Management

ACR, Arthritis Foundation Release Guideline for Manifestations of JIA

The American College of Rheumatology (ACR) and the Arthritis Foundation have released an updated guideline for the treatment of juvenile idiopathic arthritis (JIA), specifically addressing therapeutic approaches to nonsystemic polyarthritis, sacroiliitis, and enthesitis, which are common manifestations of the disorder.

The guideline for the treatment of JIA was first released in 2011 by the ACR. The phenotypes nonsystemic polyarthritis, sacroiliitis, and enthesitis were chosen for an updated guideline since a significant amount of research has been performed on these manifestations since the initial guideline, according to Sarah Ringold, MD, MS, an attending physician at Seattle Children’s Hospital and lead author of the recommendations.

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“These are patients who continue to be at risk for increased burden of disease and poor outcomes,” Ringold told Rheumatology Consultant. “While many new treatments are available for these patients, clinicians continue to face a number of questions about optimal approaches to treatment.”

Overall, the guideline includes 39 recommendations, 8 of which are strong and 31 of which are conditional. The guideline also includes input considered by the voting panel from a parent and patient panel.

“This partnership highlighted the importance of incorporating parent and patient preferences into treatment decisions and the need for shared decision-making approaches,” Ringold said.

For children and adolescents with JIA and active polyarthritis (5 or more joints ever involved), the guideline development team made 4 strong recommendations:

  • Triamcinolone hexacetonide should be administered over triamcinolone acetonide for intraarticular glucocorticoid injections;
  • A chronic low‐dose glucocorticoid should not be added, regardless of risk factors or disease activity;
  • Infliximab should be taken in combination with a disease‐modifying antirheumatic drug (DMARD); and
  • Initial therapy with a DMARD should be used over nonsteroidal anti-inflammatory drug (NSAID) monotherapy.

 

Sacroiliitis, and more >>

“An important difference from the 2011 guidelines is that initial NSAID monotherapy is no longer recommended for children with polyarthritis, given the established benefits of early initiation of DMARD therapy for these patients,” Ringold said. “These guidelines also support inactive disease as a treatment goal for children with polyarthritis, with treatment escalation recommended for patients with low disease activity.”

Ringold further added that glucocorticoid use for polyarthritis was not recommended due to potential adverse effects.

“The voting panel made this decision based on the known adverse effects of long-term systemic glucocorticoids in children and the availability of other treatment options,” she said.

In active sacroiliitis, the panel recommended against both methotrexate monotherapy and continued NSAID therapy when the addition of a tumor necrosis factor inhibitor is an option. However, the guideline developers recommend the use of NSAIDs over no treatment; this same recommendation was made for children and adolescents with active enthesitis.

Ringold noted that the recommendations are the first to specifically address enthesitis in children.

The guideline also includes recommendations on the use of physical and occupational therapy, as well as adjunctive therapies.

More research is still needed for future recommendations, Ringold said.

“Ongoing work delineating the underlying biology of JIA will be of importance in helping physicians to better understand which patients are most likely to benefit from particular treatments,” she said.

—Colleen Murphy

 

Reference:

Ringold S, Angeles‐Han ST, Beukelman T, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the treatment of juvenile idiopathic arthritis: therapeutic approaches for non‐systemic polyarthritis, sacroiliitis, and enthesitis [published online April 25, 2019]. Arthritis Rheumatol. doi:10.1002/art.40884.