Figure 1.

Treatment pathways for patients with active systemic features and varying degrees of synovitis. The Task Force Panel was asked to consider the treatments among patients with active systemic features and a physician global assessment (MD global) of <5 or ≥5 on a 10-point numerical rating scale (0–10 visual analog scale, where 0 = no disease activity and 10 = the most severe) and by active joint count (AJC; 0 joints, 1–4 joints, or >4 joints). If a recommendation is noted to be irrespective of the AJC or MD global, the recommendation was for children with an AJC ≥0 or an MD global >0, respectively. Adjunct systemic glucocorticoids (GCs) and/or intraarticular GCs may be added at any point. Children may qualify for >1 pathway, in which case it is left to the provider's discretion to choose the path they feel is most appropriate based upon specific patient characteristics and/or patient and family preferences. Steps in the progression of therapy can be additive or sequential, except that therapies with a biologic agent are sequential (combination therapy with a biologic agent is not endorsed). The recommendations in this figure are for patients with active systemic features. If the systemic features (but not the arthritis) respond to therapy, then subsequent treatment decisions should be based upon the recommendations in Figure 2. NSAIDs = nonsteroidal antiinflammatory drugs; IV = intravenous; MTX = methotrexate; TNF-α = tumor necrosis factor α.