Table 3.
General medication recommendations for children and adolescents with JIA and polyarthritis*
| Recommendation | Level of evidence |
|---|---|
|
Each recommendation is preceded by the
phrase:
“In children and adolescents with JIA and polyarthritis…” |
|
| NSAIDs | |
| • NSAIDs are conditionally recommended as adjunct therapy (PICO A.1). | Very low |
| DMARDs | |
| • Using methotrexate is conditionally recommended over leflunomide or sulfasalazine (PICO A.2, A.3). | Moderate (leflunomide); very low (sulfasalazine) |
| • Using subcutaneous methotrexate is conditionally recommended over oral methotrexate (PICO A.4). | Very low |
| Glucocorticoids | |
| • Intraarticular glucocorticoids are conditionally recommended as adjunct therapy (PICO A.5). | Very low |
| • Triamcinolone hexacetonide is strongly recommended over triamcinolone acetonide for intraarticular glucocorticoid injections (PICO A.6). | Moderate |
| • Bridging therapy with a limited course of oral glucocorticoid (<3 months) during initiation or escalation of therapy in patients with high or moderate disease activity is conditionally recommended (PICO A.7).† | Very low |
| Bridging therapy may be of most utility in the setting of limited mobility and/or significant symptoms. | |
| • Conditionally recommend against bridging therapy with a limited course of oral glucocorticoid (<3 months) in patients with low disease activity (PICO A.8). | Very low Very low |
| • Strongly recommend against adding chronic low-dose glucocorticoid, irrespective of risk factors or disease activity (PICO A.9). | |
| Biologic DMARDs | |
| • In children and adolescents with JIA and polyarthritis receiving treatment with a DMARD, combination therapy with a biologic (etanercept, adalimumab, golimumab, abatacept, or tocilizumab) is conditionally recommended over biologic monotherapy (PICO A.10, A.11, A.12, A.13, A.14). | Very low (etanercept, golimumab); low (abatacept, tocilizumab); moderate (adalimumab) |
| Combination therapy with a DMARD is strongly recommended for infliximab (PICO A.15). | Low |
| Physical therapy and occupational therapy | |
| • In children and adolescents with JIA and polyarthritis who have or are at risk of functional limitations, using physical therapy and/or occupational therapy is conditionally recommended (PICO A.16, PICO A.17). | Low (physical therapy); very low (occupational therapy) |
*
JIA = juvenile idiopathic arthritis; NSAIDs = nonsteroidal antiinflammatory drugs; PICO = Patient/Population, Intervention, Comparison, and Outcomes; DMARDs = disease-modifying antirheumatic drugs.
†
A bridging course of oral glucocorticoids was defined as a short course (<3 months) of oral glucocorticoids intended to control disease activity quickly during the initiation or escalation of therapy. 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.