Treat to target (drug-free) inactive disease in DMARD-naive juvenile idiopathic arthritis: 24-month clinical outcomes of a three-armed randomised trial.

QUESTION: Which is the best strategy to achieve (drug-free) inactive disease in juvenile idiopathic arthritis (JIA)? METHODS: In a randomised, single-blinded, study in disease-modifying anti-rheumatic drug (DMARD)-naive patients with JIA, three treatment-strategies were compared: (1) sequential DMARD-monotherapy (sulfasalazine or methotrexate (MTX)), (2) combination therapy MTX + 6 weeks prednisolone and (3) combination therapy MTX +etanercept. Treatment-to-target entailed 3-monthly DMARD/biological adjustments in case of persistent disease activity, with drug tapering to nil in case of inactive disease.After 24 months, primary outcomes were time-to-inactive-disease and time-to-flare after DMARD discontinuation. Secondary outcomes were adapted ACRPedi30/50/70/90 scores, functional ability and adverse events. RESULTS: 94 children (67 % girls) aged median (IQR) 9.1 (4.6-12.9) years were enrolled: 32 in arms 1 and 2, 30 in arm 3. At baseline visual analogue scale (VAS) physician was mean 49 (SD 16) mm, VAS patient 53 (22) mm, erythrocyte sedimentation rate 12.8 (14.7), active joints median 8 (5-12), limited joints 2.5 (1-4.8) and Childhood Health Assessment Questionnaire score mean 1.0 (0.6).After 24 months, 71% (arm 1), 70% (arm 2) and 72% (arm 3) of patients had inactive disease and 45% (arm 1), 31% (arm 2) and 41% (arm 3) had drug-free inactive disease. Time-to-inactive-disease was median 9.0 (5.3-15.0) months in arm 1, 9.0 (6.0-12.8) months in arm 2 and 9.0 (6.0-12.0) months in arm 3 (p=0.30). Time-to-flare was not significantly different (overall 3.0 (3.0-6.8) months, p=0.7). Adapted ACR pedi-scores were comparably high between arms. Adverse events were similar. CONCLUSION: Regardless of initial specific treatments, after 24 months of treatment-to-target aimed at drug-free inactive disease, 71% of recent-onset patients with JIA had inactive disease (median onset 9 months) and 39% were drug free. Tightly controlled treatment-to-target is feasible. TRIAL REGISTRATION NUMBER: 1574.

What if your research is suddenly affiliated with a tobacco manufacturing company?

The tobacco industry is accountable for an annual global death toll of approximately 8 million people and cigarette smoking is the foremost risk factor for several types of cancer. In addition, the tobacco industry has a long and controversial history of trying to influence scientific research and of engaging in other morally problematic practices. In September 2021, the respiratory community was alarmed by the takeover of Vectura Group (Vectura) by Philip Morris International. As a reaction to this acquisition, strict measures were imposed by the International Respiratory Societies to prohibit the involvement of Vectura in respiratory research and its participation in societies' activities. International Respiratory Societies argued that Vectura had become part of the tobacco industry due to this takeover and is, therefore, subject to the same rules and restrictions. From a healthcare and historical perspective, the reaction and imposed measures are very understandable. However, for researchers that were already affiliated with Vectura through long-standing agreements and for research that was funded by Vectura, the imposed measures have serious consequences. With this article, we provide an example of these consequences. By reflecting on this issue, we would like to start a conversation regarding the current measures and to encourage the respiratory community to begin thinking of a way to avoid these consequences in the future. In addition, we hope that with this conversation the Respiratory Societies can set an example for other medical societies on how to cope with possible morally tainted affiliations (eg, fast food companies, alcohol manufacturing companies) in the future.