Attainment of low disease activity and remission targets reduces the risk of severe flare and new damage in childhood lupus.

OBJECTIVES: To assess the achievability and effect of attaining low disease activity (LDA) or remission in childhood-onset SLE (cSLE). METHODS: Attainment of three adult-SLE derived definitions of LDA (LLDAS, LA, Toronto-LDA), and four definitions of remission (clinical-SLEDAI-defined remission on/off treatment, pBILAG-defined remission on/off treatment) was assessed in UK JSLE Cohort Study patients longitudinally. Prentice-Williams-Petersen gap recurrent event models assessed the impact of LDA/remission attainment on severe flare/new damage. RESULTS: LLDAS, LA and Toronto-LDA targets were reached in 67%, 73% and 32% of patients, after a median of 18, 15 or 17 months, respectively. Cumulatively, LLDAS, LA and Toronto-LDA was attained for a median of 23%, 31% and 19% of total follow-up-time, respectively. Remission on-treatment was more common (61% cSLEDAI-defined, 42% pBILAG-defined) than remission off-treatment (31% cSLEDAI-defined, 21% pBILAG-defined). Attainment of all target states, and disease duration (>1 year), significantly reduced the hazard of severe flare (P < 0.001). As cumulative time in each target increased, hazard of severe flare progressively reduced. LLDAS attainment reduced the hazard of severe flare more than LA or Toronto-LDA (P < 0.001). Attainment of LLDAS and all remission definitions led to a statistically comparable reduction in the hazards of severe flare (P > 0.05). Attainment of all targets reduced the hazards of new damage (P < 0.05). CONCLUSIONS: This is the first study demonstrating that adult-SLE-derived definitions of LDA/remission are achievable in cSLE, significantly reducing risk of severe flare/new damage. Of the LDA definitions, LLDAS performed best, leading to a statistically comparable reduction in the hazards of severe flare to attainment of clinical remission.

The detection of subclinical synovitis by ultrasound in oligoarticular juvenile idiopathic arthritis: a pilot study.

OBJECTIVES: Adult studies have demonstrated that ultrasonography (US) is more sensitive at detecting synovitis than clinical examination. The detection of subclinical disease has implications for deciding which patients receive more aggressive therapy from the outset. This study aimed to determine whether children with clinically diagnosed oligoarticular juvenile idiopathic arthritis (JIA) had US-detectable subclinical synovitis. METHODS: This was a cross-sectional pilot study conducted in a tertiary paediatric rheumatology clinic. Seventeen children with a median age of 10 years (range 3-13 years) and with oligoarticular disease of duration <12 months (median 5 months) were recruited. All subjects were DMARD and oral/i.v. corticosteroid naïve. A core set of 40 joints was clinically examined for synovitis and then scanned by a rheumatologist trained in joint US and blinded to all clinical data, at the same appointment. RESULTS: In total, 680 joints were examined both clinically and by US. Twenty-three joints were found to have clinical synovitis, and of these only 17 had synovitis confirmed by US. A further 15 joints were found to have synovitis on US examination alone. Overall, subclinical synovitis was detected in 6/17 children, mostly in the hands and feet. One child was reclassified as having polyarticular disease. CONCLUSIONS: This pilot study has highlighted a discrepancy between clinical examination and ultrasound when assessing the joints of children with JIA. US is a feasible tool for examining multiple joints and identifying subclinical synovitis, particularly when considering the small joints of the hands and feet.