2013 update of the 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: recommendations for the medical therapy of children with systemic juvenile idiopathic arthritis and tuberculosis screening among children receiving biologic medications

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.

The American College of Rheumatology is an independent, professional, medical and scientific society which does not guarantee, warrant, or endorse any commercial product or service.

Figure 1

Treatment pathways for patients with active systemic features and varying degrees of synovitis. The Task Force Panel was asked to consider the treatments among patients with active systemic features and a physician global assessment (MD global) of <5 or ≥5 on a 10-point numerical rating scale (0–10 visual analog scale, where 0 = no disease activity and 10 = the most severe) and by active joint count (AJC; 0 joints, 1–4 joints, or >4 joints). If a recommendation is noted to be irrespective of the AJC or MD global, the recommendation was for children with an AJC ≥0 or an MD global >0, respectively. Adjunct systemic glucocorticoids (GCs) and/or intraarticular GCs may be added at any point. Children may qualify for >1 pathway, in which case it is left to the provider's discretion to choose the path they feel is most appropriate based upon specific patient characteristics and/or patient and family preferences. Steps in the progression of therapy can be additive or sequential, except that therapies with a biologic agent are sequential (combination therapy with a biologic agent is not endorsed). The recommendations in this figure are for patients with active systemic features. If the systemic features (but not the arthritis) respond to therapy, then subsequent treatment decisions should be based upon the recommendations in Figure 2. NSAIDs = nonsteroidal antiinflammatory drugs; IV = intravenous; MTX = methotrexate; TNFα = tumor necrosis factor α.

Figure 2

Treatment pathways for patients without active systemic features and with varying degrees of synovitis. The Task Force Panel was asked to rate the appropriateness of therapies based on the total number of active joints (≤4 or >4). Children may qualify for >1 pathway, in which case it is left to the provider's discretion to choose the path they feel is most appropriate based upon specific patient characteristics and/or patient and family preferences. Steps in the progression of therapy can be additive or sequential, except that therapies with a biologic agent are sequential (combination therapy with a biologic agent is not endorsed). AJC = active joint count; MTX = methotrexate; NSAID = nonsteroidal antiinflammatory drug; IV = intravenous; TNFα = tumor necrosis factor α.