The American College of Rheumatology (ACR) and the Arthritis Foundation (AF) have released updated recommendations for the screening, monitoring, and treatment of juvenile idiopathic arthritis (JIA) with associated uveitis.

The guidelines were developed using a systematic literature review and rating of available evidence according to Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Pediatric rheumatologists, ophthalmologists, patient representatives, and methodologists generated clinical questions to be addressed in the guideline, and a group consensus process was used to compose the final recommendations. Each recommendation was graded by strength as conditional or strong.

A summary of the guideline is as follows:

Ophthalmic Screening of Children With JIA

● Ophthalmic screening every 3 months is conditionally recommended in children and adolescents with JIA at high risk of developing uveitis.

Ophthalmic Monitoring of Children With JIA Diagnosed With Uveitis

● The ACR/AF strongly recommend ophthalmologic monitoring within 1 month after each change of topical glucocorticoids for children and adolescents with controlled uveitis who are tapering or discontinuing topical glucocorticoids.

● Ophthalmic monitoring no less frequently than every 3 months is strongly recommended in children and adolescents with JIA and controlled uveitis on stable therapy.

● Ophthalmic monitoring within 2 months of changing systemic therapy is strongly recommended in patients with JIA and controlled uveitis who are tapering or discontinuing systemic therapy.

Recommendations for Glucocorticoid Use

● Use of prednisolone acetate 1% topical drops is conditionally recommended over difluprednate topical drops in children and adolescents with JIA and active chronic anterior uveitis.

● Adding or increasing topical glucocorticoids for short-term control is conditionally recommended over adding systemic glucocorticoids in children and adolescents with JIA and active chronic anterior uveitis.

● Topical glucocorticoids are conditionally recommended in children and adolescents with JIA who develop new chronic anterior uveitis activity despite stable systemic therapy.

● Adding systemic therapy to taper topical glucocorticoids is conditionally recommended in children and adolescents with JIA and chronic anterior uveitis who require 1 to 2 drops per day of prednisolone acetate 1% for uveitis control.

● In children and adolescents who require 1 to 2 drops per day of prednisolone acetate 1% for at least 3 months and are on systemic therapy for uveitis control, changing or escalating systemic therapy is conditionally recommended.

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Recommendations for Disease-Modifying Antirheumatic Drugs (DMARDs) and Biologics

● Subcutaneous methotrexate is conditionally recommended over oral methotrexate in children and adolescents with JIA and chronic anterior uveitis who are starting systemic treatment for uveitis.

● Initiating methotrexate and a monoclonal antibody tumor necrosis factor inhibitor (TNFi) is recommended over methotrexate monotherapy in patients with JIA and severe active chronic anterior uveitis and sight-threatening complications.

● Initiating a monoclonal antibody TNFi is conditionally recommended over etanercept in patients with JIA and active chronic anterior uveitis.

● In children and adolescents with JIA and active chronic anterior uveitis who experience an inadequate response to 1 monoclonal antibody TNFi, escalating the dose or frequency is conditionally recommended.

● Switching to another monoclonal antibody TNFi is conditionally recommended over a biologic in another category in patients who have not responded to a first monoclonal antibody TNFi at an above-standard dose or frequency.

● In patients who have not responded to methotrexate and 2 monoclonal antibody TNFi at above-standard doses or frequencies, abataceot and tocilizumab are conditionally recommended as biologic DMARD options, and mycophenolate, leflunomide, or cyclosporine are conditionally recommended as alternative non-biologic DMARD options.

Recommendations for Education About and Treatment of Acute Anterior Uveitis

● Education regarding the warning signs of acute anterior uveitis is strongly recommended in children and adolescents with spondyloarthritis in order to decrease delay in treatment, duration of symptoms, and complications of iritis.

● In patients with spondyloarthritis otherwise well-controlled with DMARDs or biologics who develop acute anterior uveitis, switching systemic immunosuppressive therapy is conditionally recommended against, in favor of topical glucocorticoids.

Recommendations for Tapering Therapy for Uveitis

● In children and adolescents with JIA and chronic anterior uveitis that is controlled on systemic therapy but who remain on 1 to 2 drops per day of prednisolone acetate 1%, tapering topical glucocorticoids first is strongly recommended over systemic therapy.

● In patients with uveitis that is well controlled on DMARD and biologic systemic therapy only, it is conditionally recommended that there be at least 2 years of well-controlled disease before tapering therapy.

Reference

Angeles-Han ST, Ringold S, Beukelman T, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the screening, monitoring, and treatment of juvenile idiopathic arthritis-associated uveitis [published online April 25, 2019]. Arthritis Care Res. doi:10.1002/acr.23871