Recommendations: Both inactivated and live virus type vaccines are strongly recommended for JIA patients who are not being treated with immunosuppressive drugs.
Inactivated vaccines are strongly recommended for patients being treated with immunosuppressive drugs; however, a conditional recommendation is that these patients not receive live virus vaccines, in accordance with Centers for Disease Control recommendations.2 Some evidence suggests that booster immunizations with live attenuated vaccines may be safe for children with JIA on specific immunosuppressants, but more work is needed to make a formal recommendation, Dr. Onel notes.
Thus, patients on immunosuppression not previously vaccinated need to rely on herd immunity for protection from measles and chicken pox, for example, rather than vaccination. Thus, it is imperative that family members and members of the household all receive appropriate immunizations.
Because the current vaccines for COVID-19 are inactivated vaccines, such vaccination is recommended for JIA patients regardless of whether they are on immunosuppression.
Recommendation: Screening for active synovitis or enthesitis using radiography prior to advanced imaging is strongly recommended against.2
Third-party payers often require clinicians to get an X-ray prior to a magnetic resonance imaging (MRI) scan, explains Dr. Cron. “But if you want to actually evaluate someone for inflammatory arthritis, X-rays tend not to be helpful in the short term. If you really want to know, particularly for the jaw, MRI is going to be much more helpful. [The X-ray] is unnecessary radiation for the child and a waste of time and money.”
Moving Forward
New data and treatment choices will be reflected in future versions of the guidelines. For example, the TNF inhibitor golimumab and the Janus kinase (JAK) inhibitor tofacitinib were both approved in 2020, after work on the guideline had already begun, and the IL-17 inhibitor secukinumab was approved just as the paper was being submitted. Janssen also has submitted an application to the U.S. Food & Drug Administration to expand the use of the IL-12/IL-23 inhibitor ustekinumab to treat juvenile psoriatic arthritis.8
“I think IL-17 blockade will likely become part of the armamentarium for kids with JIA.” says Dr. Cron. “It’s already getting studied pretty well on the adult side. JAK inhibitors will get more attention for pediatric arthritis as well, and IL-12/23 blockers may be of utility.”
Both Dr. Onel and Dr. Cron would like to see more information comparing different biologics in JIA and more information about which one might make sense for different patients. Ideally, we could work toward more of a personalized medicine approach and identify indicators via genetics, lab work and clinical signs about the best approaches for different patients.
