Australia’s first living guidelines for JIA: focus on DMARDs

By Natasha Doyle

29 Nov 2021

Australian rheumatologists have heard the call for localised, evidence-based and up-to-date guidance on DMARD use in juvenile idiopathic arthritis (JIA) and prioritised the matter in new living guidelines.

Produced by an expert panel led by paediatric rheumatologist Dr William Renton at The Royal Children’s Hospital Melbourne, the ANZMUSC and ARA-backed guidelines are the second set to go live this year after the Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis.

Like its sister guidelines, the Australian Living Guideline for the Management of Juvenile Idiopathic Arthritis has put DMARD recommendations first, though it currently only discusses DMARD use in JIA-associated uveitis patients who haven’t responded to methotrexate.

Where benefits outweigh the harms in these patients “b/tsDMARDs should be considered”, the guideline states.

“Adalimumab is recommended over other b/tsDMARDs. Etanercept is not recommended.”

This initial recommendation is “in keeping with existing international guidelines”, however, future recommendations may be more tailored to Australian practice and, hopefully, fill gaps in current guidance, Dr Renton told the limbic.

“For the next few topics, we’re looking to tackle questions that don’t have particularly good consensus or evidence base.”

“In particular, [treatment down-titration or discontinuation in patients with inactive disease] is one topic that hasn’t been specifically addressed by existing guidelines, so we’re hoping to fill that void,” he said.

The guidelines are also expected to explore the role of corticosteroids in JIA and best practice approaches to choosing disease modifying treatment based on disease subtype within JIA or in patients who have not responded or are intolerant to conventional DMARDs.

The topics were chosen after being voted as ‘high priority’ in a survey of Australian Paediatric Rheumatology Group members.

Most respondents felt Australian guidelines in JIA, and particularly these areas, would be helpful and ensure recommendations were relevant to local practice, Dr Renton said.

Having living guidelines would also allay concerns that recommendations would become outdated and unreliable, he said.

“We’re hoping to build up a workflow that allows us to add to the recommendation list at relatively frequent intervals, and similarly, in the setting of a living guideline, to review the old recommendations to ensure that nothing’s changed or that we don’t need to adjust the recommendations or add to the evidence base.”

He’s currently working on the evidence summary for the recommendation around treatment down titration and hopes to have a panel consensus by early 2022, he said.

The guidelines, along with research evidence, decision rationales and practical information are freely available via the host platform MAGICapp.

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