Latest Guidelines for Juvenile Idiopathic Arthritis (JIA) from ACR, EULAR, and BSR
The most recent comprehensive guidelines for managing JIA come from the 2021 American College of Rheumatology (ACR) guidelines, which provide detailed recommendations for oligoarthritis, temporomandibular joint arthritis, and systemic JIA based on a treat-to-target approach with consideration of risk factors for poor outcomes. 1
General Treatment Approach for JIA
Oligoarticular JIA Treatment Algorithm
- A trial of scheduled NSAIDs is conditionally recommended as part of initial therapy 1
- Intraarticular glucocorticoid injections (IAGCs) are strongly recommended as part of initial therapy 1
- Triamcinolone hexacetonide is strongly recommended as the preferred IAGC agent 1
- Oral glucocorticoids are conditionally recommended against as part of initial therapy 1
- Conventional synthetic DMARDs (csDMARDs) are strongly recommended if there is inadequate response to NSAIDs and/or IAGCs 1
- Methotrexate is conditionally recommended as the preferred csDMARD over leflunomide, sulfasalazine, and hydroxychloroquine 1
- Biologic DMARDs are strongly recommended if there is inadequate response to or intolerance of NSAIDs and/or IAGCs and at least one csDMARD 1
- No specific biologic DMARD is preferred over others 1
TMJ Arthritis Treatment Algorithm
- A trial of scheduled NSAIDs is conditionally recommended as part of initial therapy 1
- IAGCs are conditionally recommended as part of initial therapy 1
- No specific steroid agent is preferred for intraarticular injection 1
- Oral glucocorticoids are conditionally recommended against as part of initial therapy 1
- Conventional synthetic DMARDs are strongly recommended for inadequate response to or intolerance of NSAIDs and/or IAGCs 1
- Biologic DMARDs are conditionally recommended for inadequate response to or intolerance of NSAIDs and/or IAGCs and at least one csDMARD 1
- No specific biologic agent is preferred 1
Systemic JIA Treatment Algorithm
- NSAIDs are conditionally recommended as initial monotherapy 1
- Oral glucocorticoids are conditionally recommended against as initial monotherapy 1
- Conventional synthetic DMARDs are strongly recommended against as initial monotherapy 1
- Biologic DMARDs (IL-1 and IL-6 inhibitors) are conditionally recommended as initial monotherapy 1
- No specific IL-1 or IL-6 inhibitor is preferred 1
Risk Factors and Disease Monitoring
Risk Factors for Poor Outcome
- Consideration of risk factors for poor outcome is conditionally recommended to guide treatment decisions 1
- Risk factors include:
Disease Activity Monitoring
- Use of validated disease activity measures is conditionally recommended to guide treatment decisions, especially to facilitate treat-to-target approaches 1
- Imaging guidance is conditionally recommended for use with intraarticular glucocorticoid injections 1
- Radiography as a screening test prior to advanced imaging for identifying active synovitis or enthesitis is strongly recommended against 1
Medication Monitoring and Immunizations
Laboratory Monitoring
- For methotrexate: CBC, LFTs, and creatinine are strongly recommended to be monitored every 4-8 weeks initially, then every 3-4 months 1
- For TNF inhibitors: CBC and LFTs are conditionally recommended to be monitored within the first 1-2 months and every 3-4 months thereafter 1
- For tocilizumab: CBC, LFTs, and lipids require monitoring with specific parameters for dose adjustment 1
- For IL-1 inhibitors (anakinra, canakinumab): CBC and LFTs are conditionally recommended to be monitored within the first 1-2 months and every 3-4 months thereafter 1
- For tofacitinib: CBC, LFTs, and lipids require monitoring with specific parameters for dose adjustment 1
Immunization Recommendations
- TB screening is conditionally recommended prior to starting biologic DMARD therapy and when there is concern for TB exposure 1
- Immunizations (live and inactivated) are strongly recommended for children with JIA not on immunosuppression 1
- Annual influenza immunization is strongly recommended for all children with JIA 1
- Inactivated vaccines are strongly recommended for children with JIA on immunosuppression 1
- Live attenuated vaccines are conditionally recommended against for children with JIA on immunosuppression 1
- Immunization is conditionally recommended for children with active non-systemic JIA who have not yet been immunized for Measles, Mumps, Rubella, and/or Varicella prior to starting immunosuppressive medications 1
Important Considerations and Pitfalls
- The guidelines emphasize a treat-to-target approach, which requires regular assessment of disease activity and adjustment of therapy accordingly 1, 2
- Early aggressive treatment may be warranted in patients with risk factors for poor outcomes 1
- Medication choices should be guided by both efficacy and safety profiles, with consideration of the specific JIA subtype 3
- Careful monitoring for medication side effects and appropriate dose adjustments are essential for safe treatment 1
- While these guidelines provide a framework, the heterogeneity of JIA requires individualized treatment approaches based on disease subtype, severity, and patient factors 3
- The concept of "window of opportunity" suggests that early effective treatment may improve long-term outcomes 2
The ACR guidelines represent the most comprehensive and recent guidance for JIA management. While specific EULAR and BSR guidelines are not as recently updated, the ACR guidelines incorporate international evidence and are generally applicable across different healthcare systems 1.