Based on emerging new evidence and expert and patient consensus, a guideline development team organized by the American College of Rheumatology (ACR) and the Arthritis Foundation (AF) released updated recommendations for the treatment of children and adolescents with juvenile idiopathic arthritis (JIA) manifesting as non-systemic polyarthritis, sacroiliitis, or enthesitis. This report was published in Arthritis & Rheumatology.
Members of the ACR/AF guideline development team performed a systematic review of published studies and drafted a series of population, intervention, comparison, and outcomes questions focused on the management of JIA in patients with polyarthritis, sacroiliitis, and enthesitis. The quality of evidence and subsequent recommendations were rated using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Final recommendations elicited consensus from both an expert voting panel and a separate parent and patient panel.
Medication Recommendations for Patients with JIA and Polyarthritis
In children and adolescents with JIA and active polyarthritis, nonsteroidal anti-inflammatory drugs (NSAIDs) are considered appropriate for the management of symptoms and are recommended as adjunct therapy, especially during initiation or escalation of disease-modifying antirheumatic drugs (DMARD) or biologic treatments.
Methotrexate therapy is conditionally recommended over leflunomide or sulfasalazine; subcutaneous administration of methotrexate is preferred over oral methotrexate. However, it is important to note that the parent and patient voting panel expressed interest in learning about available alternatives to methotrexate, as some children find the gastrointestinal effects of methotrexate limiting.
The ACR conditionally recommends intraarticular glucocorticoid injections as an adjunct therapy, strongly endorsing the use of triamcinolone hexacetonide over triamcinolone acetonide. It should be noted that intra-articular injections may not be appropriate for a large number of joints or joints that have received multiple injections.
In patients with high or moderate disease activity, a limited course of oral glucocorticoids (<3 months) may be recommended as bridging therapy; however, bridging therapy is not recommended in patients with low disease activity. Regardless of disease activity, the ACR/AF strongly recommend against adding chronic low-dose glucocorticoids in this population given the long-term adverse effects in children.
In children and adolescents with JIA and polyarthritis, biologic combination therapy with a DMARD is strongly recommended for infliximab to reduce risk of anti-drug antibody formation. When initiating biologic treatment for additional disease control, combination therapy with a DMARD is conditionally recommended over monotherapy.
Physical Therapy and Occupational Therapy
Physical therapy and occupational therapy are conditionally recommended for patients with JIA and polyarthritis who experience functional limitations.
Recommendations for Initial and Subsequent Treatment of JIA and Polyarthritis
For all patients with JIA and polyarthritis, the ACR/AF strongly recommends initiating therapy with a DMARD over NSAID monotherapy; methotrexate monotherapy is conditionally recommended over triple DMARD therapy. Initial therapy with a DMARD is conditionally recommended over initial biologic use in patients with or without risk factors; however, the involvement of high-risk joints (cervical spine, wrist, hip) or high disease activity are situations in which initial therapy with a biologic may be preferred.
Subsequent Therapy: Low Disease Activity
In children and adolescents with low disease activity who are receiving initial DMARD or biologic therapy, escalating therapy (intra-articular glucocorticoid, optimizing DMARD or biologic dose, trial of methotrexate, or adding or changing biologics) are conditionally recommended over no escalation therapy. The degree of improvement while receiving current therapy and the specific active joint should be considerations for guiding subsequent interventions.
Subsequent Therapy: Moderate/High Disease Activity
In patients with moderate to high disease activity receiving DMARD monotherapy, the addition of a biologic is conditionally recommended over changing to a second DMARD therapy or changing to triple DMARD therapy. In patients receiving initial tumor necrosis factor (TNFi) with or without DMARD combination therapy, switching to a non-TNFi biologic is conditionally recommended over a second TNFi unless the patients demonstrated a good initial response to their first TNFi. For patients receiving their second biologic, the ACR/AF conditionally recommends using TNFi, abatacept, or tocilizumab (depending on prior biologic use) as subsequent therapy over rituximab.
Recommendations for Initial and Subsequent Treatment of JIA and Sacroiliitis
For treatment of children and adolescents with active sacroiliitis, an NSAID is strongly recommended over no treatment with an NSAID; however, adding TNFi to a patient’s treatment regimen is strongly recommended over continuing NSAID monotherapy. If a patient has contraindications to TNFi or has failed more than 1 TNFi trial, using sulfasalazine is conditionally recommended instead. The ACR/AF strongly recommends against prescribing methotrexate monotherapy in patients with active sacroiliitis; however, it may be considered as an adjunct therapy in patients with concomitant peripheral polyarthritis or in the prevention of antidrug antibodies being formed against TNFi.
Despite NSAID use, bridging therapy with a limited course of oral glucocorticoids (<3 months) is conditionally recommended for children and adolescents with active sacroiliitis and may be best utilized in patients with high disease activity, limited mobility, or significant symptom presentation. Injection of intra-articular glucocorticoids into the sacroiliac joints is conditionally recommended as adjunct therapy.
The ACR/AF conditionally recommends the use of physical therapy in children and adolescents with active sacroiliitis and who experience or risk functional limitations.
Recommendations for Initial and Subsequent Treatment of JIA and Enthesitis
In patients with active enthesitis, an NSAID is strongly recommended over no NSAID treatment. Despite NSAID use, the ACR/AF conditionally recommends treatment with TNFi over methotrexate or sulfasalazine. Bridging therapy using a limited course of oral glucocorticoids (<3 months) is conditionally recommended for children and adolescents with active enthesitis; bridging therapy may be best utilized in patients who present with high disease activity, limited mobility, or significant symptoms.
The use of physical therapy in children and adolescents with active enthesitis who have or risk functional limitations is conditionally recommended by the ACR.
Multiple authors declare affiliations with the pharmaceutical industry. Please refer to reference for a complete list of authors’ disclosures.
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