New guidelines for treating JIA to target

A treat to target approach for all patients with juvenile idiopathic arthritis should be able to achieve a 50% improvement in disease activity within three months and a target of clinical inactive disease within six months.

This is one of eight recommendations by an international task force of paediatric rheumatologists, following a systematic review of the evidence and a consensus conference.

The taskforce found the primary target should be clinical remission and notes that the availability of disease-modifying drugs makes this an achievable goal for most children.

In another recommendation they agree that minimal or low disease activity may be an alternative target in patients with long-standing disease.

“These patients are generally those with the most aggressive systemic or polyarticular forms who have experienced persistently active disease, received multiple drug therapies or accumulated substantial joint damage or comorbidities,” they say in Annals of Rheumatic Diseases.

“Therapeutic decision-making may be guided by the recent treatment recommendations for JIA issued by the ACR, which were tailored according to JIA phenotype, level of disease activity and the presence of features of poor prognosis.”

Co-author Dr Jonathon Akikusa, from the Royal Children’s Hospital Melbourne and the Murdoch Children’s Research Institute, told the limbic most centres in Australia were already treating children to target and aiming for remission or low disease activity.

“So what these guidelines do is formalise that target in a consensus-based manner and make that approach more widely disseminated so other areas where people have a different type of practice are at least aware of what the mainstream paediatric rheumatology community is moving towards.”

He said there are relatively few barriers to achieving these targets in most areas of Australia.

“There is starting to be an appropriate level of manpower to ensure that patients can be reviewed at the recommended frequencies. However there still are some states and territories where there aren’t paediatric rheumatologists practicing at all and in those states you would say the biggest barrier is around manpower to some extent and access to an integrated mulitdisciplinary team.”

The recommendations emphasise frequent assessment – as often as weekly – to achieve target and then ongoing monitoring to maintain the target.

“That really frequent monitoring is related to children with systemic disease who are the most unwell. The shortest timeline for expecting improvement is for example, ablation of fever within a week after starting treatment,” Dr Akikusa said.

“Very few families need that degree of close follow-up although some certainly do.”

The taskforce recommends that disease activity should be assessed and documented regularly using a validated composite measure however it stopped short of recommending specific outcome tools.

Dr Akikusa added that stringent treatment targets do not negate the need for including patients and their parents in decision-making.

“It is essential that there is a holistic approach to the child and their family and that we don’t become too narrowed in on what the joint count is or what the inflammatory markers are doing but that we take a step back and look at the child in context and make sure we are aware of what is happening at school, at home and what impacts of the disease, and sometimes of the treatments required, may be problematic and potentially should be addressed.”

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