Health Canada Indications and Formulary Coverage of Biologic and Synthetic Disease-Modifying Antirheumatic Drugs for Juvenile Arthritis: Are We Meeting Current Guidelines?

Objectives Equitable access to biologic and synthetic disease modifying antirheumatic drugs (bDMARD, sDMARD) is critical for enabling pediatric rheumatologists to provide evidence-based care for children with juvenile idiopathic arthritis (JIA), ± uveitis, in accordance with current treatment guidelines. We aimed to assess how the Non-Insured Health Benefits (NIHB) program for First Nations and Inuit and provincial formularies align with current pediatric rheumatology recommendations for bDMARD/sDMARD therapy. Methods Provincial formularies and NIHB program were reviewed to compile coverage of bDMARD/sDMARD for the treatment of all JIA subtypes and JIA-associated uveitis. This was compared to the Health Canada (HC) indications for these drugs and current Canadian/American treatment guidelines for polyarticular JIA (pJIA), enthesitis-related arthritis (ERA) systemic JIA (sJIA), and uveitis.[1,2] In the absence of North American guidelines, recently published literature helped us identify recommended evidence-informed treatment strategies for juvenile psoriatic arthritis (JPsA).[3] Health Canada, NIHB and all provinces were evaluated for their overall performance with bDMARD/sDMARD treatment recommendations for JIA and uveitis. A parallel assessment was conducted in adults, focusing on inflammatory arthritis and informed by recently published treatment guidelines. Results Overall, Ontario had the highest capacity to follow pediatric bDMARD/sDMARD recommendations followed by HC and Quebec (Figure 1). For JIA subtypes, all pJIA-recommended drugs were indicated and approved by HC, funded through NIHB, and covered by most provinces. For sJIA, HC and half the provinces fully met recommendations, whereas NIHB and remaining provinces ranked lower. Only Ontario met ERA treatment guidelines. HC approved one anti–IL-17 agent for ERA, which is recommended for adult ankylosing spondylitis (AS) but not included in ERA guidelines. However, it remains unfunded by NIHB and all provinces. JPsA treatment recommendations were not met by NIHB nor any province. Notably, HC has approved JPsA indications for anti–IL-17 and tofacitinib, which are included in these recommendations and in adult psoriatic arthritis (PsA) guidelines. Ontario approved half of the drugs recommended in current uveitis treatment guidelines; HC, NIHB, British Columbia and Quebec approved 25% while other provinces did not meet guidelines. Adults with inflammatory arthritis generally fully met treatment guidelines, whereas Adult Stills disease guidelines were not met by NIHB or any province. Figure 1. Alignment of Drug Coverage with Treatment Recommendations for JIA and Uveitis Across Health Canada, NIHB, and Provincial Formularies . Paediatric recommendations include polyarticular juvenile idiopathic arthritis, systemic juvenile idiopathic arthritis, juvenile psoriatic arthritis, arthritis enthesitis-related arthritis and JIA-associated uveitis. NIHB - Non-Insured Health Benefits; AB – Alberta; BC – British Columbia; MB – Manitoba; NL – Newfoundland and Labrador; NS – Nova Scotia; ON – Ontario; PH – Prince Edward Island; QC – Quebec; SK – Saskatchewan. Conclusion Access to publicly funded bDMARDs/sDMARDs for JIA and uveitis is highly variable, with most provinces and NIHB unable to fully meet treatment guidelines. Adults with inflammatory arthritis generally have full access to recommended therapies, highlighting major inequities in pediatric care and a barrier to delivering evidence-based therapies for children. References [1.] Ringold S. Arthritis Care Res 2019;71:717-34. [2.] Onel KB. Arthritis Rheumatol 2022;74:553-69. [3.] Shenoi S. Nat Rev Rheumatol 2024;20:170-81.