@article {1664, title = {Methotrexate withdrawal at 6 vs 12 months in juvenile idiopathic arthritis in remission: a randomized clinical trial.}, journal = {JAMA}, volume = {303}, year = {2010}, month = {2010 Apr 7}, pages = {1266-73}, abstract = {

CONTEXT: Novel therapies have improved the remission rate in chronic inflammatory disorders including juvenile idiopathic arthritis (JIA). Therefore, strategies of tapering therapy and reliable parameters for detecting subclinical inflammation have now become challenging questions.

OBJECTIVES: To analyze whether longer methotrexate treatment during remission of JIA prevents flares after withdrawal of medication and whether specific biomarkers identify patients at risk for flares.

DESIGN, SETTING, AND PATIENTS: Prospective, open, multicenter, medication-withdrawal randomized clinical trial including 364 patients (median age, 11.0 years) with JIA recruited in 61 centers from 29 countries between February 2005 and June 2006. Patients were included at first confirmation of clinical remission while continuing medication. At the time of therapy withdrawal, levels of the phagocyte activation marker myeloid-related proteins 8 and 14 heterocomplex (MRP8/14) were determined.

INTERVENTION: Patients were randomly assigned to continue with methotrexate therapy for either 6 months (group 1 [n = 183]) or 12 months (group 2 [n = 181]) after induction of disease remission.

MAIN OUTCOME MEASURES: Primary outcome was relapse rate in the 2 treatment groups; secondary outcome was time to relapse. In a prespecified cohort analysis, the prognostic accuracy of MRP8/14 concentrations for the risk of flares was assessed.

RESULTS: Intention-to-treat analysis of the primary outcome revealed relapse within 24 months after the inclusion into the study in 98 of 183 patients (relapse rate, 56.7\%) in group 1 and 94 of 181 (55.6\%) in group 2. The odds ratio for group 1 vs group 2 was 1.02 (95\% CI, 0.82-1.27; P = .86). The median relapse-free interval after inclusion was 21.0 months in group 1 and 23.0 months in group 2. The hazard ratio for group 1 vs group 2 was 1.07 (95\% CI, 0.82-1.41; P = .61). Median follow-up duration after inclusion was 34.2 and 34.3 months in groups 1 and 2, respectively. Levels of MRP8/14 during remission were significantly higher in patients who subsequently developed flares (median, 715 [IQR, 320-1 110] ng/mL) compared with patients maintaining stable remission (400 [IQR, 220-800] ng/mL; P = .003). Low MRP8/14 levels indicated a low risk of flares within the next 3 months following the biomarker test (area under the receiver operating characteristic curve, 0.76; 95\% CI, 0.62-0.90).

CONCLUSIONS: In patients with JIA in remission, a 12-month vs 6-month withdrawal of methotrexate did not reduce the relapse rate. Higher MRP8/14 concentrations were associated with risk of relapse after discontinuing methotrexate.

TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN18186313.

}, keywords = {Adolescent, Antirheumatic Agents, Arthritis, Juvenile, ATP-Binding Cassette Transporters, Calgranulin B, Child, Child, Preschool, Female, Humans, Infant, Male, Methotrexate, Predictive Value of Tests, Prospective Studies, Recurrence, Remission Induction}, issn = {1538-3598}, doi = {10.1001/jama.2010.375}, author = {Foell, Dirk and Wulffraat, Nico and Wedderburn, Lucy R and Wittkowski, Helmut and Frosch, Michael and Gerss, Joachim and Stanevicha, Valda and Mihaylova, Dimitrina and Ferriani, Virginia and Tsakalidou, Florence Kanakoudi and Foeldvari, Ivan and Cuttica, Ruben and Gonzalez, Benito and Ravelli, Angelo and Khubchandani, Raju and Oliveira, Sheila and Armbrust, Wineke and Garay, Stella and Vojinovic, Jelena and Norambuena, Ximena and Gamir, Mar{\'\i}a Luz and Garc{\'\i}a-Consuegra, Julia and Lepore, Loredana and Susic, Gordana and Corona, Fabrizia and Dolezalova, Pavla and Pistorio, Angela and Martini, Alberto and Ruperto, Nicolino and Roth, Johannes} } @article {1714, title = {Predictors of poor response to methotrexate in polyarticular-course juvenile idiopathic arthritis: analysis of the PRINTO methotrexate trial.}, journal = {Ann Rheum Dis}, volume = {69}, year = {2010}, month = {2010 Aug}, pages = {1479-83}, abstract = {

OBJECTIVES: To determine whether baseline demographic, clinical, articular and laboratory variables predict methotrexate (MTX) poor response in polyarticular-course juvenile idiopathic arthritis.

METHODS: Patients newly treated for 6 months with MTX enrolled in the Paediatric Rheumatology International Trials Organization (PRINTO) MTX trial. Bivariate and logistic regression analyses were used to identify baseline predictors of poor response according to the American College of Rheumatology pediatric (ACR-ped) 30 and 70 criteria.

RESULTS: In all, 405/563 (71.9\%) of patients were women; median age at onset and disease duration were 4.3 and 1.4 years, respectively, with anti-nuclear antibody (ANA) detected in 259/537 (48.2\%) patients. With multivariate logistic regression analysis, the most important determinants of ACR-ped 70 non-responders were: disease duration > 1.3 years (OR 1.93), ANA negativity (OR 1.77), Childhood Health Assessment Questionnaire (CHAQ) disability index > 1.125 (OR 1.65) and the presence of right and left wrist activity (OR 1.55). Predictors of ACR-ped 30 non-responders were: ANA negativity (OR 1.92), CHAQ disability index > 1.14 (OR 2.18) and a parent{\textquoteright}s evaluation of child{\textquoteright}s overall well-being < or = 4.69 (OR 2.2).

CONCLUSION: The subgroup of patients with longer disease duration, ANA negativity, higher disability and presence of wrist activity were significantly associated with a poorer response to a 6-month MTX course.

}, keywords = {Adolescent, Antibodies, Antinuclear, Antirheumatic Agents, Arthritis, Juvenile, Child, Child, Preschool, Disability Evaluation, Female, Follow-Up Studies, Humans, Immunosuppressive Agents, Male, Methotrexate, Prognosis, Treatment Outcome}, issn = {1468-2060}, doi = {10.1136/ard.2009.120840}, author = {Vilca, Iris and Munitis, Pablo Garcia and Pistorio, Angela and Ravelli, Angelo and Buoncompagni, Antonella and Bica, Blanca and Campos, Lucia and H{\"a}fner, Renate and Hofer, Michael and Ozen, Seza and Huemer, Christian and Bae, Sang Cheol and Sztajnbok, Flavio and Arguedas, Olga and Foeldvari, Ivan and Huppertz, Hans Iko and Gamir, Mar{\'\i}a Luz and Magnusson, Bo and Dressler, Frank and Uziel, Yosef and van Rossum, Marion A J and Hollingworth, Peter and Cawkwell, Gail and Martini, Alberto and Ruperto, Nicolino} }