Treatment Factors to Consider in Patients with JIA

PRSYM—The treatment of juvenile idiopathic arthritis (JIA) requires consideration of two competing yet equally important aspects: how to aggressively treat and prevent morbidity of disease, and how to appropriately withdraw treatment to avoid side effects while maintaining disease remission. During the virtual 2021 Pediatric Rheumatology Symposium (PRSYM), a series of speakers covered these topics in detail.

Factors in Treatment

Richard Fuhlbrigge, MD, PhD, professor and section head of pediatric rheumatology, Children’s Hospital Colorado, Aurora, began the session by describing an evidence-based approach to the care of patients with JIA. He noted that, in 2019, the ACR and Arthritis Foundation jointly published a guideline for the treatment of JIA in patients with polyarthritis, sacroiliitis and enthesitis.¹

According to the guideline, untreated JIA with active polyarthritis refers to patients with five or more joints involved and can include patients with and without positive rheumatoid factor; patients with extended oligoarthritis, enthesitis-related arthritis or psoriatic arthritis; and patients with undifferentiated disease. In patients with untreated JIA with active polyarthritis, initial treatment should include a single disease-modifying anti-rheumatic drug (DMARD) over non-steroidal anti-inflammatory drug (NSAID) monotherapy. Methotrexate is the preferred first-line DMARD. Adjunctive therapies may include NSAIDs, intra-articular glucocorticoids, physical and/or occupational therapy, and bridging therapy with a limited course of oral glucocorticoids lasting less than three months. Each of these recommendations was given a “very low” grade by the guideline developers in terms of strength of evidence.

Dr. Fuhlbrigge also discussed variables that influence treatment options: clinical features, laboratory and imaging parameters, and medication characteristics.

When assessing a patient, rheumatologists must first consider the clinical features, such as the presence or absence of systemic symptoms, the number and distribution of joints involved, and the patient’s age, pubertal status and comorbidities. Second, rheumatologists should consider laboratory and imaging parameters, including autoantibodies, acute phase reactants, genetic markers and the presence or absence of synovitis, enthesitis and erosive joint disease. Third, rheumatologists must evaluate the characteristics of medications, including weighing the risks and benefits of corticosteroids—whether systemic or intra-articular—conventional DMARDs, biologic DMARDs and combination therapies.

When choosing DMARD therapy, rheumatologists must apply best practices in medication selection, and optimal use of these medications must take into account dosing, route of administration, timing and pharmacogenomics. Although not always available, data on comparative effectiveness can help indicate if individual or combination therapies are warranted and may allow for comparisons between generic and biosimilar treatments with brand-name medications. The long-term safety and biologic effect of individual, sequential and combination therapies must also be examined, as well as the potential for loss of efficacy and the ability to plan for medication withdrawal.