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

Initial Treatment for Juvenile Idiopathic Arthritis

The initial treatment for juvenile idiopathic arthritis depends on the subtype: for oligoarticular JIA, start with scheduled NSAIDs and/or intraarticular glucocorticoid injections; for polyarticular JIA, initiate methotrexate as first-line DMARD therapy; and for systemic JIA without macrophage activation syndrome, NSAIDs are conditionally recommended as initial monotherapy while conventional synthetic DMARDs are strongly recommended against. 1

Oligoarticular JIA Initial Approach

For children with oligoarticular JIA, the treatment algorithm begins with NSAIDs and intraarticular glucocorticoids as first-line therapy. 2

• A trial of scheduled NSAIDs (not as-needed dosing) is conditionally recommended as part of initial therapy 2
• Intraarticular glucocorticoid injections (IAGCs) are strongly recommended as part of initial therapy 2, 1
• Oral glucocorticoids are conditionally recommended against as part of initial therapy 2
• Ibuprofen should be considered as the preferred NSAID over naproxen due to superior safety profile, though efficacy is similar 3
• Treatment duration exceeding 28 days is associated with significantly higher odds for complete response 3

Escalation for Oligoarticular JIA

If there is inadequate response to or intolerance of NSAIDs and/or IAGCs:

• Conventional synthetic DMARDs are strongly recommended, with methotrexate conditionally recommended as the preferred agent 2, 1
• An adequate trial of methotrexate is considered 3 months, though changing or adding therapy is appropriate if no or minimal response is observed after 6-8 weeks 1
• 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 2, 1

Polyarticular JIA Initial Approach

For polyarticular JIA, initial therapy with a DMARD is strongly recommended over NSAID monotherapy. 1

• Methotrexate monotherapy is conditionally recommended as initial therapy 1
• Subcutaneous methotrexate is conditionally recommended over oral methotrexate 1
• For patients without risk factors for poor outcome, initial therapy with a DMARD is conditionally recommended over a biologic 1
• For patients with risk factors (high-risk joint involvement including ankle, wrist, hip, sacroiliac joint, TMJ; erosive disease; enthesitis; elevated inflammatory markers; symmetric disease), initial therapy with a DMARD is still conditionally recommended over a biologic, though initial biologic therapy may be considered for those with high disease activity or at high risk of disabling joint damage 2, 1

Escalation for Polyarticular JIA

• For low disease activity with inadequate response, escalating therapy is conditionally recommended with options including IAGCs, optimization of DMARD dose, trial of methotrexate, or adding/changing biologic 1
• For moderate/high disease activity, adding a biologic to the original DMARD is conditionally recommended over changing to a second DMARD or triple DMARD therapy 1

Systemic JIA Without MAS Initial Approach

The treatment paradigm for systemic JIA differs substantially from other JIA subtypes due to its autoinflammatory nature. 2

• NSAIDs are conditionally recommended as initial monotherapy 2
• Oral glucocorticoids are conditionally recommended against as initial monotherapy 2
• Conventional synthetic DMARDs are strongly recommended against as initial monotherapy 2
• Biologic DMARDs (IL-1 and IL-6 inhibitors such as anakinra, canakinumab, or tocilizumab) are conditionally recommended as initial monotherapy, with no preferred agent 2

Escalation for Systemic JIA

• IL-1 and IL-6 inhibitors are strongly recommended over single or combination conventional synthetic DMARDs for inadequate response to or intolerance of NSAIDs and/or glucocorticoids 2
• Biologic DMARDs or conventional synthetic DMARDs are strongly recommended over long-term glucocorticoids for residual arthritis and incomplete response to IL-1 and/or IL-6 inhibitors 2

TMJ Arthritis Specific Considerations

For children with active TMJ arthritis:

• A trial of scheduled NSAIDs is conditionally recommended as part of initial therapy 2, 4
• IAGCs are conditionally recommended as part of initial therapy, though caution is warranted in skeletally immature patients due to growth plate damage risk 2, 4
• Oral glucocorticoids are conditionally recommended against as part of initial therapy 2
• Conventional synthetic DMARDs (methotrexate, leflunomide, sulfasalazine, or hydroxychloroquine) are strongly recommended for inadequate response to or intolerance of NSAIDs and/or IAGCs 2, 4

Critical Implementation Points

Early treatment initiation is critical to improve long-term outcomes and prevent permanent joint damage. 1

• Use validated disease activity measures to guide treatment decisions and facilitate treat-to-target approaches 2, 1
• Consider risk factors for poor outcome when making treatment decisions, as these should guide escalation timing 2
• FDA-approved biologic options for JIA include adalimumab (age ≥2 years) and etanercept (age ≥2 years), both indicated for polyarticular JIA and can be used alone or with methotrexate 5, 6
• NSAIDs serve primarily as bridging therapy until more definitive treatment (IAGCs or DMARDs) can be achieved, given their modest efficacy rates of only 15-17% complete response 3

Common Pitfalls to Avoid

• Do not use oral glucocorticoids as initial monotherapy for oligoarticular or systemic JIA, as they are conditionally or strongly recommended against 2
• Do not start conventional synthetic DMARDs as initial monotherapy for systemic JIA without MAS—this is strongly recommended against 2
• Avoid repeated glucocorticoid injections in skeletally immature patients due to growth plate damage risk 4
• Do not delay escalation to DMARDs in polyarticular JIA—DMARD therapy is strongly recommended over NSAID monotherapy 1
• Monitor for adverse events with NSAIDs, particularly gastrointestinal and renal complications, though ibuprofen demonstrates better safety than naproxen 3, 7