2019 American College of Rheumatology/Arthritis Foundation Guideline for the Screening, Monitoring, and Treatment of Juvenile Idiopathic Arthritis-Associated Uveitis

Abstract

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

Methods: Pediatric rheumatologists, ophthalmologists with expertise in uveitis, patient representatives, and methodologists generated key clinical questions to be addressed by this guideline. This was followed by a systematic literature review and rating of the available evidence according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. A group consensus process was used to compose the final recommendations and grade their strength as conditional or strong.

Results: Due to a lack of literature with good quality of evidence, recommendations were formulated on the basis of available evidence and a consensus expert opinion. Regular ophthalmic screening of children with JIA is recommended because of the risk of uveitis, and the frequency of screening should be based on individual risk factors. Regular ophthalmic monitoring of children with uveitis is recommended, and intervals should be based on ocular examination findings and treatment regimen. Ophthalmic monitoring recommendations were strong primarily because of concerns of vision-threatening complications of uveitis with infrequent monitoring. Topical glucocorticoids should be used as initial treatment to achieve control of inflammation. Methotrexate and the monoclonal antibody tumor necrosis factor inhibitors adalimumab and infliximab are recommended when systemic treatment is needed for the management of uveitis. The timely addition of nonbiologic and biologic drugs is recommended to maintain uveitis control in children who are at continued risk of vision loss.

Conclusion: This guideline provides direction for clinicians and patients/parents making decisions on the screening, monitoring, and management of children with JIA and uveitis, using GRADE methodology and informed by a consensus process with input from rheumatology and ophthalmology experts, current literature, and patient/parent preferences and values.

Figure 1a:. Ophthamologic screening examinations (see also Table 3).

PICO questions in brackets, quality of evidence in parentheses. Strength of recommendation indicated by colors (see legend).

Figure 1b:. Ophthamologic monitoring examinations (see also Table 3).

Recommendation number in brackets, quality of evidence in parentheses. Strength of recommendation indicated by colors (see legend). No recommendations made for patients with uncontrolled chronic anterior uveitis.

Figure 2:. Recommendations for topical glucocorticoids in patients with JIA and chronic anterior uveitis (CAU) (see also Table 3).

Recommendation number in brackets, quality of evidence in parentheses. Strength of recommendation indicated by colors (see legend). Systematic therapy defined as DMARDs and biologics. Tophical glucocorticoids refer to prednisolone acetate 1% (or equivalent). Doses of prednisolone acetate 1% greater than 1-2 drops/eye/day may be needed initially, but increase risk for ocular complications. Topical glucocorticoids should be used as short-term therapy ≤3 months. Goal is to discontinue topical glucocorticoids due to risk of glaucoma and cataracts. Periocular and intraocular injection is at the discretion of the treating ophthalamologist. *In selected complicated patients, systemic glucocorticoids can be used as short-term bridging therapy. ^† Can escalate dose or frequency pf current therapy; 3 months is the threshold for adding or changing systematic therapy in children who require topical glucocorticoids to maintain uveitis control. Changes in systematic therapy may be warranted earlier depending upon findings on the ocular examination, the duration of topical and systematic therapy, and presence of existing complications. JIA = juvenile idiopathic arthritis; CAU = chronic anterior uveitis.