Choice of biologics for children with juvenile idiopathic arthritis in the United Kingdom.

What is it about?

Etanercept is often the first choice biologic in the treatment of JIA, however there may be occasions where etanercept is not the preferred choice. Recent studies have reported that other biologic drugs such as tocilizumab, canakinumab and anakinra may be more effective for the treatment of systemic disease. Also, research suggests that adalimumab or infliximab may be the preferred treatment option for patients with a history of uveitis. Unfortunately, it is also recognised that a proportion of children will not respond to their first biologic or will experience adverse effects. There is limited evidence to support the choice of a second or further biologic in these situations, although reports to date suggest the subtype of JIA and the availability of other biologics will influence this choice. The objectives of the study were to (i) describe patients starting their first biologics for JIA, (ii) to describe characteristics over time among patients starting etanercept, and (iii) to describe patterns of second biologic prescribing. The British Society for Paediatric and Adolescent Rheumatology Etanercept Cohort Study (BSPAR-ETN), and the Biologics for Children with Rheumatic Diseases (BCRD) study collect data on patients starting biologic therapy for JIA. To 26/08/2014, 931 patients were recruited starting a first biologic (142 BCRD; 789 BSPAR-ETN). From 2010, patients with systemic JIA (a more severe subtype of the disease) were almost exclusively prescribed anakinra or tocilizumab. Choice between anti-TNF therapies was largely driven by history of chronic anterior uveitis. When investigating trends in patients starting etanercept over time, disease duration at etanercept start, patients with systemic disease, a history of uveitis, and those who received concomitant oral corticosteroids decreased over time. Patients who started a second biologic from 01/01/2010 showed a similar stratification.

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Why is it important?

These results show that although etanercept remains the most common biologic prescribed for JIA, there has been a clear shift towards the use of alternative biologics, largely driven by disease subtype and history of uveitis. It is important to note that some of these alternative biologics are unlicensed for use in JIA and so adds weight to the argument for more research in this area. The factors which influence how biologics have been selected in this study, both first-line and on switching, will also help inform future clinical practice, guidelines and research.

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