New guidelines have been drafted for the treatment of JIA, specifically addressing therapeutic approaches for non-systemic polyarthritis, sacroiliitis, and enthesitis.
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New guidelines have been drafted for the treatment of juvenile idiopathic arthritis (JIA), specifically addressing therapeutic approaches for non-systemic polyarthritis, sacroiliitis, and enthesitis.
The draft guidelines were presented at the 2018 American College of Rheumatology (ACR)/Association of Rheumatology Health Professionals (ARHP) Annual Meeting in Chicago, Illinois, on October 21 by Timothy Beukelman, MD, Associate Professor of Pediatrics at the University of Alabama at Birmingham. Dr Beukelman was the lead author of the previous 2011 ACR Recommendations for the Treatment of JIA and is a member of the core team developing the new treatment guidelines.
The ACR was motivated to update the guidelines in part because of developments in polyarthritis, including recently approved therapies and new studies about the effects of initial treatment choices. There has also been an increased emphasis on sacroiliitis, and the previous recommendations did not address enthesitis. The new recommendations are pending full approval from the ACR and the Arthritis Foundation.
Phase 1 of updating the guidelines used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. The draft recommendations are based on published evidence, patient input, and voting panel experience with a requirement of 70% consensus.
A strong recommendation was issued when the panel was confident that the desirable effect of intervention outweighs the undesirable effects in almost all patients. A conditional recommendation was issued when the desirable effects probably outweigh undesirable effects in a majority of patients.
Next: Polyarthritis recommendations
PolyarthritisSelected general recommendations
• Methotrexate is conditionally recommended over leflunomide or sulfasalazine.
• Subcutaneous methotrexate is conditionally recommended over oral methotrexate. Dr Beukelman explained that the panel thought subcutaneous methotrexate was likely to be more effective and possibly better tolerated.
• Combination therapy with a biologic and a non-biologic is conditionally recommended over biologic monotherapy, with a strong recommendation in the case of infliximab.
• Bridging therapy with less than 3 months of oral glucocorticoids is conditionally recommended in cases of moderate or high disease activity, but conditionally recommended against in cases of low disease activity.
• Chronic low-dose systemic glucocorticoid therapy is strongly recommended against.
Selected initial therapy recommendations
• Initial therapy with a disease-modifying antirheumatic drug (DMARD) is strongly recommended over nonsteroidal anti-inflammatory drug (NSAID) monotherapy. This is a departure from the 2011 guidelines.
• Initial therapy with a DMARD is conditionally recommended over a biologic. Biologic therapy may be appropriate initial therapy for certain patients, such as those with involvement of high-risk joints (eg, cervical spine, hip, wrist), with high disease activity, or at high risk for disabling joint damage. However, Dr Beukelman pointed out that the majority of the patient/parent panel voted against DMARDs as initial therapy, preferring biologic therapy.
Selected subsequent therapy recommendations
• In patients with low disease activity, escalation of therapy is conditionally recommended over no escalation. Dr Beukelman explained that the voting panel felt low disease activity should be addressed as opposed to tolerated.
• In patients with moderate or high disease activity after a first tumor necrosis factor (TNF) inhibitor, a switch to a biologic with a different mechanism is conditionally recommended over a switch to a second TNF inhibitor. The exception is in cases of secondary failure: when there is a loss of initial response, switching to a second TNF inhibitor may be appropriate.
Next: Sacroiliitis and enthesitis recommendations
• For active sacroiliitis despite NSAID therapy, TNF inhibitor therapy is strongly recommended over NSAID monotherapy.
• For active sacroiliitis despite NSAID therapy, methotrexate monotherapy is strongly recommended against.
• For active enthesitis despite NSAID treatment, TNF inhibitor therapy is conditionally recommended over methotrexate or sulfasalazine.
Dr Beukelman remarked that at this point in the process, almost 80% of the recommendations are conditional rather than strong, and almost 90% are based on low levels of evidence. He noted the need for higher quality of evidence and greater understanding of patients’ preferences to optimize treatment outcomes in JIA.
Phase 2 of the JIA Guideline Updates will begin in 2019. The ACR is currently accepting applications for participation until November 30.
3S016 ACR: Biologic Classification of JIA, 2018 Update of the ACR Treatment Guidelines for JIA. Presented at: 2018 ACR/ARHP Annual Meeting; October 20-24; Chicago, Illinois.