Defining juvenile idiopathic arthritis remission and optimum time for disease-modifying anti-rheumatic drug withdrawal: why we need a consensus.

Juvenile idiopathic arthritis (JIA) is an autoimmune disease of childhood requiring treatment with immune modulation therapy. It runs a relapsing and remitting course, with approximately half of affected children continuing with active disease into adult life. Defining clinical remission is challenging, but necessary, as it is critical in determining when potentially toxic therapy can be stopped. We found that preliminary consensus criteria for defining JIA remission are not being used in full by a representative sample of UK pediatric rheumatologists. Extending the period of remission, whilst on synthetic disease-modifying anti-rheumatic drug (DMARD) medication, beyond 6 months does not seem to reduce the risk of relapse once medication is stopped. However, we found that most clinicians state that they still require at least 1 year in remission before DMARD withdrawal. There is increasing evidence that subclinical biomarkers may help to assess disease activity, and therefore aid clinicians in determining remission. In this review we argue that agreement on remission criteria and optimum timing of DMARD withdrawal is crucial for consistent clinical practice, and further research in this area is needed.