ACR guidelines: ‘Turn the pyramid upside down’ for biologic DMARDs in JIA
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The American College of Rheumatology has released two updated guideline papers for the treatment and management of juvenile idiopathic arthritis, according to a press release.
“As rheumatologists, our patients and caregivers expect us to review the literature and weigh the evidence so that we can suggest the best treatments, while also considering their preferences,” Karen Onel, MD, chief of the pediatric rheumatology division at the Hospital for Special Surgery in New York and the lead investigator of the guidelines, said in the release.
The updates are meant to be companions to guides that were released in 2019 by the ACR and Arthritis Foundation.
Each of the new papers focuses on a different facet of disease management. The first covers pharmacologic management of JIA, with a focus on oligoarthritis, temporomandibular arthritis and systemic JIA, with and without macrophage activation syndrome. The second paper focuses on non-pharmacologic therapies, medication monitoring, immunizations and imaging.
“The original JIA guidelines were published in 2011 and 2013, and this update reflects the ever-changing rheumatology field with new criteria on how to define disease and new medications to treat those diseases,” the release said.
One big change from the new pharmacologic management guidelines is the emphasis on the use of disease-modifying antirheumatic drugs.
“These guidelines stress the early use of conventional synthetic and biologic DMARDs and the avoidance of glucocorticoids and NSAIDs. In fact, for systemic JIA the guidelines suggest using biologic DMARDs as a first line,” Onel said in the release. “We have turned the pyramid upside down.”
The non-pharmacologic guidelines stress methods for monitoring drug toxicities in patients with JIA and the role of immunization. The guidelines also recommend physical and occupational therapy in addition to a healthy diet.
The new guidelines lack specific direction regarding immunization of children with rheumatic disease against COVID-19, but directions “should be similar to those stated for inactivated vaccines,” the release said.
“There were areas that we didn’t consider at the start that now belong,” Onel said in the release. “The guidelines will have to be updated again. But that is a sign of a growing and changing field,”
The papers outlining the new recommendations are available on the ACR website.
Perspective
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Jordan T. Jones, DO, MS
The updated guidelines are important and represent acknowledgement by the pediatric rheumatology community that approach to care of JIA changes over time. It is important to continually reflect and implement new science in our approach with the goal of improving outcomes for patients with JIA. The new guidelines build upon the foundation set by previous and provide more granularity that addresses specific situations that providers and patients regularly encounter. They expand beyond therapeutic options and address commonly asked questions about recommendations on diet and immunizations.
Additionally, the focus on shared decision-making allows the patients and their caregivers to have more input and investment in their care, which is always important. The new guidelines should ultimately improve the care and management of those with JIA leading to better outcomes and better overall health.
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