2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: initiation and safety monitoring of therapeutic agents for the treatment of arthritis and systemic features

Abstract

Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are intended to provide guidance for particular patterns of practice and not to dictate the care of a particular patient. The ACR considers adherence to these guidelines and recommendations to be voluntary, with the ultimate determination regarding their application to be made by the physician in light of each patient’s individual circumstances. Guidelines and recommendations are intended to promote beneficial or desirable outcomes but cannot guarantee any specific outcome. Guidelines and recommendations developed or endorsed by the ACR are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice.

Figure 1

Treatment recommendations for patients with a history of arthritis of 4 or fewer joints. These recommendations are intended for patients with juvenile idiopathic arthritis (JIA) who have only developed active arthritis in 4 or fewer joints in total throughout the history of their disease course and are based upon duration of current therapy, disease activity, and features of poor prognosis. If criteria for escalation of therapy are not met, then continue current therapy along with adjunct nonsteroidal antiinflammatory drugs (NSAIDs) or glucocorticoid joint injections, as needed. Recommendations for reduction of therapy are not addressed. See Table 1 for definitions of disease activity and features of poor prognosis. * = sulfasalazine may be an appropriate treatment for patients with the enthesitis-related arthritis category of JIA (see text for details); MTX = methotrexate; TNFα = tumor necrosis factor α.

Figure 2

Treatment recommendations for patients with a history of arthritis of 5 or more joints. These recommendations are intended for patients with juvenile idiopathic arthritis who have developed active arthritis in 5 or more joints in total throughout the history of their disease and are based upon duration of current therapy, disease activity, and features of poor prognosis. If criteria for escalation of therapy are not met, then continue current therapy along with adjunct nonsteroidal antiinflammatory drugs (NSAIDs) or glucocorticoid joint injections, as needed. Recommendations for reduction of therapy are not addressed. See Table 2 for definitions of disease activity and features of poor prognosis. * = leflunomide may be an appropriate treatment alternative (see text for details); MTX = methotrexate; TNFα = tumor necrosis factor α.

Figure 3

Treatment recommendations for patients with systemic arthritis and active systemic features (and without active arthritis). These recommendations are intended for patients with juvenile idiopathic arthritis who have systemic arthritis with active systemic features and without active arthritis. Recommendations are based upon duration of current therapy, disease activity, and features of poor prognosis. If criteria for escalation of therapy are not met, then continue current therapy along with adjunct nonsteroidal antiinflammatory drugs (NSAIDs), as needed. Recommendations for reduction of therapy are not addressed. See Table 4 for definitions of disease activity and features of poor prognosis. MD Global = physician global assessment of overall disease activity (range 0---10).

Figure 4

Treatment recommendations for patients with systemic arthritis and active arthritis (and without active systemic features). These recommendations are intended for patients with juvenile idiopathic arthritis who have systemic arthritis with active arthritis and without active systemic features. Recommendations are based upon duration of current therapy, disease activity, and features of poor prognosis. If criteria for escalation of therapy are not met, then continue current therapy along with adjunct nonsteroidal antiinflammatory drugs (NSAIDs), as needed. Recommendations for reduction of therapy are not addressed. See Table 5 for definitions of disease activity and features of poor prognosis. MTX = methotrexate; TFNα = tumor necrosis factor α; * = initiation of anakinra for the treatment of arthritis may be less appropriate later in the disease course compared to nearer the onset of disease; † = switching from anakinra to a TNFα inhibitor may be appropriate for some patients with moderate or high disease activity, irrespective of features of poor prognosis, but there is a possible risk of unmasking latent systemic features when discontinuing anakinra.