Updated ACR guidelines for JIA treatment

02 Jun 2022


The ACR annually reviews and updates clinical practice guidelines, centering on the rapidly changing medical field.1 Based on the Patient/Population, Intervention, Comparison and Outcomes (PICO) questions and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, recommendations were made mostly depending on the commonly occurring clinical circumstances.1,2 The final vote was made upon the unanimous views of a panel including clinicians, young adults with JIA, and caretakers of children with JIA.1,2

With regard to treating JIA, the first guideline recommends the use of physical and occupational therapy; an age-appropriate and healthy diet; baseline laboratory evaluation of all medications prior to treatment initiation; annual immunization (influenza) for all JIA children and shared decision-making with patients/caregivers.1 However, it recommends against the use of herbal or supplemental interventions and the use of radiography to identify active synovitis or enthesitis.1 The guideline panelists strongly supported the idea that prior to the administration of disease-modifying antirheumatic drugs (DMARDs), age must be considered in requirements for infection screening.1

To treat oligoarthritis and TMJ, the second guideline lays recommendations, including the use of scheduled non-steroidal anti-inflammatory drugs (NSAIDs) and intraarticular glucocorticoids (IAGCs) as part of the initial therapy; with an inadequate response to NSAIDs and IAGCs, conventional synthetic DMARDs (csDMARDs) such as methotrexate were recommended; and with an impartial response or intolerance to NSAIDs and/or IAGCs and at least 1 csDMARD, biologic DMARDs were strongly recommended.2 For the initial treatment of JIA without MAS, biologic DMARDS [interleukin-1 (IL-1) and IL-6 inhibitors], NSAIDS, oral glucocorticoids and csDMARDs were recommended. For the initial treatment of JIA with MAS, biologic DMARDS (IL-1 and IL-6 inhibitors) and glucocorticoids were recommended.2 For subsequent therapy of JIA with or without MAS, IL-1 and IL-6 inhibitors were recommended over csDMARDS for inadequate response/intolerance of NSAIDS and/or glucocorticoids.2 For residual arthritis and incomplete response to IL inhibitors and in JIA without MAS, biologic DMARDS or csDMARDS were recommended.2

Dr. Karen Onel, Chief of the Pediatric Rheumatology Division at the Hospital for Special Surgery in New York of the United States (US) and the lead investigator of the guidelines, said “For many years, treatment of JIA consisted of corticosteroids, NSAIDs, physical therapy, bracing, and surgery. There were no DMARDs and even if there were, they were not tested or used in children. These guidelines stress the early use of conventional synthetic and biologic DMARDs and the avoidance of glucocorticoids and NSAIDs. In fact, for systemic JIA, the guidelines suggest using biologic DMARDs as the first line. We have turned the pyramid upside down.”

Also, the ACR has published information pertaining to guidance on coronavirus disease 2019 (COVID-19) vaccines for adults with rheumatic and musculoskeletal diseases at the time that the use of Pfizer-BioNTech COVID-19 vaccine was approved for emergency use in children aged 5-15 in the US, and the US Food and Drug Administration (FDA) granted approved for use in the 16-18 age group. In future, updates may provide details on immunizing children with rheumatic diseases against COVID-19.1

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