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Recommendation
Treating juvenile idiopathic arthritis to target: recommendations of an international task force
  1. Angelo Ravelli1,
  2. Alessandro Consolaro1,
  3. Gerd Horneff2,3,
  4. Ronald M Laxer4,
  5. Daniel J Lovell5,
  6. Nico M Wulffraat6,
  7. Jonathan D Akikusa7,
  8. Sulaiman M Al-Mayouf8,
  9. Jordi Antón9,
  10. Tadej Avcin10,
  11. Roberta A Berard11,
  12. Michael W Beresford12,
  13. Ruben Burgos-Vargas13,
  14. Rolando Cimaz14,
  15. Fabrizio De Benedetti15,
  16. Erkan Demirkaya11,
  17. Dirk Foell16,
  18. Yasuhiko Itoh17,
  19. Pekka Lahdenne18,
  20. Esi M Morgan5,
  21. Pierre Quartier19,
  22. Nicolino Ruperto20,
  23. Ricardo Russo21,
  24. Claudia Saad-Magalhães22,
  25. Sujata Sawhney23,
  26. Christiaan Scott24,
  27. Susan Shenoi25,
  28. Joost F Swart6,
  29. Yosef Uziel26,27,
  30. Sebastiaan J Vastert6,
  31. Josef S Smolen28
  1. 1Clinica Pediatrica e Reumatologia, Università degli Studi di Genova and Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina, Genoa, Italy
  2. 2Department of Pediatrics, Asklepios Klinik Sankt Augustin, Sankt Augustin, Germany
  3. 3Department of Pediatric and Adolescents Medicine, University Hospital of Cologne, Cologne, Germany
  4. 4Division od Rheumatology, University of Toronto and The Hospital for Sick Children, Toronto, Ontario, Canada
  5. 5Division of Rheumatology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
  6. 6Department of Paediatric Immunology, Wilhelmina Children’s Hospital, University Medical Center Utrecht and University of Utrecht, Utrecht, The Netherlands
  7. 7Rheumatology Unit, Department of General Medicine, The Royal Children’s Hospital and Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
  8. 8Department of Pediatric Rheumatology, King Faisal Specialist Hospital and Research Center and Alfaisal University, Riyadh, Saudi Arabia
  9. 9Division of Pediatric Rheumatology, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
  10. 10Department of Allergology, Rheumatology and Clinical Immunology, University Medical Center Ljubljana and Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
  11. 11Division of Rheumatology, Western University Children’s Hospital, London Health Sciences Centre, London, Ontario, Canada
  12. 12Institute of Translational Medicine, University of Liverpool and Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
  13. 13Rheumatology Department, Hospital General de México Eduardo Liceaga, México City, Mexico
  14. 14Pediatric Rheumatology, Azienda Ospedaliero Universitaria Meyer, Florence, Italy
  15. 15Division of Rheumatology, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù, Rome, Italy
  16. 16Pediatric Rheumatology and Immunology, University of Muenster, Muenster, Germany
  17. 17Department of Pediatrics, Nippon Medical School, Bunkyo City, Japan
  18. 18Institute of Clinical Medicine, Children’s Hospital, Helsinki University Hospital, Helsinki, Finland
  19. 19Paris-Descartes University, IMAGINE Institute, RAISE 22 National Reference Centre, Necker-Enfants Malades Hospital, Assistance Publique Hopitaux de Paris, Paris, France
  20. 20Clinica Pediatrica e Reumatologia, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
  21. 21Servicio de Inmunología y Reumatología, Hospital de Pediatría Garrahan, Buenos Aires, Argentina
  22. 22Reumatologia Pediátrica, São Paulo State University (UNESP), Botucatu, Brazil
  23. 23Department of Rheumatology, ISIC Superspeciality Hospital and Sir Ganga Ram Hospital, New Delhi, India
  24. 24Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
  25. 25Pediatric Rheumatology, Seattle Children’s Hospital and Research Center, University of Washington, Seattle, Washington, USA
  26. 26Pediatric Rheumatology Unit, Department of Pediatrics, Meir Medical Center, Kfar-Saba, Israel
  27. 27Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
  28. 28Division of Rheumatology, Department of Medicine3, Medical University of Vienna, Vienna, Austria
  1. Correspondence to Dr Angelo Ravelli, Clinica Pediatrica e Reumatologia, Istituto G. Gaslini, Genova 16147, Italy; angeloravelli{at}gaslini.org

Abstract

Recent therapeutic advances in juvenile idiopathic arthritis (JIA) have made remission an achievable goal for most patients. Reaching this target leads to improved outcomes. The objective was to develop recommendations for treating JIA to target. A Steering Committee formulated a set of recommendations based on evidence derived from a systematic literature review. These were subsequently discussed, amended and voted on by an international Task Force of 30 paediatric rheumatologists in a consensus-based, Delphi-like procedure. Although the literature review did not reveal trials that compared a treat-to-target approach with another or no strategy, it provided indirect evidence regarding an optimised approach to therapy that facilitated development of recommendations. The group agreed on six overarching principles and eight recommendations. The main treatment target, which should be based on a shared decision with parents/patients, was defined as remission, with the alternative target of low disease activity. The frequency and timeline of follow-up evaluations to ensure achievement and maintenance of the target depend on JIA category and level of disease activity. Additional recommendations emphasise the importance of ensuring adequate growth and development and avoiding long-term systemic glucocorticoid administration to maintain the target. All items were agreed on by more than 80% of the members of the Task Force. A research agenda was formulated. The Task Force developed recommendations for treating JIA to target, being aware that the evidence is not strong and needs to be expanded by future research. These recommendations can inform various stakeholders about strategies to reach optimal outcomes for JIA.

  • juvenile idiopathic arthritis
  • treatment
  • outcomes research

https://doi.org/10.1136/annrheumdis-2018-213030

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    Footnotes

    • Handling editor Dimitrios T Boumpas

    • Contributors We declare that all authors (1) contributed to the conception or design of the work, or the acquisition, analysis or interpretation of data; (2) drafted the work or revised it critically for important intellectual content; (3) provided a final approval of the version published; and (4) agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors have contributed to the development of the recommendations and the generation of the manuscript.

    • Funding This activity was supported by an unrestricted educational grant from AbbVie to the Medical University of Vienna. No company representative had any influence on the procedure or content, nor was any company representative present at any of the meetings or received the manuscript before submission.

    • Competing interests AR has received grant support and/or speaking or consultant fees from AbbVie, Bristol-Myers Squibb, Novartis, Pfizer, Roche and Johnson & Johnson; AC reports personal fees from AbbVie and non-financial support from Pfizer; GH has received research funds, advisory board membership and honorary fees from AbbVie, Pfizer and Roche; RML has been consultant and/or participated in advisory boards for AbbVie, Eli Lilly, Novartis, Sanofi and Sobi; DJL reports grants/research support from the National Institutes of Health, NIAMS, and received consultancy fees from AstraZeneca, Bristol-Myers Squibb, AbbVie, Pfizer, Roche, Novartis, UBC, Forest Research Institute, Horizon, Johnson & Johnson, Biogen, Takeda, Genentech, GlaxoSmithKline, Boehringer Ingelheim, Celgene and Janssen, and speaker bureaus from Genentech; NMW reports research grants and/or consultant fees from AbbVie and Novartis; JDA has received consultant fees from Pfizer; SMA-M does not report competing interests; JA reports grant support and/or personal fees from AbbVie, Gebro, Pfizer, Novartis, Roche and Sobi; TA has received speaking and/or consultant fees from AbbVie, Boehringer Ingelheim and Pfizer; RAB does not report competing interests; MWB does not report competing interests; RB-V does not report competing interests; RC has received consultant fees from AbbVie, Alfa Wassermann and Novartis; FDB reports grants from Hoffmann-La Roche, Bristol-Myers Squibb, Novimmune, Novartis, Abbott, Pfizer and Sobi; ED does not report competing interests; DF reports grant support and/or personal fees from Pfizer, Novartis, Roche and Sobi; YI does not report competing interests; PL has received grant support from AbbVie; EMM does not report competing interests; PQ has received speakers' fees from AbbVie, Novartis, Pfizer, Roche and Sobi, grants from AbbVie, Pfizer and Novartis, and personal fees for consultancy from AbbVie, Novartis, Novimmune and Sanofi; NR reports personal fees from AbbVie, Amgen, Biogen Idec, Alter, AstraZeneca, Baxalta Biosimilars, Boehringer, Bristol-Myers Squibb, Celgene, CrescendoBio, EMD Serono, Hoffmann-La Roche, Italfarmaco, Janssen, MedImmune, Medac, Novartis, Novo Nordisk, Pfizer, Sanofi-Aventis, Servier, Takeda and UCB Biosciences, and other financial relationships from Bristol-Myers Squibb, GlaxoSmithKline, Hoffmann-La Roche, Novartis, Pfizer, Sanofi-Aventis, Schwarz Biosciences, Abbott, Francesco Angelini SPA, Sobi and Merck Serono; RR does not report competing interests; CS-M does not report competing interests; SSa does not report competing interests; CS does not report competing interests; SSh has received speaking and advisory board fees from Novartis; JFS does not report competing interests; YU reports grant support and/or personal fees and/or non-financial support from AbbVie, Janssen, Novartis, Pfizer and Roche; SJV reports grant support from Sobi; JSS has received grant support from and/or provided expert advice to AbbVie, Amgen, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Celltrion, Gilead, Glaxo, Janssen, Lilly, Pfizer, MSD, Roche, Samsung, Novartis-Sandoz and UCB.

    • Patient consent Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement The results of the systematic literature review are not to be presented in the study, but are available to anyone upon request to the corresponding author.