CHICAGO – New draft guidelines for treating juvenile idiopathic arthritis (JIA) written by experts assembled by the American College of Rheumatology “formalize inactive disease as the goal of treatment,” Timothy G. Beukelman, MD, said at the annual meeting of the American College of Rheumatology.
“We defined low disease activity as patients with a single active joint, and the goal is to have zero active joints. Low disease activity should not be tolerated” in patients with JIA, said, a pediatric rheumatologist at the University of Alabama at Birmingham and a member of the guideline-writing committee. “Until now, treating these patients to zero active joints has not been recommended. But clinically inactive disease is a realistic target for a majority of JIA patients,” he said in an interview.
Despite this shift in the recommended treatment goal, the writing panel was forced to rely largely on their expertise rather than reported evidence. The recommendation by the committee to escalate therapy in patients with low disease activity was “conditional,” with a level of evidence deemed “very low,” Dr. Beukelman said during a talk in which he cited selected highlights from the committee’s full list of 39 recommendations.
The paucity of evidence reflected the status of many of the recommendations: 31 of the 39 recommendations were conditional, which means that the desirable effects from treatment “probably” outweigh the undesirable effects, and they may not apply to some patients. The writing panel pegged 22 of their recommendations as having a very low evidence backing and another 13 recommendations had low evidence. The JIA committee believed that none of its recommendations had strong evidence to back them up.
Dr. Beukelman defended writing recommendations despite this absence of evidence. “We should continue to write conditional recommendations when we don’t have the evidence. These recommendations had approval from at least 70% of the writing group, a diverse committee of experts. They should not be taken lightly just because they are conditional.”
Dr. Beukelman also stressed that he was presenting draft recommendations that still awaited approval from the ACR and the Arthritis Foundation, which collaborated with the ACR on this project. Once adopted, the new document would revise the existing management recommendations that the ACR approved in 2011 ().
The recommendations Dr. Beukelman outlined focused on treatment of polyarthritis, sacroiliitis, and enthesitis, and Dr. Beukelman devoted the most time to detailing some of the statements on polyarthritis. The panel conditionally recommended methotrexate over leflunomide (Arava) or sulfasalazine with moderate or very low evidence and said that subcutaneous methotrexate was conditionally preferred over oral dosing for reasons of both better efficacy and tolerability. Combination of a biologic agent with a nonbiologic received a conditional recommendation over biologic monotherapy, with moderate to very low evidence, but with a strong recommendation for this combined approach when using infliximab (Remicade), based on moderate evidence.
Another strong recommendation was to avoid treating patients with a chronic course of a low-dose, systemic glucocorticoid, based on a very low level of evidence. A brief course, less than 3 months, of an oral glucocorticoid received conditional recommendation for patients with moderate or high disease activity, based on very low evidence, but also received a conditional negative recommendation for patients with low disease activity, also based on very low evidence.
Initial therapy with a disease-modifying antirheumatic drug (DMARD) instead of monotherapy with an NSAID received a strong recommendation, based on a moderate level of evidence, while initial therapy with a DMARD received conditional support over initial therapy with a biologic agent, based on low evidence.
The panel gave a conditional endorsement to the idea of switching from a tumor necrosis factor inhibitor (TNFi) to a different biologic drug class when patients remained with moderate or high disease activity, based on a very low level of evidence.
Regarding sacroiliitis, the panel strongly recommended starting a TNFi in patients with active sacroiliitis despite NSAID treatment, based on low evidence, and the committee strongly recommended against starting methotrexate treatment in these patients, based on very low evidence. For treating active enthesitis despite NSAID treatment, the panel conditionally recommended adding a TNFi over treatment with methotrexate or sulfasalazine, based on a low level of evidence. Dr. Beukelman highlighted that the new recommendations placed increased emphasis on treating sacroiliitis, compared with the 2011 statement, and that the new recommendations dealt with treating enthesitis for the first time.
Dr. Beukelman has been a consultant to Bristol-Myers Squibb, Novartis, Sobi, and UCB.