Possible discontinuation of therapies after clinical remission in juvenile idiopathic arthritis.

Several studies have examined effects of discontinuing treatment after clinical remission in children with JIA. So far, only methotrexate and tumour necrosis factor α (TNF) inhibitors have been investigated. Overall, the relapse rate after termination of these medications was substantial. However, with the exception of one controlled trial of methotrexate, all analyses are retrospective. In addition, the results obtained for TNF-α inhibitors are variable and conclusions of existing studies are often divergent. No consistent predictors of the risk of flare were identified. Some evidence exists that low doses of medications may be sufficient to maintain remission. Because achievement of inactive disease has become increasingly more common in paediatric rheumatology practice, evidence-based data and expert recommendations to guide drug discontinuation are needed. This information should help to avoid both the risks and costs of prolonged therapy and to minimize the likelihood of disease flares. It should also be clarified whether it is more advantageous to stop treatment abruptly or to taper it gradually by reducing the dosage progressively or by increasing the interval between doses. Another key objective for future studies is to identify predictors of disease flare after treatment discontinuation. In addition, the optimal policy for discontinuation of other biologic medications used in children with JIA, such as anakinra, abatacept, tocilizumab, and canakinumab, should be established.