New juvenile idiopathic arthritis guideline emphasizes disease-modifying treatments

"Our overarching goal with the update project, including part one in 2019 and this current project, was to cover as many of the important topics as possible that affect care given to children with juvenile arthritis," says Karen Onel, MD, chief of the Division of Pediatric Rheumatology at the Hospital for Special Surgery in New York City, and the lead investigator of the guideline's Core Team. "We have estimated that half of our patients are cared for by adult rheumatologists, not pediatric rheumatologists, so these recommendations will be helpful for those physicians who may not be as familiar with all the currently available treatments for children with JIA. Also, as we developed these recommendations, we kept in mind that children with JIA represent a broad age range--from infants to teenagers." Onel will discuss the recommendations at a press conference on Monday, Nov. 9 at 8:30 a.m. (ET).

Since the last Juvenile Idiopathic Arthritis guideline was published, new medications have been approved for JIA, making the update a high priority for the ACR. More importantly, rheumatologists' treatment paradigms for JIA have shifted. These new approaches are reflected throughout the guideline, which include reduced use of steroids to treat acute inflammation and increased emphasis on biologic drugs now available for JIA that modify disease activity and target the sources of inflammation. The new guideline also strongly recommends that most children with JIA get regular immunizations for infectious diseases, an update from the last published guideline.

"Pediatric rheumatologists now more rapidly escalate disease-modifying treatment in JIA patients, and are much less likely to use oral or intravenous steroids. This is especially true for children with systemic JIA. In addition, and this is very timely, the evidence strongly shows that children with JIA should receive and will respond to vaccines without a risk of flare. We are strongly encouraging children to follow the immunization schedule when safe and to receive annual flu shots. Immunosuppressed children should still refrain from live virus immunizations, as per the Centers for Disease Control and Prevention guidelines," says Dr. Onel.

Another treatment paradigm shift reflected in the new recommendations is how nonsteroidal anti-inflammatory drugs (NSAIDs) should be used to alleviate acute joint pain in JIA patients.

"In the past, we thought of NSAIDs as a treatment to be used in benign disease, but we have moved away from this approach and now shorten the period of NSAID use based on input from parents and patients. NSAIDs don't really fix the problem of underlying inflammation and have serious side effects, especially gastritis," says Dr. Onel.

"There is a difference between what scientific evidence would support in a treatment recommendation, and how the recommended treatment might affect the quality of life of patients. We can make all the recommendations in the world, but if they don't consider all of the patient's values and preferences, and all of their needs, then we will not be achieving the level of patient care that we should attain. These recommendations reflect our goal of shared decision making," she adds. "One mother told us that having a child with arthritis affects every aspect of a family's life: finances, children missing school, parents missing work to care for their children, families having to travel long distances for pediatric rheumatology care or treatment at a hospital. This disease has an incredibly broad range of effects on families. These experiences are so important and also, so common."

The new guideline reflects the ACR's commitment to producing regular updates on clinical practice recommendations to allow rheumatologists to stay up to date on rapidly expanding treatment options for their patients with rheumatic diseases. A 16-member panel of patients and parents of children with JIA greatly contributed to the guideline's creation, along with a core team of leading pediatric rheumatologists and methodologists. Recommendations were developed by panelists using GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology to assess available evidence from current scientific literature. In 2019, the ACR published the first half of this new guideline, with recommendations on treatment of polyarthritis, uveitis, sacroiliitis and enthesitis.

The manuscripts containing the full list of recommendations and supporting evidence are currently under review and are anticipated to be simultaneously published in two of the ACR's journals, Arthritis Care & Research and Arthritis & Rheumatology, in early 2021, pending peer review.