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Randomized Controlled Trial
. 2019 Sep 4;17(1):62.
doi: 10.1186/s12969-019-0362-1.

No radiographic wrist damage after treatment to target in recent-onset juvenile idiopathic arthritis

P C E Hissink Muller  1   2 , W G van Braak  3 , D Schreurs  4 , C M Nusman  3   5 , S A Bergstra  6 , R Hemke  3 , D Schonenberg-Meinema  5 , J M van den Berg  5 , T W Kuijpers  5 , Y Koopman-Keemink  7 , M A J van Rossum  8   9 , L W A van Suijlekom-Smit  10 , D M C Brinkman  4 , C F Allaart  6 , R Ten Cate  4 , M Maas  3
Affiliations
Randomized Controlled Trial

No radiographic wrist damage after treatment to target in recent-onset juvenile idiopathic arthritis

P C E Hissink Muller et al. Pediatr Rheumatol Online J. .

Abstract

Background: To evaluate radiographic progression of patients with new-onset juvenile idiopathic arthritis (JIA) in response to an early, tightly-controlled, treatment-to-target.

Methods: Patients with JIA participating in the BeSt-for-Kids-study, randomized to 3 treatment strategy arms, were eligible if at least 1 conventional wrist-radiograph was available. Bone damage as reflected by carpal length was assessed using the Poznanski-score. The BoneXpert-method was used to determine the Bone Age (BA, > 5 years) and bone mineral density (BMD) of the wrist. These scores were evaluated over time and compared between the treatment arms and mean JADAS10-score using linear mixed models corrected for age and symptom duration.

Results: In 60 patients, 252 radiographs were analysed. Baseline age and symptom duration were different between the arms. No difference in comparison to the healthy reference population was found at baseline for the Poznanski-score (IQR varying from - 0,82; 0.68), nor for BA (varying from - 0.88 to 0.74). Baseline BMD was statistically significantly lower in arm 3 (initial treatment with etanercept and methotrexate) (- 1.48; - 0.68) compared to arm 1 (- 0.84; - 0.04) and arm 2 (- 0.93; 0.15). After treatment to target inactive disease, the Poznanski-scores and the BA remained clinically unchanged, while the BMD in arm 3 improved (p < 0.05 vs arm 1).

Conclusions: Recent-onset JIA patients, treated-to-target aimed at inactive disease, showed no signs of radiographic wrist damage (Poznanski-score, BA or BMD) either at baseline or at follow-up, irrespective of treatment arm. A lower BMD at baseline in arm 3, initially treated with methotrexate and etanercept, improved significantly after treatment.

Trial registration: NTR, NL1504 (NTR1574). Registered 01-06-2009.

Keywords: Conventional radiography; Juvenile idiopathic arthritis; Radiographic outcome; Treatment to target.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
The three treatment strategies compared in the BeSt for Kids study. Flow diagram of the three treatment strategies compared in the BeSt for Kids study; Revised diagnosis were localized scleroderma with arthritis (arm 1) and polyarteritis nodosa (arm 3). See patients and methods section for description of treatment groups. FU = follow-up, SSZ = sulfasalazine, MTX = methotrexate, ETN = etanercept, po = orally, sc = subcutaneous
Fig. 2
Fig. 2
Poznanski measurements used to determine the RM/M2 score. RM = radiometacarpal length; M2 = length of the second metacarpal
Fig. 3
Fig. 3
a,b,c – Poznanski-score depicted in Z-scores of RM/M2 ratio. a represents patients in arm 1, b represents patients in arm 2, c represents patients in arm 3. d,e, f- Bone Age depicted in Z-score. d represents patients in arm 1, e represents patients in arm 2, f represents patients in arm 3. g,h,i. Bone Mineral Density depicted in Z-scores. g represents patients in arm 1, h represents patients in arm 2, i represents patients in arm 3. Each graph line represents one individual patient from baseline to follow-up. Each dot represents one patient with a single radiograph available
Fig. 4
Fig. 4
a: Predicted Z-score RM/M2 over time, b: Predicted Z-score Bone Age over time, c: Predicted Z-score BMD over time. All predictions are from Linear Mixed Models, corrected for age and symptom duration for Poznanski score, corrected for symptom duration for BA and BMD. BA = Bone Age, BMD = Bone Mineral Density
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