medwireNews: The ACR and the National Arthritis Foundation have published two guidelines on juvenile idiopathic arthritis (JIA), one providing recommendations for the treatment of polyarthritis, sacroiliitis, and enthesitis, and the other focusing on detecting and treating uveitis.
In the first guideline, Sarah Ringold (Seattle Children’s Hospital, Washington, USA) and co-authors combined a systematic review with a group consensus approach to develop 39 recommendations for pharmacologic and nonpharmacologic treatment of non-systemic polyarthritis, sacroiliitis, and enthesitis.
The guidance for polyarthritis includes a conditional recommendation for the use of nonsteroidal anti-inflammatory drugs (NDAIDs) or intraarticular glucocorticoids as adjunct therapy, as well as a strong recommendation against the use of chronic low-dose glucocorticoids and a conditional recommendation for physical or occupational therapy among children and adolescents with functional limitations.
The taskforce notes that an “important difference from the 2011 recommendations is that initial NSAID monotherapy for polyarthritis is no longer recommended, given the established benefits of early initiation of DMARD treatment.”
Ringold and colleagues add that an area of “particular debate” was whether or not to recommend biologics as an initial therapy for children with polyarthritis, with a final decision to recommend nonbiologic DMARD therapy. However, they say “it was noted that there may be some patients for whom initial biologic therapy is indicated,” and “currently ongoing studies may better clarify which patients are most likely to benefit from initial biologic therapy.”
For patients with JIA and sacroiliitis, Ringold and colleagues provide strong recommendations for the use of tumor necrosis factor (TNF) inhibitors over continued NSAID treatment in those with an inadequate response, and a strong recommendation against methotrexate monotherapy. They strongly recommend NSAID treatment over no NSAID for patients with enthesitis, and provide a conditional recommendation for TNF inhibitors over methotrexate or sulfasalazine in this patient population.
The authors note that recommendations on individual biologics were considered, but “subsequently dropped by the Voting Panel, given mostly equivalent data for safety and efficacy between the biologics and lack of head-to-head comparisons.”
They caution that the quality of evidence as determined by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method “was overall low and most recommendations were conditional,” emphasizing that “all treatment decisions must be individualized, with consideration of the unique aspects of each patient’s presentation, medical history, and preferences.”
The uveitis guidelines were also developed using a systematic review using the GRADE methodology followed by a consensus approach, and involved a taskforce of pediatric rheumatologists, ophthalmologists, patient representatives, and methodologists.
Sheila Angeles-Han (Cincinnati Children’s Hospital Medical Center, Ohio, USA) and colleagues provide recommendations on screening for uveitis, along with monitoring, treatment, and education for those diagnosed with the condition.
The guidelines include a strong recommendation for ophthalmologic monitoring during the first month after each change of topical glucocorticoids among children with controlled uveitis who are tapering glucocorticoids, and a conditional recommendation for patients with severe active chronic anterior uveitis and sight-threatening complications to start immediate combination therapy with methotrexate and a monoclonal antibody TNF inhibitor.
“Prevention of sight-threatening complications from uveitis is most important,” said Angeles-Han in a press release.
“It is crucial that children with JIA undergo scheduled ophthalmology screening to detect uveitis early since children are usually asymptomatic,” she added.
The authors conclude that “[a]lthough the quality of evidence was very low, and most recommendations were therefore conditional, this guideline fills an important clinical gap in the care of children with JIA-associated uveitis and may be updated as better evidence becomes available.”
Both guidelines have been published in Arthritis & Rheumatology and Arthritis Care & Research.
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