The Specialist Forum Volume 13 No 11 November 2013 | Page 42

ARTHRITIS

global <5 and an AJC >0 and for patients with an MD global ?5
irrespective of the AJC.
• Adjunct GC therapy at any point is recommended.
• Intraarticular GC injection is suitable as adjunct therapy at any time.
• MTX or leflunomide is recommended for patients with an MD global
<5 and an AJC >0 after treatment with GC monotherapy, an IL-1
inhibitor, or tocilizumab.
• MTX or leflunomide is recommended for patients with an MD global
?5 and an AJC >0, only after a trial of an IL-1 inhibitor or tocilizumab.
• Initiation of MTX or leflunomide is not recommended for patients
with an AJC of 0 irrespective of the MD global.
• Initiation of a TNF? inhibitor is recommended for patients with an
AJC >4 irrespective of the MD global after a trial of an IL-1 inhibitor
or tocilizumab.
• Initiation of a TNF? inhibitor is recommended for patients with an
AJC >0 irrespective of the MD global after a trial of both an IL-1
inhibitor and tocilizumab (sequentially).
• Use of a TNF? inhibitor for patients with an MD global <5 and an
AJC of 0 is not recommended, except in patients who had tried
both an IL-1 inhibitor and tocilizumab (sequentially) or a DMARD
plus either an IL-1 inhibitor or tocilizumab.
• Use of a TNF? inhibitor for patients with an MD global ?5 and an
AJC of 0 is not recommended, except in patients who had tried an
IL-1 inhibitor or tocilizumab.
• Tocilizumab is recommended as a therapeutic option for patients
with continued disease activity following GC monotherapy, MTX
or leflunomide or anakinra, irrespective of the MD global and
AJC.
• Tocilizumab is also recommended for patients with an MD global ?5
irrespective of the AJC despite prior NSAID monotherapy.

Inappropriate options for continued disease
activity

Figure  2: Treatment pathways for patients without active systemic
features and with varying degrees of synovitis

Initial therapeutic options
• Intraarticular GC injection is recommended as an initial treatment
option for patients with an AJC ?4.
• Intraarticular GC injection as the only therapeutic intervention was
uncertain for patients with an AJC >4. The utility of repeating intraarticular injection as the only intervention was uncertain in a joint
or joints currently affected.
• Initiation of MTX or leflunomide is recommended for patients with
an AJC >4.
• Initiation of NSAID monotherapy in a patient without prior treatment
for a maximum period of one month is recommended as one treatment approach for patients with an AJC >0.
• Continuing NSAID monotherapy for longer than two months for
patients with continued disease activity was inappropriate.

• Use of IVIG is not recommended irrespective of the AJC and MD
global.
• Use of nonbiologic DMARD combination therapy (MTX plus
leflunomide and/or a calcineurin inhibitor) was uncertain irrespective
of the AJC and MD global.
• Use of rilonacept is not recommended as initial therapy irrespective
of the MD global and AJC.
• Use of rilonacept is uncertain for continued disease activity after
a trial of other therapeutic options irrespective of the AJC and MD
global.
• Use of rituximab is not recommended for patients with an AJC of
0 irrespective of the MD global. Use of rituximab for patients with
an MD global <5 and an AJC <4 is not recommended, except in
patients who had tried both an IL-1 inhibitor and tocilizumab.
• Use of rituximab for patients with an MD global <5 and an AJC
>4 or an MD global ?5 and an AJC >0 is not recommended,
except in patients who had tried both an IL-1 inhibitor and
tocilizumab (sequentially) or a DMARD plus either an IL-1 inhibitor
or tocilizumab.

Therapeutic options for continued disease
activity

Systemic JIA without active systemic features
and varying degrees of active synovitis

Citation: Ringold S, Weiss PF, Beukelman T, DeWitt EM, Ilowite NT,
Kimura Y, Laxer RM,Lovell DJ, Nigrovic PA, Robinson AB, Vehe RK. 2013
Update of the 2011 American College of Rheumatology Recommendations
for the Treatment of Juvenile Idiopathic Arthritis. Arthritis & Rheumatism.
Vol. 65, No. 10, October 2013, pp 2499–2512, DOI 10.1002/art.38092.

The TFP was asked to rate the appropriateness of therapies based
on the total number of active joints (?4 joints or >4 joints). Each of the
recommendations below is irrespective of the MD global.

• Use of abatacept was recommended for patients with an AJC >0
after treatment with MTX or leflunomide, anakinra, or tocilizumab.
• Anakinra was recommended as a therapeutic option for patients
with an AJC >4 following failed intraarticular injection or NSAID
monotherapy.
• Use of anakinra was also recommended for patients with an AJC
>0 following treatment with MTX or leflunomide.
• Initiation of canakinumab was recommended for patients with an
AJC >4 only after a trial of a DMARD plus anakinra or tocilizumab,
a DMARD plus a TNF? inhibitor, or abatacept.
• Use of MTX or leflunomide was recommended as an option for
an AJC >0 following treatment with intraarticular injection, NSAID
monotherapy, an IL-1 inhibitor or tocilizumab.
• Initiati on of a TNF? inhibitor was recommended for patients with
an AJC >0 after treatment with MTX or leflunomide, anakinra, or
tocilizumab.
• Initiation of tocilizumab was recommended for an AJC >0 following
treatment with anakinra or MTX or leflunomide.? R

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November 2013 | Rheumatology Forum