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
Title
Treatment of Juvenile Idiopathic Arthritis (JIA): Recommendations for Non-Pharmacologic Therapies, Medication Monitoring, Immunizations, and Imaging.
Authoring Organization
American College of Rheumatology
Publication Month/Year
February 24, 2022
Last Updated Month/Year
August 14, 2023
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