Recommendations for treat-to-target strategies in JIA

Expert guidance on general treatment approaches for children with juvenile idiopathic arthritis.

Juvenile idiopathic arthritis, commonly referred to as JIA, is an umbrella term for a group of inflammatory arthritis conditions with unknown cause which begin in children before the age of 16. The types of arthritis that sit under this umbrella are shown in the figure below. JIA is the most common type of arthritis seen in children, which causes pain, swelling and stiffness in one or more joints, as well as other symptoms like fever and fatigue (tiredness). Recent advances in the management of JIA have improved the likelihood of children achieving positive outcomes, such as better control of their disease. This means that doctors can aim for even higher treatment targets, such as complete remission. Research in people with rheumatoid arthritis has shown that outcomes are improved if treatment aims at achieving low disease activity, with frequent
adjustments of treatment in order to achieve that goal. Similar approaches are now being taken in JIA. This management strategy (or treatment plan) is called ‘treat to target’.

The authors hoped to gain a better understanding of the available published evidence and research supporting the use of treat-to-target strategies in JIA, in order to develop and publish a set of recommendations.

The work done to develop the recommendations did not involve direct research with patients, but was based on an in-depth review of existing research evidence in the form of a systematic literature review and a series of consensus-based procedures involving experts in JIA.

The basis of the recommendations was a systematic literature review, which aims to identify all the published evidence on a particular topic and draw it together into one summary. In this case a group of experts in JIA evaluated a systematic review on the role of ‘treat to target’. Based on the extracted evidence the experts drafted
8 recommendations for doctors to use.

The authors developed eight recommendations for the use of treat-to-target strategies in children with JIA. As well as the recommendations, there are a set of general principles for treatment. These say that the treatment target and strategy should be based on shared decisions between the child and/or the parents and the paediatric rheumatology healthcare team. They note that JIA is an umbrella group of different conditions that may require
different treatment approaches. The goal of treating a child with JIA is to control the signs and symptoms of the condition, as well as to prevent joint damage and toxicity from treatments, and to improve physical function, growth and development, quality of life and social lives. To achieve these goals, it is important to address the
underlying inflammation involved in JIA.

1. The target for children with JIA is clinical remission
• Clinical remission means that there are no signs and symptoms of inflammatory disease activity.

2. Minimal (or low) disease activity is an alternative target, particularly in children who have had JIA for a long time
• Remission may be difficult to achieve in some children, especially those who have had the condition for a long time, or who have very aggressive systemic or polyarticular forms of JIA with persistently
active disease, or children who have received multiple treatments or who have substantial joint damage or other linked diseases (often called comorbidities).

3. The target should be based on each individual child’s characteristics and agreed with the child and/or the parents.
• The target and the tools to achieve it will be different for different people. Therefore, every child should have their own individual target.
• Decisions about treatment and targets should be made with the child and the parents.

4. Disease activity should be assessed and recorded regularly.
• Doctors use clinical tools to assess and monitor disease activity. These might be a combination of clinical examinations such as the number of swollen joints, laboratory results, and parent- or patient
feedback, often called patient-reported outcomes. When several elements are combined like this it is called a composite measure.
• It is up to doctors to choose the most appropriate tool to use in their clinic.
• These assessments should be performed at every clinic visit.

5. How often assessments are done depends on the type of JIA, level of disease activity and whether there are any non-joint symptoms.
• Some children may require weekly assessments, such as those who have systemic JIA with active systemic manifestations such as fever or rashes.
• Children with high/moderate disease activity should be seen every 1–3 months.
• Children who are in clinical remission can be seen less often.

6. All children should show at least a 50% improvement in disease activity within 3 months of starting treatment, and the target should be reached within 6 months.
• All categories of JIA should aim for targets to be met within 6 months.
• The only exception is in children with systemic JIA with active systemic symptoms, where resolution of fever should be achieved within 1 week.

7. Treatment should be adjusted until the target is achieved.
• There are better long-term outcomes if targets are met early.
• Adjusting treatment might mean changing the dose, administration, or type of medicine, if needed (usually evaluated every 3 months or more frequently, as needed).

8. Once the target has been achieved, there should be ongoing monitoring to make sure the results are sustained.
• Some children may be able to stop treatment and maintain their clinical remission; others may need to continue taking their medicine. This will vary between individuals.
• Clinic visits will continue to monitor the remission.

Yes – this is the first set of recommendations to address specific treatment targets and to describe the strategy to reach therapeutic goals in JIA. A key difference from previous treatment recommendations for this condition is that the authors have not made specific suggestions or advice about which medicines to use, apart from the avoidance of long-term steroid use. This should mean that the recommendations can be used in all regions and
countries around the world, regardless of which medicines are available.

The systematic literature review showed that clinical trials of a treat-to-target approach have not been done in JIA. This means that the evidence underlying the recommendation is not strong, and more research needs to be done to confirm that a treat-to-target approach works for children with JIA. Another limitation is that there were no children and young people with JIA or their parents or carers involved in developing the recommendations. However, the authors plan to share the recommendations with parent/patient organisations to gather their feedback.

The authors have designed a research agenda to look into treat-to-target approaches in JIA.

These recommendations provide important information about managing JIA. If you have JIA, or if you look after a child with the condition, they may be useful to help you understand what to expect from treatment.

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Date prepared: June 2018
Summary based on research article published on: 10th May 2018
From: Ravelli, A. et al. Treating juvenile idiopathic arthritis to target: recommendations of an International task force. Ann Rheum Dis 2018;77:819–28. doi:annrheumdis-2018-213030

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