12. Prescribing Patterns in Juvenile Idiopathic Arthritis: A Survey of Current Practice in the United Kingdom

Abstract

Background: The 2015 NHS-England (NHSE) interim policy statement and NICE Technology Appraisal for the treatment of JIA (TA373) inform optimal prescribing of biologics in JIA. It is not yet clear whether UK-based clinicians routinely treat new patients according to the NHSE interim statement/NICE TA373, acknowledging that there is no obligation for UK clinicians from the devolved nations to follow NHSE guidance. Understanding current prescribing patterns in children with JIA is a necessary precursor to development of targeted or accelerated early treatment pathways for children with JIA. The aims of this study were to describe prescribing patterns in children presenting to UK paediatric rheumatology (PRh) teams with a new diagnosis of JIA, with reference to the NHSE interim statement for JIA and collate opinion regarding accelerated early treatment pathways in children with new-onset polyarticular-pattern JIA. Methods: In March 2016, 19 UK-based PRh consultants (1 representative from each NHSE PRh provider) were invited to complete an online survey using SurveyMonkey software. Responders were asked to provide data regarding numbers of patients diagnosed between 2015 and 2016 with oligoarticular and polyarticular-pattern JIA, current treatment approaches and opinion regarding earlier use of biologics. Results: 14/19 (74%) responders from England (n=12), Scotland (n=1) and Northern Ireland (n=1) completed all or most of the questionnaire. Median number of patients per centre with new-onset oligoarticular and polyarticular-pattern JIA was 19 (IQR 13.5-40) and 10 (IQR 6-20) respectively. 85% responders reported always or mostly treating patients according to the NHSE interim statement. Responders commonly used intra-articular corticosteroids during initial treatment of new-presentation JIA (100% and 92% in oligoarticular and polyarticular-pattern respectively). Co-administration of oral or intravenous corticosteroids was reported. Theatre availability, disease severity and patient choice influenced choice of steroid regime. For children with oligoarticular-pattern disease, disease severity and/ or hip, wrist, finger or temporo-mandibular joint involvement were the most common reasons for early introduction of DMARD. For children with polyarticular-pattern disease, 100% responders commenced methotrexate at presentation. Four (29%) responders reported using anti-TNF as first-line treatment in spondyloarthropathy, enthesitis, sacroiliac involvement or positive HLA-B27. For patients with polyarticular-pattern JIA, 45-77% responders (varying by ILAR subtype) reported starting anti-TNF with methotrexate at diagnosis would be a good idea if guidelines and funding allowed. Feedback suggested poorer adherence to NHSE interim policy statement in Scotland and Northern Ireland (in was not possible to statistically compare data by country due to small numbers). 100% responders reported interest in recruiting to a study trailing an accelerated treatment pathway in children with polyarticular-pattern JIA. Conclusion: The majority of responding UK PRh centres surveyed prescribe according to NHSE interim policy statement. There was overwhelming support for an accelerated care pathway study in children with polyarticular-pattern JIA. Clinicians already prescribe anti-TNF medication at baseline in certain circumstances.