2021 American College of Rheumatology Guideline for the Treatment of Juvenile Idiopathic Arthritis: Recommendations for Nonpharmacologic Therapies, Medication Monitoring, Immunizations, and Imaging

Abstract

Objective To provide recommendations for the management of juvenile idiopathic arthritis (JIA) with a focus on nonpharmacologic therapies, medication monitoring, immunizations, and imaging, irrespective of JIA phenotype. Methods We developed clinically relevant Patient/Population, Intervention, Comparison, and Outcomes questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation approach was used to rate the quality of evidence (high, moderate, low, or very low). A Voting Panel including clinicians and patients/caregivers achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. Results Recommendations in this guideline include the use of physical therapy and occupational therapy interventions; a healthy, well‐balanced, age‐appropriate diet; specific laboratory monitoring for medications; widespread use of immunizations; and shared decision‐making with patients/caregivers. Disease management for all patients with JIA is addressed with respect to nonpharmacologic therapies, medication monitoring, immunizations, and imaging. Evidence for all recommendations was graded as low or very low in quality. For that reason, more than half of the recommendations are conditional. Conclusion This clinical practice guideline complements the 2019 American College of Rheumatology JIA and uveitis guidelines, which addressed polyarthritis, sacroiliitis, enthesitis, and uveitis, and a concurrent 2021 guideline on oligoarthritis, temporomandibular arthritis, and systemic JIA. It serves as a tool to support clinicians, patients, and caregivers in decision‐making. The recommendations take into consideration the severity of both articular and nonarticular manifestations as well as patient quality of life. Although evidence is generally low quality and many recommendations are conditional, the inclusion of caregivers and patients in the decision‐making process strengthens the relevance and applicability of the guideline. It is important to remember that these are recommendations. Clinical decisions, as always, should be made by the treating clinician and patient/caregiver.

2021 American College of Rheumatology Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Oligoarthritis, Temporomandibular Joint Arthritis, and Systemic Juvenile Idiopathic Arthritis

“…The initial literature review included topics addressed in this report and in the second report (9), and identified 4,308 articles in searches for all PICO questions through August 7, 2019. A July 9, 2020 search update identified 367 more references, for a total of 4,675 articles after duplicates and non-English publications were removed.…”

Pediatric uveitis: Role of the pediatrician

“…Pediatric investigations prior to commencement of biologic DMARDs treatment should include work up to rule out tuberculosis (Quantiferon/T-spot, chest x-ray), serology for varicella zoster virus (VZV), hepatitis B, and hepatitis C (and HIV when appropriate). Immunizations should be updated prior to starting immunosuppression, according to national recommendations including live attenuated vaccines such as MMR and varicella vaccine when patient is seronegative ( 155 , 156 ). Monitoring of compliance with medications and topical treatment is particularly important in children and adolescent patients.…”

“…It is recommended that household contacts of children on immunosuppression are to up to date with immunizations. Children on immunosuppression should follow their normal national immunization schedule for non-live/inactivated vaccines and receive annual influenza vaccine ( 156 ). For live attenuated vaccines, in particular varicella and MMR, data suggest these vaccines may still be safe and effective but are usually not recommended in children on biologic DMARDs and systemic corticosteroids ( 164 , 165 ).…”

Advances in Musculoskeletal Imaging in Juvenile Idiopathic Arthritis

“…In 2022, the updated American College of Rheumatology Guidelines for JIA were published without significant modification in the part regarding imaging compared with the previous edition from 2013 [ 9 ]. Conventional radiography—according to recommendation—should be restricted to the assessment of JIA-associated damage or to investigate alternative diagnoses.…”

“…Conventional radiography—according to recommendation—should be restricted to the assessment of JIA-associated damage or to investigate alternative diagnoses. Their use as a screening test prior to advanced imaging, for the purpose of identifying active synovitis or enthesitis, is strongly discouraged [ 9 ]. The role of ultrasound (US) is conditionally recommended for guidance of intraarticular injections or to localize the distribution of inflammation [ 9 ].…”