Horton Daniel B, Onel Karen B, Beukelman Timothy, Ringold Sarah
From the Division of Pediatric Rheumatology, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Institute for Health, Health Care Policy and Aging Research, Rutgers Biomedical and Health Sciences, New Brunswick, New Jersey; Division of Pediatric Rheumatology, Department of Pediatrics, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York; Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama; Seattle Children's Hospital and Research Institute, University of Washington School of Medicine, Seattle, Washington, USA.
D.B. Horton, MD, MSCE, Assistant Professor of Pediatrics, Division of Pediatric Rheumatology, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Institute for Health, Health Care Policy and Aging Research, Rutgers Biomedical and Health Sciences; K.B. Onel, MD, Chief, Division of Pediatric Rheumatology, Department of Pediatrics, Hospital for Special Surgery, Weill Cornell Medical College; T. Beukelman, MD, MSCE, Associate Professor, Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham; S. Ringold, MD, MS, Assistant Professor, Seattle Children's Hospital, University of Washington School of Medicine.
J Rheumatol. 2017 Mar;44(3):352-360. doi: 10.3899/jrheum.161078. Epub 2017 Feb 1.
To assess the attitudes and strategies of pediatric rheumatology clinicians toward withdrawing medications for children with clinically inactive juvenile idiopathic arthritis (JIA).
Members of the Childhood Arthritis and Rheumatology Research Alliance (CARRA) completed an anonymous electronic survey on decision making and approaches for withdrawing medications for inactive nonsystemic JIA. Data were analyzed using descriptive statistics.
Of 388 clinicians in CARRA, 124 completed surveys (32%), predominantly attending pediatric rheumatologists. The most highly ranked factors in decision making for withdrawing medications were the duration of clinical inactivity, drug toxicity, duration of prior activity, patient/family preferences, joint damage, and JIA category. Diagnoses of rheumatoid factor-positive polyarthritis and persistent oligoarthritis made respondents less likely and more likely, respectively, to withdraw JIA medications. Three-quarters of respondents waited for 6-12 months of inactive disease before stopping methotrexate (MTX) or biologics, but preferences varied. There was also considerable variability in the strategies used to reduce, taper, or stop medications for clinically inactive JIA; most commonly, clinicians reported slow medication tapers lasting at least 2 months. For children receiving combination MTX-biologic therapy, 63% of respondents preferred stopping MTX first. Most clinicians reported using imaging only seldom or sometimes to guide decision making, but most were also reluctant to withdraw medications in the presence of asymptomatic imaging abnormalities suggestive of subclinical inflammation.
Considerable variability exists among pediatric rheumatology clinicians regarding when and how to withdraw medications for children with clinically inactive JIA. More research is needed to identify the most effective approaches to withdraw medications and predictors of outcomes.
评估儿科风湿病临床医生对停用临床非活动型幼年特发性关节炎（JIA）患儿药物的态度和策略。
儿童关节炎与风湿病研究联盟（CARRA）的成员完成了一项关于停用非系统性非活动型JIA药物的决策制定和方法的匿名电子调查。使用描述性统计分析数据。
在CARRA的388名临床医生中，124人完成了调查（32%），主要是儿科风湿病主治医生。停用药物决策中排名最靠前的因素是临床非活动期的时长、药物毒性、先前活动期的时长、患者/家属偏好、关节损伤和JIA类别。类风湿因子阳性多关节炎和持续性寡关节炎的诊断分别使受访者停用JIA药物的可能性降低和增加。四分之三的受访者在停用甲氨蝶呤（MTX）或生物制剂前等待6至12个月的疾病非活动期，但偏好各不相同。对于临床非活动型JIA，在减少、逐渐减量或停用药物的策略方面也存在很大差异；最常见的是，临床医生报告药物逐渐减量至少持续2个月。对于接受MTX与生物制剂联合治疗的儿童，63%的受访者倾向于先停用MTX。大多数临床医生报告很少或有时使用影像学来指导决策，但大多数人在存在提示亚临床炎症的无症状影像学异常时也不愿停用药物。
儿科风湿病临床医生在何时以及如何停用临床非活动型JIA患儿药物方面存在很大差异。需要更多研究来确定停用药物的最有效方法和预后预测因素。
