Treatment of Juvenile Idiopathic Arthritis (JIA): Recommendations for Non-Pharmacologic Therapies, Medication Monitoring, Immunizations, and Imaging

Publication Date: February 24, 2022
Last Updated: September 2, 2022

Treatment

Non-Pharmacologic Therapies

A discussion of healthy, age-appropriate diet is strongly recommended. ( Very low , Strong )
608
Use of a specific diet to treat JIA is strongly recommended against. ( Very low , Strong )
608
Use of supplemental or herbal interventions specifically to treat JIA is conditionally recommended against. ( Very low , Conditional )
608
Physical and occupational therapy (PT/OT) are conditionally recommended regardless of concomitant pharmacologic therapy. ( Very low , Conditional )
608

Medication Monitoring

Non-steroidal anti-inflammatory drugs (NSAIDS): Monitoring via CBC counts, LFTs, and renal function tests every 6–12 months is conditionally recommended ( Very low , Conditional )
608
Methotrexate: Monitoring via CBC counts, LFTs, and renal function tests within the first 1–2 months of usage and every 3–4 months thereafter is strongly recommended. ( Very low , Strong )
608
Decreasing the methotrexate dosage or withholding methotrexate is conditionally recommended if a clinically relevant elevation in LFTs or decreased neutrophil or platelet count is found ( Very low , Conditional )
608
Use of folic/folinic acid in conjunction with methotrexate is strongly recommended in conjunction with methotrexate ( Very low , Strong )
608
Sulfasalazine: Monitoring via CBC counts, LFTs, and renal function tests within the first 1–2 months of usage and every 3–4 months thereafter is conditionally recommended. ( Very low , Conditional )
608
Decreasing the sulfasalazine dosage or withholding sulfasalazine is conditionally recommended if a clinically relevant elevation in LFTs or decreased neutrophil or platelet count is found. ( Very low , Conditional )
608
Leflunomide: Monitoring via CBC counts and LFTs within the first 1–2 months of usage and every 3–4 months thereafter is conditionally recommended ( Very low , Conditional )
608
Altering leflunomide administration is conditionally recommended if a clinically relevant elevation in LFT results occurs (temporary hold of leflunomide for alanine transaminase (ALT) >3× the upper limit of normal [ULN]), as per package insert. ( Very low , Conditional )
608
Baseline and annual retinal screening after starting hydroxychloroquine are conditionally recommended. ( Very low , Conditional )
608
Hydroxychloroquine: Monitoring via CBC counts and LFTs annually is conditionally recommended. ( Very low , Conditional )
608
Tumor necrosis factor inhibitors (TNFi): Monitoring via CBC counts and LFTs annually is conditionally recommended. ( Very low , Conditional )
608
Abatacept: Doing no routine laboratory monitoring is conditionally recommended. ( Very low , Conditional )
608
Tocilizumab:
Monitoring via CBC counts and LFTs within the first 1–2 months of usage and every 3–4 months thereafter is conditionally recommended. ( Very low , Conditional )
608
Monitoring of lipid levels every 6 months is conditionally recommended, as per the package insert. ( Very low , Conditional )
608
Altering tocilizumab administration is conditionally recommended if monitoring reveals elevated LFT results (if 1–3 times the ULN decrease the dosage or increase the interval between doses, if >3 times the ULN withhold administration, if >5 times the ULN discontinue treatment), neutropenia (500–1,000/mm3), or thrombocytopenia (50,000–100,000/mm3), as per the package insert. ( Very low , Conditional )
608
Anakinra: Monitoring via CBC counts and LFTs within the first 1–2 months of usage and every 3–4 months thereafter is conditionally recommended. ( Very low , Conditional )
608
Canakinumab: Monitoring via CBC counts and LFTs within the first 1–2 months of usage and every 3–4 months thereafter is conditionally recommended. ( Very low , Conditional )
608
Tofacitinib:
Monitoring via CBC counts and LFTs within the first 1–2 months of usage and every 3–4 months thereafter is conditionally recommended. (, Conditional )
608
Monitoring of lipid levels 1–2 months after starting treatment is conditionally recommended, as per the package insert. (, Conditional )
608
Altering tofacitinib administration is strongly recommended if monitoring reveals laboratory abnormalities of concern. Specifically, medication should be discontinued if the hemoglobin level is <8 gm/dl or decreases by >2 gm/dl, or for severe neutropenia (<500/mm3) or lymphopenia (<500/mm3), as per the package insert. (, Strong )
608
Given recent approval for JIA and limited experience, recommendations are as per clinical trial, Food and Drug Administration (FDA) guidance and evidence in adults.

Infection Surveillance/Immunizations

No consensus achieved. ( Very low , )
608
Immunization is conditionally recommended for children with active non-systemic JIA who have not yet been immunized for Measles, Mumps, Rubella and/or Varicella prior to starting immunosuppressive medications. ( Very low , Conditional )
608
Tuberculosis (TB) screening is conditionally recommended prior to starting biologic disease-modifying antirheumatic drug (DMARD) therapy and when there is a concern for TB exposure thereafter. ( Very low , Conditional )
608
Immunizations (live and inactivated) are strongly recommended for children with JIA who are not receiving immunosuppressive treatment. ( Very low , Strong )
608
Annual inactivated influenza immunization is strongly recommended for all children with JIA. ( Low , Strong )
608
Inactivated vaccines are strongly recommended for children with JIA who are receiving immunosuppressive treatment. ( Very low , Strong )
608
Live attenuated vaccines are conditionally recommended against for children with JIA who are receiving immunosuppressive treatment. ( Low , Conditional )
608
Vaccines are strongly recommended for household contacts of children with JIA who are receiving immunosuppressive treatment. ( Very low , Strong )
608

Imaging

Use of radiographs as a screening test prior to advanced imaging, for the purpose of identifying active synovitis or enthesitis, is strongly recommended against. ( Very low , Strong )
608
Imaging guidance is conditionally recommended for use with intra-articular glucocorticoid (IAGC) injections of joints that are difficult to access, or to specifically localize the distribution of inflammation. ( Very low , Conditional )
608

Recommendation Grading

Disclaimer

Overview

Title

Treatment of Juvenile Idiopathic Arthritis (JIA): Recommendations for Non-Pharmacologic Therapies, Medication Monitoring, Immunizations, and Imaging.

Authoring Organization

Publication Month/Year

February 24, 2022

Last Updated Month/Year

August 14, 2023

Document Type

Guideline

Country of Publication

US

Inclusion Criteria

Male, Female, Adolescent, Child

Health Care Settings

Ambulatory

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Treatment, Management

Diseases/Conditions (MeSH)

D001171 - Arthritis, Juvenile

Keywords

juvenile idiopathic arthritis, JIA

Source Citation

Onel KB, Horton DB, Lovell DJ, et al. 2021 American College of Rheumatology Guideline for the Treatment of Juvenile Idiopathic Arthritis (JIA): Recommendations for Non-Pharmacologic Therapies, Medication Monitoring, Immunizations, and Imaging.

Methodology

Number of Source Documents
85
Literature Search Start Date
July 31, 2019
Literature Search End Date
July 2, 2020