The American College of Rheumatology (ACR), in partnership with the Arthritis Foundation (AF), released two guidelines on juvenile idiopathic arthritis (JIA). One guideline aims to provide therapeutic approaches for non-systemic polyarthritis, sacroiliitis, and enthesitis; and the other focuses on the screening, monitoring and treatment of JIA with associated uveitis.
Juvenile arthritis (JA) is a common, chronic childhood disease that affects nearly 300,000 children in the United States. According to the AF; juvenile arthritis is not a disease in itself but is an umbrella term used to describe the autoimmune and inflammatory conditions or pediatric rheumatic diseases; like JIA, that can develop in children younger than 16. With JIA, the term idiopathic means.” All forms of JIA are with decreasing health-related quality of life, the risk for permanent joint damage; the likelihood that the disease may persist into adulthood.
JIA polyarthritis guideline
1. Conditional recommendations that NSAIDs and intraarticular glucocorticoids should each used as an adjunct therapy.
2. A strong recommendation against adding chronic low-dose glucocorticoid; regardless of risk factors or disease activity.
3. A conditional recommendation to get physical therapy and/or occupational therapy for children and adolescents with JIA and polyarthritis who have; or are at risk for, functional limitations.
These recommendations highlight the importance of prompt and effective treatment for children with JIA and polyarthritis, sacroiliitis, and enthesitis. “They also support relatively tight disease control, with an inactive disease as the goal. While it is anticipated that these recommendations will lead to improved outcomes for children with JIA and these phenotypes, they also emphasize the ongoing need to generate high-quality data about treatment effectiveness in JIA.”
The extra-articular manifestations
As noted, JIA can impair a child’s quality of life especially when extra-articular manifestations occur. A common manifestation is uveitis, which can a chronic or acute disease. Chronic anterior uveitis (CAU) develops in 10-20 % of children with JIA, is usually asymptomatic, and there is rarely external evidence of inflammation. On the other hand, acute anterior uveitis (AAU) is a distinctly different form of uveitis and typically occurs in children with spondyloarthritis (i.e., those with enthesitis-related or psoriatic arthritis).
Therefore the JIA guidelines developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology; which provides rigorous standards for judging the quality of the literature available and assigns strengths to the recommendations that are largely based on the quality of the available evidence. So the guideline process also included significant input from patients and parents; which was made possible through the ACR and AF partnership.
Although the quality of evidence was low or very low and most recommendations therefore conditional for both; these guidelines fill an important clinical gap in the care of children with JIA, including non-systemic polyarthritis; sacroiliitis and enthesitis, and JIA-uveitis, and may update as better evidence becomes available.