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Juvenile Idiopathic Arthritis - Non-Pharmacologic Therapies, Medication Monitoring, Immunizations, and Imaging

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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.

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