Updated JIA Treatment Recommendations

Abstract

Source: Beukelman T, Patkar NM, Saag KG, et al. 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: initiation and safety monitoring of therapeutic agents for the treatment of arthritis and systemic features. Arthritis Care Res. 2011; 63(4): 465– 482; doi: 10.1002/acr.20460Over the past 12 years, treatment options for juvenile idiopathic arthritis (JIA) have increased due to the introduction of a new class of medicines, the biologics such as tumor necrosis factor (TNF) alpha inhibitor. This expansion of JIA therapeutic options has made feasible the first evidence-based treatment recommendations for a pediatric rheumatic disease.1 These guidelines were developed after a systematic review of 221 articles by a large, interdisciplinary team convened by the American College of Rheumatology.Five JIA treatment groups were defined: systemic arthritis patients with active systemic features (ie, fever, rash) but no active arthritis; systemic arthritis patients lacking active systemic features but having active arthritis; patients with no more than four active joints; patients with at least five active joints; and patients with active sacroiliac joint involvement.For each group, stepwise recommendations were made based upon the level of disease activity (low, moderate, or high) and the presence of poor prognostic features. Active joints were defined as joints with swelling or limited range of motion and pain or tenderness. For patients with no more than four active joints of any activity level, intra-articular glucocorticoid injections (IAC) with triamcinolone hexacetonide were recommended as initial treatment. Patients with low activity and no poor prognostic factors can be started on a nonsteroidal anti-inflammatory drug (NSAID), but then should receive IAC if they continue to have activity after two months, while patients with high activity and a poor prognostic feature should be started on methotrexate immediately. Poor prognostic features were defined as radiographic damage (ie, bone erosion), hip or cervical spine arthritis, or ankle or wrist arthritis associated with marked or prolonged elevated inflammatory marker (ie, erythrocyte sedimentation rate, C-reactive protein).For patients with at least five active joints, initial treatment with NSAIDs alone was considered inappropriate beyond two months. Initial treatment with methotrexate was recommended for all high activity patients, and for moderate activity patients who have a poor prognostic feature. Methotrexate was also recommended for low activity patients with a poor prognostic feature following one month of NSAID and for moderate activity patients without features of poor prognosis after one to two months of NSAIDs. If a patient continues to have moderate or high disease activity after three months of methotrexate treatment, the addition of a TNF alpha inhibitor was recommended; this was also recommended for low disease activity patients after six months of methotrexate treatment. Patients who continue to have active disease could be changed to a different TNF alpha inhibitor or switched to abatacept, an anti-T cell agent.Systemic arthritis patients can be treated with NSAIDs alone during their initial evaluation, but those with active fever and physician global assessment of very high disease activity should be treated with systemic glucocorticoids and possibly the biologic anakinra. Methotrexate was considered inappropriate for initial management of these patients, but considered appropriate for systemic patients with active arthritis following no more than one month of NSAIDs.These recommendations are a useful reference for pediatricians, but are not intended to serve as a treatment protocol. Treatment still needs to be individualized based upon specific patient features, and initiated and managed by a physician familiar with treating JIA.