The American College of Rheumatology (ACR) has issued new guidelines for treating juvenile idiopathic arthritis (JIA) that emphasize the use of disease-modifying therapies that have recently become available.
The 2021 Guideline for the Treatment of Juvenile Idiopathic Arthritis was presented at ACR Convergence, the annual meeting of the ACR, held online this year Nov. 5–9.
JIA encompasses several arthritis conditions that affect children and teenagers. While there are distinctions between different types of JIA, all are characterized by abnormal inflammation at the joints.
The ACR first put out guidelines for JIA treatment in 2011 and 2013. The new recommendations, which address pharmacologic and non-pharmacologic treatments, are the culmination of a two-part update of the ACR’s JIA guidelines. The first update was issued in 2019.
“Our overarching goal with the update project, including part one in 2019 and this current project, was to cover as many of the important topics as possible that affect care given to children with juvenile arthritis,” Karen Onel, MD, chief of the division of pediatric rheumatology at the Hospital for Special Surgery in New York City, and the lead investigator of the guideline’s core team, said in a press release.
“We have estimated that half of our patients are cared for by adult rheumatologists, not pediatric rheumatologists, so these recommendations will be helpful for those physicians who may not be as familiar with all the currently available treatments for children with JIA,” Onel said. “Also, as we developed these recommendations, we kept in mind that children with JIA represent a broad age range — from infants to teenagers.”
The updated guidelines reflect changes in JIA treatment in recent years, brought on largely by the availability of disease-modifying therapies. The guidelines recommend reducing the use of steroids to treat acute inflammation, placing increased emphasis on the use of biologic therapies that can limit the inflammation that drives disease in JIA. Examples include Ilaris (canakinumab), Humira (adalimumab), and Kineret (anakinra).
“Pediatric rheumatologists now more rapidly escalate disease-modifying treatment in JIA patients, and are much less likely to use oral or intravenous [into-the-vein] steroids. This is especially true for children with systemic JIA,” Onel said.
The guidelines strongly recommend that most children with JIA get vaccinated to protect against infectious diseases.
“The evidence strongly shows that children with JIA should receive and will respond to vaccines without a risk of flare. We are strongly encouraging children to follow the immunization schedule when safe and to receive annual flu shots,” added Onel.
Onel also said that certain vaccines that use live viruses should not be given to children who are immunosuppressed, as per guidelines from the Centers for Disease Control and Prevention.
The updated guidelines also offer new recommendations on the use of nonsteroidal anti-inflammatory drugs (NSAIDs) — medications such as aspirin and ibuprofen — to alleviate acute joint pain in people with JIA.
“In the past, we thought of NSAIDs as a treatment to be used in benign disease, but we have moved away from this approach and now shorten the period of NSAID use based on input from parents and patients,” Onel said. However, “NSAIDs don’t really fix the problem of underlying inflammation and have serious side effects, especially gastritis [stomach inflammation].”
Importantly, these guidelines are just that — guidelines. Onel stressed that decisions about any one person’s care ultimately need to be jointly made by the patient, his or her family, and the healthcare providers.
“There is a difference between what scientific evidence would support in a treatment recommendation, and how the recommended treatment might affect the quality of life of patients. We can make all the recommendations in the world, but if they don’t consider all of the patient’s values and preferences, and all of their needs, then we will not be achieving the level of patient care that we should attain,” Onel said. “These recommendations reflect our goal of shared decision making.”
She added that the effects of JIA can extend far beyond direct impacts on health — it can impact finances, a child’s ability to go to school, parents’ ability to get to work, and more.
“This disease has an incredibly broad range of effects on families. These experiences are so important and also, so common,” Onel said.
Manuscripts with the full guidelines are expected to be published in two of the ACR’s journals — Arthritis Care & Research and Arthritis & Rheumatology — early next year.