopathic arthritis in the United States,” was published in the journal Arthritis Care & Research.
Biologics are a type of disease-modifying antirheumatic drugs (DMARDs). They are particularly useful for patients who are intolerant to, or do not respond to synthetic (conventional) DMARDs, such as methotrexate.
Evidence increasingly suggests that early treatment with biologics can greatly benefit sJIA patients and reduce the need for glucocorticoids, which are commonly used in hospitalized patients despite their known side effects. The frequency with which biologics are prescribed as first-line treatments, however, remains unknown.
Aiming to assess differences in treatment given children diagnosed in a U.S. hospital, as well as trends and factors associated with first-line biologic and glucocorticoid use, researchers with the Children’s Hospital of Pennsylvania and colleagues reviewed the records of 534 patients with new-onset sJIA, who were treated and discharged from hospitals in the Pediatric Health Information System from 2008 to 2019.
Their median age was 6, 52% were male, and 66% were white. The median length of patients’ hospital stay was six days. Almost 8% of patients needed intensive care, and nearly 12% developed macrophage activation syndrome — potentially life-threatening — during their stay.
Close to one-third (29.2%) of these children were given a biologic — mostly Kineret (anakinra), but also Ilaris (canakinumab) or Actemra (tocilizumab). But a majority, 57.9%, were treated with glucocorticoids, and 7.7% received methotrexate.
During the study period, the overall use of biologic therapies significantly increased, while methotrexate use significantly declined, the researchers reported. In turn, glucocorticoid use remained high. This trend, however, varied by hospital volume.
Hospitals admitting more patients over a year — those with high annual volume — had greater use of biologics as first-line treatments and lower glucocorticoid use. For instance, hospitals admitting 21,000 patients or more per year used biologics considerably more.
Intensive care unit (ICU) stays during the first two days in a hospital — an indication of disease severity — and discharges that occurred toward the end of the study period also correlated with greater biologic use, although to a lesser degree than hospital volume.
The observation that biologic use increased over the study period falls in line with the first successful uses of biologics, reported in 2005, and with results of clinical trials demonstrating these treatments’ safety and efficacy, the team said.
Notably, the American College of Rheumatology updated its treatment guidelines for JIA in 2013, recommending Kineret as an initial therapy for sJIA, as well as Ilaris or Actemra for patients with persistent disease activity.
Investigators hypothesized that physicians at higher-volume facilities may have more experience and greater comfort with biologics, allowing for its greater use. “These sites may also have easier access to biologics through the inpatient pharmacy, whereas smaller sites may rely more on outpatient pharmacies and patient assistance programs,” they wrote.
Although the researchers expected to find differences in treatment by hospital, the association of biologics and glucocorticoid use with hospital volume was new. Identifying barriers to the use of evidence-based care is critical to improving patient outcomes, they said.
“These results underscore the need for comparative efficacy studies and improved treatment standardization,” the team concluded.