MARAJIA Expert Consensus Guidelines for Methotrexate Use in Juvenile Idiopathic Arthritis

Sep 28, 2018

Ten evidence-based recommendations for the most commonly prescribed drug for JIA.

Reference1. Ferrara G, Mastrangelo G, Barone P, et al; Rheumatology Italian Study Group. Methotrexate in juvenile idiopathic arthritis: advice and recommendations from the MARAJIA expert consensus meeting. Pediatr Rheumatol Online J. 2018;16:46. doi: 10.1186/s12969-018-0255-8.

Ferrara and other members of the Methotrexate Advice and Recommendations on Juvenile Idiopathic Arthritis (MARAJIA) expert panel report their evidence-based recommendations for the use of methotrexate (MTX) in juvenile idiopathic arthritis (JIA).¹ Thumb through the slides for an overview of the key clinical issues and 10 recommendations from the expert meeting.

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One of the most common chronic conditions of childhood, juvenile idiopathic arthritis (JIA) encompasses systemic arthritis, oligoarthritis, polyarthritis (rheumatoid factor negative), polyarthritis (rheumatoid factor positive), psoriatic arthritis, enthesitis-related arthritis, and undifferentiated arthritis that begins before age 16.

NSAID, nonsteroidal anti-inflammatory drug.

Methotrexate (MTX) is usually well tolerated in patients with juvenile idiopathic arthritis (JIA).

The therapeutic range of methotrexate for juvenile idiopathic arthritis is 8.5 to 15 mg/m²/week. Children seem to tolerate much higher doses than adults.

The bioavailability of methotrexate has also been shown to be greater in the fasting state in children with juvenile idiopathic arthritis.

There is general agreement to wait at least 12 weeks to assess the efficacy of methotrexate (MTX) in juvenile idiopathic arthritis. MTX withdrawal may result in disease flare in more than 50% of patients-and in an even greater percentage of younger children.

Folic acid led to a significant reduction of side effects, while preserving the efficacy of methotrexate therapy.

Although there is a lack of randomized controlled studies on the subject, the available data suggest that methotrexate is useful for preventing the onset of uveitis and improving disease activity in patients with juvenile idiopathic arthritis.

TNF-Î±, tumor necrosis factor alpha.

Two retrospective cohort studies recommended completion of a maximal response timeframe and achievement of the maximum effective dose by the parenteral route before consideration of combination therapy.

Although methotrexate is the first-choice treatment in juvenile idiopathic arthritis, about one-third of patients fail to respond. In current clinical practice, no assessment of biomarkers predictive of treatment response has been conducted.

The European League Against Rheumatism (EULAR) guidelines recommend adherence to the national vaccination guidelines for live-attenuated vaccines in pediatric patients unless the patients are on high-dose immunosuppressants, high-dose cortisone, or biological agents.

Because of the high variability in the use of methotrexate in the management of juvenile idiopathic arthritis (JIA), the adoption of a consensus approach by a group of practitioners expert in the use of the drug in treating patients with JIA has the potential to guide clinicians and improve the understanding and management of this condition.