APLAR consensus on the management of JIA

APLAR consensus on the management of JIA

Revised CPG statements for voting

This survey assesses the level of agreement among the consensus panel members group on the remaining recommendations. These recommendations were drafted based on current literature.

You will indicate your level of agreement with each recommendation using a simple yes or no format. A recommendation will be accepted if at least 80% of the total voting members agree with it.

Please enter your name: *

The following recommendation statement apply to children and adolescents with polyarticular course JIA who achieved INACTIVE disease

Statement 15

Original:

In patients taking a combination of methotrexate and TNFi, we suggest withdrawal of MTX first over withdrawal of TNFi after six months of inactive disease.

Revised:

In patients taking a combination of methotrexate and TNFi, there is insufficient evidence on the order of medication withdrawal after six months of inactive disease.

Certainty of evidence: D

Strength of recommendation: 2 (weak)

Narrative reason for downgrading to NO recommendation: Indeed, there is only 1 observation study showing that stopping TNFi first resulted in more flares. However, in the region, due to the higher cost and access to TNFi and increase risk of anti-drug antibodies after stopping MTX first, the panel feels that discontinuing TNFi would be more beneficial and more practical. This decision should be discussed with individual patients – shared decision making

Q. Do you agree with the revised statement? *

Please suggest changes you would like to make to the recommendation along with your rationale: *

The following recommendation statements apply to monitoring disease activity in children and adolescents with polyarticular course JIA

like make Please

Statement 17

Original:

In patients with positive rheumatoid factor/anti-citrullinated protein antibodies, we recommend performing X-ray of the wrists, hands, forefeet and other symptomatic joints at diagnosis, one year after disease onset and when transiting from pediatric to adult healthcare.

Revised:

In patients with positive rheumatoid factor/anti-citrullinated protein antibodies or negative rheumatoid factor/anti-citrullinated protein antibodies with adverse prognostic factors*, we recommend performing routine X-ray of the wrists, hands, forefeet and other affected joints** at diagnosis, one year after disease onset and when transiting from pediatric to adult healthcare.

*Adverse prognostic factors include early involvement of wrists; distal involvement; symmetrical arthritis, elevated ESR/CRP or bone erosions on previous radiographs.

**Affected joints: Joints with active arthritis, limited range of motion or deformities.

Certainty of evidence: B

Strength of recommendation: 1 (strong)

Narrative explanation:

These adverse prognostic factors are associated with a pattern of joint damage over time similar to that seen in RF/ACPA-positive pJIA.

Prospective studies were reviewed, with special attention to early pJIA. Erosions and JSN occurred preferentially at the hands, wrists and feet joints that were sometimes asymptomatic, x-rays at the diagnosisprovides a reference for assessing disease progression. It is supported by ‘adult’ recommendations for rheumatoid arthritis, which has a similar structural evolution.

---- this means that we do x-rays of those hands, wrists and feet joints even without symptomatic arthritis---Panel must decide if this stays??

Reason for 1 year and at transit: Prospective studies found evidence of joint damage even in asymptomatic joints. Patients with long-standing disease had high prevalences of joint erosions (30–70 % in historical studies), close to those in adults with RA. In RA, joint destruction at asymptomatic sites is a major predictor of adverse outcomes. However, radiographic progression with erosions in asymptomatic joints is not well documented in JIA and may have been underestimated. In a study of 471 joints in 67 patients with polyarticular JIA, radiographs showed erosions at the hands and feet in 36 % and 39 % of cases, respectively. Our literature review identified some data on the best times for X-rays. One study suggested a higher risk of radiographic progression within the first year after disease onset. The experts felt that CR contributed to ease the transition from pediatric to adult healthcare.

Q. Do you agree with the revised statement? *

Please suggest changes you would like to make to the recommendation along with your rationale: *

The following recommendation statements apply to monitoring disease activity in children and adolescents with polyarticular course JIA

Statement 18

Original:

In patients with positive rheumatoid factor/anti-citrullinated protein antibodies, clinicians may consider X-ray of the symptomatic joints at diagnosis. At follow-up, clinicians may consider X-ray in patients who remained persistently symptomatic longer than three months.

Revised:

In patients with negative rheumatoid factor/anti-citrullinated protein antibodies without adverse prognostic factors, clinicians may consider X-ray of symptomatic joints at their own discretion.

Certainty of evidence: D

Strength of recommendation: 2 (weak)

Narrative explanation:

In the French guideline – In new-onset, RF/ACPA-negative pJIA without adverse prognostic factors, at diagnosis, x-rays should be confined to symptomatic* joints. This recommendation is based on expert opinion. – However, I am not certain that any of us (old or young) would do any x-rays as a routine??? ----- Panel need to decide whether you want to do it on a routine basis?? Or at your discretion with whatever reason, you have (assess damage, differential diagnosis, etc). There is no data, and this is just their expert opinion.

Q. Do you agree with the revised statement? *

Please suggest changes you would like to make to the recommendation along with your rationale: *

The following recommendation statements apply to children and adolescents with ACTIVE TMJ arthritis

Original:

In skeletally immature patients, we recommend against intra-articular glucocorticoids.
In skeletally mature patients, clinicians may consider intra-articular glucocorticoids in patients with refractory TMJ or significant orofacial symptoms.

Revised:

Clinicians may consider intraarticular glucocorticoids injection as an adjunct therapy. However, clinicians should be cautious with repeated glucocorticoid injections.

Certainty of evidence: D

Strength of recommendation: 2 (weak)

Narrative explanation: I only found that the mandibular eminence matures around 20 years old. As mentioned in the voting session…skeletally immature (general skeletons, typically reached by the end of the teenage years) whether it correlates with TMJ joint maturity or not – no data. Taking Sulaiman concern along with no clear evidence and to avoid unnecessary confusion, we will adopt the ACR guideline and ignore the orofacial guideline regarding the maturity of the skeleton. However, cautious remains for repeated injection. Indeed, data have shown that mandibular growth arrest occurred in some skeletal immature TMJ IA. Others include known adverse events – nerve injury, calcification etc.

Use as adjunct therapy – meaning as part of active joint treatment and not the main therapy.

So, here we collapse into TMJ 2 statement only, drop by 1.

Q. Do you agree with the revised statement? *

Please suggest changes you would like to make to the recommendation along with your rationale: *