Dr. Evelyn Rozenblyum and Dr. Natasha Gakhal
CHICAGO—At a session of ACR Convergence 2025, attendees absorbed key insights into the management of juvenile idiopathic arthritis (JIA). Two experts on JIA coordinated the joint lecture: pediatric rheumatologist Evelyn Rozenblyum, MD, FRCPC, and adult rheumatologist Natasha Gakhal, MD, FRCPC, MSc, both of Women’s College Hospital, University of Toronto, Canada.
Together, Dr. Rozenblyum and Dr. Gakhal founded and co-lead a JIA young adult clinic at Women’s College Hospital, a clinic in which interprofessionals, and pediatric and adult rheumatologists collaboratively manage young adults aged 17– 25 and help meet this population’s special needs as they transition to adult care.
Becoming an Adult Patient
The majority of pediatric patients with JIA will eventually require adult care, noted Dr. Rozenblyum, and many still have a high burden of disease during this transition. Of patients with active disease, the vast majority require therapy with disease-modifying anti-rheumatic drugs (DMARDs) into adulthood.
Dr. Evelyn Rozenblyum
Dr. Rozenblyum noted that, for a variety of reasons, many young adults with JIA fail to successfully transition to adult care. “It’s important that we think about thoughtful ways to prepare them for transition from pediatric to adult care within the healthcare system,” she said
It’s also critical to address psychosocial issues in young adults with JIA because they navigate not just their disease, but also new challenges of moving through the adult world, some of which directly affect their healthcare options and their overall health and wellbeing. In some reports, young adults with JIA tend to have worse educational and vocational outcomes, especially if their disease is uncontrolled, Dr. Gakhal said.
Providers should not just ask about symptoms related to disease activity, but also about mood, education and vocation, substance use and pregnancy considerations. “First and foremost, we should control their disease, but we can also connect them with resources,” Dr. Gakhal said.
Dr. Rozenblyum and Dr. Gakhal also discussed uveitis and arthritis of the temporomandibular joint (TMJ), two aspects of care with ongoing questions and implications in this young adult population with JIA.
Clinical Pearls in Uveitis
About 10–30% of JIA patients develop uveitis. Dr. Rozenblyum noted this is usually an asymptomatic chronic anterior type of uveitis, different from most presentations in adult rheumatology.1 If not addressed, such uveitis can lead to such complications as synechiae (i.e., adhesion of the papillary muscles due to inflammation), cataracts, glaucoma and vision loss. Because it is usually asymptomatic, screening becomes even more important.
Certain factors increase the risk of uveitis in JIA, including oligoarticular presentation, antinuclear antibody positivity and being female. Patients younger than 7 are also at higher risk, as well as patients whose diagnosis occurred within the last four years.1
Dr. Rozenblyum explained that guidelines from the ACR and the Canadian Rheumatology Association are similar with respect to uveitis screening in pediatrics. Essentially, patients with more risk factors require more frequent screening, with the recommended frequency varying from every three months to annually depending on the specific risk factors present.2,3
Practitioners can alternatively follow a simplified recommendation on uveitis screening from the Multinational Interdisciplinary Working Group for Uveitis in Childhood, which provides screening frequency recommendations based simply on current patient age and their age at diagnosis.4
If a patient is already being treated for uveitis, screening should be every one to two months while adjusting therapy and every three months if stable on treatment. For patients in remission and off medication, the recommendation is every four months for the first four years, with screening every six to 12 months until age 18.3,4
Guidelines for uveitis screening in patients with JIA after age 18 are not available due to the relative lack of data in this group, noted Dr. Rozenblyum. But she pointed to a 2021 study that followed JIA patients into young adulthood, which showed that some patients first developed uveitis after the age of 18 and greater than four years after their diagnosis even though factors make them relatively lower risk.5
“How long should we screen our patients in the adult world for uveitis? The real answer is that we don’t know,” Dr. Rozenblyum said. “But many continue to have active disease in adulthood, so it’s likely a good idea to keep going.” Every six to 12 months may be a reasonable approach, she added.
For treatment, close collaboration with ophthalmology is key. Prednisolone eye drops are the first-line treatment, adding another conventional synthetic DMARD, such as methotrexate or mycophenolate mofetil, if needed. If still insufficient, anti-tumor necrosis factor (TNF) monoclonal antibodies can used or another biologic for refractory disease, such as tocilizumab, abatacept or rituximab.2
Before considering withdrawing medication, patients should be in remission for two to three years. Dr. Rozenblum shared that recent data also support a slow taper over an abrupt one to reduce the risk of, and time to, flares.6,7
Clinical Pearls in TMJ Arthritis
Dr. Natasha Gakhal
The TMJ, one of the most frequently used joints in the body, continues to mature during a person’s twenties. “Even subtle dysfunction can cause significant daily pain and functional issues,” Dr. Gakhal said.
The scientific literature reports a wide range in incidence of TMJ involvement in patients with JIA likely due to different diagnostic methods and patient populations, but it may be quite frequent. Relatedly, TMJ involvement is often difficult to diagnose early because inflammation may be initially asymptomatic or subtle in presentation, and structural damage may already be present at the time of diagnosis.
Untreated TMJ arthritis can cause quite significant complications, impairing such tasks as eating and speaking and causing other problems, such as receding jaw or jaw underdevelopment, teeth misalignment, facial asymmetry and sleep apnea.
“Decreased maximal jaw opening is the sign most indicative of TMJ involvement,” Dr. Gakhal said. A simple way to assess this symptom is by seeing the number of finger breaths the patient can fit in their mouth. Less than three often indicates a problem. More formally, one can measure the distance between the patients upper and lower incisors when they open their jaw as wide as possible. This measurement should be at least 40 mm or more.8
Other joint findings may include deviation of the mandible, tenderness or crepitus while opening the jaw or tenderness of the masticatory muscles. It is important to note the TMJ is also prone to mechanical issues unrelated to JIA that may appear on physical exams or imaging.
Dr. Gakhal explained that X-ray and ultrasound are of limited utility, and magnetic resonance imaging (MRI) is the diagnostic gold standard. However, she emphasized that it must be performed with gadolinium contrast, using a specific MRI protocol for inflammatory disease, as opposed to the type of scan that may be used for head and neck cancer.
These images should be interpreted by a radiologist with expertise in musculoskeletal inflammatory disease and involvement of the TMJ. An expert can help distinguish the bone marrow edema and contrast enhancement consistent with synovitis from active JIA from reactive synovitis from prior damage or reactive synovitis from unrelated mechanical issues.
For treatment, a specialized physiotherapist with expertise in TMJ involvement can be very helpful. Dr. Gakhal noted that oral nonsteroidal anti-inflammatory drugs have limited value. Conventional DMARDs, such as methotrexate, may be needed, escalating to biologic DMARDs, such as TNF-inhibitors or tocilizumab, if indicated.9
“Use cortisone injections sparingly and with caution,” Dr. Gakhal said, “because they can affect the mandibular growth in an immature skeleton.”
Ruth Jessen Hickman, MD, a graduate of the Indiana University School of Medicine, is a medical and science writer in Bloomington, Ind.
References
- Sandborg CI, Schulert GS, Kimura Y. Juvenile idiopathic arthritis. N Engl J Med. 2025 Jul 10;393(2):162–174.
- Angeles-Han ST, Ringold S, Beukelman T, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the screening, monitoring, and treatment of juvenile idiopathic arthritis-associated uveitis. Arthritis Care Res (Hoboken). 2019 Jun;71(6):703–716.
- Berard R, Ng HY, Human A, et al. Canadian Rheumatology Association recommendations for the screening, monitoring, and treatment of juvenile idiopathic arthritis-associated uveitis. J Rheumatol. 2023 Mar;50(3):390–399.
- Foeldvari I, Bohn M, Petrushkin H, et al. A practical approach to uveitis screening in children with juvenile idiopathic arthritis. Br J Ophthalmol. 2025 Feb 24;109(3):372–376.
- Rypdal V, Glerup M, Songstad NT, et al. Uveitis in juvenile idiopathic arthritis: 18-year outcome in the population-based Nordic cohort study. Ophthalmology. 2021 Apr;128(4):598–608.
- Marino A, Cicinelli MV, Miserocchi E, et al. Recurrence risk in pediatric noninfectious uveitis during adalimumab tapering: An international multicenter retrospective study. Arthritis Rheumatol. 2025 Sep;77(9):1254–1262.
- Acharya NR, Ramanan AV, Coyne Abet al. Stopping of adalimumab in juvenile idiopathic arthritis-associated uveitis (ADJUST): A multicentre, double-masked, randomised controlled trial. Lancet. 2025 Jan 25;405(10475):303–313.
- de Sonnaville WFC, Speksnijder CM, et al. Clinically established temporomandibular involvement in adults with juvenile idiopathic arthritis. J Rheumatol. 2023 Nov;50(11):1462–1470.
- Onel KB, Horton DB, Lovell DJ, et al. 2021 American College of Rheumatology guideline for the treatment of juvenile idiopathic arthritis: Therapeutic approaches for oligoarthritis, temporomandibular joint arthritis, and systemic juvenile idiopathic arthritis. Arthritis Rheumatol. 2022 Apr;74(4):553–569.
