What are the Great Ormond Street Hospital (GOSH) guidelines for rheumatology?

From the Guidelines

The Great Ormond Street Hospital (GOSH) rheumatology guidelines recommend a stepwise approach to managing pediatric rheumatological conditions, prioritizing methotrexate as the first-line DMARD and biologic agents for inadequate response, with a focus on achieving disease remission and minimizing medication side effects. The treatment approach typically involves:

• Initial treatment with NSAIDs like naproxen (10-20 mg/kg/day divided twice daily) or ibuprofen (30-40 mg/kg/day divided three to four times daily) for pain and inflammation control 1
• Methotrexate as the first-line DMARD at 10-15 mg/m² once weekly (oral or subcutaneous), with folic acid supplementation (1 mg daily except on methotrexate day) 1
• Biologic agents, such as TNF inhibitors like etanercept (0.8 mg/kg weekly, maximum 50 mg) or adalimumab (24 mg/m² every 2 weeks, maximum 40 mg), for inadequate response after 3-6 months 1
• Regular monitoring, including clinical assessment every 3-6 months, laboratory tests (CBC, liver function, renal function) every 2-3 months, and ophthalmology screening for uveitis 1
• Corticosteroids, such as prednisolone at 0.5-2 mg/kg/day (maximum 60 mg) with tapering over 4-8 weeks, for acute flares 1
• Multidisciplinary care, involving physiotherapy, occupational therapy, and psychological support, for optimal outcomes 1 Key considerations in treatment decisions include:
• Achieving disease remission
• Preventing joint damage
• Maintaining growth and development
• Minimizing medication side effects
• Incorporating patient preferences and values into decision-making 1

From the Research

Rheumatology GOSH Guideline

• The treatment of juvenile idiopathic arthritis (JIA) typically involves non-steroidal anti-inflammatory drugs or disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate or sulfasalazine 2.
• However, some patients may not respond to these treatments, and toxicities may limit long-term use or diminish compliance, leading to the development of new therapeutic agents such as biologic agents 2.
• Biologic agents, including anti-tumor necrosis factor (TNF)-α, anti-interleukin (IL)-1, and anti-IL6, have shown improvements in the treatment of both systemic and non-systemic JIA 2, 3.
• Other treatment options, such as anti-cell therapies, small molecules, and biosimilars, are also being explored, although many are not yet commercially available for use in children 2.
• A systematic review of disease-modifying antirheumatic drugs for JIA found that methotrexate may be superior to conventional therapy, and that continued treatment with biologic DMARDs can decrease the risk of flare-ups 4.
• The use of non-steroidal anti-inflammatory drugs for the treatment of JIA has decreased in recent years, potentially due to the increased use of aggressive modern therapies such as methotrexate and biologic modifiers 5.
• A study comparing the efficacy and safety of ibuprofen and naproxen in the treatment of oligoarticular JIA found that both drugs had similar efficacy, but ibuprofen had a better safety profile 6.

Treatment Options

• Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen are commonly used to treat JIA, particularly oligoarticular JIA 6.
• Disease-modifying antirheumatic drugs (DMARDs) such as methotrexate and sulfasalazine are also used to treat JIA, and may be more effective than NSAIDs in some cases 2, 4.
• Biologic agents, including anti-TNF-α, anti-IL-1, and anti-IL6, are being increasingly used to treat JIA, particularly in patients who do not respond to traditional therapies 2, 3.

Safety and Efficacy

• The safety and efficacy of different treatment options for JIA are being continually studied, with a focus on minimizing adverse events and maximizing treatment outcomes 2, 3, 6, 4, 5.
• A study found that ibuprofen had a better safety profile than naproxen in the treatment of oligoarticular JIA, with fewer adverse events reported 6.
• The use of biologic agents in JIA has been shown to be effective and safe, although long-term safety data are still needed 3.