Screening, Monitoring, and Treatment of Juvenile Idiopathic Arthritis–Associated Uveitis

Publication Date: April 25, 2019
Last Updated: December 15, 2022

Treatment

Recommendations for ophthalmic screening

In children and adolescents with JIAb at high risk of developing uveitis:
  • Ophthalmic screening every 3 months is conditionally recommended.
( Conditional , Very Low )
607

Recommendations for ophthalmic monitoring

In children and adolescents with JIA and controlled uveitis who are:
Tapering or discontinuing topical glucocorticoids, ophthalmic monitoring within 1 month after each change of topical glucocorticoids is strongly recommended over monitoring less frequently. ( Strong , Very Low )
607
On stable therapy, ophthalmic monitoring no less frequently than every 3 months is strongly recommended over monitoring less frequently. ( Strong , Very Low )
607
Tapering or discontinuing systemic therapy, ophthalmic monitoring within 2 months of changing systemic therapy is strongly recommended over monitoring less frequently. ( Strong , Very Low )
607

Recommendations for glucocorticoid use

In children and adolescents with JIA and active CAU:
Using prednisolone acetate 1% topical drops is conditionally recommended over difluprednate topical drops. ( Conditional , Very Low )
607
Adding or increasing topical glucocorticoids for short-term control is conditionally recommended over adding systemic glucocorticoids. ( Conditional , Very Low )
607
In children and adolescents with JIA and CAU still requiring 1–2 drops/day of prednisolone acetate 1% (or equivalent) for uveitis control:
If not on systemic therapy, adding systemic therapy in order to taper topical glucocorticoids is conditionally recommended over not adding systemic therapy and maintaining topical glucocorticoids only. ( Conditional , Very Low )
607
If still requiring 1–2 drops/day of prednisolone acetate 1% (or equivalent) for at least 3 months and on systemic therapy, changing or escalating systemic therapy is conditionally recommended over maintaining current systemic therapy. ( Conditional , Very Low )
607
In children and adolescents with JIA who develop new CAU activity despite stable systemic therapy:c

Topical glucocorticoids prior to changing/escalating systemic therapy is conditionally recommended over changing/escalating systemic therapy immediately.

( Conditional , Very Low )
607

Recommendations for DMARDs and biologics

In children and adolescents with JIA and active CAU who are/have:
Starting systemic treatment for uveitis: Using subcutaneous methotrexate is conditionally recommended over oral methotrexate. ( Conditional , Very Low )
607
Starting a TNFi: Starting a monoclonal antibody TNFi is conditionally recommended over etanercept. ( Conditional , Very Low )
607
Severe active CAU and sight-threatening complications: Starting methotrexate and a monoclonal antibody TNFi immediately is conditionally recommended over methotrexate as monotherapy. ( Conditional , Very Low )
607
Inadequate response to one monoclonal TNFi at standard JIA dose: Escalating the dose and/or frequency of the monoclonal TNFi to above standard is conditionally recommended over switching to another monoclonal antibody TNFi. ( Conditional , Very Low )
607
Failed a first monoclonal antibody TNFi at above-standard dose and/or frequency: Changing to another monoclonal antibody TNFi is conditionally recommended over a biologic in another category. ( Conditional , Very Low )
607
Failed methotrexate and 2 monoclonal antibody TNFi at above-standard dose and/or frequency: Abatacept or tocilizumab are conditionally recommended as biologic DMARD options, and mycophenolate, leflunomide, or cyclosporine as alternative non-biologic options. ( Conditional , Very Low )
607

Recommendations for education about and treatment of AAU

In children and adolescents with spondyloarthritis:
Strongly recommend education regarding the warning signs of AAU for the purpose of decreasing delay in treatment, duration of symptoms, or complications of iritis. ( Strong , Very Low )
607
Well-controlled with systemic immunosuppressive therapy (DMARD, biologics) who develop an isolated short-lived episode of AAU: Conditionally recommend against switching systemic immunosuppressive therapy immediately in favor of treating with topical glucocorticoids first. ( Conditional , Very Low )
607

Recommendations for tapering therapy for uveitis:

In children and adolescents with JIA and CAU that is controlled on systemic therapy but remain on 1–2 drops/day of prednisolone acetate 1% (or equivalent): Tapering topical glucocorticoids first is strongly recommended over systemic therapy. ( Strong , Very Low )
607
In children and adolescents with JIA and uveitis that is well controlled on DMARD and biologic systemic therapy only. Conditionally recommend that there be at least 2 years of well-controlled disease before tapering therapy. ( Conditional , Very Low )
607

a Each recommendation had very low quality level of evidence.
b High-risk children are those with oligoarthritis, polyarthritis (rheumatoid factor negative), psoriatic arthritis, or undifferentiated arthritis who are also antinuclear antibody positive, younger than 7 years of age at JIA onset, and have JIA duration of 4 years or less.
c Definition of new CAU activity: no prior uveitis or loss of control of previously controlled uveitis.

Recommendation Grading

Overview

Title

Screening, Monitoring, and Treatment of Juvenile Idiopathic Arthritis–Associated Uveitis

Authoring Organization

American College of Rheumatology

Publication Month/Year

April 25, 2019

Last Updated Month/Year

February 23, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

To develop recommendations for the screening, monitoring, and treatment of uveitis in children with juvenile idiopathic arthritis (JIA).

 

Inclusion Criteria

Male, Female, Adolescent, Child, Infant

Health Care Settings

Ambulatory, Childcare center, Outpatient

Intended Users

Nurse, nurse practitioner, optometrist, physician, physician assistant

Scope

Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D014605 - Uveitis, D001171 - Arthritis, Juvenile

Keywords

juvenile idiopathic arthritis, uveitis, JIA

Source Citation

Angeles‐Han, S.T., Ringold, S., Beukelman, T., Lovell, D., Cuello, C.A., Becker, M.L., Colbert, R.A., Feldman, B.M., Holland, G.N., Ferguson, P.J., Gewanter, H., Guzman, J., Horonjeff, J., Nigrovic, P.A., Ombrello, M.J., Passo, M.H., Stoll, M.L., Rabinovich, C.E., Sen, H.N., Schneider, R., Halyabar, O., Hays, K., Shah, A.A., Sullivan, N., Szymanski, A.M., Turgunbaev, M., Turner, A. and Reston, J. (2019), 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Screening, Monitoring, and Treatment of Juvenile Idiopathic Arthritis–Associated Uveitis. Arthritis Care Res, 71: 703-716. doi:10.1002/acr.23871