2019 American College of Rheumatology/Arthritis Foundation Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Non‐Systemic Polyarthritis, Sacroiliitis, and Enthesitis

Abstract

Objective To develop treatment recommendations for children with juvenile idiopathic arthritis manifesting as non‐systemic polyarthritis, sacroiliitis, or enthesitis. Methods The Patient/Population, Intervention, Comparison, and Outcomes (PICO) questions were developed and refined by members of the guideline development teams. A systematic review was conducted to compile evidence for the benefits and harms associated with treatments for these conditions. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of evidence. A group consensus process was conducted among the Voting Panel to generate the final recommendations and grade their strength. A Parent and Patient Panel used a similar consensus approach to provide patient/caregiver preferences for key questions. Results Thirty‐nine recommendations were developed (8 strong and 31 conditional). The quality of supporting evidence was very low or low for 90% of the recommendations. Recommendations are provided for the use of nonsteroidal antiinflammatory drugs, disease‐modifying antirheumatic drugs, biologics, and intraarticular and oral glucocorticoids. Recommendations for the use of physical and occupational therapy are also provided. Specific recommendations for polyarthritis address general medication use, initial and subsequent treatment, and adjunctive therapies. Good disease control, with therapeutic escalation to achieve low disease activity, was recommended. The sacroiliitis and enthesitis recommendations primarily address initial therapy and adjunctive therapies. Conclusion This guideline provides direction for clinicians, caregivers, and patients making treatment decisions. Clinicians, caregivers, and patients should use a shared decision‐making process that accounts for patients’ values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.

Frequency of biologic switching and the outcomes of switching in children and young people with juvenile idiopathic arthritis: a national cohort study

“…Additionally, among children with polyarticular course juvenile idiopathic arthritis for whom a first biologic was ineffective, no evidence was found to indicate that switching classes of biologic was more beneficial than initiation of treatment with a second bio logic within the same class, despite current ACR guidelines. 10 Ideally, a randomised trial comparing different second biologics could help address this question with more certainty. Further study of patients requiring multiple biologics is vital to enable patient specific treatment pathways, accurate prognosis discuss ions, and costeffectiveness analysis for service provisions.…”

“…(ACR) guide lines 10 suggest treatment with a different class of biologic. The use of real-world data to identify the optimum choice of second biologic is methodologically challenging because of the potential of confounding by indication; patients might be prescribed a certain biological therapy due to their characteristics (ie, systemic features, disease severity), and thus comparing the treatments might be confounded by these characteristics.…”

Consensus protocols for the diagnosis and management of the hereditary autoinflammatory syndromes CAPS, TRAPS and MKD/HIDS: a German PRO-KIND initiative

“…Stratified treatment approaches are increasingly made available for childhood rheumatic diseases. Disease subtype, risk factors at onset and disease activity are the foundation for the traditional stratified ACR juvenile idiopathic arthritis (JIA) treatment recommendations [49,50]. Similarly, the Childhood Arthritis and Rheumatology Research Alliance (CARRA) CTPs for juvenile dermatomyositis stratify approaches based on subtype and disease activity [51,52].…”

“…The PRO-KIND CAPS/TRAPS/MKD/HIDS CTP approach follows the model set by Swart [55] and Consolaro [56] for JIA. The composite patient and physicianpartnered disease activity instrument Juvenile Arthritis Disease Activity Score (JADAS) [57] was integrated into clinical care as the anchor of treatment decision making [50]. This has facilitated impactful treat-to-target strategies resulting in better outcomes [55].…”

The Patient and Parent Perspective on Methotrexate in Recent Juvenile Idiopathic Arthritis Guidelines: Comment on the Article by Ringold et al

“…In June 2019, the ACR/AF JIA guideline was published . The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used .…”