More JIA Flares Seen During COVID Lockdown in Italy

Disease flares increased among children with juvenile idiopathic arthritis (JIA) during the COVID-19 lockdown in Italy, researchers reported.

In a single-center study, the rate of disease flare among JIA patients who had been in a state of inactive disease was 16.9% (95% CI 10.8-24.7) after Italy went into lockdown in March 2020, according to a study by Maria Alessio, MD, and colleagues from the University of Naples Federico II.

In contrast, during the same period in the previous year, the rate of flare was only 6.3% (95% CI 2.8-12.1, P=0.009), the team reported in the study online in Arthritis Care & Research.

This elevated rate of flare was observed even though drug adherence remained high throughout the pandemic, and was likely a result of decreased physical activity. “Our data highlight the need for implementing healthcare management of patients with JIA, including personalized at-home exercise programs, in case of new lockdowns,” the authors wrote.

Italy was the first country in Europe to experience an outbreak of COVID-19, beginning in February 2020, and there were “immediate far-reaching health and social implications,” the researchers noted.

Children with JIA could be considered a vulnerable group in the setting of a pandemic because of home confinement, limitation of non-essential healthcare visits, and reliance on immunosuppressive medications.

Some research has focused on the effects of the pandemic on adults with inflammatory and autoimmune diseases, but little is known about the impact on pediatric patients.

To address this concern, Alessio’s group conducted a retrospective study that included 126 patients who had inactive disease and were seen pre-pandemic, during the months of September 2018 and March 2019 and then re-evaluated between March and June 2019 (group A), as well as 124 patients with inactive disease initially seen between September 2019 and March 2020 and re-evaluated between March and June 2020 (group B).

Inactive disease was defined as no joints with active arthritis, no systemic manifestations, no uveitis, normal acute-phase reactants, duration of morning stiffness less than 15 minutes, and a physician global assessment score of zero.

Overall, the characteristics of the two groups were similar, with the majority of patients being female. Age at disease onset averaged 4 years, and median disease duration at the time of study entry was 5.2 years. The predominant JIA subtype was oligoarticular.

Ongoing treatments at the time of study entry also were similar in the two groups, with approximately 40% receiving methotrexate and 44% being on biologics.

Among group B patients, 25% had only a remote re-evaluation visit, and 25% also had their re-evaluation visit postponed for at least 1 month.

At the re-evaluation visit, patients in group B had been out of school for a median 3 months.

Five patients in group B had temporary drug interruptions lasting for more than a week, with four of those unrelated to COVID-19. Only one patient who was receiving monthly tocilizumab infusions delayed her treatment because of COVID-19 concerns, but did not develop a disease flare.

“In our cohort, only one patient delayed the scheduled treatment due to apprehension of SARS-CoV-2 infection, downsizing the possible impact of the pandemic outbreak on treatment adherence and thus on disease course,” the researchers wrote.

In group A, 62.3% reported regular physical activity during follow-up compared with only 3.6% of patients in group B (P<0.00001).

Among the patients in group B who flared, treatment changes included initiation of a nonsteroidal anti-inflammatory drug in 16, a new conventional disease-modifying antirheumatic or biologic drug in four, and intra-articular corticosteroid injections in three.

Among the 21 patients in group B who flared, data on out-of-school physical activity were available for 18 patients, with 12 having interrupted their physical activity during lockdown.

Exercise is recommended for patients with JIA to limit inflammation and improve symptoms. In addition, lymphocytes from children with low levels of physical activity have shown a more inflammatory profile, which suggests that activity can exert a positive effect on systemic inflammation.

“Therefore, the physical inactivity associated with home confinement could be a possible explanation for clinical worsening in our patients,” the researchers noted.

The increased risk of relapse among children with JIA during the COVID-19 lockdown has important clinical implications for at-home exercise, particularly in case new lockdowns are needed during the evolving pandemic, Alessio and co-authors cautioned.

Limitations of the study, the team said, included the retrospective, observational design and the single-center setting.