Key Points
` These treatment recommendations emphasize:
• Non-pharmacologic therapies
• Tailored monitoring for medication toxicity by pharmacologic agent
• Importance of immunizations for all children with juvenile idiopathic arthritis ( JIA)
• Judicious use of imaging modalities
• Importance of shared decision-making with the patient/caregiver
Table 1. Quality of Evidence and Strength of Recommendations
Quality of
Evidence Interpretation
High-quality
evidence
Studies that provide high confidence in the effect estimate. New data
from future studies are thought unlikely to change the effect.
Moderate-quality
evidence
Studies that provide confidence that the true effect is likely to be close
to the estimate but could be substantially different.
Low-quality
evidence
Studies that provide limited confidence about the effect. e true effect
may be substantially different from the estimate.
Very low-quality
evidence
Studies that provide very little certainty about the effect. e true
effect may be quite different from the estimate.
Strength of
Recommendation Interpretation
Strong
recommendation
Supported by moderate- to high-quality evidence (e.g., multiple
randomized controlled trials). Recommended course of action would
apply to all or almost all patients. Only a small proportion of clinicians/
patients would not want to follow the recommendation. In rare instances,
a strong recommendation may be based on very low- to low-certainty
evidence. For example, an intervention may be strongly recommended if
it is considered benign, low-cost, without harms, and the consequence of
not performing the intervention may be catastrophic. An intervention
may be strongly recommended against if there is high certainty of more
harm than the comparison with very low or low certainty about its
benefit.
Conditional
recommendation
Supported by lower-quality evidence or a close balance between
desirable and undesirable outcomes. Recommended course of action
would apply to the majority of the patients, but the alternative is
a reasonable consideration. Conditional recommendations always
warrant a shared decision-making approach.
Ungraded Position
Statement
Evidence for a PICO question did not support a graded
recommendation or did not favor one intervention over the other;
guidance for this question provided by the voting panel.
Treatment
Table 2. Non-Pharmacologic Therapies
Recommendations
A discussion of healthy, age-appropriate diet
recommended.
Use of a specific diet to treat JIA is strongly
against.
Use of supplemental or herbal interventions
JIA is conditionally recommended against.
Physical and occupational therapy (PT/OT)
recommended regardless of concomitant pharmacologic
Table 3. Medication Monitoring
Recommendations
Non-steroidal anti-inflammatory drugs (NSAIDS):
via CBC counts, LFTs, and renal function tests
is conditionally recommended.
Methotrexate: Monitoring via CBC counts,
function tests within the first 1–2 months of
months thereaer is strongly recommended.
Decreasing the methotrexate dosage or withholding
is conditionally recommended if a clinically
LFTs or decreased neutrophil or platelet count
Use of folic/folinic acid in conjunction with
strongly recommended in conjunction with
Sulfasalazine: Monitoring via CBC counts,
function tests within the first 1–2 months of
months thereaer is conditionally recommended.
Decreasing the sulfasalazine dosage or withholding
is conditionally recommended if a clinically
LFTs or decreased neutrophil or platelet count
Lef lunomide: Monitoring via CBC counts
first 1–2 months of usage and every 3–4 months
conditionally recommended.
Altering leflunomide administration is conditionally
recommended if a clinically relevant elevation
occurs (temporary hold of leflunomide for alanine
(ALT) >3× the upper limit of normal [ULN]),
insert.
