Transforming Treatment for JRA
For patients with juvenile rheumatoid arthritis (JRA), the last decade hasn’t seen treatment advances so much as a treatment revolution.
“It’s been unbelievable,” says Daniel Lovell, MD, pediatric rheumatologist and interim director of the Division of Rheumatology at Cincinnati Children’s. “The use of biologic agents has changed our whole perspective about what we should and can expect from treatment and outcomes.”
At Cincinnati Children’s, Dr. Lovell led the national study that demonstrated the effectiveness of the first biologic agent for the condition, and he chairs the research-focused Pediatric Rheumatology Collaborative Study Group.
Understanding of the condition is so much better now, in fact, that clinicians around the world have adopted a broader term – juvenile idiopathic arthritis (JIA) – to describe it. JIA isn’t a single disease, but rather a group of related chronic diseases.
Roughly one in 1,000 children under age 16 suffers from JIA, which is characterized by episodes of joint swelling, pain and stiffness that persist at least six weeks and cannot be explained by other causes.
Biologic Therapies Improve Outcomes
Enbrel®, the first biologic therapy for JIA, was approved for use in 1999. “Biologic” refers to materials produced by our bodies, such as genes and cell matter.
Before such treatments, the best outcome patients could hope for was to keep symptoms in check, says Dr. Lovell. Although nearly half the patients treated with earlier drugs experienced improvement in symptoms, those therapies did not prevent joint damage. As a result, patients often had severe joint degeneration by the time they reached adulthood.
“Today we have treatments that, for 75 percent of the kids who have JIA affecting multiple joints, can result in inactive disease,” he says. And progress hasn’t slowed. Earlier this year the Food and Drug Administration approved two more drugs for treatment of JIA – Remicade® and Humira®. Because the three drugs act in different ways, there’s a good chance that patients who do not improve with one will have positive results with another, Dr. Lovell says.
These new drugs “have changed the whole way we interact with JIA patients,” he says. Before, patients who had active JIA, even though symptoms were in check, still had to come in frequently for therapy. “Now, with inactive JIA, they can come in every three or six months, and we can often achieve excellent disease control in just a couple months.”
Building on What We Know
Outcomes have been so promising that Cincinnati Children’s is coordinating a clinical study to determine whether early, aggressive treatment of newly diagnosed JIA patients can get them to the point of drug-free remission.
The medical center is also pursuing three areas of genetic research to promote better understanding of JIA, says David Glass, MD, associate director of the Cincinnati Children’s Research Foundation.
In one area, researchers seek to identify the chemical base pairs in human DNA that may cause JIA. In another, they are focusing on why cells cause the joint damage seen in JIA, which genes are responsible and why they have been “turned on” in JIA. A third area of investigation aims to identify genes that affect how the body uses the drug methotrexate, one of the most common JIA treatments, so researchers can better predict which patients will respond to it.
The upshot of this research, says Dr. Glass, is “to understand who will get JIA, what will be the actual outcome and how patients will respond to treatment.”
Finding the answers to those questions, he says, will lead to the next breakthroughs in the treatment of JIA.
