Treatment of Juvenile Idiopathic Arthritis:Therapeutic Approaches for Non‐Systemic Polyarthritis, Sacroiliitis, and Enthesitis
Treatment
Table 3. General medication recommendations for children and adolescents with JIA and polyarthritis
NSAIDs
DMARDs
Glucocorticoids
- Bridging therapy may be of most utility in the setting of limited mobility and/or significant symptoms.
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.
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.
Table 4. General guidelines for the initial and subsequent treatment of children and adolescents with JIA and polyarthritisa,b
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.
Initial therapy
All patients
Patients without risk factors:b
Patients with risk factors:
- 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.
Subsequent therapy: Low disease activity (cJADAS-10 ≤2.5 and ≥1 active joint)
For children receiving a DMARD and/or biologic:
- 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.
Subsequent therapy: Moderate/high disease activity (cJADAS-10 >2.5)
If patient is receiving DMARD monotherapy:
If patient is receiving first TNFi (± DMARD):
- A second TNFi may be appropriate for patients with good initial response to their first TNFi (i.e., secondary failure).
If patient is receiving second biologic:
Table 5. Recommendations for the initial and subsequent treatment of children and adolescents with JIA and sacroiliitis
In children and adolescents with active sacroiliitis despite treatment with NSAIDs:
Glucocorticoids
In children and adolescents with active sacroiliitis despite treatment with NSAIDs:
- Bridging therapy may be of most utility in the setting of high disease activity, limited mobility, and/or significant symptoms.
Physical therapy
Table 6. Recommendations for the initial and subsequent treatment of children and adolescents with JIA and enthesitis
In children and adolescents with active enthesitis despite treatment with NSAIDs:
- Bridging therapy may be of most utility in the setting of high disease activity, limited mobility, and/or significant symptoms.
Physical therapy
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
Last Updated Month/Year
April 13, 2023
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