Roberto Carrasco

Trends in paediatric rheumatology referral times and disease activity indices over a ten-year period among children and young people with Juvenile Idiopathic Arthritis: results from the childhood arthritis prospective Study

Objectives. The medical management of JIA has advanced significantly over the past 10 years. It is not known whether these changes have impacted on outcomes. The aim of this analysis was to identify and describe trends in referral times, treatment times and 1-year outcomes over a 10-year period among children with JIA enrolled in the Childhood Arthritis Prospective Study. Methods. The Childhood Arthritis Prospective Study is a prospective inception cohort of children with new-onset inflammatory arthritis. Analysis included all children recruited in 2001–11 with at least 1 year of follow-up, divided into four groups by year of diagnosis. Median referral time, baseline disease pattern (oligoarticular, polyarticular or systemic onset) and time to first definitive treatment were compared between groups. Where possible, clinical juvenile arthritis disease activity score (cJADAS) cut-offs were applied at 1 year. Results. One thousand and sixty-six children were included in the analysis. The median time from symptom onset and referral to first paediatric rheumatology appointment (22.7–24.7 and 3.4–4.7 weeks, respectively) did not vary significantly (∼20% seen within 10 weeks of onset and ∼50% within 4 weeks of referral). For oligoarticular and polyarticular disease, 33.8–47 and 25.4–34.9%, respectively, achieved inactive disease by 1 year, with ∼30% in high disease activity at 1 year. A positive trend towards earlier definitive treatment reached significance in oligoarticular and polyarticular pattern disease. Conclusion. Children with new-onset JIA have a persistent delay in access to paediatric rheumatology care, with one-third in high disease activity at 1 year and no significant improvement over the past 10 years. Contributing factors may include service pressures and poor awareness. Further research is necessary to gain a better understanding and improve important clinical outcomes.

Treatment prescribing patterns in patients with juvenile idiopathic arthritis (JIA): Analysis from the UK Childhood Arthritis Prospective Study (CAPS).

Objective Initial treatment of juvenile idiopathic arthritis (JIA) is largely based on the extent of joint involvement, disease severity and ILAR category. The licensing of biologic therapies for JIA has expanded treatment options. The aims of the study are (1) to describe treatment prescribing patterns in JIA over the first 3 years following first presentation to paediatric rheumatology and (2) to determine whether patterns of treatment have changed as biologics have become more widely available. Methods Children with at least 3 years of follow-up within the Childhood Arthritis Prospective Study (CAPS) were included. For analysis, children were placed into one of five groups according to their initial presentation to paediatric rheumatology: oligoarthritis (oJIA), polyarthritis (pJIA), systemic (sJIA), enthesitis-related arthritis (ERA) and psoriatic arthritis (PsA). Treatment patterns over 3 years were described. Results Of 1051 children, 58% received synthetic disease-modifying anti-rheumatic drugs (sDMARD) and 20% received biologics over the 3 years. Use of sDMARDs and biologics was higher in more severe disease presentations (sJIA and pJIA); however, 35% and 10% who presented with oJIA were also treated with sDMARDs and biologics, respectively. The number of children receiving sDMARD after 2006 was higher (p = 0.02); however, there was no difference in biologic prescribing before and after 2006 (p = 0.4). Conclusions A high proportion of children presenting with JIA received sDMARDs plus/minus biologics during 3 years of follow-up. This was most common for patients with severe JIA but was also prescribed for patients with oligoarticular disease, despite the lack of evidence for effectiveness in this category.

Patterns of pain over time among children with juvenile idiopathic arthritis

Objectives Pain is a very common symptom of juvenile idiopathic arthritis (JIA). Disease activity alone cannot explain symptoms of pain in all children, suggesting other factors may be relevant. The objectives of this study were to describe the different patterns of pain experienced over time in children with JIA and to identify predictors of which children are likely to experience ongoing pain. Methods This study used longitudinal-data from patients (aged 1–16 years) with new-onset JIA. Baseline and up to 5-year follow-up pain data from the Childhood Arthritis Prospective Study (CAPS) were used. A two-step approach was adopted. First, pain trajectories were modelled using a discrete mixture model. Second, multinomial logistic regression was used to determine the association between variables and trajectories. Results Data from 851 individuals were included (4 years, median follow-up). A three-group trajectory model was identified: consistently low pain (n=453), improved pain (n=254) and consistently high pain (n=144). Children with improved pain or consistently high pain differed on average at baseline from consistently low pain. Older age at onset, poor function/disability and longer disease duration at baseline were associated with consistently high pain compared with consistently low pain. Early increases in pain and poor function/disability were also associated with consistently high pain compared with consistently low pain. Conclusions This study has identified routinely collected clinical factors, which may indicate those individuals with JIA at risk of poor pain outcomes earlier in disease. Identifying those at highest risk of poor pain outcomes at disease onset may enable targeted pain management strategies to be implemented early in disease thus reducing the risk of poor pain outcomes.

Growth patterns in early juvenile idiopathic arthritis: Results from the Childhood Arthritis Prospective Study (CAPS)

Objectives To investigate early vertical growth patterns and factors associated with poor growth in a modern inception cohort of UK children with juvenile idiopathic arthritis (JIA) using data from the Childhood Arthritis Prospective Study (CAPS). Methods A study period of 3 years was chosen. Children included in this analysis had a physician diagnosis of JIA and had height measurements available at both baseline and at 3-years of follow-up. Height is presented as z-scores calculated using World Health Organisation growth standards for age and gender. Growth over the 3-year period was assessed using change in z-score and height velocity. Univariable and multivariable linear regressions were used to identify factors associated with height z-score at baseline and change of height z-score at 3 years. Results 568 patients were included; 65% female, median baseline age 7.4 years [interquartile range (IQR) 3.6, 11.2], median symptom duration at presentation 5.5 months [IQR 3.1, 11.6]. Height z-score decreased significantly from baseline to 3 years (p ≤ 0.0001); baseline median height z-score was −0.02 (IQR −0.71, 0.61), decreasing to −0.47 (IQR −1.12, 0.24) at 3 years. Growth restriction, defined as change of height z-score ≤−0.5, was observed in 39% of patients. At 3 years, higher baseline height z-score was the strongest predictor for a negative change in height z-score [−0.3 per unit of baseline height z-score (95% CI: −0.36, −0.24), p < 0.0001]. Conclusions Although overall height at 3 years after initial presentation to rheumatology is within the population norm, as a cohort, children with JIA experience a reduction of growth in height over the first 3 years of disease. Late presentation to paediatric rheumatology services is associated with lower height at presentation. However, patients with the lowest height z scores at presentation were also the most likely to see an improvement at 3 years. The impact of JIA on growth patterns is important to children and families and this study provides useful new data to support informed clinical care.

Predictors of Disability in Children with Inflammatory Arthritis, Two and Three Years After First Presentation to Paediatric Rheumatology. Results From the Childhood Arthritis Prospective Study (CAPS)

Background Inflammatory arthritis (IA) in children is a chronic and often disabling disease with variable outcome. Up to 1/3 of children are reported to have active disease progressing into adulthood. The Childhood Arthritis Prospective Study (CAPS) is a prospective longitudinal inception cohort study which aim is to identify genetic and environmental predictors of shortand long-term outcome of childhood IA. Previously, we reported that the strongest predictor of persistent disability at oneyear (as measured by the CHAQ) was moderate to severe disability at first presentation. The objective of this study was to extend the one year analysis to look at both two and three year outcomes.

Depressive symptoms, pain and disability for adolescent patients with juvenile idiopathic arthritis: results from the Childhood Arthritis Prospective Study.

Abstract Objectives To determine if depressive symptoms assessed near diagnosis associate with future measures of pain, disability and disease for adolescent patients diagnosed with JIA. Methods Data were analysed from JIA patients aged 11–16 years recruited to the Childhood Arthritis Prospective Study, a UK-based inception cohort of childhood-onset arthritis. Depressive symptoms (using the Mood and Feelings Questionnaire; MFQ), active and limited joint count, disability score (Childhood Health Assessment Questionnaire), pain visual analogue scale and patient’s general evaluation visual analogue scale were collected. Associations between baseline measures (first visit to paediatric rheumatologist) were analysed using multiple linear regression. Linear mixed-effect models for change in the clinical measures of disease over 48 months were estimated including MFQ as an explanatory variable. Results Data from 102 patients were analysed. At baseline, median (IQR) age was 13.2 years (11.9–14.2 years) and 14.7% scored over the MFQ cut-off for major depressive disorder. At baseline, depressive symptoms significantly associated with all clinical measures of disease (P ⩽ 0.01). High baseline depressive symptoms scores predicted worse pain (P ⩽ 0.005) and disability (P ⩽ 0.001) 12 months later but not active and limited joint counts. Conclusions Adolescent patients with JIA and depressive symptoms had more active joints, pain and disability at the time of their first specialist appointment. The associations between baseline depression and both pain and disability continued for at least one year, however, this was not the case for active joint count.

16. Clinical Factors Associated with Non-Response to Methotrexate in Children with Juvenile Idiopathic Arthritis: Results from the Childhood Arthritis Response to Treatment Consortium

Sunil Sampath, Jamie C Sergeant, Sebastien Viatte, Roberto Carrasco, Joanna Cobb, Samantha L Smith, Anne Hinks, Lucy R Wedderburn, Michael W Beresford, Childhood Arthritis Response to Medication Study (CHARMS), Childhood Arthritis Prospective Study (CAPS), British Society for Paediatric and Adolescent Rheumatology Etanercept Cohort Study (BSPAR-ETN), Biologics for Children with Rheumatic Diseases Study (BCRD) Kimme L Hyrich and Wendy Thomson Arthritis Research UK Centre for Epidemiology, Arthritis Research UK Centre for Genetics and Genomics, The University of Manchester, NIHR Manchester Musculoskeletal Biomedical Research Unit, Paediatric Rheumatology Department, Great Ormond Street Hospital for Children NHS Trust, UCL Institute of Child Health, Alder Hey Children’s NHS Foundation Trust Hospital, and Institute of Translational Medicine (Child Health), University of Liverpool

OP0300 Do Depressive Symptoms at Disease Onset Associate with Future Disease Activity for Adolescent Patients with Jia? Results from The Childhood Arthritis Prospective Study (CAPS)

Background Adolescents with rheumatic disease have a four times higher incidence of depression than healthy peers. Studies in adults have shown an association between depression and worse disease in rheumatoid arthritis, yet this association has never been explored in detail for patients with JIA or in a purely adolescent population. Objectives This study investigates the association between depressive symptoms and 1) disease activity at onset and 2) future disease activity. Methods Data are from JIA patients in the Childhood Arthritis Prospective Study, a nationwide inception cohort of childhood onset arthritis. Patients are recruited within 6 months of disease onset and the first study visit is identified as “baseline”. Patients were included in this analysis if they were aged 11–16 at baseline. Depressive symptoms were assessed using the Mood and Feelings Questionnaire (MFQ). Associations at baseline were analysed using Spearmans correlation. Separate piecewise linear mixed-effect models for change in active joint count and disability (Childhood Health Assessment Questionnaire (CHAQ)) over 48 months was estimated. A change point at 12 months allowed for different rates of change between 0–12 months and 12–48 months. MFQ score at baseline was included as a covariate Results 102 patients were included. At baseline, mean age was 12.7 years (SD1.4) and 15.7% were taking DMARDS. 56.7% were female, 52.0% had persistent oligoarticular arthritis, 30.4% had polyarticular arthritis and 17.6% had enthesitis related arthritis. 14.7% scored over the MFQ cut-off for probable depression (>27) at baseline. At baseline, depressive symptoms significantly associated with disability (r=0.51, p<0.000) and active joint count (r=0.32, p=0.001). Longitudinal analysis showed that depressive symptoms, active joint count and disability rapidly decreased during the first 12 months after baseline and then stabilised. After 12 months, baseline depressive symptoms no longer associated with active joint count whereas disability for those with high baseline depressive symptoms continued to be higher than those with low depressive symptoms (Figure 1). Conclusions At disease onset, 14.7% adolescents with JIA have significant depressive symptoms. Those with more depressive symptoms have higher numbers of inflamed joints and more disability. In the 12 months after disease onset, a reduction in disease activity is mirrored by improvements in mental health. After the first year, baseline depression no longer associates with subsequent disease activity but remains associated with higher disability. This highlights the importance of psychological health assessment for adolescent patients with JIA and underlines the need for psychological support fully integrated into their routine care. Disclosure of Interest None declared

Trends in paediatric rheumatology referral times and disease activity indices over a ten-year period among children with juvenile idiopathic arthritis: results from the childhood arthritis prospective study

The medical management of children and adolescents with juvenile idiopathic arthritis (JIA) has advanced significantly over the past ten years. The UK BSPAR Standards of Care (2009) stipulate that children with JIA should see a paediatric rheumatology team (PRh) within ten weeks of symptom onset and within four weeks of referral. It is not known how often these standards are met or whether they have impacted on outcomes.

Treatment prescribing patterns in a cohort of patients with juvenile idiopathic arthritis (JIA). Data from the childhood arthritis prospective study (CAPS)

Juvenile idiopathic arthritis (JIA) is a heterogenous disease, classified according to the International League of Associations for Rheumatology (ILAR). Initial treatment is based largely on disease severity; intra-articular injections for oligoarthritis, methotrexate (MTX) for polyarthritis and systemic presentations. The recent licensing of biologic therapies for use in JIA has revolutionised treatment of the disease. It is not currently known what proportion of children who present with polyarthritis will require biologic therapy. Although not studied formally, it is recognised a proportion of children with oligoarthritis will also require systemic therapy to control symptoms.