Management Of Juvenile Idiopathic Arthritis Research Articles

Seronegative Polyarticular Juvenile Idiopathic Arthritis: A Case Report.

Juvenile idiopathic arthritis (JIA) is a chronic rheumatologic childhood disorder of unknown etiology usually presenting with peripheral arthritis. Usually involving the small joints symmetrically, polyarticular JIA is characterized by involvement of 5 or more peripheral joints and is further categorized depending on RA Factor positivity. We aim to report a case of seronegative polyarticular JIA to increase awareness regarding this disease. A 15-year-old boy presented with 3-month history of bilateral symmetrical joint pains, swelling and morning stiffness lasting 3-4 hours. For his ankle and knee pain, he had consulted a local doctor who suspected Rheumatic Fever and started penicillin and analgesics resulting in minimal improvement. He was a student but was unable to attend school in last 2 months due to this illness and had become bed-bound for last 2 weeks. On examination, there was swelling and tenderness of ankles, knees, elbows, wrists, metacarpophalangeal and proximal interphalangeal joints bilaterally. On investigation, ESR, CRP and serum ferritin were raised with normal complete blood count, urinalysis, liver and renal function tests, ASO test, blood and urine cultures, TSH, serum CPK and serum aldolase. Echocardiography did not reveal any abnormalities. His ANA, RA factor and Anti-CCP antibodies were negative. He was diagnosed with Seronegative Polyarticular Juvenile Idiopathic Arthritis and started on oral prednisolone and methotrexate. Currently the patient is asymptomatic on methotrexate 20mg/week. Our patient with symmetrical polyarthritis had negative ANA, RA Factor and Anti-CCP antibodies leading to a diagnosis of seronegative polyarticular JIA. Early screening and prompt management of JIA is required to improve prognosis and reduce risk of disability. The differential diagnosis of childhood joint pains is wide and variable including diseases of autoimmune, cardiac and haematological systems. For diagnosis of JIA, arthritis persisting for more than 6 weeks with onset of symptoms prior to 16 years of age is required with exclusion of secondary causes of joint inflammation. Keywords: Juvenile Idiopathic Arthritis, ANA, RA Factor, Anti-CCP antibodies, Methotrexate.

A Review on Drugs Used in the Management of Juvenile Idiopathic Arthritis

Juvenile idiopathic arthritis (JIA) is the most widespread rheumatic disease and main cause of disability in children. The disorder includes various classified forms depending on the affected joints’ location and number, as well as the presence or absence of various inflammatory markers. The specific cause is not known but is believed to involve a combination of genetic, humoral, and environmental factors. The aims of treating JIA are to reduce inflammation, reach remission, alleviate pain, sustain function, and do so with minimal side effects. Nonsteroidal anti-inflammatory drugs are still beneficial in mild cases, while intra-articular steroid injections remain the most common treatment for patients with oligoarticular juvenile idiopathic arthritis. Disease-modifying drugs like methotrexate and leflunomide have shown to be effective and safe, but in numerous patients, the disease continues to be active even with this therapy. These patients are given more specific medical care like tumour necrosis factor -alpha (TNF-α) inhibitors, interleukin-1 inhibitors, interleukin-6 inhibitors, selective costimulation modulators, and selective B-cell blockade. Treatment comes with risks, as several medications necessitate monitoring and patient education to manage potential complications. If left untreated, the disease can progress and become chronic, leading to significant illness and potentially having a devastating impact on the child’s quality of life. Despite the advancements in modern therapies improving patient outcomes, a significant portion of individuals still do not respond to treatment. This underscores the necessity for a deeper comprehension of disease development and recovery in order to properly categorize patients for appropriate treatment options.

A clinical perspective on imaging in juvenile idiopathic arthritis

In recent years, imaging has become increasingly important to confirm diagnosis, monitor disease activity, and predict disease course and outcome in children with juvenile idiopathic arthritis (JIA). Over the past few decades, great efforts have been made to improve the quality of diagnostic imaging and to reach a consensus on which methods and scoring systems to use. However, there are still some critical issues, and the diagnosis, course, and management of JIA are closely related to clinical assessment. This review discusses the main indications for conventional radiography (XR), musculoskeletal ultrasound (US), and magnetic resonance imaging (MRI), while trying to maintain a clinical perspective. The diagnostic-therapeutic timing at which one or the other method should be used, depending on the disease/patient phenotype, will be assessed, considering the main advantages and disadvantages of each imaging modality according to the currently available literature. Some brief clinical case scenarios on the most frequently and severely involved joints in JIA are also presented.Graphical abstract

Impact of the COVID-19 Pandemic on the Management of Juvenile Idiopathic Arthritis: Analysis of United States Commercial Insurance Data.

Given limited information on health care and treatment utilization for juvenile idiopathic arthritis (JIA) during the pandemic, we studied JIA-related health care and treatment utilization in a commercially insured retrospective US cohort. We studied rates of outpatient visits, new disease-modifying antirheumatic drug (DMARD) initiations, intra-articular glucocorticoid injections (iaGC), dispensed oral glucocorticoids and opioids, DMARD adherence, and DMARD discontinuation by quarter in March 2018-February 2021 (Q1 started in March). Incident rate ratios (IRR, pandemic vs prepandemic) with 95% confidence intervals (CIs) were estimated using multivariable Poisson or Quasi-Poisson models stratified by diagnosis recency (incident JIA, <12 months ago; prevalent JIA, ≥12 months ago). Among 1294 children diagnosed with JIA, total and in-person outpatient visits for JIA declined during the pandemic (IRR, 0.88-0.90), most markedly in Q1 2020. Telemedicine visits, while higher during the pandemic, declined from 21% (Q1) to 13% (Q4) in 2020 to 2021. During the pandemic, children with prevalent JIA, but not incident JIA, had lower usage of iaGC (IRR, 0.60; 95% CI, 0.34-1.07), oral glucocorticoids (IRR, 0.47; 95% CI, 0.33-0.67), and opioids (IRR, 0.44; 95% CI, 0.26-0.75). Adherence to and discontinuation of DMARDs was similar before and during the pandemic. In the first year of the pandemic, visits for JIA dropped by 10% to 12% in commercially insured children in the United States, declines partly mitigated by use of telemedicine. Pandemic-related declines in intra-articular glucocorticoids, oral glucocorticoids, and opioids were observed for children with prevalent, but not incident, JIA. These changes may have important implications for disease control and quality of life.

Managing juvenile idiopathic arthritis within the context of their life: What we learnt from children and youth living with juvenile idiopathic arthritis and their parents.

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children and causes short- and long-term disability. Optimal management requires pharmacologic and non-pharmacologic interventions. Few studies have explored the youth and family experience of the management of JIA. This study's objective was to explore the management experience of youth with JIA and their parents. This qualitative study used semi-structured interviews with youth 12-18years of age with JIA receiving biological medication and parents of children with JIA on biological medication. Participants were recruited in clinics using convenience sampling. A thematic analysis approach was employed for data analysis. Nine youth and 14 parents participated. Four themes were identified that encompassed an overarching theme of participants managing JIA within the context of their life: aspects of life affected by JIA and its management, lived experience with JIA management, medication decision-making, and involvement in decision-making. Juvenile idiopathic arthritis management is situated within the context of their life but is normally (outside acute events) not central. Two dimensions were added to those in the literature: parents' overall approaches to health and the sense of urgency surrounding decision-making. Our findings reinforce the importance of person- and family-centred care in paediatric rheumatology. That is, identifying what matters most to youth and their parents given their current life circumstances to provide a foundation for discussions of how they want to manage their JIA.

E23 Pediatric rheumatology in primary care in Tunisia

Abstract Background Primary care medicine is the first line of defence in the management of all diseases, and pediatric rheumatology is no exception to this rule. The aim of our work was to assess the management of rheumatological manifestations in the pediatric population, particularly in cases of suspected juvenile idiopathic arthritis (JIA). Methods A self-administered survey via google forms, was conducted among Tunisian primary care practitioners, during the month of February 2023. They were asked about their usual practice when children with articular symptoms consulted them. Results Our work included 33 practitioners, 25 of whom were women and eight men, with a female to male ratio of 3:1 and a mean age of 26 years [25–57]. Eighty-eight percent were family medicine residents (n = 29), nine percent were public health physicians (n = 3) and three percent were private physicians (n = 1). The average number of years in practice was three years [1–26]. Fifty-eight percent (n = 19) practiced in a university hospital, 18% (n = 6) in a regional hospital, 21% (n = 7) in a local dispensary, and three percent (n = 1) in a private practice. Regarding the number of pediatric-aged consultations per week, 70% (n = 23) reported seeing less than five patients and 21% more than ten per week (n = 7). A rheumatological reason for these patients was found in less than five consultations per week according to 94% of practitioners (n = 31). Forty-eight per cent (n = 16) of participants expressed anxiety when asked how they felt about managing a rheumatological case in this population, nine per cent (n = 3) were confident, 21% felt fearful (n = 7), 27% (n = 8) were indifferent and three per cent (n = 1) were alert. Forty-two per cent (n = 14) suspected JIA in a patient. In 77% of cases, the patients were seen repeatedly for polyarthralgia, 47% for arthritis, 18% for spinal pain, and 47% for systemic manifestations. 79% believe that early management of JIA brings a benefit in terms of health costs. When asked about their sources of training in JIA, 76% said it was through clinical courses and nine per cent through medical days, six per cent webinars and workshops and three per cent felt they had not received any training. As for sources of information, 31% through peer groups, 49% on medical websites, 27% through medical journals and 49% through medical school courses. To the question ‘On a scale of 0–5, how would you rate your training in the management of rheumatological manifestations in children and adolescents’ the answers were 0 in 21% of cases, 1 in 42% of cases, 2 in 12% and 3 in 24%. When faced with a suspicion of JIA, 49% of practitioners referred patients to pediatrics, 64% to rheumatology, 55% initiated a biological and imaging work-up and 18% prescribed symptomatic treatment. For the treatment, 67% prescribed paracetamol, 58% NSAIDs, 15% corticosteroids, 9% did not prescribe any treatment and three percent admitted not knowing what to prescribe in this situation. Conclusion JIA may affect functional and even vital prognosis of young patients. The detection and early management of the disease depend on the reinforcement of training and awareness for primary care physicians.

The effect of TNF treatment uptake on incident hospital admission in Western Australia

ObjectiveTreatment strategies for juvenile idiopathic arthritis (JIA) have shifted significantly over the last 20 years. We examined the effect of the introduction of government-subsidised TNF inhibitor (TNFi) treatment on incident hospitalisation for JIA.MethodsWestern Australian (WA) hospital data were used to identify patients < 16 years hospitalised with JIA between 1990 and 2012. Changes in the number of patients with an incident hospitalisation, overall admissions and admissions for joint aspiration were examined using join-point regression TNFi dispensing data from 2002–2012 was used to describe defined daily doses (DDD)/1000 population/day.ResultsWe included 786 patients (59.2% girls, median age 8 years) with a first-time admission with JIA. The annual incident admission rate was 7.9 per 100,000 person-years (95%CI: 7.3, 8.4) which did not change significantly between 1990 and 2012 (annual percentage change (APC): 1.3, 95%CI: -0.3, 2.8). Annual hospital-based prevalence of JIA reached 0.72/1000 in 2012. DDD for TNFi usage rose steadily from 2003 indicating TNFi usage by 1/2700 children in 2012, while overall admission rates (APC 3.7; 95%CI: 2.3, 5.1) and admission rates for joint injections (APC 4.9%; 95%CI: 3.8, 6.0) also increased significantly in that period.ConclusionIncident inpatient admission rates for JIA were stable over a 22-year period. The uptake of TNFi was not associated with lower admission rates for JIA, due mainly to an increase in admissions for joint injection. These results indicate a notable but unexpected change in hospital-based management of JIA since the introduction of TNFi therapy in WA, where hospital-based prevalence of JIA is slightly higher than in North America.

Juvenile Idiopathic Arthritis for the General Practitioner

Musculoskeletal complaints are common among children in the primary care setting. Joint pain can be categorized as either inflammatory or noninflammatory (also known as mechanical), and differentiating between these 2 categories affects a physician's differential diagnosis and plan for evaluation. Patients with inflammatory arthritis will frequently present to the primary care physician with musculoskeletal complaints. Specific features in the history and physical examination distinguish juvenile idiopathic arthritis (JIA) from other musculoskeletal etiologies. (1)JIA is the most common cause of inflammatory joint pain in children younger than 16 years, with a variable worldwide incidence; in Europe and North America, the incidence is approximately 7.8 to 8.3 per 1,000, with prevalence rates between 12.8 and 45 per 100,000. (2) It is thought that as many as 8 million children in the world have chronic arthritis. (2) Given its prevalence, it is important for the primary care physician to be able to appropriately recognize this condition and in doing so prevent a delay in diagnosis and management. Arthritis is a common cause of disability in children, and complications of JIA can be severe. Many therapies used in JIA have adverse effects and contraindications (specifically vaccinations and teratogen exposure) that require recognition by the primary care physician. This article discusses the differences between inflammatory and noninflammatory joint pain, the diagnosis and various categories of JIA, long-term outcomes and complications associated with JIA, and the general management of JIA with special emphasis on adverse effects and contraindications of therapies.

Total Knee Arthroplasty In Patients With Juvenile Idiopathic Arthritis

Medical and surgical management of knee pain in juvenile idiopathic arthritis (JIA) is rapidly evolving. It is important for the orthopaedic surgeon to remain informed. In this review, we discuss the recent trends in surgical management of JIA in light of recent medical advances for the disease. The purpose of this article is to summarize current recommendations for TKA in patients with JIA.

Efficacy of Folinic Acid in Comparison to Folic Acid for Reducing Side Effects of Methotrexate in Children with Juvenile Idiopathic Arthritis

Background: Methotrexate (MTX) is the most effective and commonly used disease-modifying anti-rheumatic drug in the management of juvenile idiopathic arthritis. Several patients develop side effects, which may lead to low quality of life and non-compliance to MTX. To reduce MTX-induced side effects, folic acid supplementation is prescribed by most rheumatologists. Even after that, some patients have symptoms while receiving MTX. Objectives: To assess the efficacy of folinic acid in comparison to folic acid for reducing the side effects of MTX in JIA patients. Material and methods: In this prospective observational study, newly diagnosed cases of JIA who would be getting MTX were included by purposive sampling. Data were collected using a predesigned questionnaire. Among 40 patients, 20 received folinic acid (Group A), and 20 received folic acid (Group B). Disease activity levels were assessed by JADAS-27 (Juvenile Arthritis Disease Activity Score). Contents from the MISS (MTX Intolerance severity score) questionnaire were used to assess the side effects. All patients were evaluated at baseline, 6th, and 12th weeks. Results: There were significant differences in the frequency of MTX-related adverse events between folinic acid (Group A) and folic acid (Group B). Group A patients only had nausea (10% and 15% in the 6th & 12th week respectively) and vomiting (5% at both follow-ups). On the other hand, in addition to nausea (70% and 95% in the 6th & 12th week) and vomiting (20% and 90% in the 6th & 12th week), folic acid group patients had restlessness, crying, and irritability. Self-discontinuation of MTX was present in the folic acid group (5% & 10% in the 6th & 12th week). Improvement of disease activity was more in the folinic acid group. Conclusion: The folinic acid group had significantly fewer side effects. Improvement of disease activity was more and compliance was also better among them. Methotrexate (MTX) is the most effective and commonly used disease-modifying anti-rheumatic drug in the management of juvenile idiopathic arthritis. A number of patients develop side effects, which may lead to low quality of life and non-compliance to MTX. To reduce MTX induced side effects, folic acid supplementation is prescribed by most rheumatologists. Even after that, some patients have symptoms while receiving MTX.

Assessment of Factor Affecting the Quality of Life in Children with Juvenile Idiopathic Arthritis

Abstract&#x0D; Introduction and Objectives: Juvenile idiopathic arthritis (JIA) is a frequently seen chronic rheumatoid disease in childhood, which may cause disability and severely affect quality of life (QoL). The aim of present study was to assess relationships between disease activation and socio-cultural status of family, QoL, anxiety level, and depression level in patients with JIA and their parents.&#x0D; Methods: The study included 100 patients with JIA. The socio-demographic data were obtained from all patients. Child- and parent-reported PedsQL, Beck depression inventory (BDI), Kovacs' Child Depression Inventory (CDI), SCARED child version, CHAQ discomfort and disability scales were applied and JADAS-27 score was calculated in a cross-sectional manner. Then, we compared the characteristics of patients with the scales’ results.&#x0D; Results: JADAS-27, BDI, and CHAQ discomfort scores were higher and child- and parent-reported PedsQL scores were lower in patients with active disease than patients on remission (p&lt;0.05). The SCARED score was higher in girls than boys. The CHAQ disability score was high in children aged 8-12 years (p&lt;0.05). JADAS-27 and CHAQ disability scores were significantly low in patients with better compliance to treatment. Parental statements about changes in mental health after diagnosis were consistent with results of depression and anxiety scales of children.&#x0D; Conclusions: Quality of life is adversely affected in children with JIA, which may result in depression and anxiety. In management of JIA, one of our goals should be maintaining QoL. Further comprehensive studies in relationships between QoL and depression, anxiety, socio-demographic parameters, disease activation and social circle of patient are needed.

Contribution of Ultrasound in Current Practice for Managing Juvenile Idiopathic Arthritis.

The interest and application of musculoskeletal ultrasound (MSUS) in juvenile idiopathic arthritis (JIA) are increasing. Numerous studies have shown that MSUS is more sensitive than clinical examination for detecting subclinical synovitis. MSUS is a well-accepted tool, easily accessible and non-irradiating. Therefore, it is a useful technique throughout JIA management. In the diagnostic work-up, MSUS allows for better characterizing the inflammatory involvement. It helps to define the disease extension, improving the classification of patients into JIA subtypes. Moreover, it is an essential tool for guiding intra-articular and peritendinous procedures. Finally, during the follow-up, in detecting subclinical disease activity, MSUS can be helpful in therapeutic decision-making. Because of several peculiarities related to the growing skeleton, the MSUS standards defined for adults do not apply to children. During the last decade, many teams have made large efforts to define normal and pathological US features in children in different age groups, which should be considered during the US examination. This review describes the specificities of MSUS in children, its applications in clinical practice, and its integration into the new JIA treat-to-target therapeutic approach.

Role of Rehabilitation in Comprehensive Management of Juvenile Idiopathic Arthritis: When and How?

Juvenile idiopathic arthritis (JIA), the most common chronic rheumatological disorder in children, can result in significant disability and poorer health-related quality of life. Rehabilitation aimed at pain management, optimizing musculoskeletal function, improving endurance and achieving independence in activities of daily living, and participation in age-appropriate activities, is a vital component in the comprehensive management of children with this condition. Rehabilitation strategies depend on the phase of the disease and focus on pain alleviation in the active phase and improving mobility and function in the inactive phase. Rehabilitation in JIA is multidisciplinary and includes exercise therapy, physical modalities, orthotic and assistive devices, and gait training. Exercise therapy has demonstrated improvement in muscle strength, bone mineral density, exercise capacity, and quality of life, without negative consequences of pain or exacerbation of arthritis. Common exercise interventions for children with JIA include mobilization, strengthening, aerobic exercises, Pilates-based exercises, aquatic therapy, and recreation. Physical modalities such as thermotherapy, cryotherapy, electrotherapy, ultrasound, and low-power laser therapy are commonly employed. Orthotic devices play an important role in joint protection, prevention and reduction of joint deformities, and assistance with function and gait. Assistive devices are prescribed to improve functional ability and independence in activities of daily living in children with disabilities. There have been recent advances in the field of rehabilitation with the advent of robotics, virtual reality, and telerehabilitation.

11 Evaluation of doctors’ knowledge (excluding rheumatologists and pediatricians) of juvenile idiopathic arthritis

BackgroundJuvenile idiopathic arthritis (JIA) is the most common pediatric inflammatory arthritis. However, this disease is not fully understood by all practitioners.ObjectivesThe objective of this survey is to assess the level of knowledge and attitudes of doctors excluding rheumatologists and pediatricians on the management of JIA.MethodsIn this cross-sectional descriptive study, an anonymous questionnaire composed of 20 questions, designed with the Google-Forms software, was sent via social networks to doctors from different specialties (excluding rheumatologists and pediatricians) and to interns and residents of the University Hospitals of Tunis.ResultsA total of 100 physicians responded to the questionnaire (61 women and 39 men). The mean age was 31.01 ± 5.64 [24–51] years. Fifty-seven percent of the participants were in training, 27% worked in public hospitals and 16% in private clinics. Most participants were general practitioners (32%), followed by ophthalmologists (9%), gynecologists (7%), and internists (5%). the mean length of service was 4.99 ± 4.5 [0–22] years. Thirty-six participants affirmed they have been confronted with patients with JIA. Twenty percent of participants believed they have knowledge about JIA. Among them, 25% believed they have sufficient knowledge, the others had superficial knowledge. Thirty-four percent of participants knew the definition of the disease according to the age, 17% knew its frequency and 18% had an idea about its various sub forms. The most frequent sub form was known only by 32 participants.Regarding the complications of JIA, only 25% of the participants thought of the macrophage activation syndrome in case of deterioration of the general state, fever, and pancytopenia. In addition, 44% of participants knew that JIA can be complicated by ocular involvement.Concerning the presence of rheumatoid factors and anti-nuclear antibodies during JIA, 64% and 60% respectively answered that their presence was not necessary.Concerning the care of JIA, 64% of participants referred these patients to rheumatologists, 31% to a pediatrician, and 5% took care of them themselves.The interest of methotrexate and biological treatments were known by 48% of the participants. However, 37% of participants had no idea of the therapeutic management of JIA.Concerning the prognosis, only 25% of the participants know the sub forms of bad prognosis. However, 48% had no idea about the prognosis of the disease.ConclusionThe level of knowledge of doctors on JIA is low to average. Training for physicians on this potentially serious disease is needed.

Update of evidence- and consensus-based guidelines for the treatment of juvenile idiopathic arthritis (JIA) by the German Society of Pediatric and Juvenile Rheumatic Diseases (GKJR): New perspectives on interdisciplinary care

BackgroundNew therapeutic strategies for juvenile idiopathic arthritis (JIA) have evolved within the past ten years, and as a result, an update of the 2011 recommendations of the German management guidelines was initiated. MethodsA systemic literature review was performed, overarching principles were proposed and pre-selected via an online survey followed by two multidisciplinary consensus conferences. Pharmacological and non-pharmacological treatments were discussed, statements were proposed and ultimately agreed upon by nominal group technique (NGT). Results12 overarching therapeutic principles, as well as 9 recommendations on pharmacological and 5 on non-pharmacological treatments for JIA were agreed upon. ConclusionThis report summarizes the recent update of the interdisciplinary, consensus-based German guidelines on the management of JIA. The multi- and interdisciplinary participation of all caregivers was central for this patient-focused update. With these guidelines, physicians can choose an evidence-based approach, which allows better tailored treatment in this vulnerable cohort of children and adolescents.

What are the factors associated with the duration of remission of intra-articular corticosteroid injection in juvenile idiopathic arthritis?

Intra-articular corticosteroid injection (IACI) is generally used in the management of juvenile idiopathic arthritis (JIA) to obtain rapid relief of active synovitis and functional recovery and to prevent the need for regular systemic therapy. The aim of this study was to investigate the outcome of IACI treatment and the factors associated with remission of synovitis. The clinical records of JIA patients who received IACI between January 2014 and December 2020 in two pediatric rheumatology centers were reviewed. The procedure was evaluated in terms of efficacy, factors that may affect the duration of remission, procedural and drug-related complications. During the study period, 134 patients received 227 injections and 37 joints were injected more than once. One hundred and six (79%) patients had persistent oligoarticular disease. At the time of injection, all patients were receiving non-steroidal anti-inflammatory drugs, 74 patients were on methotrexate, and 14 patients were on biologics. The median duration of remission without exacerbation of synovitis treated with IACI was 15 (range 1-64) months. The inactivity rate was 81% at the 6th month after the injection. It has been shown that being less than 7years old at disease onset and low initial CRP levels were correlated with a long remission period (p < 0.05). Despite the differences were not statistically significant, the duration of remission was longer in boys, in ANA positives, in HLA-B27 negatives, in patients with concurrent methotrexate treatment and in patients not receiving biologic therapy (p > 0.05). Only two patients (1.5%, 95% CI - 0.6 to 3.5) developed cutaneous hypopigmentation and subcutaneous atrophy as side effects of injection. Intra-articular corticosteroid injection was more effective especially in patients with low initial CRP levels and younger than 7years of age. The duration of remission was longer in these patients. Key Points • Intra-articular corticosteroid injection is an effective method for controlling joint inflammation and achieving long-term remission without significant side effects. • Intra-articular corticosteroid injection can be preferred in all forms of juvenile idiopathic arthritis as primary therapy or to relieve the patient while waiting for the effect of systemic agents or to avoid increasing the dose of systemic drugs. • It can be recommended as a treatment option at any stage of the disease, especially in young patients and patients with low initial CRP values.

Modified Delphi study to identify priority clinical questions for the Australian living guidelines for the management of Juvenile Idiopathic Arthritis

BackgroundJuvenile Idiopathic Arthritis (JIA) is the most common rheumatic inflammatory disease in childhood. Optimal management requires clinicians to be up to date with the rapidly evolving evidence base. ‘Living’ evidence-based clinical practice guidelines, which integrate new evidence as soon as it is available, are a novel method to enhance the translation of research into practice. To determine the most relevant questions that should be prioritised in national Australian JIA living guidelines, we invited Australian and New Zealand paediatric rheumatologists and other relevant health professionals to identify and rank their most important questions in order of priority.MethodsAll 47 members of the Australian Paediatric Rheumatology Group (APRG) were invited to participate in a modified Delphi study comprising two rounds. The first round identified demographic information of respondents, current attitudes to guideline use and invited submission of priority management questions. The second round asked respondents to rank 27 collated and refined questions identified in round one in order of priority.ResultsThere were 29 (62%) and 28 (60%) responses to the first and second survey rounds respectively. About two thirds were rheumatologists or trainees (66, 68%), nearly half had more than 10 years of experience (45, 46%) and practice setting was largely hospital (79, 86%) and urban (86, 75%). Most respondents used clinical guidelines in their practice (72% sometimes, 24% often), most frequently American College of Rheumatology (ACR) (66%) and European Alliance of Associations for Rheumatology (EULAR) (59%) guidelines. Reported barriers to guideline use included that they are not up to date and access difficulties. Most respondents (83%) considered Australian guidelines were necessary and two-thirds indicated they would use them if integrated into practice software. The highest ranked topics were down-titration and discontinuation of disease modifying anti-rheumatic drugs (ranked first), best outcome measures (second) and treatment targets in JIA (third).ConclusionsThere is strong clinician support for the development of Australian living guidelines for JIA. Consensus was reached on the ten top-ranked priority questions. Our guidelines will develop evidence-based recommendations for these high priority questions that will be updated in real time as needed to facilitate rapid translation of evidence into clinical practice.

AB1250 TOFACITINIB IS A SAFE AND EFFECTIVE TREATMENT OPTION FOR JUVENILE IDIOPATHIC ARTHRITIS

BackgroundThe management of juvenile idiopathic arthritis(JIA) is often constrained by the limited number of oral drugs available. Whether JAK inhibitors would add a much needed therapeutic armamentarium in this regard needs to be explored.ObjectivesTo assess the safety and efficacy of tofacitinib in juvenile idiopathic arthritis (JIA) patient who were prescribed during the period January 2021 to December 2021.MethodsIt’s a retrospective study of JIA patients who were prescribed tofacitinib during the period Jan 21 to Dec 21 with minimum of 3 months’ follow-up after prescribing tofacitinib. The demographics,details of medications,investigations parameters and any adverse events were noted.ResultsThere were a total of 35 patients who were given tofacitinib during this period. Male is to female ratio is 25:10, mean age of 12.91(4.81) yrs., the mean disease duration was 58.6 months. Enthesitis related arthritis(ERA) was the commonest seen in 12, followed by oligo articular in 10, polyarticular in 7 and systemic onset in 6. In the ERA group 10 were HLA B27 +VE, of the oligo articular 6 were ANA +VE, in the polyarticular one was RF +ve. Out of the 35,14 were already on biologicals (tocilizumab and anti TNFs). Tofacitinib was stopped in 8 patients during this period, 5 as they achieved remission, 2 with no response and one because of itching and abdominal pain. There were no documented infections. There was significant reduction in the inflammatory markers (ESR, CRP), leucocyte count and platelet count.Before tofaAfter tofap valueMethotrexate in mg (week) mean(stdev)9.64(1.94)8.88(3.34)0.66Steroid in mg mean (stdev)3(2.35)2.8(1.8)0.91Leucocyte count mean(stdev)11242(1858)7884(1471)0.005Platelet count in lakhsMean(stdev)4.51(0.48)3.37(0.82)0.017ESR mm/1hr57.75(17.25)30.83(11.48)0.009CRP mg/L25.36(10.9)12.36(7.97)0.05ConclusionTofacitinib seems to be a promising drug in the management of JIA with good safety profile and efficacy.

Updated clinical practice treat-to-target guidelines for JIA management: the Egyptian College of Pediatric Rheumatology initiative

BackgroundThese updated guidelines aimed to provide appropriate and convenient guidelines for the treatment of various types of juvenile idiopathic arthritis (JIA).Using the Delphi technique, this study was conducted to reach expert consensus on a treat-to-target management strategy for JIA. According to the PICO (patient/population, intervention, comparison, and outcomes) approach, the preliminary scientific committee identified a total of 17 key clinical questions. To assemble evidence on the advantages and dangers associated with JIA treatments, an evidence-based, systematic literature review was conducted. Researchers and clinicians with experience in JIA management were identified by the core leadership team. To establish a consensus on the management suggestions for JIA patients, a Delphi approach (2 rounds) was used.ResultsAn online survey was applied to the expert panel (n = 27), and 26 of them completed both rounds. At the conclusion of round 2, a total of eighteen (18) recommendation items were gathered, which were divided into four sections to address the four key JIA categories. The percentage of those who agreed with the recommendations (ranks 7–9) ranged from 83.2 to 100% (average 86.8%). The phrasing of all 18 clinical standards identified by the scientific committee was agreed upon (i.e. 75% of respondents strongly agreed or agreed). Algorithms have been proposed for the management of JIA polyarthritis, oligoarthritis, and systemic JIA.ConclusionA wide and representative panel of experts initiated a consensus about the management of JIA. The created guidelines give a complete approach to the management of JIA for all healthcare professionals involved in its management, as well as a means of monitoring and evaluating these guidelines on a regular basis.

Can ultrasound help to overcome uncertainty in clinical joint assessment in juvenile idiopathic arthritis?

Assessment of active synovitis is crucial for the management of juvenile idiopathic arthritis (JIA). We aimed to investigate the correlation of musculoskeletal ultrasound (MSUS) and clinical examination results and relate them to arthritis relapse rate. JIA patients with questionable presence of active arthritis (Q-joints) and controls (JIA and healthy children) were recruited. MSUS of Q-joints, active joints and their inactive counterparts was performed at study entry. Standard disease activity parameters were prospectively recorded. Of 481 joints of 138 JIA patients, 99 joints (20.6%) of 58 patients had one or more Q-joints with 54/99 (54.5%) having MSUS features of active disease. Clinically inactive joints had lower proportion of MSUS synovitis (78/253, 30.8%) while MSUS activity was present in 114/129 (88.4%) of clinically active joints and in 2/105 (1.9%) joints of 36 healthy controls. Within the 15-month follow-up 23/99 (22%) Q-joints and 31/253 (12%) clinically inactive joints relapsed. Joints with subclinical synovitis relapsed more frequently than MSUS inactive ones (p<0.001). The relapse rate was higher in MSUS-active Q-joints (19/23, 82%) than in clinically inactive ones (16/31, 52%) with MSUS synovial hypertrophy as the main relapse predictor in multivariate analysis. Ankle and knee joints relapsed most frequently. Acknowledgement of joints with questionable synovitis may contribute to the assessment of disease activity in JIA. Presence of MSUS synovitis carries a clinically meaningful risk of disease recurrence in these joints. In clinical practice, our findings encourage timely MSUS assessment of the joints in question, especially in patients without any other features of active disease.