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Juvenile idiopathic arthritis

Key sources
The following summarized guidelines for the evaluation and management of juvenile idiopathic arthritis are prepared by our editorial team based on guidelines from the American College of Rheumatology (ACR 2023; 2022; 2019; 2013), the European League Against Rheumatism (EULAR 2022), the Royal College of Ophthalmologists (RCOphth 2020), the Arthritis Foundation (AF/ACR 2019), the German Society of Pediatric Rheumatology (GKJR/BVA/DGRh/DOG 2019), the Ministry of Health, Labour and Welfare of Japan (MHLW 2018), and the Single Hub and Access Point for Pediatric Rheumatology in Europe (SHARE initiative 2018).
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Guidelines

1.Diagnostic investigations

Diagnostic imaging: do not obtain radiography as a screening test before advanced imaging for the purpose of identifying active synovitis or enthesitis.
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  • Ophthalmic screening

  • Pretreatment evaluation

2.Medical management

Management of oligoarticular juvenile idiopathic arthritis, nonsteroidal anti-inflammatory drugs: consider initiating a trial of scheduled NSAIDs as part of initial therapy in patients with active oligoarticular JIA.
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  • Management of oligoarticular JIA (corticosteroids)

  • Management of oligoarticular JIA (DMARDs and biologics)

  • Management of oligoarticular JIA (treatment monitoring)

  • Management of polyarticular JIA (NSAIDs)

  • Management of polyarticular JIA (corticosteroids)

  • Management of polyarticular JIA (DMARDs)

  • Management of polyarticular JIA (biologics)

  • Management of systemic-onset JIA (NSAIDs)

  • Management of systemic-onset JIA (corticosteroids)

  • Management of systemic-onset JIA (DMARDs)

  • Management of systemic-onset JIA (biologics)

  • Management of systemic-onset JIA (IVIg)

  • Management of sacroiliitis

  • Management of enthesitis

  • Management of TMJ arthritis

  • Management of uveitis (general principles)

  • Management of uveitis (topical corticosteroids)

  • Management of uveitis (conventional DMARDs)

  • Management of uveitis (biological DMARDs)

  • Management of uveitis (systemic corticosteroids)

  • Management of uveitis (ocular corticosteroid injections)

  • Management of uveitis (NSAIDs)

  • Management of uveitis (cycloplegics)

  • Management of uveitis (assessment of treatment response)

  • Management of uveitis (treatment tapering)

3.Nonpharmacologic interventions

Dietary modifications: counsel patients regarding a healthy, age-appropriate diet.
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  • Physical and occupational therapy

4.Therapeutic procedures

Intra-articular corticosteroids, oligoarticular juvenile idiopathic arthritis
Administer intra-articular corticosteroids as part of initial therapy in patients with active oligoarticular JIA.
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Prefer triamcinolone hexacetonide over triamcinolone acetonide for intra-articular corticosteroid injections.
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  • Intra-articular corticosteroids (polyarticular JIA)

  • Intra-articular corticosteroids (systemic-onset JIA)

  • Intra-articular corticosteroids (sacroiliitis)

  • Intra-articular corticosteroids (TMJ arthritis)

  • Intra-articular corticosteroids (imaging guidance)

5.Preventative measures

Routine immunizations: as per ACR 2023 guidelines, consider offering high-dose or adjuvanted influenza vaccination, rather than regular-dose influenza vaccination, in ≥ 65 years old patients with rheumatic or musculoskeletal diseases and in 18-65 years old patients with rheumatic or musculoskeletal diseases on immunosuppressive medications.
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  • Prophylaxis for P. jirovecii pneumonia

6.Follow-up and surveillance

Treatment monitoring, nonsteroidal anti-inflammatory drugs: consider obtaining a CBC, liver function tests and renal function tests every 6-12 months for monitoring of patients taking NSAIDs.
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  • Treatment monitoring (DMARDs)

  • Treatment monitoring (hydroxychloroquine/chloroquine)

  • Treatment monitoring (biologics)