Figure 1.

Summary of primary recommendations for the initial and subsequent treatment of children with juvenile idiopathic arthritis (JIA) and active polyarthritis (see also Tables 3 and 4; for patients with sacroiliitis and/or enthesitis, see also Tables 5 and 6). The clinical Juvenile Arthritis Disease Activity Score based on 10 joints (cJADAS-10) was used to define low disease activity (≤2.5 with ≥1 active joint) versus moderate/high disease activity (>2.5). Although it is provided as a general parameter, the cJADAS-10 should be interpreted within the clinical context. An adequate trial of methotrexate was considered to be 3 months. If no or minimal response is observed after 6–8 weeks, it was agreed that changing or adding therapy may be appropriate. Shared decision-making between the physician, parents, and patient, including discussion of recommended treatments and potential alternatives, is recommended when initiating or escalating treatment. The Patient/Population, Intervention, Comparison, and Outcomes (PICO) questions are shown in brackets, and quality of evidence is shown in parentheses. DMARD = disease-modifying antirheumatic drug; NSAID = nonsteroidal antiinflammatory drug; PT = physical therapy; OT = occupational therapy; TNFi = tumor necrosis factor inhibitor.

* Disease-modifying antirheumatic drug (DMARD) therapy (methotrexate, leflunomide, or sulfasalazine) over biologic recommendation for patients without and those with risk factors, although initial biologic therapy may be appropriate for some patients with risk factors and involvement of high-risk joints, high disease activity, and/or those judged by their physician to be at high risk of disabling joint damage.

** Adding a biologic may be considered in biologic-naive patients with continued low disease activity after escalating therapy (not formally addressed in the guidelines).