GuidelinesIn the Journals

ACR, Arthritis Foundation recommend against chronic glucocorticoids in JIA treatment

Sarah Ringold

Health care providers should avoid prescribing chronic low-dose glucocorticoids — regardless of risk factors or disease activity — when treating children with juvenile idiopathic arthritis manifesting as non‐systemic polyarthritis, sacroiliitis or enthesitis, according to recommendations published in Arthritis Care & Research.

The American College of Rheumatology, in partnership with the Arthritis Foundation, released several recommendations in a pair of guidelines, one focused on therapeutic approaches for non‐systemic polyarthritis, sacroiliitis or enthesitis in JIA, and the other on the screening, monitoring and treatment of JIA with associated uveitis.

“These recommendations highlight the importance of prompt and effective treatment for children with JIA and polyarthritis, sacroiliitis and enthesitis,” Sarah Ringold, MD, MS, attending physician at Seattle Children’s Hospital and the principal investigator on the polyarthritis guideline, said in a press release. “They also support relatively tight disease control, with inactive disease as the goal. While it is anticipated that these recommendations will lead to improved outcomes for children with JIA and these phenotypes, they also emphasize the ongoing need to generate high-quality data about treatment effectiveness in JIA.”

The researchers developed the JIA guidelines using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, which provides standards for judging the quality of the literature available. The method also assigns strengths to each recommendation, based on the quality of the available evidence. The researchers also included input from patients and parents, which were gathered through the ACR and Arthritis Foundation partnership.

In addition, the researchers conducted a group consensus with a voting panel to craft the final recommendations and grade their strength. A parent-and-patient panel also used a consensus approach to provide their preferences for key questions.

In the guideline detailing therapeutic approaches for non‐systemic polyarthritis, sacroiliitis or enthesitis in JIA, the researchers ultimately developed eight strong and 31 conditional recommendations. In addition to their strong recommendation against adding chronic low-dose glucocorticoids, the researchers included conditional guidance that NSAIDs and intraarticular glucocorticoids should both be used as adjunct therapy. In addition, there is a conditional recommendation for physical and/or occupational therapy for children and adolescents with JIA and polyarthritis who have, or are at risk for, functional limits.

Alternately, the guidelines for JIA-associated uveitis include a strong recommendation for ophthalmologic monitoring within one month after each change of topical glucocorticoids for young patients with controlled uveitis who are tapering or discontinuing glucocorticoids. There is also a strong recommendation for ‘warning sign’ education for acute anterior uveitis to improve treatment delays, as well as shorten the duration of symptoms, in spondyloarthritis.

The researchers also noted a conditional recommendation for the initiation of methotrexate and a monoclonal antibody TNF inhibitor immediately in children and adolescents with severe, active chronic anterior uveitis and sight-threating complications.

“Prevention of sight-threatening complications from uveitis is most important,” Sheila T. Angeles-Han, MD, MSc, a rheumatologist at the Cincinnati Children’s Hospital and principal investigator for the uveitis guideline, said in the release. “It is crucial that children with JIA undergo scheduled ophthalmology screening to detect uveitis early since children are usually asymptomatic.” – by Jason Laday

Disclosures: Ringold and Angeles-Han report no relevant financial disclosures. Please see the full studies for additional author disclosures.

Sarah Ringold

Health care providers should avoid prescribing chronic low-dose glucocorticoids — regardless of risk factors or disease activity — when treating children with juvenile idiopathic arthritis manifesting as non‐systemic polyarthritis, sacroiliitis or enthesitis, according to recommendations published in Arthritis Care & Research.

The American College of Rheumatology, in partnership with the Arthritis Foundation, released several recommendations in a pair of guidelines, one focused on therapeutic approaches for non‐systemic polyarthritis, sacroiliitis or enthesitis in JIA, and the other on the screening, monitoring and treatment of JIA with associated uveitis.

“These recommendations highlight the importance of prompt and effective treatment for children with JIA and polyarthritis, sacroiliitis and enthesitis,” Sarah Ringold, MD, MS, attending physician at Seattle Children’s Hospital and the principal investigator on the polyarthritis guideline, said in a press release. “They also support relatively tight disease control, with inactive disease as the goal. While it is anticipated that these recommendations will lead to improved outcomes for children with JIA and these phenotypes, they also emphasize the ongoing need to generate high-quality data about treatment effectiveness in JIA.”

The researchers developed the JIA guidelines using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, which provides standards for judging the quality of the literature available. The method also assigns strengths to each recommendation, based on the quality of the available evidence. The researchers also included input from patients and parents, which were gathered through the ACR and Arthritis Foundation partnership.

In addition, the researchers conducted a group consensus with a voting panel to craft the final recommendations and grade their strength. A parent-and-patient panel also used a consensus approach to provide their preferences for key questions.

In the guideline detailing therapeutic approaches for non‐systemic polyarthritis, sacroiliitis or enthesitis in JIA, the researchers ultimately developed eight strong and 31 conditional recommendations. In addition to their strong recommendation against adding chronic low-dose glucocorticoids, the researchers included conditional guidance that NSAIDs and intraarticular glucocorticoids should both be used as adjunct therapy. In addition, there is a conditional recommendation for physical and/or occupational therapy for children and adolescents with JIA and polyarthritis who have, or are at risk for, functional limits.

Alternately, the guidelines for JIA-associated uveitis include a strong recommendation for ophthalmologic monitoring within one month after each change of topical glucocorticoids for young patients with controlled uveitis who are tapering or discontinuing glucocorticoids. There is also a strong recommendation for ‘warning sign’ education for acute anterior uveitis to improve treatment delays, as well as shorten the duration of symptoms, in spondyloarthritis.

The researchers also noted a conditional recommendation for the initiation of methotrexate and a monoclonal antibody TNF inhibitor immediately in children and adolescents with severe, active chronic anterior uveitis and sight-threating complications.

“Prevention of sight-threatening complications from uveitis is most important,” Sheila T. Angeles-Han, MD, MSc, a rheumatologist at the Cincinnati Children’s Hospital and principal investigator for the uveitis guideline, said in the release. “It is crucial that children with JIA undergo scheduled ophthalmology screening to detect uveitis early since children are usually asymptomatic.” – by Jason Laday

Disclosures: Ringold and Angeles-Han report no relevant financial disclosures. Please see the full studies for additional author disclosures.