What is the initial treatment for juvenile idiopathic arthritis (JIA) in pediatric patients?

Initial Treatment for Juvenile Idiopathic Arthritis in Pediatric Patients

For oligoarticular JIA, begin with intraarticular glucocorticoid injections (strongly recommended) and/or a trial of scheduled NSAIDs (conditionally recommended), with triamcinolone hexacetonide as the preferred intraarticular agent. 1, 2

Treatment Algorithm by JIA Subtype

Oligoarticular JIA (Most Common Presentation)

First-Line Therapy:

• Intraarticular glucocorticoid injections (IAGCs) are strongly recommended as part of initial therapy 1, 2
• Triamcinolone hexacetonide is strongly recommended as the preferred agent over other corticosteroid preparations 1, 2
• A trial of scheduled NSAIDs is conditionally recommended as part of initial therapy 1, 2
• Oral glucocorticoids are conditionally recommended AGAINST as part of initial therapy 1, 2

Second-Line Therapy (Inadequate Response to NSAIDs/IAGCs):

• Conventional synthetic DMARDs are strongly recommended if there is inadequate response to scheduled NSAIDs and/or IAGCs 1, 2
• Methotrexate is conditionally recommended as the preferred agent over leflunomide, sulfasalazine, and hydroxychloroquine (in that order of preference) 1, 2

Third-Line Therapy (Inadequate Response to csDMARDs):

• Biologic DMARDs are strongly recommended if there is inadequate response to or intolerance of NSAIDs and/or IAGCs AND at least one conventional synthetic DMARD 1, 2
• There is no preferred biologic agent among available options 1

Systemic JIA Without Macrophage Activation Syndrome

Initial Monotherapy Options:

• 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, 3
• IL-1 or IL-6 inhibitors are conditionally recommended as initial monotherapy 1, 2, 3

For Inadequate Response:

• IL-1 and IL-6 inhibitors are strongly recommended over conventional synthetic DMARDs for inadequate response to or intolerance of NSAIDs and/or glucocorticoids 3
• For residual arthritis with incomplete response to IL-1/IL-6 inhibitors, biologic DMARDs or csDMARDs are strongly recommended over long-term glucocorticoids 3

Temporomandibular Joint (TMJ) Arthritis

Initial Therapy:

• A trial of scheduled NSAIDs is conditionally recommended as part of initial therapy 1, 2
• IAGCs are conditionally recommended as part of initial therapy 1, 2
• There is no preferred agent for intraarticular injection in TMJ arthritis 1
• Oral glucocorticoids are conditionally recommended against as part of initial therapy 1

Escalation for Inadequate Response:

• 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 conventional synthetic DMARD 1

Critical Treatment Considerations

Risk Stratification

Conditionally recommended to guide treatment decisions - assess for poor prognostic features including: 1, 2

• Involvement of ankle, wrist, hip, sacroiliac joint, and/or TMJ
• Presence of erosive disease or enthesitis
• Delay in diagnosis
• Elevated inflammatory markers
• Symmetric disease

Disease Activity Monitoring

• Use validated disease activity measures to guide treatment decisions and facilitate treat-to-target approaches 1, 2
• An adequate trial of methotrexate is considered 3 months, with changing or adding therapy appropriate if no or minimal response after 6-8 weeks 3

Medication Monitoring Requirements

For Methotrexate: 2

• CBC, LFTs, and creatinine strongly recommended every 4-8 weeks initially, then every 3-4 months

For TNF Inhibitors: 2

• CBC and LFTs conditionally recommended within first 1-2 months and every 3-4 months thereafter

For IL-1 Inhibitors (anakinra, canakinumab): 2

• CBC and LFTs conditionally recommended within first 1-2 months and every 3-4 months thereafter

Pre-Treatment Requirements

• TB screening is conditionally recommended prior to starting biologic DMARD therapy 2
• Complete all age-appropriate vaccinations prior to initiating treatment 2, 4

Common Pitfalls to Avoid

Do not use oral glucocorticoids as initial monotherapy - they are conditionally recommended against in both oligoarticular and systemic JIA due to unacceptable toxicities despite universal response 1, 2, 5

Do not start conventional synthetic DMARDs as initial monotherapy in systemic JIA - they are strongly recommended against, with IL-1/IL-6 inhibitors preferred 2, 3

Do not delay escalation of therapy - early treatment initiation is critical to improve long-term outcomes and prevent permanent joint damage 3

Do not continue ineffective therapy - if minimal or no response after 6-8 weeks of methotrexate, changing or adding therapy is appropriate rather than waiting the full 3-month trial 3