Ixekizumab in children with active psoriatic and enthesitis-related juvenile idiopathic arthritis (COSPIRIT-JIA): a multicentre, open-label, 16-week, Bayesian trial including a randomised reference group to adalimumab

Background Juvenile psoriatic arthritis and enthesitis-related arthritis are two categories of juvenile idiopathic arthritis (JIA). Despite available treatments including non-steroidal anti-inflammatory drugs, glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (DMARDs), and biological DMARDs, a substantial proportion of people do not adequately respond to treatment or do not have long-lasting clinical remission. The aim of this trial was to show the efficacy and safety of ixekizumab in children with active enthesitis-related arthritis and juvenile psoriatic arthritis. Methods COSPIRIT-JIA is an ongoing multicentre, open-label, phase 3 study of ixekizumab, with a randomised adalimumab reference group, in children with a diagnosis of enthesitis-related arthritis (aged 6 to <18 years) and juvenile psoriatic arthritis (aged 2 to <18 years). Eligible participants had three or more active peripheral joints (presence of swelling or limited motion with pain or tenderness) and a bodyweight of at least 10 kg. Participants received subcutaneous administration of either ixekizumab or adalimumab using a weight-based dosing regimen (ixekizumab 40–160 mg starting dose then 20–80 mg once every 4 weeks; and adalimumab 20–40 mg once every 2 weeks). The primary endpoint was the percentage of ixekizumab-treated participants meeting the JIA-American College of Rheumatology (ACR) 30 (defined as at least 30% improvement from baseline in three of any six core outcome variables, with no more than one of the other variables worsening by more than 30%) response criteria at week 16. A Bayesian analysis was used to assess JIA-ACR30 response rate at week 16. Safety data were summarised using descriptive statistics for all participants who received at least one dose of either treatment. People with lived experience of JIA were not involved in the design or conduct of this study. The trial was registered with ClinicalTrials.gov , NCT04527380 . Findings The study enrolled 101 patients (ixekizumab n=81, adalimumab n=20) between April 13, 2021, and April 2, 2024, of whom the initial 40 participants naive to biological DMARD treatment were randomly assigned 1:1 to ixekizumab or adalimumab and the additional 61 participants were assigned to ixekizumab. Of the 81 participants who received ixekizumab, 60 were biological DMARD naive (40 with enthesitis-related arthritis and 20 with juvenile psoriatic arthritis) and 21 were biological DMARD experienced (14 with enthesitis-related arthritis and seven with juvenile psoriatic arthritis). The median age of the participants in the ixekizumab group was 14 years (12·0–15·0), of whom 36 (44%) of 81 were female, and 69 (85%) of 81 were White. At week 16, 90% (54 of 60; 95% CI 82·4–97·6) of biological DMARD-naive participants and 86% (18 of 21; 70·7–100·0) of biological DMARD-experienced participants receiving ixekizumab had a JIA-ACR30 response. Treatment-emergent adverse events were mostly mild (46%) or moderate (36%) for the ixekizumab group, with no severe treatment-emergent adverse events reported. The safety profile was consistent with adult psoriatic arthritis or spondyloarthritis and paediatric psoriasis indications. Interpretation Ixekizumab was well tolerated and effective for the treatment of children with enthesitis-related arthritis and juvenile psoriatic arthritis who are candidates for biological DMARD therapy. Funding Eli Lilly and Company.