Screening, Monitoring, and Treatment of Juvenile Idiopathic Arthritis–Associated Uveitis
Publication Date: April 25, 2019
Last Updated: December 15, 2022
Treatment
Recommendations for ophthalmic screening
In children and adolescents with JIAb at high risk of developing uveitis:
- Ophthalmic screening every 3 months is conditionally recommended.
607
Recommendations for ophthalmic monitoring
In children and adolescents with JIA and controlled uveitis who are:
Tapering or discontinuing topical glucocorticoids, ophthalmic monitoring within 1 month after each change of topical glucocorticoids is strongly recommended over monitoring less frequently. ( Strong , Very Low )
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On stable therapy, ophthalmic monitoring no less frequently than every 3 months is strongly recommended over monitoring less frequently. ( Strong , Very Low )
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Tapering or discontinuing systemic therapy, ophthalmic monitoring within 2 months of changing systemic therapy is strongly recommended over monitoring less frequently. ( Strong , Very Low )
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Recommendations for glucocorticoid use
In children and adolescents with JIA and active CAU:
Using prednisolone acetate 1% topical drops is conditionally recommended over difluprednate topical drops. ( Conditional , Very Low )
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Adding or increasing topical glucocorticoids for short-term control is conditionally recommended over adding systemic glucocorticoids. ( Conditional , Very Low )
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In children and adolescents with JIA and CAU still requiring 1–2 drops/day of prednisolone acetate 1% (or equivalent) for uveitis control:
If not on systemic therapy, adding systemic therapy in order to taper topical glucocorticoids is conditionally recommended over not adding systemic therapy and maintaining topical glucocorticoids only. ( Conditional , Very Low )
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If still requiring 1–2 drops/day of prednisolone acetate 1% (or equivalent) for at least 3 months and on systemic therapy, changing or escalating systemic therapy is conditionally recommended over maintaining current systemic therapy. ( Conditional , Very Low )
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In children and adolescents with JIA who develop new CAU activity despite stable systemic therapy:c
Topical glucocorticoids prior to changing/escalating systemic therapy is conditionally recommended over changing/escalating systemic therapy immediately.
( Conditional , Very Low )607
Recommendations for DMARDs and biologics
In children and adolescents with JIA and active CAU who are/have:
Starting systemic treatment for uveitis: Using subcutaneous methotrexate is conditionally recommended over oral methotrexate. ( Conditional , Very Low )
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Starting a TNFi: Starting a monoclonal antibody TNFi is conditionally recommended over etanercept. ( Conditional , Very Low )
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Severe active CAU and sight-threatening complications: Starting methotrexate and a monoclonal antibody TNFi immediately is conditionally recommended over methotrexate as monotherapy. ( Conditional , Very Low )
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Inadequate response to one monoclonal TNFi at standard JIA dose: Escalating the dose and/or frequency of the monoclonal TNFi to above standard is conditionally recommended over switching to another monoclonal antibody TNFi. ( Conditional , Very Low )
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Failed a first monoclonal antibody TNFi at above-standard dose and/or frequency: Changing to another monoclonal antibody TNFi is conditionally recommended over a biologic in another category. ( Conditional , Very Low )
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Failed methotrexate and 2 monoclonal antibody TNFi at above-standard dose and/or frequency: Abatacept or tocilizumab are conditionally recommended as biologic DMARD options, and mycophenolate, leflunomide, or cyclosporine as alternative non-biologic options. ( Conditional , Very Low )
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Recommendations for education about and treatment of AAU
In children and adolescents with spondyloarthritis:
Strongly recommend education regarding the warning signs of AAU for the purpose of decreasing delay in treatment, duration of symptoms, or complications of iritis. ( Strong , Very Low )
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Well-controlled with systemic immunosuppressive therapy (DMARD, biologics) who develop an isolated short-lived episode of AAU: Conditionally recommend against switching systemic immunosuppressive therapy immediately in favor of treating with topical glucocorticoids first. ( Conditional , Very Low )
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Recommendations for tapering therapy for uveitis:
In children and adolescents with JIA and CAU that is controlled on systemic therapy but remain on 1–2 drops/day of prednisolone acetate 1% (or equivalent): Tapering topical glucocorticoids first is strongly recommended over systemic therapy. ( Strong , Very Low )
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In children and adolescents with JIA and uveitis that is well controlled on DMARD and biologic systemic therapy only. Conditionally recommend that there be at least 2 years of well-controlled disease before tapering therapy. ( Conditional , Very Low )
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a Each recommendation had very low quality level of evidence.
b High-risk children are those with oligoarthritis, polyarthritis (rheumatoid factor negative), psoriatic arthritis, or undifferentiated arthritis who are also antinuclear antibody positive, younger than 7 years of age at JIA onset, and have JIA duration of 4 years or less.
c Definition of new CAU activity: no prior uveitis or loss of control of previously controlled uveitis.
Overview
Title
Screening, Monitoring, and Treatment of Juvenile Idiopathic Arthritis–Associated Uveitis
Authoring Organization
American College of Rheumatology