Canadian Rheumatology Association Recommendations for the Screening, Monitoring, and Treatment of Juvenile Idiopathic Arthritis-associated Uveitis

Abstract

ObjectiveTo develop Canadian recommendations for the screening, monitoring and treatment of uveitis associated with Juvenile Idiopathic Arthritis (JIA).MethodsRecommendations were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE)-Adolopment approach. A working group of 14 pediatric rheumatologists, 6 ophthalmologists, 2 methodologists and 3 caregiver/patient representatives reviewed recent American College of Rheumatology (ACR)/Arthritis Foundation (AF) recommendations and worked in pairs to develop evidence-to-decision (EtD) tables. A survey to assess agreement and recommendations requiring group discussion was completed. EtD tables were presented, discussed, and voted upon at a virtual meeting, to produce the final recommendations. A health equity framework was applied to all aspects of the adolopment process including EtD tables, survey responses, and virtual meeting discussion.ResultsThe survey identified that 7 of the nineteen recommendations required rigorous discussion. Seventy-five percent of working group members attended the virtual meeting to discuss controversial topics as they pertained to the Canadian environment, including timing to first eye exam, frequency of screening, escalation criteria for systemic and biologic therapy, and the role of non-biologic therapies. Equity issues related to access to care and advanced therapeutics across Canadian provinces and territories were highlighted. Following the virtual meeting, 5 recommendations were adapted, 2 recommendations were removed, and 1 was developed de novo.ConclusionRecommendations for JIA-associated uveitis were adapted to the Canadian context by a Working Group of pediatric rheumatologists, ophthalmologists with expertise in the management of uveitis and parent/patient input utilizing lenses for cost, equity, and access.

Comparative efficacy and safety of different drugs in patients with systemic juvenile idiopathic arthritis: A systematic review and network meta-analysis

“…If it is safe for the child to delay treatment, it is recommended that biological agents be started at least 2 weeks after routine vaccination with inactivated or subunit vaccines, and at least 4 weeks after vaccination with live vaccines. [31] Unfortunately, for many children with active sJIA, it is not feasible or safe to delay treatment and wait for vaccination. Live vaccines are not recommended during treatment with biologics.…”

Screening, Monitoring, and Treating Children With Juvenile Idiopathic Arthritis-Associated Uveitis: Visualizing Better Outcomes

“…Further, the ophthalmologists state that a standardized definition of severe or sight-threatening complications does not exist. 6 However, the ACR/AF guideline provides a definition, and we suggest that an experienced ophthalmologist should be able to determine whether a child's eye disease is severe or has sight-threatening complications. Severity of uveitis has been defined previously by a number of groups and include the presence of complications at baseline, the presence of posterior synechiae, visual acuity, grade of anterior chamber inflammation at baseline, or presence of anterior chamber flare.…”

“…In this issue of The Journal of Rheumatology, Berard et al present the Canadian Rheumatology Association (CRA) screening, monitoring, and treatment recommendations for JIA-U to consider Canadian contextual differences, as healthcare in Canada is provincial rather than federal jurisdiction, and there is varied access to rheumatologists, ophthalmologists, and biologic therapies. 6 Most importantly, we commend the authors as they ensured that equity was reflected in the CRA recommendations, wherein they considered implementation in rural and remote areas, Indigenous populations, low socioeconomic status, and those with difficulties accessing treatment. This is especially important as easy access to rheumatologists, uveitis specialists, or pediatric ophthalmologists for uveitis detection and monitoring as well as to costly biologic therapy is not always possible in every setting.…”

“…We congratulate the authors on this important paper and acknowledge the significant amount of time and effort required to craft their recommendations. Our editorial focuses on contrasting the differences in the recommendations that were adapted by Berard et al, 6 and considering problems with current methods of ophthalmic screening and monitoring for uveitis.…”

“…All agree with the importance of regular ophthalmic screening to detect uveitis early, ophthalmic monitoring to ensure that a child adequately responds to local and/or systemic therapy, and appropriate and effective treatment that is optimized to prevent ocular damage. As newly addressed by Berard et al, 6 it is critical that issues associated with equity are kept at the forefront, because recommendations may not be applicable or even possible in all patients, especially in areas without easy access to rheumatologists, uveitis specialists, pediatric ophthalmologists, slit lamp biomicroscopy, or imaging modalities that would affect the ability to detect JIA-U accurately and in a timely manner. Further, biologics to treat uveitis such as TNFi, abatacept, and tocilizumab may not be readily available, and DMARDs such as methotrexate, leflunomide, cyclosporine, and mycophenolate may be the only therapeutic options.…”