Karen Onel, MD, on A Preview of the ACR Guideline for the Management of JIA

The American College of Rheumatology (ACR) guideline for the management of juvenile idiopathic arthritis (JIA) is currently under review and will soon be published. In this video, the lead investigator of the guideline’s Core Team, Karen Onel, MD, previews the guideline, which addresses treatments for systemic JIA, oligoarthritis, and temporomandibular joint arthritis and includes recommendations for medication monitoring and immunizations. Dr Onel had discussed the recommendations—which are the culmination of a 2-part update of the ACR’s JIA guidelines published in 2011 and 2013—during ACR Convergence.

Additional Resource:

Onel K. Presentation of the new JIA guidelines. Preview presented at: American College of Rheumatology Convergence 2020; November 5-9, 2020; Virtual. 

Karen Onel, MD, is chief of Pediatric Rheumatology at Hospital for Special Surgery and a professor of Clinical Pediatrics at Weill Cornell Medical School. 

TRANSCRIPT:

Hi, I’m Dr Karen Onel. I’m chief of the Division of Pediatric Rheumatology at Hospital for Special Surgery in New York and a professor of Clinical Pediatrics at Weill Cornell Medical College.

I’m here to bring you up‑to‑date on our new guidelines for the treatment of children with oligoarthritis, TMJ arthritis, systemic arthritis, as well as our new recommendations for medication monitoring and infection screening with a final recommendation for immunizations.

These are draft guidelines. They need to still be approved by the ACR, but they were recently presented at ACR Convergence, which is the annual meeting for the American College of Rheumatology. A few things that are seminally different from recommendations in the past, and I would like to highlight those. 

The first is we really want to stress a decreased reliance both on nonsteroidal anti‑inflammatory drugs as well as glucocorticoids. There are many new therapies that have become available in the last several years. Both the rheumatologists who participated in making these guidelines, as well as the patients and parents, were both in favor of these recommendations.

Firstly, nonsteroidal anti‑inflammatory drugs are not able to actually put the disease into remission, and many of the patients and parents complained about gastrointestinal side effects. As for glucocorticoids, the numerous side effects in childhood including the effects on growth and bone health really outweigh their use for treating the disease.

Secondly, as regards to systemic arthritis, the panels, both of them wanted to recommend early use of biologic therapy as these medications are able to put children directly into remission. This is a sick group of children who have had fever now for weeks. Parents and patients alike were both eager for a medication that would lead to rapid response.

These guidelines specifically leave out time frames for advancement of therapy. The reason for that is we want physicians to be able to make these decisions to move ahead when necessary if a patient is worsening and not feel beholden to any particular timeframe.

For immunizations, the panel had a strong recommendation for immunization for all children with juvenile arthritis. There’s ample evidence that children with arthritis on medications, off medications will respond and that immunizations do not provoke a flare.

For children off immunotherapy, the recommendation is for both live and inactivated vaccines as per the CDC and “Red Book” guidelines. For children on immunosuppressive medications, we strongly recommend treatment with inactivated vaccines.

We’re conditionally recommending against live virus vaccines until there’s more data to show that it’s safe, although there is burgeoning literature suggesting that boosters may be appropriate, and we hope to be able to update this over the next few years.

Annual flu recommendations were recommended for both groups strongly, and PNEUMOVAX recommended for children who are receiving immunotherapy. Strong recommendations were given for occupational physical therapy for children irrespective of medical use.

Although specific diets and supplements were not recommended specifically to treat juvenile arthritis, we did recommend that physicians have a conversation about a healthy age appropriate diet with all of the patients.

Finally, we wanted to stress the fact that these are guidelines. These are recommendations and suggestions. At the end, the decision of what treatments are most appropriate to use should remain a decision between the care provider, the doctor, the nurse practitioner, the PA and the patients so that we are able to get to the best treatments we possibly can for the patients we take care of to bring them into a healthy adulthood, which is the goal for all of us.