Table 1.

Management of juvenile idiopathic arthritis (JIA) 2015. Position statement by the Pediatric Committee of the Canadian Rheumatology Association (CRA).

Position Statement
General treatment principles In accordance with the recommendations of the British Society for Paediatric and Adolescent Rheumatology (BSPAR) and the American College of Rheumatology (ACR), the Canadian Rheumatology Association agrees that treatment of the child with JIA should be initiated without delay^2,4,5 Children with JIA living in communities with no access to ongoing pediatric rheumatology care should be reviewed by a pediatric rheumatology team at least annually Treatment should be tailored to individual patient characteristics based on the number of affected joints, the presence of active systemic features, the degree of disease activity and the presence of poor prognostic factors^4,5 Response to treatment should be assessed frequently, and treatment modified according to the results of the assessment. The goal of treatment is to attain a state of inactive disease with full, pain-free function, if possible Exercise, physiotherapy, and occupational therapy All children and adolescents with JIA should be assessed and treated as indicated by a physiotherapist and/or occupational therapist with specific expertise in the management of childhood arthritis Physical activity and exercise, both recreational and prescriptive, may improve outcomes in children with JIA^6,7,8 Therapy should focus on returning children to normal physical function and to participation in age-appropriate social and physical activities to the fullest extent possible to facilitate optimal physical, emotional and psychosocial development^6,7,8 Pharmacologic therapy Access to recommended medications should be available to all children with JIA, wherever they live in Canada Nonsteroidal antiinflammatory drugs (NSAID) — Several NSAID should be available as liquid preparations for the management of children who cannot swallow tablets, and to facilitate accurate dosing in small children Intraarticular corticosteroids — Intraarticular corticosteroid injections may be used as first-line treatment of oligoarthritis without the need of a trial of systemic medications, including NSAID⁹. They may also be used as adjunctive therapy in other categories of JIA. Triamcinolone hexacetonide has been shown to have longer duration of action than other preparations^9,10,11. It is the first choice of medication for intraarticular injections and should be considered the standard of care Disease-modifying antirheumatic drugs (DMARD) — The Pediatric Committee of the CRA endorses the ACR recommendations for the use of DMARD, such as methotrexate or leflunomide^4,5 Biologic agents — Prompt access to biologic agents for management of JIA through provincial governmental funding programs, and for aboriginal children, through federal government funding programs, should be equitable across Canadian provinces and territories Several newer biologics that merit attention: — Tocilizumab should be considered as initial treatment in systemic JIA and as an option in treating children with persistently active polyarticular course JIA who have failed (or are intolerant of) methotrexate or another DMARD^12,13 — Canakinumab may be considered for the treatment of systemic JIA in patients who are 2 years of age or older and who have active systemic features and/or active arthritis¹⁴ — Other biologic therapies including rituximab¹⁵, golimumab¹⁶, and certolizumab¹⁷ have been used in adults with rheumatoid arthritis and in a limited number of children with JIA. The off-label use of these medications may be considered for children with refractory disease on a case-by-case basis The role of imaging to monitor disease activity and damage Imaging plays a key role in the assessment of children with JIA¹⁸. Current ACR recommendations identify radiographic damage (erosions or joint space narrowing by radiograph) as a poor prognostic feature^4,5. However, there is a shift from the use of conventional radiography to newer imaging modalities, such as ultrasound (US) and magnetic resonance imaging (MRI), to detect early or subclinical disease activity, and damage to joints, entheses, and tendon sheaths US and MRI are considered valuable imaging tools to identify disease activity and damage. MRI may be especially helpful in assessing disease activity in joints that are difficult to assess clinically, such as the temporomandibular, sacroiliac, hip, and subtalar joints¹⁹. Standardized protocols and validated scoring systems for US and MRI are currently being developed and should be incorporated into future guidelines²⁰ Uveitis screening and management Early detection and treatment of uveitis are critical to the prevention of complications and preservation of vision Regular screening and treatment of uveitis associated with JIA should be performed according to the most up-to-date evidence-based guidelines^21,22,23 Management of enthesitis, sacroiliitis, and spondylitis in children The CRA and Spondyloarthritis Research Consortium of Canada (SPARCC) have recently developed treatment recommendations for spondyloarthritis²⁴. These include recommendations regarding the treatment of children. The CRA Pediatric Committee membership will assess these recommendations in full at a later date.

Position Statement

General treatment principles
- In accordance with the recommendations of the British Society for Paediatric and Adolescent Rheumatology (BSPAR) and the American College of Rheumatology (ACR), the Canadian Rheumatology Association agrees that treatment of the child with JIA should be initiated without delay^2,4,5
- Children with JIA living in communities with no access to ongoing pediatric rheumatology care should be reviewed by a pediatric rheumatology team at least annually
- Treatment should be tailored to individual patient characteristics based on the number of affected joints, the presence of active systemic features, the degree of disease activity and the presence of poor prognostic factors^4,5
- Response to treatment should be assessed frequently, and treatment modified according to the results of the assessment. The goal of treatment is to attain a state of inactive disease with full, pain-free function, if possible
Exercise, physiotherapy, and occupational therapy
- All children and adolescents with JIA should be assessed and treated as indicated by a physiotherapist and/or occupational therapist with specific expertise in the management of childhood arthritis
- Physical activity and exercise, both recreational and prescriptive, may improve outcomes in children with JIA^6,7,8
- Therapy should focus on returning children to normal physical function and to participation in age-appropriate social and physical activities to the fullest extent possible to facilitate optimal physical, emotional and psychosocial development^6,7,8
Pharmacologic therapy
- Access to recommended medications should be available to all children with JIA, wherever they live in Canada
- Nonsteroidal antiinflammatory drugs (NSAID)
  - — Several NSAID should be available as liquid preparations for the management of children who cannot swallow tablets, and to facilitate accurate dosing in small children
- Intraarticular corticosteroids
  - — Intraarticular corticosteroid injections may be used as first-line treatment of oligoarthritis without the need of a trial of systemic medications, including NSAID⁹. They may also be used as adjunctive therapy in other categories of JIA. Triamcinolone hexacetonide has been shown to have longer duration of action than other preparations^9,10,11. It is the first choice of medication for intraarticular injections and should be considered the standard of care
- Disease-modifying antirheumatic drugs (DMARD)
  - — The Pediatric Committee of the CRA endorses the ACR recommendations for the use of DMARD, such as methotrexate or leflunomide^4,5
- Biologic agents
  - — Prompt access to biologic agents for management of JIA through provincial governmental funding programs, and for aboriginal children, through federal government funding programs, should be equitable across Canadian provinces and territories
- Several newer biologics that merit attention:
  - — Tocilizumab should be considered as initial treatment in systemic JIA and as an option in treating children with persistently active polyarticular course JIA who have failed (or are intolerant of) methotrexate or another DMARD^12,13
  - — Canakinumab may be considered for the treatment of systemic JIA in patients who are 2 years of age or older and who have active systemic features and/or active arthritis¹⁴
  - — Other biologic therapies including rituximab¹⁵, golimumab¹⁶, and certolizumab¹⁷ have been used in adults with rheumatoid arthritis and in a limited number of children with JIA. The off-label use of these medications may be considered for children with refractory disease on a case-by-case basis
The role of imaging to monitor disease activity and damage
- Imaging plays a key role in the assessment of children with JIA¹⁸. Current ACR recommendations identify radiographic damage (erosions or joint space narrowing by radiograph) as a poor prognostic feature^4,5. However, there is a shift from the use of conventional radiography to newer imaging modalities, such as ultrasound (US) and magnetic resonance imaging (MRI), to detect early or subclinical disease activity, and damage to joints, entheses, and tendon sheaths
- US and MRI are considered valuable imaging tools to identify disease activity and damage. MRI may be especially helpful in assessing disease activity in joints that are difficult to assess clinically, such as the temporomandibular, sacroiliac, hip, and subtalar joints¹⁹. Standardized protocols and validated scoring systems for US and MRI are currently being developed and should be incorporated into future guidelines²⁰
Uveitis screening and management
- Early detection and treatment of uveitis are critical to the prevention of complications and preservation of vision
- Regular screening and treatment of uveitis associated with JIA should be performed according to the most up-to-date evidence-based guidelines^21,22,23
Management of enthesitis, sacroiliitis, and spondylitis in children
- The CRA and Spondyloarthritis Research Consortium of Canada (SPARCC) have recently developed treatment recommendations for spondyloarthritis²⁴. These include recommendations regarding the treatment of children. The CRA Pediatric Committee membership will assess these recommendations in full at a later date.