The American College of Rheumatology has updated its guidelines for systemic juvenile idiopathic arthritis. All patients with synovitis and arthritis in 5 or more joints should start an IL-1 receptor antagonist, they say, and some may need glucocorticoid therapy as well.
Ringold S, Weiss PF, Beukelman T, et al. 2013 Update of the 2011 American College of Rheumatology Recommendations for the Treatment of Juvenile Idiopathic Arthritis: Recommendations for the Medical Therapy of Children With Systemic Juvenile Idiopathic Arthritis and Tuberculosis Screening Among Children Receiving Biologic Medication.Arthritis Care & Research, (2013) doi: 10.1002/art.30892 First published online: September 24, 2013
Patients with active systemic juvenile idiopathic arthritis (JIA) in 5 or more joints and any degree of synovitis should be started on an interleukin-1 (IL-1) receptor antagonist such as anakinra (Kineret), according to newly-updated treatment recommendations from the American College of Rheumatology (ACR).
It is acceptable to add intravenous or oral glucocorticoids (GC) at any point, for a maximum of 2 weeks, t when the active systemic JIA physicians’ global assessment (MD global) is <5 and there is an active joint count (AJC) of >4 - and in all patients with an MD global, irrespective of their AJC, the 2013 ACR recommendations also say.
However, continuing GC monotherapy for a month or more is inappropriate, the ACR adds.
Other recommendations for active systemic JIA issued by the ACR are:
• Initiating NSAID monotherapy is one approach for patients without prior treatment and who have an MD global of <5, irrespective of AJC; but continuing NSAIDs are inappropriate if there is continued disease activity.
• Patients with continued disease activity after 2 weeks of GCs or NSAID monotherapy may receive anakinra.
• For JIA patients with continued disease activity after 1 month of treatment with anakinra (irrespective of MD global, and with an AJC0- >4 cq), consider canakinumab, tocilizumab, MTX and leflunomide, or a tumor necrosis factor-alpha (TNF-α) inhibitor.
• Abatacept is recommended only for patients with an MD global of ≥5 and an AJC of >4 -- only after a trial of both an IL-1 inhibitor and tocilizumab (sequentially).
• Abatacept is not appropriate for JIA patients with active joints irrespective of their MD global, with the exception of those who have tried both IL-1 inhibitor and tocilizumab sequentially (in which case its use is uncertain).
• The guideline recommends Intraarticular GC injections as an adjunct therapy at any time.
The ACR also advises against repeat tuberculosis (TB) screening for JIA patients with or without active systemic features who initially test negative.