Juvenile idiopathic arthritis: Old disease, new tactics
Beyond NSAIDs and disease-modifying antirheumatic drugs are now biologic agents and anti-interleukin drugs that can augment therapy.
PRACTICE RECOMMENDATIONS
› Pair the findings of your clinical exam with the results of imaging and laboratory testing to make the diagnosis of juvenile idiopathic arthritis (JIA), as it is a diagnosis of exclusion. B
› Individualize treatment based on where the patient falls in the JIA disease spectrum to increase the likelihood that medical therapy will be effective. A
› Consider treating diagnosed JIA with an available biologic agent, which can provide a long asymptomatic period. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Poly-articular JIA patients present with mild fever, weight loss, and anemia.
Enthesis-related arthritis patients have findings of enthesopathy; asymmetric arthritis of the lower extremities, particularly the Achilles tendon29; and recurrent acute, symptomatic iridocyclitis.30
Juvenile psoriatic arthritis can involve any joint but is readily differentiated from pJIA by involvement of distal interphalangeal joints and psoriatic skin and nail changes.29
Investigations
Imaging
Radiography is still the most widely used imaging tool for making the diagnosis of JIA. Plain films demonstrate structural joint damage and disturbances of growth and maturation in bones. Radiography has poor sensitivity for detecting acute synovitis and limited utility in visualizing erosion changes early in the course of disease, however, which has led to increased use of ultrasonography (US) and contrast-enhanced magnetic resonance imaging (MRI) to diagnose JIA.30
Contrast-enhanced MRI is superior to US for detecting early inflammation and monitoring subsequent joint disease. Of course, MRI is more expensive than US, and less widely available. Other imaging options are computed tomography and positron emission tomography, but these scans are not as sensitive as contrast-enhanced MRI and have the disadvantage of radiation exposure (in the former) and cost (in the latter).
Continue to: Laboratory testing
