Treatment Approach for Suspected Juvenile Idiopathic Arthritis
For a child with suspected juvenile idiopathic arthritis, initiate scheduled NSAIDs immediately while expediting rheumatology referral, and do not delay starting methotrexate once the diagnosis is confirmed, as NSAIDs are adjunct therapy only and early DMARD therapy is crucial to prevent permanent joint damage. 1
Initial Assessment and Immediate Management
Diagnostic Workup
- Obtain laboratory studies including CBC with differential, ESR, and CRP to assess inflammation 1
- Order plain radiographs and ultrasound to detect effusion and assess for other joint involvement 1
- Look for systemic symptoms such as fever, multiple joint involvement, and morning stiffness that raise concern for JIA 1
First-Line Therapy While Awaiting Rheumatology Consultation
- Start scheduled NSAIDs immediately as adjunct therapy 2, 1
- Ibuprofen is the first-line NSAID at weight-appropriate dosing 3
- Naproxen is the preferred alternative for chronic inflammatory conditions 3, 4
- Allow an adequate trial of at least 8 weeks of NSAID therapy 4
- Avoid aspirin due to risk of Reye's syndrome 3
Subtype-Specific Treatment Algorithms
Oligoarticular JIA (≤4 joints)
Initial therapy:
- Scheduled NSAIDs are conditionally recommended 2, 1
- Intraarticular glucocorticoid injections are conditionally recommended as part of initial therapy 2, 1
- Triamcinolone hexacetonide is strongly recommended over triamcinolone acetonide for intraarticular injections 2, 1
- Oral glucocorticoids are conditionally recommended against 2, 1
Second-line therapy (inadequate response to NSAIDs/IAGCs):
- Conventional synthetic DMARDs are strongly recommended 2, 1
- Methotrexate is conditionally recommended as the preferred agent over leflunomide, sulfasalazine, and hydroxychloroquine 2, 1
- Subcutaneous methotrexate is conditionally recommended over oral methotrexate 2
Third-line therapy:
- Biologic DMARDs are strongly recommended after failure of NSAIDs/IAGCs and at least one conventional synthetic DMARD 1
Polyarticular JIA (≥5 joints)
Initial therapy:
- NSAIDs are conditionally recommended as adjunct therapy 2
- Methotrexate should be initiated as first-line disease-modifying therapy without delay 4
- Subcutaneous methotrexate is conditionally recommended over oral methotrexate 2
- Intraarticular glucocorticoids are conditionally recommended as adjunct therapy 2
- Bridging therapy with limited course of oral glucocorticoid (<3 months) during initiation or escalation of therapy in patients with high or moderate disease activity is conditionally recommended 2
- Bridging therapy is conditionally recommended against in patients with low disease activity 2
- Chronic low-dose glucocorticoids are strongly recommended against irrespective of risk factors or disease activity 2
Escalation for inadequate response:
- Biologic DMARDs (TNF inhibitors, IL-6 inhibitors, abatacept) are recommended 2
- Combination therapy with a DMARD is conditionally recommended over biologic monotherapy for etanercept, adalimumab, golimumab, abatacept, or tocilizumab 2
- Combination therapy with a DMARD is strongly recommended for infliximab 2
Systemic JIA (with fever and systemic features)
Initial monotherapy options:
- NSAIDs are conditionally recommended 2, 1
- IL-1 and IL-6 inhibitors (anakinra, canakinumab, tocilizumab) are conditionally recommended as initial monotherapy 2
- Oral glucocorticoids are conditionally recommended against 2, 1
- Conventional synthetic DMARDs are strongly recommended against as initial monotherapy 2, 1
Escalation:
- IL-1 and IL-6 inhibitors are strongly recommended over conventional synthetic DMARDs for inadequate response to NSAIDs and/or glucocorticoids 1
Enthesitis-Related Arthritis
Initial therapy:
- NSAIDs are strongly recommended as first-line therapy 1
- Physical therapy is conditionally recommended for those with or at risk for functional limitations 1
- Bridging oral glucocorticoids (<3 months) may be considered if high disease activity, limited mobility, or significant symptoms are present 1
Escalation:
- TNF inhibitors are strongly recommended for sacroiliitis 1
- TNF inhibitors are conditionally recommended over methotrexate or sulfasalazine for enthesitis 1
Temporomandibular Joint (TMJ) Arthritis
Initial therapy:
- Scheduled NSAIDs are conditionally recommended 2
- Intraarticular glucocorticoids are conditionally recommended 2
- Oral glucocorticoids are conditionally recommended against 2
Second-line therapy:
- Conventional synthetic DMARDs are strongly recommended for inadequate response to or intolerance of NSAIDs and/or IAGCs 2
Third-line therapy:
- Biologic DMARDs are conditionally recommended for inadequate response to or intolerance of NSAIDs and/or IAGCs and at least 1 conventional synthetic DMARD 2
Adjunctive Therapies
Physical and Occupational Therapy
- Physical therapy and/or occupational therapy is conditionally recommended for children who have or are at risk for functional limitations 2, 1
Critical Treatment Principles
Treat-to-Target Approach
- Use validated disease activity measures (such as cJADAS-10) to guide treatment decisions and facilitate treat-to-target approaches 1
- Low disease activity is defined as cJADAS-10 ≤2.5 with ≥1 active joint 2
- Moderate/high disease activity is defined as cJADAS-10 >2.5 2
Poor Prognostic Features Requiring Aggressive Treatment
- Consider poor prognostic features to guide treatment escalation: involvement of ankle, wrist, hip, sacroiliac joint, TMJ, erosive disease, enthesitis, delay in diagnosis, elevated inflammation markers, and symmetric disease 1
- Positive rheumatoid factor, positive anti-CCP antibodies, and joint damage are additional risk factors 2
Critical Pitfalls to Avoid
Timing and Escalation Errors
- Do not delay disease-modifying therapy when NSAIDs are used for JIA, as NSAIDs are adjunct therapy only 3, 1, 4
- Insidious onset joint pain should not be dismissed as simple overuse without ruling out inflammatory arthritis, as early DMARD therapy is crucial to prevent permanent joint damage 1
- An adequate trial of methotrexate is considered to be 3 months, but if no or minimal response is observed after 6-8 weeks, changing or adding therapy may be appropriate 2
Glucocorticoid Misuse
- Prolonged oral glucocorticoids should not be used as monotherapy and are only recommended for short-term bridging (<3 months) 2, 1
- Chronic low-dose glucocorticoids should be avoided in adolescents with musculoskeletal pain 3
Monitoring Requirements
- For chronic NSAID use, monitor CBC, liver function tests, and renal function tests every 6-12 months, as well as blood pressure 3
- NSAID-induced asthma history is a contraindication for NSAID use 3