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Early treatment with DMARDs for juvenile idiopathic arthritis polyarthritis is now preferred over beginning patients on NSAID monotherapy, per updated treatment guidelines.
The American College of Rheumatology and the Arthritis Foundation have updated the 2013 treatment guidelines for juvenile idiopathic arthritis (JIA), which includes juvenile non-systemic polyarthritis, sacroiliitis, and enthesitis.
Led by Sarah Ringold, M.D., of Seattle Children's Hospital, the expert panel suggests 39 recommendations (eight strong and 31 conditional). However, they note the quality of evidence was very low or low for 90 percent of the recommendations.
“Because the quality of evidence was overall low and most recommendations were conditional, clinicians, caregivers, and patients should use a shared decision-making process when considering these recommendations,” the authors wrote.
In this update, patient and parent are central to the decision-making process. The guidelines emphasize the importance of shared decision-making and information sharing about treatment options.
This is the first version of treatment guidelines for JIA that are based on the GRADE methodology-or, the Grading of Recommendations Assessment, Development and Evaluation-which incorporates a more transparent decision-making process and suggests recommendations based on recently published data. The 2011 and 2013 guidelines were developed using the RAND/UCLA Appropriate Method.
The GRADE methodology emphasizes that the strength of recommendations be aligned with the quality of evidence, the balance of benefits and harms, and patient preferences for treatment options.
Among the most noteworthy changes: Early treatment with DMARDs for polyarthritis is now preferred over beginning patients on NSAID monotherapy. And, although non-biologic DMARD therapy is recommended as initial therapy for children with polyarthritis-especially those with risk factors-there may be some cases in which biologic therapy may be appropriate. And, the authors emphasize the need escalate care in cases of low disease activity and the need to adopt a treatment strategy that will achieve and maintain complete disease control.
Biologic therapy remains an active area of research, particularly in pediatrics where studies are underway for JAK inhibitors and IL-17 and IL-12/23 inhibitors.
Sarah Ringold, Sheila T. Angeles-Han, Timothy Beukelman, et al. "2019 American College of Rheumatology/Arthritis Foundation Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Non-Systemic Polyarthritis, Sacroiliitis, and Enthesitis," Arthritis & Rheumatology, Vol. 71, No. 6, June 2019, pp 846–863, DOI 10.1002/art.40884.