Experienced pediatric rheumatologists have long been aware that the risk of recurrence is much higher for psoriatic arthritis and polyarthritis with a positive rheumatoid factor than for other subgroups. Unfortunately, the results for these subgroups are not separately reported. With the dramatic responses we now see with the newer biologic therapies, the questions of how and when to stop therapy become even more important.
Perhaps the most important lesson in Dr. Foell's study is that more than half of the children ultimately flared. Given that our goal is to prevent joint damage and long-term disability, does the high incidence of recurrence tell us that we should be stopping methotrexate sooner, or perhaps not stopping methotrexate at all? We need careful analysis of each of the many different diseases which masquerade as JIA—with long-term follow-up, including radiographic studies of joint damage—before we can conclude whether we are treating for too long or not long enough. Indeed, for each of the diseases lumped together as JIA, the answer may be different.
THOMAS J.A. LEHMAN, M.D., is chief of pediatric rheumatology at the Hospital for Special Surgery in New York. He reported having no financial conflicts of interest relevant to this research.
