The American College of Rheumatology (ACR) recently released a look at recommendations set to be featured in an upcoming clinical practice guideline for juvenile idiopathic arthritis (JIA). ACR notes that the guidelines are for pediatric and adult patients and are meant to promote aggressive treatment of JIA early to preserve function and maximize quality of life outcomes. Additionally, the guideline encourages timely screening and monitoring along with shared decision-making among patients, caregivers, and clinicians. The full guideline manuscript is anticipated to publish in Arthritis & Rheumatology and Arthritis Care & Research at a later date.
The following recommendations from the ACR 2026 JIA publication are all “Strong” recommendations. View the full-text version to view the “Conditional” recommendations and recommendations with no strength rating.
Key Recommendations from the 2025 ACR JIA Update:
Treatment of Systemic Juvenile Idiopathic Arthritis Recommendations
Initial Therapy: sJIA Without MAS
- In people with newly diagnosed sJIA without MAS:
- We strongly recommend bDMARD (IL-1i or IL-6i) therapies as first-line treatment. There is no preferred agent.
- We strongly recommend against NSAIDs as initial monotherapy.
- We strongly recommend against csDMARDs as initial monotherapy.
Initial Therapy: sJIA with MAS
- In people with newly diagnosed sJIA with MAS:
- We strongly recommend bDMARD (IL-1i or IL-6i) therapies as first-line treatment. There is no preferred agent.
- We strongly recommend systemic glucocorticoids as part of initial therapy.
Subsequent Therapy: sJIA and MAS
- In people with inactive sJIA or Without History of MAS:
- We strongly recommend tapering and discontinuing glucocorticoids after clinical inactive disease (CID) has been attained for sJIA.
Associated Lung Disease
- In people with sJIA:
- We strongly recommend that the presence or development of lung disease should not be considered an absolute contraindication to the use of IL-1/6 inhibitors.
Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Polyarthritis, Oligoarthritis, Enthesitis, Dactylitis, Temporomandibular Joint Arthritis, and Deprescribing Recommendations
General Recommendations
- In people with non-systemic JIA:
- GPS: Risk factors for poor outcomes (e.g., involvement of ankle, wrist, sacroiliac (SI) joint, hip and/or TMJ, presence of erosive disease, enthesitis, delay in diagnosis, elevated inflammatory markers, rheumatoid factor (RF) or cyclic citrullinated peptide (CCP) positivity, symmetric disease) should be considered in non-systemic JIA to guide treatment decisions.
Polyarthritis
- In people with polyarthritis:
- We strongly recommend triamcinolone hexacetonide as the preferred agent for IAGC injections.
- We strongly recommend DMARDs (csDMARD and/or bDMARDs) as first-line therapy.
Oligoarthritis
- In people with oligoarthritis:
- We strongly recommend IAGCs as first-line therapy.
- We strongly recommend triamcinolone hexacetonide as the preferred agent for IAGC injections. We strongly recommend csDMARDs over no csDMARDs for an inadequate response to scheduled NSAIDs and/or IAGCs.
- We strongly recommend bDMARDs for an inadequate response to or intolerance of NSAIDs and/or IAGCs and first-line csDMARD.
Enthesitis
- In people with enthesitis:
- We strongly recommend DMARDs (csDMARDs and/or bDMARDS as first-line therapy.
Dactylitis
- In people with dactylitis:
- We strongly recommend IAGCs and tendon injections as adjuncts to initial therapy.
- We strongly recommend DMARDs (csDMARDS and/or bDMARDs) as first-line therapy.
TMJ Arthritis
- In people with TMJ arthritis:
- We strongly recommend DMARDs (csDMARDS and/or bDMARDs) as first-line therapy.
Subsequent Therapy
- In people with JIA with inadequate response or intolerance to first-line csDMARD:
- We strongly recommend bDMARDS.
Treatment of Juvenile Idiopathic Arthritis: Recommendations for Nonpharmacologic Management, Medication Monitoring, and Imaging Recommendations
Non-Phamacologic Therapies
- In people with JIA:
- We strongly recommend against use of a specific diet alone to treat JIA; however, a discussion of healthy, age-appropriate diet is encouraged.
- We strongly recommend assessment for transition readiness and creation of a transition plan.
Medication Monitoring
- In people with JIA receiving chronic treatment with oral or intravenous glucocorticoids:
- We strongly recommend monitoring for dyslipidemia, hyperglycemia, bone and ocular health at least annually.
- We strongly recommend monitoring growth (height and weight) and blood pressure at least twice a year.
Methotrexate
- In people with JIA receiving treatment with methotrexate:
- We strongly recommend monitoring via CBCD, LFTs, and renal function tests within the first 1-2 months of usage and every 3-4 months thereafter.
- We strongly recommend using folic/folinic acid in conjunction with methotrexate.
Screening, Monitoring, and Treatment of Juvenile Idiopathic Arthritis – Associated Uveitis Recommendations
Ophthalmic Screening
- In children and adolescents with JIA at high risk of developing CAU:
- We strongly recommend ophthalmic screening every three months as compared to monitoring less frequently.
Ophthalmic Monitoring of Children with JIA Diagnosed with CAU
- In children and adolescents with JIA and controlled CAU on stable therapy:
- We strongly recommend ophthalmic monitoring no less frequently than every three months as compared to monitoring less frequently.
- In children and adolescents with JIA and controlled CAU who are tapering or stopping glucocorticoids:
- We strongly recommend ophthalmic monitoring within one month after each change of topical glucocorticoids as compared to monitoring less frequently.
- In children and adolescents with JIA and controlled CAU who are tapering or discontinuing DMARDs:
- We strongly recommend ophthalmic monitoring within two months of changing DMARD therapy as compared to monitoring less frequently.
Check out our other recent rheumatology guideline spotlights and be sure to sign up for alerts to stay informed on the latest published guidelines and articles.