Can We Successfully Discontinue Anti-Tumor Necrosis Factor-α Treatment in Children with Non-Systemic Juvenile Idiopathic Arthritis? The Experience of a Tertiary Center

<b>Background:</b> Some patients with juvenile idiopathic arthritis (JIA) can successfully undergo withdrawal of treatment with anti-tumor necrosis factor alpha (anti-TNF-α) therapy, which may reduce economic and treatment-related burdens and the potential morbidity of treatment for at least 6 months. Currently, no guidelines exist on the appropriate withdrawal of anti-TNF-α therapy once clinically inactive disease (CID) has been achieved. This study aimed to assess the possibility of withdrawing anti-TNF-α therapy in children with non-systemic JIA after achieving long-term clinical remission. <b>Methods:</b> This single-center retrospective cohort study included data from 137 non-systemic JIA patients treated with anti-TNF-α therapy (etanercept or adalimumab) and having maintained CID for at least 24 months during treatment. Demographic, laboratory, and treatment data were collected at JIA onset, at the initiation of anti-TNF-α therapy, every 6 months during therapy, and at the time of disease flare. Anti-TNF-α therapy was discontinued abruptly after discussing it with the patients and their families in each case. Outcomes were assessed using standard criteria for remission in JIA (ACRpedi and Wallace criteria). <b>Results:</b> Following withdrawal of TNF-α inhibitors, 93/137 patients (67.9%) experienced a disease flare, with a median time to flare of 7 months (3; 14). Thirty-two percent of patients remained in remission for a median of 63 months. Absence of flare during the first 22 months after discontinuation was associated with prolonged biologic-free remission (odds ratio 682; 95% CI 38.6-12,062; <i>p</i> < 0.0001), with 83% sensitivity and 100% specificity (area under the ROC curve 0.967). Most flares involved arthritis (76%) and/or uveitis (24%), primarily affecting knees, ankles, and wrists. Inflammatory markers were generally lower at flare compared to baseline. Biological therapy was resumed in 84/93 patients (90.3%), achieving at least a 50% improvement according to ACRpedi criteria within 3 months and remission according to Wallace criteria within 6 months. <b>Conclusion:</b> Over two-thirds of patients with non-systemic JIA who achieve CID experience a flare within seven months of anti-TNF-α discontinuation. Re-initiation of biologic therapy is effective in restoring remission. These results indicate that prolonged biologic-free remission is possible in a subset of patients, highlighting the need for individualized withdrawal strategies and careful post-discontinuation monitoring.