ACR and AF Release Guidelines for 2 Subtypes of Juvenile Idiopathic Arthritis

The American College of Rheumatology (ACR) and the Arthritis Foundation (AF) this week released guidelines for treating 2 subtypes of juvenile idiopathic arthritis (JIA), which affects nearly 300,000 children in the United States.

One guideline discusses therapeutic approaches for non-systemic polyarthritis, sacroiliitis, and enthesitis; the other focuses on the screening, monitoring, and treatment of JIA with associated uveitis.

Juvenile arthritis is an umbrella term used to describe the autoimmune and inflammatory conditions or pediatric rheumatic diseases, like JIA, that can develop in children younger than 16, according to the AF.

To address polyarthritis, guideline development teams created Patient/Population, Intervention, Comparison, and Outcomes (PICO) questions, and conducted a systematic review to compile evidence for the benefits and harms associated with treatments for these conditions.

As opposed to previously published guidelines, which use a different model to address the quality of the evidence, this report uses GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology, which the authors say provides greater transparency.

From that, 39 recommendations were developed (8 strong and 31 conditional). While the quality of supporting evidence was very low or low for 90% of the recommendations, the report said recommendations should not be used to limit or deny access to therapies.

In addition, the report noted that “quality” as used in the review does not refer to methodologic quality of studies mentioned, but instead to rate the article(s) in relation to the PICO question, such as if the population or intervention being studied does not completely match what is being asked by the question.

The report noted that there was a debate among the voting panel regarding the appropriateness of the use of biologics as initial therapy in children with polyarthritis, particularly for those with risk factors.

Ultimately, non—biologic disease-modifying antirheumatic drug (DMARD) therapy was recommended, but the report said there may be some patients for whom initial biologic therapy is indicated. Current studies may better clarify which patients are most likely to benefit from first-line biologic therapy.

Some of the recommendations from the polyarthritis guideline include:

• Conditional recommendations that NSAIDs and intraarticular glucocorticoids should each be used as adjunct therapy.
• Starting treatment with a biologic (etanercept, adalimumab, golimumab, abatacept, or tocilizumab) combination therapy with a disease-modifying antirheumatic drug is conditionally recommended over biologic monotherapy.
• A conditional recommendation for using methotrexate over leflunomide or sulfasalazine.
• A strong recommendation against adding chronic low-dose glucocorticoid, regardless of risk factors or disease activity.
• A conditional recommendation to get physical therapy and/or occupational therapy for children and adolescents with JIA and polyarthritis who have, or are at risk for, functional limitations.

The second guideline focuses on uveitis, which can be a chronic or acute disease. Chronic anterior uveitis (CAU) develops in 10% to 20% of children with JIA; it is usually asymptomatic, and there is rarely external evidence of inflammation.

Acute anterior uveitis (AAU) is a distinctly different form of uveitis and typically occurs in children with spondyloarthritis.

Due to a lack of literature with good quality of evidence, recommendations were formulated on the basis of available evidence and a consensus expert opinion.

Similar to the other guideline, the report said the quality of evidence was very low, and most recommendations were therefore conditional; however, the guideline fills an important clinical gap in the care of children with JIA-associated uveitis until better evidence becomes available.

Methotrexate is the usual first-line systemic immunosuppressive agent, followed by tumor necrosis factor (TNF) inhibitors like infliximab and adalimumab.

Despite the frequency with which these drugs are used for uveitis, only 1 large randomized controlled trial studying children with JIA-associated uveitis has been published.

JIA-associated uveitis guideline recommendations include:

• Regular ophthalmic monitoring and screening of children with JIA; the frequency should be based on individual risk factors.
• A strong recommendation to get ophthalmologic monitoring within 1 month after each change of topical glucocorticoids rather than monitoring less frequently for children and adolescents with controlled uveitis who are tapering or discontinuing topical glucocorticoids.
• A conditional recommendation to start methotrexate and a TNF immediately rather than methotrexate as a monotherapy in children and adolescents with severe, active CAU and sight-threating complications.
• A strong recommendation for education regarding the warning signs of AAU for the purpose of decreasing delay in treatment, duration of symptoms, or complications of iritis for children and adolescents with spondyloarthritis.