Treatment of Juvenile Idiopathic Arthritis:Therapeutic Approaches for Non‐Systemic Polyarthritis, Sacroiliitis, and Enthesitis
Publication Date: April 25, 2019
Treatment
Table 3. General medication recommendations for children and adolescents with JIA and polyarthritis
Each recommendation is preceded by the phrase: “In children and adolescents with JIA and active polyarthritis…”
NSAIDs
NSAIDs are conditionally recommended as adjunct therapy. (, Very Low )
607
DMARDs
Using methotrexate is conditionally recommended over leflunomide or sulfasalazine.
leflunomide (, Moderate )
607
sulfasalazine (, Very Low )
607
Using subcutaneous methotrexate is conditionally recommended over oral methotrexate. (, Very Low )
607
Glucocorticoids
Intra-articular glucocorticoids are conditionally recommended as adjunct therapy. (, Very Low )
607
Triamcinolone hexacetonide is strongly recommended over triamcinolone acetonide for intra-articular glucocorticoid injections. (, Moderate )
607
Bridging therapy with a limited course of oral glucocorticoid (<3 months) during initiation or escalation of therapy in patients with high or moderate disease activity is conditionally recommended.a
- Bridging therapy may be of most utility in the setting of limited mobility and/or significant symptoms.
a A bridging course of oral glucocorticoids was defined as a short course (<3 months) of oral glucocorticoids intended to control disease activity quickly during the initiation or escalation of therapy. An adequate trial of methotrexate was considered to be 3 months. If no or minimal response is observed after 6–8 weeks, it was agreed that changing or adding therapy may be appropriate.
607
Conditionally recommend against bridging therapy with a limited course of oral glucocorticoid (<3 months) in patients with low disease activity. (, Very Low )
607
Strongly recommend against adding chronic low-dose glucocorticoid, irrespective of risk factors or disease activity. (, Very Low )
607
Biologic DMARDs
- In children and adolescents with JIA and polyarthritis, initiating treatment with a biologic combination therapy with a DMARD is conditionally recommended over biologic monotherapy.
etanercept, golimumab (, Very Low )
607
abatacept, or tocilizumab (, Low )
607
adalimumab (, Moderate )
607
Combination therapy with a DMARD is strongly recommended for infliximab. (, Low )
607
Physical therapy and occupational therapy
- In children and adolescents with JIA and polyarthritis who have or are at risk of functional limitations, using physical therapy and/or occupational therapy is conditionally recommended.
physical therapy (, Low )
607
occupational therapy (, Very Low )
607
Table 4. General guidelines for the initial and subsequent treatment of children and adolescents with JIA and polyarthritisa,b
a Disease activity (moderate/high and low) as defined by the clinical Juvenile Disease Activity Score based on 10 joints (cJADAS-10) is provided as a general parameter and should be interpreted within the clinical context.
b Risk factors include the presence of any of the following: positive anti-cyclic citrullinated peptide antibodies, positive rheumatoid factor, or presence of joint damage. An adequate trial of methotrexate was considered to be 3 months. If no or minimal response is observed after 6–8 weeks, it was agreed that changing or adding therapy may be appropriate. For the purposes of these recommendations, triple DMARD therapy is methotrexate, sulfasalazine, and hydroxychloroquine. The term biologic refers toTNFi, abatacept, or tocilizumab for each of the recommendations, with the exception of the recommendation for patients with JIA and polyarthritis and moderate or high disease activity despite a second biologic, which includes rituximab. Shared decision-making between the physician, parents, and patient, including discussion of recommended treatments and potential alternatives, is recommended when initiating or escalating treatment.
b Risk factors include the presence of any of the following: positive anti-cyclic citrullinated peptide antibodies, positive rheumatoid factor, or presence of joint damage. An adequate trial of methotrexate was considered to be 3 months. If no or minimal response is observed after 6–8 weeks, it was agreed that changing or adding therapy may be appropriate. For the purposes of these recommendations, triple DMARD therapy is methotrexate, sulfasalazine, and hydroxychloroquine. The term biologic refers toTNFi, abatacept, or tocilizumab for each of the recommendations, with the exception of the recommendation for patients with JIA and polyarthritis and moderate or high disease activity despite a second biologic, which includes rituximab. Shared decision-making between the physician, parents, and patient, including discussion of recommended treatments and potential alternatives, is recommended when initiating or escalating treatment.
Each recommendation is preceded by the phrase: “In children and adolescents with JIA and active polyarthritis…”
Initial therapy
All patients
Initial therapy with a DMARD is strongly recommended over NSAID monotherapy. (, Moderate )
607
Using methotrexate monotherapy as initial therapy is conditionally recommended over triple DMARD therapy. (, Low )
607
Patients without risk factors:b
Initial therapy with a DMARD is conditionally recommended over a biologic. (, Low )
607
Patients with risk factors:
Initial therapy with a DMARD is conditionally recommended over a biologic, recognizing that there are situations where initial therapy that includes a biologic may be preferred.
- Initial biologic therapy may be considered for patients with risk factors and involvement of high-risk joints (e.g., cervical spine, wrist, or hip), high disease activity, and/or those judged by their physician to be at high risk of disabling joint damage.
607
Subsequent therapy: Low disease activity (cJADAS-10 ≤2.5 and ≥1 active joint)
For children receiving a DMARD and/or biologic:
Escalating therapy is conditionally recommended over no escalation of therapy.
- Escalation of therapy may include: Intra-articular glucocorticoid injection(s), optimization of DMARD dose, trial of methotrexate if not done, and adding or changing biologic.
607
Subsequent therapy: Moderate/high disease activity (cJADAS-10 >2.5)
If patient is receiving DMARD monotherapy:
Adding a biologic to original DMARD is conditionally recommended over changing to a second DMARD. (, Low )
607
Adding a biologic is conditionally recommended over changing to triple DMARD therapy. (, Low )
607
If patient is receiving first TNFi (± DMARD):
biologic (tocilizumab or abatacept) is conditionally recommended over switching to a second TNFi.
- A second TNFi may be appropriate for patients with good initial response to their first TNFi (i.e., secondary failure).
607
If patient is receiving second biologic:
Using TNFi, abatacept, or tocilizumab (depending on prior biologics received) is conditionally recommended over rituximab. (, Very Low )
607
Table 5. Recommendations for the initial and subsequent treatment of children and adolescents with JIA and sacroiliitis
In children and adolescents with active sacroiliitis, treatment with an NSAID is strongly recommended over no treatment with an NSAID. (, Very Low )
607
In children and adolescents with active sacroiliitis despite treatment with NSAIDs:
Adding TNFi is strongly recommended over continued NSAID monotherapy. (, Low )
607
Using sulfasalazine for patients who have contraindications to or have failed a TNFi is conditionally recommended. (, Low )
607
Strongly recommend against using methotrexate monotherapy. (, Very Low )
607
Glucocorticoids
In children and adolescents with active sacroiliitis despite treatment with NSAIDs:
Bridging therapy with a limited course of oral glucocorticoid (<3 months) during initiation or escalation of therapy is conditionally recommended.a
- Bridging therapy may be of most utility in the setting of high disease activity, limited mobility, and/or significant symptoms.
a A bridging course of oral glucocorticoids was defined as a short course (<3 months) of oral glucocorticoids intended to control disease activity quickly during the initiation or escalation of therapy.
607
Intra-articular glucocorticoid injection of the sacroiliac joints as adjunct therapy is conditionally recommended. (, Very Low )
607
Physical therapy
In children and adolescents with sacroiliitis who have or are at risk for functional limitations, using physical therapy is conditionally recommended. (, Very Low )
607
Table 6. Recommendations for the initial and subsequent treatment of children and adolescents with JIA and enthesitis
In children and adolescents with active enthesitis, NSAID treatment is strongly recommended over no treatment with an NSAID. (, Very Low )
607
In children and adolescents with active enthesitis despite treatment with NSAIDs:
Using a TNFi is conditionally recommended over methotrexate or sulfasalazine. (, Low )
607
Bridging therapy with a limited course of oral glucocorticoids (<3 months) during initiation or escalation of therapy is conditionally recommended.a
- Bridging therapy may be of most utility in the setting of high disease activity, limited mobility, and/or significant symptoms.
a A bridging course of oral glucocorticoids was defined a short course (<3 months) of oral glucocorticoids intended to control disease activity quickly during the initiation or escalation of therapy.
607
Physical therapy
In children and adolescents with enthesitis who have or are at risk for functional limitations, using physical therapy is conditionally recommended. (, Very Low )
607
Recommendation Grading
Disclaimer
Overview
Title
Treatment of Juvenile Idiopathic Arthritis:Therapeutic Approaches for Non‐Systemic Polyarthritis, Sacroiliitis, and Enthesitis
Authoring Organization
American College of Rheumatology
Publication Month/Year
April 25, 2019
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
To develop treatment recommendations for children with juvenile idiopathic arthritis manifesting as non‐systemic polyarthritis, sacroiliitis, or enthesitis.
Inclusion Criteria
Female, Male, Adolescent, Child, Infant
Health Care Settings
Ambulatory, Childcare center, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management, Treatment
Diseases/Conditions (MeSH)
D001171 - Arthritis, Juvenile, D010372 - Pediatrics, D058566 - Sacroiliitis
Keywords
juvenile idiopathic arthritis, sacroiliitis, enthesitis, JIA, Non‐Systemic Polyarthritis
Source Citation
Ringold, S., Angeles‐Han, S.T., Beukelman, T., Lovell, D., Cuello, C.A., Becker, M.L., Colbert, R.A., Feldman, B.M., Ferguson, P.J., Gewanter, H., Guzman, J., Horonjeff, J., Nigrovic, P.A., Ombrello, M.J., Passo, M.H., Stoll, M.L., Rabinovich, C.E., Schneider, R., Halyabar, O., Hays, K., Shah, A.A., Sullivan, N., Szymanski, A.M., Turgunbaev, M., Turner, A. and Reston, J. (2019), 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Non‐Systemic Polyarthritis, Sacroiliitis, and Enthesitis. Arthritis Care Res, 71: 717-734. doi:10.1002/acr.23870