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 Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are intended to provide guidance for patterns of practice and not to dictate the care of a particular patient. The ACR considers adherence to the recommendations within this guideline to be voluntary, with the ultimate determination regarding their application to be made by the health care provider in light of each patient's individual circumstances. Guidelines and recommendations are intended to promote beneficial or desirable outcomes, but cannot guarantee any specific outcome. Guidelines and recommendations developed and endorsed by the ACR are subject to periodic revision, as warranted by the evolution of medical knowledge, technology, and practice. ACR recommendations are not intended to dictate payment or insurance decisions. These recommendations cannot adequately convey all uncertainties and nuances of patient care.The American College of Rheumatology is an independent, professional, medical and scientific society that does not guarantee, warrant, or endorse any commercial product or service. RINGOLD ET AL 718 |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 a...

2019 American College of Rheumatology/Arthritis Foundation Guideline for the Screening, Monitoring, and Treatment of Juvenile Idiopathic Arthritis–Associated Uveitis

“…Overall, clinicians, parents, and patients should use a shared decision‐making process that considers patients’ preferences and values. Recommendations for the treatment of children with JIA manifesting as non‐systemic polyarthritis, sacroiliitis, and enthesitis were developed concomitantly and are presented separately .…”

2019 American College of Rheumatology/Arthritis Foundation Guideline for the Screening, Monitoring, and Treatment of Juvenile Idiopathic Arthritis–Associated Uveitis

“…Recommendations for the treatment of children with JIA manifesting as non-systemic polyarthritis, sacroiliitis, and enthesitis were developed concomitantly and are presented separately (12). Recognizing the importance of close collaboration and communication between pediatric rheumatologists and ophthalmologists, this guideline was developed in collaboration with experts from both specialties.…”

“…Overall, clinicians, parents, and patients should use a shared decision-making process that considers patients' preferences and values. Recommendations for the treatment of children with JIA manifesting as non-systemic polyarthritis, sacroiliitis, and enthesitis were developed concomitantly and are presented separately (12).…”

Treating juvenile idiopathic arthritis to target: what is the optimal target definition to reach all goals?

“…The first issue is the lack of a single 'best' target. Although most would agree that clinical inactive disease (CID) or remission is the ultimate target, there are multiple ways in which this disease state can be assessed in the clinical setting [2][3][4][5][6]. Wallace's preliminary criteria capture more objective measures of inflammation, and can be regarded a narrow target [7].…”