ACR Issues New Guidelines for Tx of Juvenile Idiopathic Arthritis

The American College of Rheumatology issued its first guidelines for the treatment of juvenile idiopathic arthritis on March 30.

"Our goal was to provide evidence and consensus-based guidance that reflects the current state of the field and is useful to clinicians of all levels of experience with the treatment of JIA. The recommendations are important because the treatment of JIA has undergone major changes over the last decade with the introduction of biologic therapeutic agents," Dr. Timothy G. Beukelman, lead author of the paper, said in an interview. The ACR says that the recommendations are not meant to dictate care, and it considers adherence to be voluntary.

The guidelines are published in Arthritis Care and Research (2011;63:465-82).

Up until now, there have been no validated guidelines for the treatment of JIA. Recognizing this, in 2008, the ACR issued a formal request for proposals to develop recommendations. The recommendations were written by a core expert panel of international pediatric rheumatology experts. A separate task force panel that included internationally recognized pediatric rheumatology clinicians, a pediatric rheumatology nurse, a general pediatrician, and a patient representative also provided input.

Dr. Thomas J.A. Lehman, professor of clinical pediatrics at Cornell University, New York, noted in an interview that: "While these new guidelines are useful in emphasizing the importance of promptly initiating appropriate disease-modifying therapy for children with active juvenile idiopathic arthritis, they are flawed in their failure to recognize the many variations in the severity of the variations of the disease.

The recommendations are "as evidenced based as possible," and also include expert opinion. They were developed after a systematic literature review that identified 244 pharmacotherapeutic studies, both controlled and uncontrolled. These studies were reviewed by the core expert panel which then prepared a summary report of the scientific evidence. The core expert panel also prepared more than 1,500 clinical scenarios for each medication of interest, categorizing hypothetical patients using all possible combinations of key clinical parameters. By a formal group assessment process, the TFP then made their recommendations, based on the published literature as well as ratings of the appropriateness of each medical intervention.

While the ILAR classification divides JIA into six distinct categories, these recommendations describe five JIA treatment groups: history of arthritis of four or fewer joints; history of arthritis of five or more joints; active sacroiliac arthritis; systemic arthritis with active systemic features and without active arthritis; and systemic arthritis with active arthritis and without active systemic features. Specific features for poor prognosis are described for each category, as well as disease activity levels. For instance, the features of poor prognosis for children with a history of arthritis in five or more joints are satisfaction of at least one of the following: arthritis of the hip or cervical spine, positive rheumatoid factor or anticyclic citrullinated peptide antibodies, or radiographic damage. "Risk stratification is crucial for guiding optimal treatment," according to Dr. Beukelman.

The recommendations focus on the initiation and safety monitoring of therapeutic agents used in the treatment of JIA, specifically NSAIDs, intra-articular glucocorticoid injections, nonbiologic disease-modifying antirheumatic drugs (DMARDs), biologic DMARDs, and systemic glucocorticoids. Medications used "off label" as part of common and widely accepted practice were considered.

Treatment algorithms are provided for those with a history of arthritis in four or fewer joints, history of arthritis in five or more joints, and systemic arthritis with active systemic features or active arthritis. Decision-making guidance regarding severity of disease or the presence of prognostic factors is included. For instance, for patients with a history of arthritis of five or more joints, a patient on methotrexate (with or without an adjunctive NSAID or joint injections) should move on to a tumor necrosis factor (TNF) -alpha inhibitor after 3 months if disease activity is moderate or high or after 6 months if disease activity is low, regardless of the presence of poor prognostic features.

Dr. Lehman, who is also chief of the division of pediatric rheumatology at the Hospital for Special Surgery in New York, noted that, "It is very appropriate to argue for the increased use of IL1 [interleukin-1] inhibitors in children with systemic onset disease. However, there are several different diseases included in the other forms of juvenile idiopathic arthritis for many of which it is not appropriate to start with methotrexate. Indeed, in this era, one must wonder if it wouldn\'t be more appropriate to begin children with an anti-TNF, which has a more rapid onset of action and is more effective in suppressing disease activity and preventing damage."

According to the International League of Associations for Rheumatology, JIA is defined as an arthritis of unknown etiology that begins before the 16th birthday and persists for at least 6 weeks with other known conditions excluded. About 1 in 1,000 children have JIA, and the condition can persist into adulthood, resulting in significant long-term morbidity.

Dr. Beukelman and Dr. Lehman had no relevant financial disclosures.

The American College of Rheumatology issued its first guidelines for the treatment of juvenile idiopathic arthritis on March 30.

"Our goal was to provide evidence and consensus-based guidance that reflects the current state of the field and is useful to clinicians of all levels of experience with the treatment of JIA. The recommendations are important because the treatment of JIA has undergone major changes over the last decade with the introduction of biologic therapeutic agents," Dr. Timothy G. Beukelman, lead author of the paper, said in an interview. The ACR says that the recommendations are not meant to dictate care, and it considers adherence to be voluntary.

The guidelines are published in Arthritis Care and Research (2011;63:465-82).

Up until now, there have been no validated guidelines for the treatment of JIA. Recognizing this, in 2008, the ACR issued a formal request for proposals to develop recommendations. The recommendations were written by a core expert panel of international pediatric rheumatology experts. A separate task force panel that included internationally recognized pediatric rheumatology clinicians, a pediatric rheumatology nurse, a general pediatrician, and a patient representative also provided input.

Dr. Thomas J.A. Lehman, professor of clinical pediatrics at Cornell University, New York, noted in an interview that: "While these new guidelines are useful in emphasizing the importance of promptly initiating appropriate disease-modifying therapy for children with active juvenile idiopathic arthritis, they are flawed in their failure to recognize the many variations in the severity of the variations of the disease.

The recommendations are "as evidenced based as possible," and also include expert opinion. They were developed after a systematic literature review that identified 244 pharmacotherapeutic studies, both controlled and uncontrolled. These studies were reviewed by the core expert panel which then prepared a summary report of the scientific evidence. The core expert panel also prepared more than 1,500 clinical scenarios for each medication of interest, categorizing hypothetical patients using all possible combinations of key clinical parameters. By a formal group assessment process, the TFP then made their recommendations, based on the published literature as well as ratings of the appropriateness of each medical intervention.

While the ILAR classification divides JIA into six distinct categories, these recommendations describe five JIA treatment groups: history of arthritis of four or fewer joints; history of arthritis of five or more joints; active sacroiliac arthritis; systemic arthritis with active systemic features and without active arthritis; and systemic arthritis with active arthritis and without active systemic features. Specific features for poor prognosis are described for each category, as well as disease activity levels. For instance, the features of poor prognosis for children with a history of arthritis in five or more joints are satisfaction of at least one of the following: arthritis of the hip or cervical spine, positive rheumatoid factor or anticyclic citrullinated peptide antibodies, or radiographic damage. "Risk stratification is crucial for guiding optimal treatment," according to Dr. Beukelman.

The recommendations focus on the initiation and safety monitoring of therapeutic agents used in the treatment of JIA, specifically NSAIDs, intra-articular glucocorticoid injections, nonbiologic disease-modifying antirheumatic drugs (DMARDs), biologic DMARDs, and systemic glucocorticoids. Medications used "off label" as part of common and widely accepted practice were considered.

Treatment algorithms are provided for those with a history of arthritis in four or fewer joints, history of arthritis in five or more joints, and systemic arthritis with active systemic features or active arthritis. Decision-making guidance regarding severity of disease or the presence of prognostic factors is included. For instance, for patients with a history of arthritis of five or more joints, a patient on methotrexate (with or without an adjunctive NSAID or joint injections) should move on to a tumor necrosis factor (TNF) -alpha inhibitor after 3 months if disease activity is moderate or high or after 6 months if disease activity is low, regardless of the presence of poor prognostic features.

Dr. Lehman, who is also chief of the division of pediatric rheumatology at the Hospital for Special Surgery in New York, noted that, "It is very appropriate to argue for the increased use of IL1 [interleukin-1] inhibitors in children with systemic onset disease. However, there are several different diseases included in the other forms of juvenile idiopathic arthritis for many of which it is not appropriate to start with methotrexate. Indeed, in this era, one must wonder if it wouldn\'t be more appropriate to begin children with an anti-TNF, which has a more rapid onset of action and is more effective in suppressing disease activity and preventing damage."

According to the International League of Associations for Rheumatology, JIA is defined as an arthritis of unknown etiology that begins before the 16th birthday and persists for at least 6 weeks with other known conditions excluded. About 1 in 1,000 children have JIA, and the condition can persist into adulthood, resulting in significant long-term morbidity.

Dr. Beukelman and Dr. Lehman had no relevant financial disclosures.

The American College of Rheumatology issued its first guidelines for the treatment of juvenile idiopathic arthritis on March 30.

"Our goal was to provide evidence and consensus-based guidance that reflects the current state of the field and is useful to clinicians of all levels of experience with the treatment of JIA. The recommendations are important because the treatment of JIA has undergone major changes over the last decade with the introduction of biologic therapeutic agents," Dr. Timothy G. Beukelman, lead author of the paper, said in an interview. The ACR says that the recommendations are not meant to dictate care, and it considers adherence to be voluntary.

The guidelines are published in Arthritis Care and Research (2011;63:465-82).

Up until now, there have been no validated guidelines for the treatment of JIA. Recognizing this, in 2008, the ACR issued a formal request for proposals to develop recommendations. The recommendations were written by a core expert panel of international pediatric rheumatology experts. A separate task force panel that included internationally recognized pediatric rheumatology clinicians, a pediatric rheumatology nurse, a general pediatrician, and a patient representative also provided input.

Dr. Thomas J.A. Lehman, professor of clinical pediatrics at Cornell University, New York, noted in an interview that: "While these new guidelines are useful in emphasizing the importance of promptly initiating appropriate disease-modifying therapy for children with active juvenile idiopathic arthritis, they are flawed in their failure to recognize the many variations in the severity of the variations of the disease.

The recommendations are "as evidenced based as possible," and also include expert opinion. They were developed after a systematic literature review that identified 244 pharmacotherapeutic studies, both controlled and uncontrolled. These studies were reviewed by the core expert panel which then prepared a summary report of the scientific evidence. The core expert panel also prepared more than 1,500 clinical scenarios for each medication of interest, categorizing hypothetical patients using all possible combinations of key clinical parameters. By a formal group assessment process, the TFP then made their recommendations, based on the published literature as well as ratings of the appropriateness of each medical intervention.

While the ILAR classification divides JIA into six distinct categories, these recommendations describe five JIA treatment groups: history of arthritis of four or fewer joints; history of arthritis of five or more joints; active sacroiliac arthritis; systemic arthritis with active systemic features and without active arthritis; and systemic arthritis with active arthritis and without active systemic features. Specific features for poor prognosis are described for each category, as well as disease activity levels. For instance, the features of poor prognosis for children with a history of arthritis in five or more joints are satisfaction of at least one of the following: arthritis of the hip or cervical spine, positive rheumatoid factor or anticyclic citrullinated peptide antibodies, or radiographic damage. "Risk stratification is crucial for guiding optimal treatment," according to Dr. Beukelman.

The recommendations focus on the initiation and safety monitoring of therapeutic agents used in the treatment of JIA, specifically NSAIDs, intra-articular glucocorticoid injections, nonbiologic disease-modifying antirheumatic drugs (DMARDs), biologic DMARDs, and systemic glucocorticoids. Medications used "off label" as part of common and widely accepted practice were considered.

Treatment algorithms are provided for those with a history of arthritis in four or fewer joints, history of arthritis in five or more joints, and systemic arthritis with active systemic features or active arthritis. Decision-making guidance regarding severity of disease or the presence of prognostic factors is included. For instance, for patients with a history of arthritis of five or more joints, a patient on methotrexate (with or without an adjunctive NSAID or joint injections) should move on to a tumor necrosis factor (TNF) -alpha inhibitor after 3 months if disease activity is moderate or high or after 6 months if disease activity is low, regardless of the presence of poor prognostic features.

Dr. Lehman, who is also chief of the division of pediatric rheumatology at the Hospital for Special Surgery in New York, noted that, "It is very appropriate to argue for the increased use of IL1 [interleukin-1] inhibitors in children with systemic onset disease. However, there are several different diseases included in the other forms of juvenile idiopathic arthritis for many of which it is not appropriate to start with methotrexate. Indeed, in this era, one must wonder if it wouldn\'t be more appropriate to begin children with an anti-TNF, which has a more rapid onset of action and is more effective in suppressing disease activity and preventing damage."

According to the International League of Associations for Rheumatology, JIA is defined as an arthritis of unknown etiology that begins before the 16th birthday and persists for at least 6 weeks with other known conditions excluded. About 1 in 1,000 children have JIA, and the condition can persist into adulthood, resulting in significant long-term morbidity.

Dr. Beukelman and Dr. Lehman had no relevant financial disclosures.