The feasibility of existing JADAS10 cut-off values in clinical practice: a study of data from The Finnish Rheumatology Quality Register

This Finnish-register-based study showed that, at the latest visit, a small but noticeable proportion of the polyarticular patients in CID and over 50% of the polyarticular patients in LDA had an AJC > 0 according to the latest JADAS10 cut-offs by Trincianti et al. [20]. Furthermore, approximately one third of the polyarticular patients in the LDA group had an AJC of two or more, and a considerably smaller proportion of patients was classified as HDA using JADAS10 and cJADAS10 cut-offs by Trincianti et al., even in the newly diagnosed DMARD-naïve patients. Using the JADAS10 and cJADAS10 cut-offs by Consolaro et al. resulted in the lowest proportion of LDA patients with an AJC of two, both for oligoarticular and polyarticular patients.

The divergence between the studies seeking to find optimal JADAS10 cut-off values might be due to differences in the cohorts as well as the statistical approaches chosen for the analyses. However, above all, the differences are due to divergent classifications of the disease activity states used as a reference. The disease activity states set by Beukelman et al. [10] and used in the studies by Backström et al. [17, 18] are not validated and the HDA definition is set very high. Moreover, the Beukelman criteria [10] state that a patient having a VAS over 2 already has MDA, even if the physician sees no signs of disease activity. This is also the weakness of the disease activity states set by Magni-Manzoni et al. [9] and used in the studies by Consolaro et al. [16, 19], since they state that a patient having a VAS over 2.1 has MDA, even if, again, the physician sees no signs of disease activity. However, the strength of those criteria is that they are objective and can be interpreted in approximately the same way, irrespective of the physician using them. In the latest study on this topic, which was a large multinational study by Trincianti et al. [20], disease activity states were established according to the opinion of the expert, which we suspect is a varying standard. Moreover, these cut-offs were not validated for JIA diagnoses other than those of persisted or extended oligoarthritis and seronegative polyarthritis. They are not intended for seropositive polyarthritis, psoriatic arthritis, nor enthesitis-related JIA.

It is important to include the patient´s perspective in evaluating disease activity but the PaGA parameter in JADAS and cJADAS is prone to rise the JADAS/cJADAS although there are no objective signs of inflammation. It has recently been shown that PaGA correlate better with measures of Health Related Qualify of Life than measures of disease activity [22].

Recommendations for treating Juvenile JIA to target have been formulated by an international task force [23]. Specific treatment targets and guidance on general treatment strategies were described with intention to improve patient care in clinical practice. Despite the ongoing discussion of optimal goals, the main treatment target is preferably CID, and when this is not possible, LDA [23, 24]. Thus, using cut-offs where approximately one third of LDA patients has an AJC of two or more is not optimal. The proportion of LDA patients with an AJC of two was clearly lowest in both oligoarticular and polyarticular patients using the JADAS10 and cJADAS10 cut-offs by Consolaro et al., which is their great advantage.

Another clear benefit of the cut-offs by Consolaro et al. is that the cut-offs for CID are the same regardless of the disease course. The other existing cut-offs require division of the patients in terms of oligoarticular and polyarticular disease courses. Since the oligoarticular and polyarticular disease courses are, rather than different disease entities, spectra of disease activity for different forms of arthritis that come under an umbrella diagnosis of JIA, we think it is both logical and practical to have only one set of JADAS10 cut-offs for disease-activity states, regardless of the oligoarticular or polyarticular disease course.

The strengths of this study are the large number of analysed patients and the inclusion of both newly diagnosed DMARD-naïve patients and patients with a more long-lasting disease course.

A limitation of this study is the lack of an international perspective. It has been shown that physicians in Northern Europe and Finland tend to score PhGA lower than those in other parts of the world [25]. Thus, the results might have been different for a more geographically widespread population.

In conclusion, we found the cut-offs by Consolaro et al. to be the most feasible both in clinical work and in research, since the cut-off levels for CID do not result in patients with AJC ≥ 1 being misclassified as in remission, and the proportion of patients with an AJC of two in the LDA group is the lowest using these cut-offs. A further clear benefit of the Consolaro et al. cut-offs is that the cut-off level is the same for CID in oligoarticular and polyarticular patients.

留言 (0)

沒有登入
gif