The management of juvenile idiopathic arthritis (JIA) with an oligoarticular presentation involves a stepwise approach, starting with nonsteroidal anti-inflammatory drugs (NSAIDs), followed by intra-articular corticosteroids, disease-modifying antirheumatic drugs (DMARDs), and potentially biologic agents. Regular monitoring of disease activity and response to treatment is required.
Initial therapy
- NSAIDs: The American College of Rheumatology (ACR) 2022 guidelines recommend initiating a trial of scheduled NSAIDs as part of initial therapy in patients with active oligoarticular JIA
- Intra-articular corticosteroids: The ACR 2022 guidelines also recommend administering intra-articular corticosteroids as part of initial therapy in this patient population. Triamcinolone hexacetonide is preferred over triamcinolone acetonide for intra-articular corticosteroid injections
- Oral corticosteroids: However, the use of oral corticosteroids as part of initial therapy is not recommended
Subsequent therapy
- DMARDs: If there is an inadequate response to NSAIDs and/or intra-articular corticosteroids, the ACR 2022 guidelines recommend initiating conventional synthetic DMARDs. Methotrexate is preferred over leflunomide, sulfasalazine, or hydroxychloroquine
- Biologic DMARDs: For patients with an inadequate response to or intolerance of NSAIDs, intra-articular corticosteroids, and at least one conventional synthetic DMARD, the initiation of biologic DMARDs is recommended. However, there is insufficient evidence to recommend a preferred biologic DMARD
Monitoring
- Disease activity measures: The ACR 2022 guidelines recommend using validated disease activity measures to guide treatment decisions, especially to facilitate treat-to-target approaches
- Risk factors for poor outcome: These include involvement of the ankle, wrist, hip, sacroiliac joint and/or temporomandibular joint, presence of erosive disease or enthesitis, delay in diagnosis, elevated levels of inflammatory markers, and symmetric disease
Personalized approach
- Genetic markers: Polymorphic variants in the osteopontin gene have been associated with the disease course in oligoarticular JIA, suggesting a potential role for genetic markers in characterizing patients at risk of a worse outcome
- Biomarkers: Studies have identified key biomarkers such as JUN, CXCL8, SOCS3, and KRAS for RF-negative polyarticular JIA and JUN, CXCL8, SOCS3, PTGS2, and NFKBIA for oligoarticular JIA
In conclusion, the management of oligoarticular JIA involves a stepwise approach, starting with NSAIDs and intra-articular corticosteroids, followed by DMARDs and potentially biologic agents if the response is inadequate. Regular monitoring of disease activity and response to treatment is crucial, and a personalized approach considering genetic markers and biomarkers may optimize management strategies