Dr. Daniel Horton
Daniel Horton, MD, MSCE, associate professor of pediatrics and epidemiology at Rutgers University, New Brunswick, N.J., reviewed the recommendations for polyarthritis, oligoarthritis, enthesitis, dactylitis and temporomandibular joint (TMJ) arthritis. Although this recommendation is not a change, he underscored that it was important to remember to consider the risk factors for poor outcomes, such as the involvement of the ankle, wrist, sacroiliac joint, hip or TMJ, or erosive or symmetric disease, when making treatment decisions because this might warrant rapid escalation or alternative medications.
- DMARDs, biologic and/or conventional, are now strongly recommended as part of initial therapy for polyarthritis, enthesitis, dactylitis and TMJ arthritis.
- Oral methotrexate is now conditionally recommended over subcutaneous methotrexate. And methotrexate is conditionally recommended over alternative conventional agents, which vary depending on the phenotype.
- Tumor necrosis factor (TNF) inhibitors are conditionally recommended as the first bDMARD over other bDMARDs, which vary depending on the phenotype.
- For TNF inhibitors users, it is conditionally recommended to use a csDMARD concurrently to improve effectiveness and prevent anti-drug antibodies.
- Oral GCs are conditionally recommended against as part of initial therapy. If used, they should be used at the lowest effective dose and for the shortest duration possible.
- It is conditionally recommended against doing routine monitoring for anti-drug antibody levels because they might not be neutralizing and because of the added cost of this monitoring, Dr. Horton said.
- In the event of an inadequate initial response or intolerance to a TNF inhibitor, it is conditionally recommended to try a second TNFi or a medication with a different mechanism, such as an IL-6 inhibitor, a T cell co-stimulation-modulator, IL-17 inhibitor, IL-12/23 inhibitor or JAK inhibitor.
- For clinical remission on combination DMARDs, tapering or stopping csDMARDs first is conditionally recommended over tapering or stopping bDMARDs or tsDMARDS.
- For clinical remission on bDMARDs, it is conditionally recommended to taper DMARDs over immediately stopping DMARDs to prevent an exacerbation.
- For clinical remission on DMARDS, when considering a taper or a stop, it is conditionally recommended to do imaging of joints that are difficult to assess, such as the TMJ or the C-spine, Dr. Horton said.
- For a flare after a DMARD taper or stop, it is conditionally recommended to restart the most recently effective DMARD regimen over starting a new regimen.
JIA-Associated Uveitis
Dr. Sheila Angeles-Han
Sheila Angeles-Han, MD, MSc, professor of pediatrics and assistant professor of ophthalmology at Cincinnati Children’s Hospital, discussed changes to JIA-associated uveitis recommendations.
