JIA and Remission: What You Should Know

By Stephanie Watson

When children are sick, their parents’ primary goal is to get them fully well again. With some conditions—like juvenile idiopathic arthritis (JIA)—a cure isn’t yet possible. So, for parents of children with arthritis, the goal shifts from a complete resolution to a long-term reprieve from symptoms, called remission.

What Is Remission?
In the past, the meaning of remission varied, depending on which research you read. Because the term was used inconsistently, parents and health care providers often misunderstood its meaning. “Remission was defined differently in different studies. That was very confusing,” says Susan Shenoi, MBBS, MS, pediatric rheumatologist at Seattle Children’s Hospital and assistant professor of pediatric rheumatology at the University of Washington. 

To cut through the confusion, a group of doctors developed standardized criteria for remission in children with arthritis. Carol A. Wallace, MD, who is also a pediatric rheumatologist at Seattle Children’s Hospital and the University of Washington, headed up the project, along with her colleagues at the Childhood Arthritis and Rheumatology Research Alliance (CARRA).

The study asked pediatric rheumatologists from around the world to answer questionnaires about how they defined remission. Through their responses, Dr. Wallace’s team determined that remission comes in three phases: inactive disease, clinical remission on medication and clinical remission off medications. 

Criteria for inactive disease includes:
1.    NO joints with active arthritis.
2.    NO fever, rash, serositis (inflammation of tissues lining the lungs, heart, or other organs).
3.    NO active uveitis (inflammation of the eye).
4.    NORMAL C-reactive proteins and erythrocyte sedimentation rate (ESR).
5.    NO disease activity on the physician's global assessment of disease activity.

“After a patient has met the criteria for inactive disease for a minimum of six months continuously, the patient can then be considered in a state of clinical remission on medication,” Dr. Wallace explains. To achieve clinical remission off medication, a child must meet the criteria for inactive disease for a minimum of 12 continuous months after stopping all arthritis medications.

How Likely Are Kids with JIA to Achieve Remission?
“I think a child’s chances of going into remission are better now because we’re more aggressive, we’re treating it earlier and we now have biologics,” Dr. Wallace says. Still, getting to remission can take some time. A significant number of kids still have signs of active disease within the first two years after their diagnosis, finds a 2017 study in Current Rheumatology Reports.

The likelihood of achieving remission depends on several factors—including how long a child has had JIA. Within the first year and a half after diagnosis, 7% of kids achieve remission. Within 10 years after diagnosis, about 47% of children have reached that goal, according to a 2017 study in Seminars in Arthritis and Rheumatism.

The type of arthritis a child has also plays a big role in determining whether they get to remission. “Patients with oligoarticular arthritis have the best prognosis, and more long-term remission,” says Nancy Pan, MD, a pediatric rheumatologist at the Hospital for Special Surgery in New York. At the other end of the spectrum are kids with rheumatoid-factor positive polyarticular JIA, who are least likely to achieve remission.

How Long Does Remission Last?
“Nearly 90% of children [with JIA] achieve inactive disease, but the key is whether they can come off their medications and stay in remission,” Dr. Wallace says. 

The duration of remission hinges on the arthritis type and treatment, and it can vary depending on the child. “JIA is a very unpredictable disease,” Dr. Shenoi says. “There can be periods of active disease, or flares, and periods of inactive disease. This tends to vary a lot from child to child and even in the same child.”

The Best Ways to Achieve Remission
Early, aggressive treatment with drugs like biologics, methotrexate and steroids is critical to getting children with JIA into remission. “Recent studies show that the earlier you treat, the better the outcomes,” Dr. Shenoi says.

Although there still isn’t a cure for JIA, the new generation of medications has dramatically improved the outlook for these children. “Twenty or 30 years ago, some of these kids may have been in wheelchairs,” says Dr. Pan. “We’ve been able to avoid that recently with these new medications.”

“Biologics have absolutely revolutionized the way we treat juvenile arthritis,” Dr. Shenoi adds. “Kids are doing much better with these newer medications and are able to stay active, play sports and participate in things they should be taking part in at their age. It’s been amazing.”