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.

Synovial fluid mesenchymal progenitor cells from patients with juvenile idiopathic arthritis demonstrate limited self-renewal and chondrogenesis

“…It is widely believed that JIA is not a single disorder, but a disease state that consists of a heterogeneous group of inflammatory diseases affecting joints with a prevalence of one in a thousand children 48 . While there are numerous front-line drugs that these children can be treated with 2 , 3 , there is a growing body of literature examining the use of mesenchymal stem/progenitor cells for the treatment of adult and childhood arthritis 8 , 10 . However, we still lack a clear understanding of how MPC populations are impacted by arthritic disease states and how this could influence treatment efficacy 25 , 30 , 49 – 51 .…”

“…Juvenile idiopathic arthritis (JIA) is the most common chronic childhood rheumatic disease with an estimated incidence of one in a thousand (~ 25,000 Canadian children 1 ) 2 , 3 . Early diagnosis and treatment of JIA is essential to achieve optimal patient outcomes and while patient outcomes of JIA have improved over the last decade, many still face the possibility of continuing disease activity, medication-associated morbidity and life-long disability 4 .…”

“…Therefore, it is essential to understand if, how and why stem/progenitor cell function is altered in patients with JIA. Furthermore, it is widely accepted that once a patient is diagnosed with arthritis, it may only be a matter of time before some level of invasive intervention is required to moderate the symptoms (pain, loss of function and mobility) associated with disease progression 2 , 3 . Understanding the role of endogenous stem/progenitor cells in the apparent lack of cartilage homeostasis and/or repair is paramount in developing novel therapeutics to restore the repair capacity of these cells, and ultimately heal damaged tissue.…”

MRI for axial SpA: Diagnosis, disease activity assessment, and recent advances

“…15 More research is needed to define and standardize the best approach to imaging and the role of MRI in children with juvenile SpA. 16…”

“…Gadolinium contrast may be considered in selected patients to detect synovitis, which may occur in the absence of bone marrow edema, after weighing against possible contrast‐related side effects such as injection‐site discomfort and hypersensitivity 15 . More research is needed to define and standardize the best approach to imaging and the role of MRI in children with juvenile SpA 16 …”