Table 3. Medication Monitoring (cont'd)
Recommendations Certainty of Evidence
Baseline and annual retinal screening aer starting
hydroxychloroquine are conditionally recommended.
Very low
Hydroxychloroquine: Monitoring via CBC counts and LFTs
annually is conditionally recommended.
Very low
Tumor necrosis factor inhibitors (TNFi): Monitoring via CBC
counts and LFTs annually is conditionally recommended.
Very low
Abatacept: Doing no routine laboratory monitoring is
conditionally recommended.
Very low
Tocilizumab: Monitoring via CBC counts and LFTs
within the first 1–2 months of usage and every 3–4 months
thereaer is conditionally recommended.
Very low
Monitoring of lipid levels every 6 months is conditionally
recommended, as per the package insert.
Altering tocilizumab administration is conditionally
recommended if monitoring reveals elevated LFT results (if
1–3 times the ULN decrease the dosage or increase the interval
between doses, if >3 times the ULN withhold administration,
if >5 times the ULN discontinue treatment), neutropenia
(500–1,000/mm
3
), or thrombocytopenia (50,000–100,000/mm
3
),
as per the package insert.
Very low
Anakinra: Monitoring via CBC counts and LFTs within the
first 1–2 months of usage and every 3–4 months thereaer is
conditionally recommended.
Very low
Canakinumab: Monitoring via CBC counts and LFTs
within the first 1–2 months of usage and every 3–4 months
thereaer is conditionally recommended.
Very low
Tofacitinib: Monitoring via CBC counts and LFTs
within the first 1–2 months of usage and every 3–4 months
thereaer is conditionally recommended.
Given recent
approval for JIA and
limited experience,
recommendations
are as per clinical
trial, Food and Drug
Administration (FDA)
guidance and evidence
in adults.
Monitoring of lipid levels 1–2 months aer starting treatment is
conditionally recommended, as per the package insert.
Altering tofacitinib administration is strongly recommended
if monitoring reveals laboratory abnormalities of concern.
Specifically, medication should be discontinued if the
hemoglobin level is <8 gm/dl or decreases by >2 gm/dl, or for
severe neutropenia (<500/mm
3
) or lymphopenia (<500/mm
3
),
as per the package insert.
Table 4. Infection Surveillance/Immunizations
Recommendations Certainty of Evidence
No consensus achieved. Very low
Immunization is conditionally recommended for children
with active non-systemic JIA who have not yet been
immunized for Measles, Mumps, Rubella and/or Varicella
prior to starting immunosuppressive medications.
Very low
Tuberculosis (TB) screening is conditionally recommended
prior to starting biologic disease-modifying antirheumatic
drug (DMARD) therapy and when there is a concern for TB
exposure thereaer.
Very low
Immunizations (live and inactivated) are strongly
recommended for children with JIA who are not
receiving immunosuppressive treatment.
Very low
Annual inactivated influenza immunization is strongly
recommended for all children with JIA.
Low
Inactivated vaccines are strongly recommended for children
with JIA who are receiving immunosuppressive
treatment.
Very low
Live attenuated vaccines are conditionally recommended
against for children with JIA who are receiving
immunosuppressive treatment.
Low
Vaccines are strongly recommended for household contacts
of children with JIA who are receiving immunosuppressive
treatment.
Very low
Table 5. Imaging
Recommendations Certainty of Evidence
Use of radiographs as a screening test prior to advanced
imaging, for the purpose of identifying active synovitis or
enthesitis, is strongly recommended against.
Very low
Imaging guidance is conditionally recommended for use with
intra-articular glucocorticoid (IAGC) injections of joints that
are difficult to access, or to specifically localize the distribution
of inflammation.
Very low
Treatment
