Figure 1: Summary of the primary recommendations for the initial and subsequent treatment of children with JIA and active polyarthritis (see also Tables 3 and 4; for patients with sacroiliitis and/or enthesitis, see also Tables 5 and 6).

PICO questions in brackets, quality of evidence in parentheses. Strength of recommendation indicated by colors (see legend). 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 high/moderate disease activity (> 2.5). While this 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.

* DMARD over biologic recommended for patients without and 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 naïve patients with continued low disease activity after escalating therapy (not formally addressed in the guidelines)

DMARD = non-biologic disease modifying anti-rheumatic drug (methotrexate, leflunomide or sulfasalazine).

TNFi = tumor necrosis factor inhibitor, triple DMARD therapy = methotrexate, sulfasalazine, and hydroxychloroquine, NSAID = non-steroidal anti-inflammatory drug, PT = physical therapy, OT = occupational therapy.