Initial Treatment Recommendations for Juvenile Idiopathic Arthritis

Initial Therapy Algorithm

The British Society for Rheumatology recommends initial therapy with a disease-modifying antirheumatic drug (DMARD), specifically methotrexate, rather than NSAID monotherapy for all JIA patients 1, 2
Methotrexate monotherapy is the preferred initial DMARD therapy, according to the British Society for Rheumatology 1, 3
Subcutaneous methotrexate administration is preferred over oral administration for better bioavailability, as recommended by the British Society for Rheumatology 1

For patients with low disease activity, DMARD therapy is still recommended over NSAID monotherapy, according to the British Society for Rheumatology 1, 3
For patients with moderate to high disease activity, methotrexate is recommended as initial treatment, and bridging therapy with a limited course of oral glucocorticoids (<3 months) during initiation of therapy may be considered, as recommended by the British Society for Rheumatology 2, 3, 4
Intraarticular glucocorticoid injections may be used, with triamcinolone hexacetonide preferred over triamcinolone acetonide, according to the British Society for Rheumatology 1

For patients with risk factors (positive anti-cyclic citrullinated peptide antibodies, positive rheumatoid factor, or presence of joint damage), DMARD therapy is still recommended as initial treatment, according to the British Society for Rheumatology 4
Initial biologic therapy may be considered for patients with risk factors and involvement of high-risk joints (e.g., cervical spine, wrist, or hip), high disease activity, or those judged to be at high risk of disabling joint damage, as recommended by the British Society for Rheumatology 2, 4

If inadequate response to methotrexate occurs, adding a biologic agent (TNF inhibitor, abatacept, or tocilizumab) is recommended rather than switching to another DMARD, according to the British Society for Rheumatology 2, 3
For patients with low disease activity despite DMARD therapy, escalation of therapy may still be needed for complete disease control, as recommended by the British Society for Rheumatology 1, 2

Early initiation of DMARD therapy in children with JIA is crucial for optimal disease outcomes and to avoid permanent joint damage, according to the British Society for Rheumatology 1, 3
The goal of treatment is to prevent joint damage and decreased health-related quality of life, as recommended by the British Society for Rheumatology 1