From the Guidelines
Emergency department treatment for juvenile idiopathic arthritis (JIA) should focus on managing acute pain and inflammation with NSAIDs, such as naproxen or ibuprofen, while coordinating with rheumatology for ongoing care. The initial management includes NSAIDs for pain relief and inflammation reduction, with consideration of intra-articular corticosteroid injections for severe pain or significant joint swelling 1. Systemic corticosteroids, such as oral prednisone, may be used for severe systemic symptoms but should be limited due to growth concerns. Pain control can be supplemented with acetaminophen.
Key considerations in the ED include:
- Physical assessment to evaluate all major joints for swelling, warmth, and limited range of motion
- Laboratory tests, including CBC, ESR, CRP, and joint imaging, to assess disease activity
- Ruling out septic arthritis, which requires immediate antibiotic treatment
- Referral to pediatric rheumatology for follow-up within 1-2 weeks, as JIA requires long-term management with disease-modifying antirheumatic drugs (DMARDs) that are not initiated in the ED
According to the 2019 American College of Rheumatology guideline, initial therapy with a DMARD is strongly recommended over NSAID monotherapy, with methotrexate monotherapy conditionally recommended over triple DMARD therapy 1. The guideline also emphasizes the importance of shared decision-making between the physician, parents, and patient when initiating or escalating treatment.
In terms of specific treatment, the guideline conditionally recommends adding a biologic to the original DMARD over changing to a second DMARD or triple DMARD therapy for patients with moderate to high disease activity 1. However, the ED treatment should prioritize acute pain and inflammation management, with long-term management decisions made in consultation with pediatric rheumatology.
From the Research
ED Treatment for Juvenile Idiopathic Arthritis
The emergency department (ED) treatment for juvenile idiopathic arthritis (JIA) involves a multi-faceted approach, including:
- Nonsteroidal anti-inflammatory drugs (NSAIDs) for mild disease 2
- Intra-articular corticosteroid injections for oligoarthritis 3, 4
- Disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate, sulfasalazine, and leflunomide for extended oligoarthritis and polyarthritis 5, 3, 6
- Biological agents, including tumor necrosis factor alpha (TNFα) inhibitors, interleukin-1 blockade, interleukin-6 blockade, selective costimulation modulators, and selective B-cell blockade, for patients unresponsive to DMARDs 5, 3, 6
- Glucocorticoids, such as prednisone, for achieving rapid disease control in patients with severe polyarthritis or systemic-onset disease 4
Treatment Goals
The primary goals of treatment for JIA include:
- Suppressing inflammation
- Achieving remission
- Relieving pain
- Maintaining function
- Minimizing toxicity 6
Treatment Approach
The treatment approach for JIA should be individualized based on the disease subtype and severity, and may involve a combination of the above treatments 3, 6. A team of healthcare professionals, including a pediatric rheumatologist, ophthalmologist, orthopedist, pediatric psychiatrist, and physiotherapist, should be involved in the treatment and management of JIA 5.