What is the initial treatment approach for a child or adolescent diagnosed with juvenile idiopathic arthritis (JIA)?

Treatment of Juvenile Idiopathic Arthritis

The initial treatment approach for JIA is subtype-specific: oligoarticular JIA should start with scheduled NSAIDs and intraarticular glucocorticoid injections (strongly recommended triamcinolone hexacetonide), polyarticular JIA requires immediate DMARD therapy with methotrexate (not NSAID monotherapy), and systemic JIA should begin with NSAIDs or proceed directly to IL-1/IL-6 inhibitors while avoiding conventional DMARDs as initial monotherapy. 1, 2, 3

Initial Treatment by JIA Subtype

Oligoarticular JIA

• Start with scheduled NSAIDs as first-line therapy (conditionally recommended) 1, 3
• Add intraarticular glucocorticoid injections (IAGCs) as part of initial therapy (strongly recommended) 1, 3
  • Triamcinolone hexacetonide is strongly recommended over triamcinolone acetonide or other steroid preparations 1, 3
• Avoid oral glucocorticoids as initial therapy (conditionally recommended against) 1, 3

If inadequate response to NSAIDs and/or IAGCs:

• Escalate to conventional synthetic DMARDs (strongly recommended) 1
• Methotrexate is the preferred first-line DMARD over leflunomide, sulfasalazine, and hydroxychloroquine 1, 2
• If inadequate response to at least one DMARD, add biologic DMARDs (strongly recommended) 1

Polyarticular JIA

• DMARD therapy is strongly recommended over NSAID monotherapy as initial treatment 2
• Methotrexate monotherapy is the preferred initial DMARD (conditionally recommended) 2
• Subcutaneous methotrexate is conditionally recommended over oral formulation 2, 3
• NSAIDs serve only as adjunct therapy, not primary treatment 3

For patients with poor prognostic features (high-risk joint involvement including hip/wrist/ankle, high disease activity, risk of disabling joint damage):

• Initial biologic therapy may be considered instead of starting with methotrexate alone 2
• Poor prognostic features include: erosive disease, symmetric disease, elevated inflammatory markers, delay in diagnosis, enthesitis, or TMJ involvement 1, 2, 3

If inadequate response to methotrexate monotherapy:

• Adding a biologic to the original DMARD is conditionally recommended over switching to a second DMARD or triple DMARD therapy 2
• An adequate trial of methotrexate is 3 months, but escalation may be appropriate after 6-8 weeks if minimal/no response 2, 3

Systemic JIA (without Macrophage Activation Syndrome)

• NSAIDs are conditionally recommended as initial monotherapy 1, 2, 3
• Oral glucocorticoids are conditionally recommended against as initial monotherapy 1, 2, 3
• Conventional synthetic DMARDs are strongly recommended against as initial monotherapy 1, 2, 3

For inadequate response to NSAIDs and/or glucocorticoids:

• IL-1 or IL-6 inhibitors are strongly recommended over conventional synthetic DMARDs 1, 2, 3
• There is no preferred agent between IL-1 and IL-6 inhibitors 2

Critical caveat: Younger age (≤8 years), fewer joints involved (≤5), and lower CRP (≤13 mg/dL) predict better response to NSAID monotherapy 4. Patients outside these parameters should not undergo prolonged NSAID trials and should escalate quickly to biologics 4.

Enthesitis-Related Arthritis and Sacroiliitis

• NSAIDs are strongly recommended as first-line therapy for both enthesitis and sacroiliitis 1, 3

For active sacroiliitis despite NSAIDs:

• Adding TNF inhibitors is strongly recommended over continued NSAID monotherapy 1
• Sulfasalazine may be used for patients with contraindications to or failure of TNF inhibitors (conditionally recommended) 1
• Methotrexate monotherapy is strongly recommended against 1

For active enthesitis despite NSAIDs:

• TNF inhibitors are conditionally recommended over methotrexate or sulfasalazine 1, 3

Glucocorticoid Use Across All Subtypes

• Bridging oral glucocorticoids (<3 months) during initiation or escalation of therapy are conditionally recommended for high disease activity, limited mobility, or significant symptoms 1, 2, 3
• Chronic low-dose oral glucocorticoids are strongly recommended against irrespective of disease activity or risk factors 2
• Intraarticular glucocorticoid injections of sacroiliac joints are conditionally recommended as adjunct therapy 1

Adjunctive Therapies

• Physical therapy and/or occupational therapy are conditionally recommended for patients with or at risk for functional limitations 1, 2, 3

Disease Activity Monitoring

• Use validated disease activity measures (especially cJADAS-10) to guide treatment decisions and facilitate treat-to-target approaches 1, 2, 3
  • Low disease activity: cJADAS-10 ≤2.5 with ≥1 active joint 2, 3
  • Moderate/high disease activity: cJADAS-10 >2.5 2, 3

Critical Pitfalls to Avoid

• Never use NSAID monotherapy as initial therapy for polyarticular JIA—this is a fundamental error as DMARD therapy is strongly recommended 2, 3
• Never use conventional synthetic DMARDs as initial monotherapy for systemic JIA—they are strongly recommended against; proceed directly to IL-1/IL-6 inhibitors if NSAIDs fail 1, 2, 3
• Never use chronic oral glucocorticoids as maintenance therapy—only short-term bridging (<3 months) is acceptable 1, 2, 3
• Do not delay DMARD initiation in polyarticular JIA—early treatment is critical to prevent permanent joint damage 2, 3
• Do not trial NSAID monotherapy in systemic JIA patients who are >8 years old, have >5 joints involved, or CRP >13 mg/dL—these patients require rapid escalation 4