Management Of Juvenile Idiopathic Arthritis Research Articles

Juvenile Idiopathic Arthritis and Athletic Participation: Are We Adequately Preparing for Sports Integration?

Children with juvenile idiopathic arthritis (JIA) now have well-controlled disease due to improved therapies and management strategies. Children with JIA are more active than in the past and often participate in dynamic, high-loading sports. Standard measures of disease control include examination findings, laboratory values, and patient-directed surveys. However, these standards do not address the subtle deficits in biomechanics and neuromuscular control, which could place affected joints at higher risk for injury. Currently, there are limited evidence-based guidelines to structure conditioning recommendations as to the fitness and mechanics needed to provide safe integration into sports in this population; therefore, tools that objectively measure function with high accuracy and precision may be warranted. Previous work using 3-dimensional motion analysis demonstrated usefulness in guiding physical therapy treatment to correct these deficits. The use of a multidisciplinary team, including physical therapy, rheumatology, and sports medicine, is crucial for preparing these children to return to play. We suggest that the child transition into a sport preparatory–conditioning program to address any underlying deficits. A pediatric exercise specialist who is sensitive to the needs of this population can work with a physical therapist to then appropriately integrate the child safely into sport. Encouraging an active lifestyle is vital to the management of JIA and does not worsen the symptoms associated with childhood arthritis.

New takes on categorization and treatment

In 2011, new treatment recommendations for juvenile idiopathic arthritis (JIA) were proposed, inroads were made towards understanding the heterogeneity of this disease, and data were presented demonstrating the potential efficacy of DMARD combination therapies for JIA treatment. These advances hold promise for improved management of JIA in 2012 and beyond.

Interdisziplinäre S2-Therapieleitlinie der Juvenilen Idiopathischen Arthritis (2. Auflage)

Treatment of Juvenile Idiopathic Arthritis (JIA) has improved quality of life in children and adolescents with JIA. Standardisation of care offers the chance to improve the quality of care of those patients. New studies have been published after completion of our last treatment guideline (2007). An updated consensus process is mandatory. A systematic literature analysis in PUBMED (key words: juvenile idiopathic (rheumatoid) arthritis, therapy; limits: humans, published in the last 3 years, all child 0-18 years, clinical trial) revealed 17 relevant studies. Studies relating to diagnosis of JIA, Uveitis, vaccination, transition were excluded. Representatives nominated by scientific societies and organisations were invited to consensus conferences which were hosted by a professional moderator. The following societies were invited: Berufsverband der Kinder- und Jugendärzte (BVKJ), Deutsche Gesellschaft für Kinder- und Jugendmedizin (DGKJ), Deutsche Gesellschaft für Rheumatologie (DGRh), Deutsche Ophthalmologische Gesellschaft (DOG), Deutsche Rheuma-Liga Bundesverband, Verein zur Förderung und Unterstützung rheumatologisch erkrankter Kinder und deren Eltern, Vereinigung für Kinderorthopädie, Zentraler Verband der Physiotherapeuten und Krankengymnasten (ZVK). Consensus conferences were each attended by more than 95% of the nominated representatives. Consensus statements were confirmed by nominal group technique and Delphi method. Updated consensus statements regarding drug therapy, symptomatic and surgical management of JIA were compiled and judged strictly by the criteria of Evidence-Based Medicine (EBM).

Impact of a 2-yr anti-TNF treatment on the quality of life in JIA patients: a parent's/patient’s view

Background The use of biologic factors in the management of Juvenile Idiopathic Arthritis (JIA) has changed dramatically the course and outcome of the disease. They control the disease symptoms and hinder the joint damage which may provoke major functional limitations, thus affecting the patients’ Health Related Quality of Life (HRQoL). Aim To evaluate changes in the HRQoL variables in patients with JIA, under anti-TNF treatment. Methods 49 patients with refractory to conventional therapy JIA, aged 2-18 years, were studied. They were receiving either Etanercept or Adalimumab for the first time or they were switchers from one anti-TNF to the other one (10/49). All patients were clinically and laboratory assessed pre-treatment and thereafter every 6 months, until the completion of 2 years. At the same timepoints, the following variables were collected: the Childhood Health Assessment Questionnaire (CHAQ) Disability Index (DI), the patient’s/parent’s global assessment of pain and wellbeing (P/PVAS) and the physician’s global assessment (MDVAS) through the visual analogue scale (VAS). Results During anti-TNF treatment, all the above mentioned core set variables P/PVAS showed a significant improvement (p<0.05). Similarly, the improvement of MDVAS was positively correlated with the improvement of CHAQ DI (rsq=0.43), of VAS pain (rsq=0.66) and of VAS wellbeing (rsq=0.64). No correlation between VAS wellbeing and JIA duration was found. Pain was the only independent factor related with a poor score of wellbeing. Conclusion This study shows that all variables associated with HRQoL in patients with JIA can be substantially improved after 2 years of anti-TNF treatment.

Orthodontic and dentofacial orthopedic management of juvenile idiopathic arthritis: a systematic review of the literature

To systematically review the literature published on orthodontic treatment principles in patients with juvenile idiopathic arthritis (JIA). Several electronic databases (PubMed, Medpilot, Web of Science, and DIMDI) and orthodontic and rheumatologic literature were systematically searched for studies published until May 2010. The articles were rated by two independent reviewers and included after three selection steps (title-abstract-full text). Articles had to be studies performed on ≥ 5 patients with a disease onset before the age of 16. The selection process resulted in the inclusion of three publications on dentofacial orthopedics and six on combined surgical orthodontic therapy. The three studies on dentofacial orthopedics aimed to improve the mandibular retrusion by means of removable functional appliances (activator). Whereas these orthodontic approaches comprised relatively large and homogeneous patient samples (14, 22, and 72 subjects, aged 6-16), the surgical studies were basically case series with a large age span of the patients (5-12 subjects, aged 10-44). In these surgical treatment approaches, orthodontics was limited to pre-surgical leveling and post-surgical finishing, while the skeletal discrepancy was treated surgically by a variety of techniques (costochondral grafts, bilateral sagittal spilt osteotomy, Le Fort I, and genioplasty). The treatment goals of both approaches were improvement of esthetics and function and/or pain reduction, and both approaches showed satisfactory results. Because of the heterogeneity of the subject material and the low level of evidence of the papers, it is difficult to draw any conclusions on the orthodontic/dentofacial orthopedic management of JIA. It appears as if removable functional appliances may be beneficial in adolescent patients with JIA.

Juvenile Idiopathic Arthritis

Significant advances have taken place in recent years in our understanding of the aetiopathogenesis, management, and clinical outcome of juvenile idiopathic arthritis (JIA). Fundamental to this advancement has been international collaborative efforts of the clinical scientific community and all those involved in the multidisciplinary care of children and young people with JIA. A key factor has been facing the challenge of developing a robust classification system for JIA, a clinically very heterogeneous group of conditions. JIA illustrates the necessity of disease classification to enable scientific progress but also the iterative and evolving process this entails. What is emerging is the imperative to improve our understanding of the biologic and genetic basis of JIA to underpin classification systems. Growing emphasis is centered on improved holistic care and outcome of children and young people with JIA. The expectation of patients, their families, and clinicians is the goal of inactive disease, remission off treatment, and the health and psychosocial well-being of young people emerging into adulthood. Validated tools that reflect these challenges are being developed, including those measuring disease improvement, flare, remission and minimal disease activity, health-related quality of life, and composite scores of activity and damage. Clinical research networks have driven success in developing an evidence-base for the treatment of JIA. Randomized comparative trials have demonstrated the benefit of early use of intra-articular corticosteroid injections, and the importance of methotrexate as the first-line, disease-modifying antirheumatic drug in JIA. The introduction of biologic therapies has opened a major new epoch in the medical management of JIA, with recent trials published on etanercept, infliximab, adalimumab, abatacept, tocilizumab, and anakinra. This review focuses on recent advances in JIA, especially developments in its classification, validation of appropriate measures of holistic outcome, and the specific contribution of established and newer pharmacologic agents available for treating children and young people.

Gene engineering biological therapy for juvenile arthritis

The mechanisms of action of currently used genetic engineering biological agents (GEBAs) include inhibition of cytokines, interleukins, and T cells and depletion of B cells. GEBAs were originally accessible mainly for the treatment of refractory juvenile idiopathic arthritis (JIA), including systemic-onset JIA (Still's disease), which allowed one to do away with the long-term use of high doses of glucocorticoids or cytostatics. Since 2000, a number of randomized double-blind placebo-controlled and open-label pilot studies have convincingly demonstrated the efficacy of GEBAs in children and adolescents. Although the tumor necrosis factor-a (TNF-a) inhibitors etanercept and adalimumab are chiefly used to treat refractory polyarticular JIA, interleukin 1 and 6 blockers showed satisfactory results in treating systemic JIA. Abacept is regarded as a treatment option for patients with polyarticular JIA when disease modifiers and TNF-a inhibitors are ineffective. The place of rituximab in the management of JIA has not certainly defined so far. However, GEBA therapy cannot completely cure the disease as before despite the progress achieved. GEBAs have potentially a number of serious side effects, among which there are severe infections and there is a risk of developing malignancies and autoimmune processes. Their administration requires careful monitoring to reveal the early development of serious adverse reactions, thus preventing a poor outcome.

The Diagnosis and Management of Juvenile Idiopathic Arthritis

BACKGROUND Definition Juvenile arthritis is the most common rheumatic childhood disease in the United States. According to the Arthritis Foundation (2009), juvenile arthritis is any form of arthritis or arthritis condition that develops in persons younger than 18 years. The Centers for Disease Control and Prevention (2009) list three clinical classification schemes for childhood arthritis: juvenile

Foot related impairments and disability in juvenile idiopathic arthritis persist despite modern day treatment paradigms

Background: Foot problems such as synovitis, growth disturbance and deformity are considered common in juvenile idiopathic arthritis (JIA) and have been previously reported in over 90% of cases. The medical management of JIA appears to have improved recently however little is known about the impact of new regimes on localised joints such as in the foot. This pilot study aimed to investigate the prevalence of foot related impairments and disability, and survey the medical and podiatric management of patients in a cohort of UK children with JIA. Methods: This study was a tertiary care based cross-sectional survey. Thirty consecutive JIA patients with a history of foot and ankle arthritis completed the juvenile arthritis foot disability index questionnaire (JAFI) (0-4 for each domain), child health assessment questionnaire (CHAQ) (0-3), and pain visual analogue scale (VAS) (0-100mm). Foot deformity score (0-38), active and limited joint counts (0-77) and walking speed (m/s) were measured also recorded. Foot care provision over the previous 12 months was determined from the medical records in 23/ 30 participants. Results were analysed using simple descriptive statistics and expressed as median (range). Results: Children received biologic agents in 35%, DMARDs in 65%, and 90% of participants had received multiple intra-articular cortico-steroid injections. Median (range) values for foot disease outcomes were JAFI impairment = 1 (0-3), JAFI activity limitation = 1 (0-4) JAFI participation restriction 1 (0-3), CHAQ = 0.38 (0-2), VAS pain = 22 (0-79), foot deformity = 6 (0-20), active joints = 0 (0-7), limited joints (0-31), walking speed = 1.09 (0.84- 1.38). The JAFI scores represent mild foot related impairment and disability. Gait defects, deformity or abnormal foot posture, and/or active foot disease were the main reasons for referral. 43% of children received specialist podiatry care comprising footwear advice, orthotic therapy, and silicone digital appliances together with intrinsic muscle strengthening exercises. Conclusions: Despite DMARD/biologic regimes and specialist podiatry, foot related impairment and disability persists in JIA children. Foot care appears to be in line with current recommendations. Further study is required to determine the long-term consequences of these changes found during childhood in the foot.

Tumor Necrosis Factor Inhibitors in the Management of Juvenile Idiopathic Arthritis

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disorder of unknown origin that is often treated with a variety of disease-modifying agents. Tumor necrosis factor (TNF) inhibitors are a group of genetically engineered biologic agents that target the proinflammatory cytokine TNF. This review focuses on the use of TNF inhibitors in JIA. Etanercept was the first TNF inhibitor approved for use in children with moderate to severe polyarticular-course JIA following encouraging results from a randomized, double-blind, placebo-controlled, multicenter trial in children. Open-label extension studies of the original trial involving 8 years of follow-up demonstrated the long-term safety and efficacy of etanercept in children. Other studies from established registries also corroborate the safety of etanercept in JIA. The second TNF inhibitor to be approved for use in JIA is adalimumab following recent favorable results from another randomized, placebo-controlled, multicenter study in polyarticular-course JIA. While infliximab is not approved by the US FDA for use in JIA, it is frequently used in clinical practice for this indication. However, because the chimeric structure of infliximab incorporates murine components, it has the potential for allergic and infusion reactions. Patient responses to individual TNF inhibitors may vary depending on concomitant medications such as methotrexate, and also on the category of JIA.

Pitfalls in the diagnosis and management of juvenile idiopathic arthritis: a retrospective case-note analysis

<h3>Background</h3> Juvenile idiopathic arthritis (JIA) is the most common cause of persistent arthritis in children. It is defined as arthritis of unknown aetiology presenting before the 16th birthday, persisting for at least 6 weeks and where other known causes of arthritis have been excluded. JIA is no longer considered as a benign condition as long-term studies have shown that JIA may persist in to adulthood with disability. <h3>Aims/Methods</h3> In order to improve their services, the authors performed a retrospective case-note analysis of children younger than 16 years of age who were diagnosed with JIA over a 10-year period (2000–2008). A proforma was used to collect the information on the type of JIA, age of onset, age at diagnosis, source of referrals and past medical history. Evidence has shown that patients who receive treatment late may suffer from a more persisting inflammation and disability. Early use of disease-modifying antirheumatic drugs during the first 3 months of onset has been associated with an optimal control of the disease. <h3>Results</h3> 41 case notes were retrieved. 18 referred by the general practitioner (GP) and 13 via an orthopaedic surgeon. Delay in diagnosis was defined as 3 months from the start of the joint symptoms; that is joint swelling and pain. 21/41 were oligoarticular JIA of which seven were extended form, 13/41 polyarticular JIA, five with systemic onset and one with enthesitis related arthritis and one with arthritis associated with inflammatory bowel disease. Eight had a history of trauma before presentation and six had a recent infection. Delay in diagnosis was observed in 14 out of 41 cases (%36); two cases parents could not appreciate the significance of the symptoms, in 12 delayed diagnosis occurred by the professionals. Most delays by the professionals were from the orthopaedic surgeons (10 out of 12). Eight were under orthopaedic surgeon, referred by accident and emergency and GP with a history of a trivial injury before joint swelling. Two had previous history of tonsilitis with diagnosis of reactive arthritis, one case with hip pain and slight elevation of inflammatory markers treated conservatively with possible toxic synovitis. One child with finger joints swelling was under follow ups with no clear diagnosis. <h3>Conclusion</h3> The authors conclude from the clinical notes that trivial injury is relatively common in children. A detailed history indicating the severity of injury and a thorough examination as well as early referral to paediatrician could significantly reduce the rate of delayed diagnosis.

The role of exercise therapy in the management of juvenile idiopathic arthritis

The current review summarizes the existing knowledge about exercise therapy in the management of juvenile idiopathic arthritis (JIA) along with activity level, functional abilities and exercise capacity of this population. Current studies show that children with JIA are considerably less active than their peers. They have significantly impaired aerobic and anaerobic exercise capacity. The inactivity, decreased exercise capacity and disease course lead to deconditioning and disability. Adolescent girls with polyarticular rheumatoid factor-positive subtype appear to be most vulnerable to disability. Recent trials suggest that structured aerobic training or low-intensity programs do not exacerbate arthritis and can lead to improved physical fitness, quality of life and functional abilities in children and adolescents with JIA. Inactivity in pediatric patients with JIA leads to deconditioning and disability and decreased bone mass, reduced quality of life and possibly increased mortality in adulthood. Although advances in pharmacology have improved the lives of children with JIA, management should also include a moderate, consistent exercise program or more active lifestyle. Physical activity may improve exercise capacity, decrease disability in adulthood, improve quality of life and, in some patients, decrease disease parameters. Further studies are needed to assess practicality of various programs and long-term effects of exercise in children and adolescents with JIA.

Preventing tuberculosis in children receiving anti-tnf treatment

Anti-tumor necrosis factor (TNF) treatment has been a breakthrough in the management of juvenile idiopathic arthritis (JIA). However, they are associated with a significant risk of tuberculosis. We evaluated JIA patients who received etanercept treatment from an eastern Mediterranean country with moderate tuberculosis frequency. JIA patients under anti-TNF treatment, etanercept, were enrolled to the study. Chest X-rays, Tuberculin Skin Test (TST), clinical histories, family screening, and physical examinations were reviewed retrospectively. If TST was above 10 mm in a patient with one Bacillus Calmette-Guerin, cultures and, if needed, thorax computerized tomography were obtained. These patients received 1-2 months of isoniazid (INH) treatment which was followed by an INH prophylaxis for a period of 9 months while etanercept treatment was started. All were re-evaluated within 3 months intervals. A total of 36 patients under etanercept treatment were enrolled to the study. Mean age of the patients was 14.00 years (range 4-22 years). Median duration of disease was 36.00 months (range 4-216 months). Median duration of etanercept therapy was 11.5 months (3-48 months) at final evaluation. Seven patients had an initial TST score above 10 mm. All received INH treatment as outlined above. They had normal examinations and X-rays during followup. With proper initial evaluation, anti-TNF treatment is safe even in countries where tuberculosis is moderately frequent. An initial 1-2 months of INH treatment followed by chemoprophylaxis for 9 months is suggested for children with a TST of >10 mm.

New advances in the management of juvenile idiopathic arthritis—1: Non-biological therapy

Juvenile idiopathic arthritis (JIA) is the most common paediatric rheumatic disease with significant long-term morbidity and mortality. Major advances have taken place in recent years in our understanding and the...

New advances in the management of juvenile idiopathic arthritis—2: The era of biologicals

Juvenile idiopathic arthritis (JIA) is the most common paediatric rheumatic disease with significant long-term morbidity and mortality. Major advances have taken place in recent years in our understanding and the...

Juvenile idiopathic arthritis in adulthood and orthopaedic intervention

There have been marked changes in the management of juvenile idiopathic arthritis (JIA) over recent decades, mainly with earlier use of methotrexate (MTX). Our aim was to describe orthopaedic interventions in a large group of adults with JIA followed up over several decades. This was a retrospective observational study of adult JIA patients attending a teaching hospital clinic, with information collated on JIA subtype, disease duration, orthopaedic interventions, and exposure to MTX. The study included 144 patients with median disease duration of 19 years. Survival analysis showed that joint surgery was observed in the majority (75%) of patients with disease duration over 40 years with a trend for less joint surgery in patients with oligoarticular JIA. In total, 41 patients (28.5%) had received joint surgery, and 17/41 (41%) have required multiple procedures. Of those who have required joint surgery, 20/41 (48%) had started MTX in their adult years, with only 5/41 (12%), starting MTX prior to first joint replacement and none within 5 years of disease onset. Of the patients who have not had joint surgery to date, most (46/103, 45%) were receiving MTX or another immunosuppressive agent; in the majority of cases, MTX was started within 2 years of disease onset. Many adults with JIA require joint replacement surgery and ongoing immunosuppressive treatments, emphasising that JIA is not a benign disease. Many patients who have had joint replacement surgery have had exposure to MTX albeit after many years after disease onset; it remains to be seen whether patients who have received MTX therapy early in their disease course will ultimately have less requirement for joint surgery.

Surfing for Juvenile Idiopathic Arthritis: Perspectives on Quality and Content of Information on the Internet

To determine the quality and content of English language Internet information about juvenile idiopathic arthritis (JIA) from the perspectives of consumers and healthcare professionals. Key words relevant to JIA were searched across 10 search engines. Quality of information was appraised independently by 2 health professionals, 1 young adult with JIA, and a parent using the DISCERN tool. Concordance of the website content (i.e., accuracy and completeness) with available evidence about the management of JIA was determined. Readability was determined using Flesch-Kincaid grade level and Reading Ease Score. Out of the 3000 Web pages accessed, only 58 unique sites met the inclusion criteria. Of these sites only 16 had DISCERN scores above 50% (indicating fair quality). These sites were then rated by consumers. Most sites targeted parents and none were specifically developed for youth with JIA. The overall quality of website information was fair, with a mean DISCERN quality rating score of 48.92 out of 75 (+/- 6.56, range 34.0-59.5). Overall completeness of sites was 9.07 out of 16 (+/- 2.28, range 5.25-13.25) and accuracy was 3.09 out of 4 (+/- 0.86, range 2-4), indicating a moderate level of accuracy. Average Flesch-Kincaid grade level and Reading Ease Score were 11.48 (+/- 0.74, range 10.1-12.0) and 36.36 (+/- 10.86, range 6.30-48.1), respectively, indicating that the material was difficult to read. Our study highlights the paucity of high quality Internet health information at an appropriate reading level for youth with JIA and their parents.

Damage-Associated Molecular Patterns – Emerging Targets for Biologic Therapy of Childhood Arthritides

Juvenile idiopathic arthritis (JIA) is a group of chronic childhood arthritides of unknown origin. Although the use of glucocorticoids and immunosuppressants brought a substantial improvement in treatment, the present therapeutic regime could not be considered satisfactory. As inflammation seems to be an essential part of pathogenesis of JIA, efforts have been made to develop pharmaceutical means to mitigate the innate immune system. Emerging targets for treatment are alarmins, a family of multifunctional intracellular proteins with strong pro-inflammatory activity. In the context of JIA, particularly interesting are high mobility group box 1 (HMGB-1) and three members of the S100 family: S100A8, S100A9, and S100A12. No definite conclusion can be made at the time, but both animal models and clinical studies support the concept of alarmins as possible key mediators of JIA. Therefore, pharmacological interference with alarmin pathways could turn out to be an excellent strategy for long-term management of JIA. Several options have been tested and they either inhibit the release of alarmins or sequester the already secreted ones. Although still very few in number, therapeutic experiments on mice are quite optimistic. Thus, it was the purpose of the present review to give an overview of the present knowledge on the topic and to bring this exciting new therapeutic possibility to the focus of rheumatologists.

Current management of juvenile idiopathic arthritis

AbstractOur series Prescribing in children gives practical advice for successful management of childhood problems in general practice. Here, the author describes the available treatment options for juvenile idiopathic arthritis and their place in management. Copyright © 2009 Wiley Interface Ltd

Challenges in the management of juvenile idiopathic arthritis with etanercept

Challenges in the management of juvenile idiopathic arthritis with etanercept Clare E Pain, Liza J McCannAlder Hey Children&rsquo;s NHS Foundation Trust, Eaton Road, Liverpool, UKAbstract: Biologic agents have been designed with the help of immunological studies to target particular areas of the immune system which are thought to play a role in the pathogenesis of disease. Etanercept is a soluble anti-tumor necrosis factor alpha (TNF-&alpha;) agent licensed for the treatment of active poly-articular juvenile idiopathic arthritis (JIA) in children aged 4 to 17 years who have failed to respond to methotrexate alone, or who have been intolerant of methotrexate. The safety and efficacy of etanercept in this patient group has been established by one randomized controlled trial and several longitudinal studies. This, together with the fact that until recently etanercept was the only anti-TNF licensed in JIA, has made it the most common first choice biologic for many clinicians. However, there are still many unanswered questions about etanercept, including its efficacy and safety in different subtypes of JIA, in children under 4 years of age and in those with uveitis. There are still concerns about the long term safety of TNF antagonists in the pediatric age group and unanswered questions about increased risks of malignancy and infection. Although adult studies are useful to improve understanding of these risks, they are not a substitute for good quality pediatric research and follow-up studies. Adult trials often include greater numbers of patients. However, they evaluate a different population and drug behavior may vary in children due to differences in metabolism, growth and impact on a developing immune system. In addition, rheumatoid arthritis is a different disease than JIA. Clinicians need to carefully weigh up the risk benefit ratio of anti-TNF use in children with JIA and push for robust clinical trials to address the questions that remain unanswered. This article summarizes the evidence available for use of etanercept in children with JIA and highlights aspects of treatment in need of further research.Keywords: juvenile idiopathic arthritis, biologic therapy, etanercept