Initial Treatment for Juvenile Idiopathic Arthritis (JIA)
The initial treatment for a child diagnosed with Juvenile Idiopathic Arthritis (JIA) should include a trial of scheduled nonsteroidal anti-inflammatory drugs (NSAIDs) along with intraarticular glucocorticoid injections (IAGCs) as part of initial therapy, with treatment decisions guided by JIA subtype and risk factors for poor outcomes. 1, 2
Treatment Approach by JIA Subtype
Oligoarticular JIA
- A trial of scheduled NSAIDs is conditionally recommended as part of initial therapy 1
- IAGCs are strongly recommended as part of initial therapy, with triamcinolone hexacetonide as the strongly preferred agent 1
- Oral glucocorticoids are conditionally recommended against as part of initial therapy 1
- Conventional synthetic DMARDs (disease-modifying antirheumatic drugs) are strongly recommended if there is inadequate response to NSAIDs and/or IAGCs 1
- Methotrexate is conditionally recommended as the preferred DMARD over leflunomide, sulfasalazine, and hydroxychloroquine 1
Temporomandibular Joint (TMJ) Arthritis
- A trial of scheduled NSAIDs is conditionally recommended as part of initial therapy 1
- IAGCs are conditionally recommended as part of initial therapy, with no preferred steroid type 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
Systemic JIA without Macrophage Activation Syndrome (MAS)
- NSAIDs are conditionally recommended as initial monotherapy 1, 2
- Oral glucocorticoids are conditionally recommended against as initial monotherapy 1, 2
- Conventional synthetic DMARDs are strongly recommended against as initial monotherapy 2
- Biologic DMARDs, such as IL-1 and IL-6 inhibitors, are conditionally recommended as initial monotherapy 2
Non-systemic Polyarthritis, Sacroiliitis, and Enthesitis
- For sacroiliitis: NSAIDs are strongly recommended as initial therapy; if inadequate response, adding TNF inhibitors is strongly recommended 1
- For enthesitis: NSAIDs are strongly recommended as initial therapy; if inadequate response, TNF inhibitors are conditionally recommended over methotrexate or sulfasalazine 1
Factors Influencing Treatment Decisions
Risk Factors for Poor Outcome
- Consideration of risk factors for poor outcome is conditionally recommended to guide treatment decisions 1, 2
- These risk factors include:
- Involvement of ankle, wrist, hip, sacroiliac joint, and/or TMJ
- Presence of erosive disease or enthesitis
- Delay in diagnosis
- Elevated levels of inflammation markers
- Symmetric disease 1
Disease Activity Monitoring
- Use of validated disease activity measures is conditionally recommended to guide treatment decisions, especially to facilitate treat-to-target approaches 1, 2
Treatment Escalation Algorithm
- Initial therapy: Trial of scheduled NSAIDs ± IAGCs 1, 2
- If inadequate response after 2-4 weeks:
- If still inadequate response:
Common Pitfalls and Caveats
- Avoid oral glucocorticoids as initial monotherapy in all JIA subtypes due to long-term side effects 1
- Do not delay escalation to DMARDs if response to NSAIDs is inadequate, as early control of inflammation is crucial for preventing joint damage 1, 4
- For systemic JIA, NSAID monotherapy may be effective only in a subset of patients (≤8 years old, ≤5 joints involved, CRP ≤13 mg/dL) 5
- Monitor for medication side effects - methotrexate requires monitoring of CBC, liver function tests, and creatinine every 4-8 weeks initially, then every 3-4 months 2, 6
- Consider TNF inhibitors earlier in patients with risk factors for poor outcomes 1
- Screen for tuberculosis prior to starting biologic DMARD therapy 2, 3
The evidence supporting these recommendations is generally of low to very low certainty, but represents the most current expert consensus from the American College of Rheumatology guidelines 1.