NSAIDs downgraded in new guidelines for juvenile arthritis

Initial NSAID monotherapy for polyarthritis in juvenile idiopathic arthritis (JIA) has been rejected in the most recent 2019 American College of Rheumatology / Arthritis Foundation guidelines.

The guidelines differ from the earlier 2011 version in recognising ‘the established benefits of early initiation of DMARD treatment’.

As a result, NSAIDs have been downgraded to adjunct therapy, particularly during initiation or escalation of therapy with DMARDs and/or biologics.

Intra-articular glucocorticoids are also conditionally recommended as adjunct therapy.

The guidelines team acknowledged mostly equivalent data for safety and efficacy between the biologics and the lack of head-to-head comparisons.

“The exceptions were that TNFi are specifically recommended for sacroiliitis, and rituximab is considered only after TNFi, abatacept, and tocilizumab have been tried,” they said.

The guidelines also include recommendations for escalating care in the setting of low disease activity – “highlighting the importance of achieving and maintaining complete disease control, which was not previously addressed”.

There are recommendations against oral glucocorticoids as bridging therapy in patients with low disease activity and a strong recommendation against long-term low-dose glucocorticoids, regardless of risk factors or disease activity.

However the committee found the quality of supporting evidence was low or very low for 90% of the recommendations.

“While it is anticipated that these recommendations will lead to improved outcomes for children with JIA and these phenotypes, they also emphasise the ongoing need to generate high-quality data about treatment effectiveness in JIA,” lead author Dr Sarah Ringold from the Seattle Children’s Hospital said.

A second guideline document focuses on the screening, monitoring and treatment of JIA with associated uveitis.

Recommendations include:

  • A strong recommendation for ophthalmologic monitoring within one month after each change of topical glucocorticoids rather than less frequent monitoring for children and adolescents with controlled uveitis who are tapering or discontinuing topical glucocorticoids.
  • A conditional recommendation to start methotrexate and a monoclonal antibody TNFi immediately, rather than methotrexate as a monotherapy in children and adolescents with severe, active chronic anterior uveitis and sight-threatening complications.
  • A strong recommendation for education regarding the warning signs of acute anterior uveitis for the purpose of decreasing delay in treatment, duration of symptoms, or complications of iritis for children and adolescents with spondyloarthritis.

“Prevention of sight-threatening complications from uveitis is most important. It is crucial that children with JIA undergo scheduled ophthalmology screening to detect uveitis early, since children are usually asymptomatic,” said Dr Sheila Angeles-Han, a rheumatologist at the Cincinnati Children’s Hospital and principal investigator for the guidelines.

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