The Journal of the Arkansas Medical Society Med Journal Jan 2019 Final 2 | Page 19

TABLE 2: American Academy of Pediatrics Guidelines for Ophthalmologic
Examination in Children with Juvenile Idiopathic Arthritis
JIA Subtype
Age of Onset <7 Years Age of Onset >7 Years
Every 3-4 months
Every 6 months Every 6 months
Every 6 months
Every 3-4 months
Every 6 months Every 6 months
Every 6 months
Systemic Onset JIA Every 12 months Every 12 months
Enthesis Related Arthritis Every 12 months Every 12 months
Oligoarticular JIA
ANA+
ANA-
Poly Articular JIA
ANA+
ANA-
Management
Management of JIA includes anti-inflamma-
tory drugs, corticosteroids (oral and intra-articu-
lar), and disease-modifying antirheumatic drugs
(DMARDS) like methotrexate (oral or subcutane-
ous). Biological response modifiers (BRM) are
being used more frequently in the treatment of
JIA. These include TNF inhibitors (tumor necrosis
factor [TNF] inhibitors) (eg, etanercept, adalim-
umab, infliximab, golimumab) as well as other
BRM that act by blocking the interleukin (IL)-6
receptor (tocilizumab), anti IL-1 inhibitor (anakin-
ra), inhibitor of T cell costimulation (abatacept)
or anti B cell treatment with rituximab. These
agents are associated with increased risk of in-
fections, hence ensuring appropriate vaccination
status and prompt evaluation of fevers is crucial.
The choice of pharmacological therapy is guided
by the severity of disease activity and the pres-
ence or absence of features indicating a poor
prognosis. 9, 10
A multidisciplinary team approach to the
treatment of JIA is key in ensuring adherence
and prevention of complications of this chronic
illness. Physical therapy can help to relieve
pain and to address range of motion, muscle
strengthening, activities of daily living, and con-
ditioning exercises. Occupational therapy pro-
vides mechanisms for joint protection, improv-
ing range of motion, and attention to activities
of daily living. Nutritionists can help in weight
management, optimizing nutrition, particularly
to address anemia and generalized osteoporo-
sis. Psychosocial interventions include counsel-
ing for patient but also for family to help them
cope with the diagnosis. Working closely with
the child’s school teacher to provide academic
counseling and school-life adjustments such as
an extra set of books for home use, rolling back-
pack, elevator pass etc., can be a great source
of relief to the child and family. 5, 8
The goal of therapy is to achieve remission
and to prevent or control joint damage, loss of
function, and pain.   With the advances in medi-
cal treatment, there has been a reduced need
for surgical interventions such as synovectomy,
osteotomy, arthrodesis, or hip and knee replace-
ment.
JIA is the most common rheumatic disease
that affects children. General practitioners play a
crucial role in the management of children with
JIA by facilitating the initial diagnosis, ensuring
adherence, monitoring for complications of the
disease and its treatment, ensuring immuniza-
tions are up-to-date, and providing ongoing edu-
cation and support to the family.
References:
1. Petty RE, Southwood TR, Manners P, Baum
J, Glass DN, Goldenberg J, et al.International
League of Associations for Rheumatology. In-
ternational League of Associations for Rheu-
matology classification of juvenile idiopathic
arthritis: second revision, Edmonton, 2001. J
Rheumatol. 2004;31(2):390–392.
2. Hahn YS, Kim JG. Pathogenesis and clini-
cal manifestations of juvenile rheuma-
toid arthritis. Korean J Pediatr. 2010 Nov;
53(11):921-30.
3. Helmick CG, Felson DT, Lawrence RC, Gabriel
S, Hirsch R, Kwoh CK, et al. Estimates of the
prevalence of arthritis and other rheumatic
conditions in the United States. Part I. Arthri-
tis Rheum. 2008 Jan. 58(1):15-25.
4. Riebschleger M, Becker ML, Ruch-Ross
HS, Laskosz, Radabaugh C, Ferguson PJ,
Schikler KN, Hong SD. The Pediatric Rheu-
matology Workforce in 2015: A Survey of Pe-
diatric Rheumatologists [abstract]. Arthritis
Rheumatol. 2015; 67 (suppl 10).
5. Lovell DJ. Juvenile Idiopathic Arthritis: Clini-
cal Features. Kippel JH, Stone JH, Crofford
LJ, White PH, Eds. Primer on the Rheumatic
Diseases. 13th Ed. Springer Science, New
York: 2008.
6. Cassidy J, Kivlin J, Lindsley C, Nocton J. Oph-
thalmologic examinations in children with ju-
venile rheumatoid arthritis. Pediatrics. 2006
May. 117(5):1843-5.
7. American Academy of Pediatrics Section on
Rheumatology and Section on Ophthalmol-
ogy. American Academy of Pediatrics Section
on Rheumatology and Section on Ophthal-
mology: guidelines for ophthalmologic exam-
inations in children with juvenile rheumatoid
arthritis. Pediatrics. 1993;92(2):295–296.
8. Cassidy JT, Petty RE. Textbook of Pediatric
Rheumatology. 4th ed. Philadelphia: W.B
Saunders; 2001. p. 258.
9. Ringold S, Weiss PF, Beukelman T, et al.
2013 Update of the 2011 American College
of Rheumatology Recommendations for the
Treatment of Juvenile Idiopathic Arthritis:
Recommendations for the Medical Therapy
of Children With Systemic Juvenile Idiopathic
Arthritis and Tuberculosis Screening Among
Children Receiving Biologic Medications. Ar-
thritis Rheum. Oct 2013. 65 (10):2499–2512.
10. Beukelman T, Patkar NM, Saag KG, Tolleson-
Rinehart S, Cron RQ, Dewitt EM, et al. 2011
American College of Rheumatology recom-
mendations for the treatment of juvenile idio-
pathic arthritis: Initiation and safety monitor-
ing of therapeutic agents for the treatment of
arthritis and systemic features. Arthritis Care
Res (Hoboken). 2011 Apr. 63(4):465-82.
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