Earlier DMARDs, Less Steroids for Pediatric Rheumatology: New Guidelines

Updated guidelines for managing juvenile idiopathic arthritis (JIA) are placing greater emphasis on early disease-modifying antirheumatic drug (DMARD) therapy and significantly reducing reliance on glucocorticoids, particularly in growing children. This shift, as explained by rheumatologist Susan Shenoi, MS, reflects a growing understanding of the potential long-term side effects associated with steroid use in pediatric populations.

Understanding Juvenile Idiopathic Arthritis

Juvenile idiopathic arthritis, or JIA, is the most common type of arthritis in children and adolescents. It’s an autoimmune condition, meaning the body’s immune system mistakenly attacks its own tissues, leading to inflammation in the joints. Unlike adult rheumatoid arthritis, JIA encompasses several subtypes, each with distinct characteristics and treatment approaches. These subtypes include systemic JIA, oligoarticular JIA, polyarticular JIA (RF positive and RF negative), enthesitis-related arthritis, and psoriatic arthritis. The specific type of JIA a child has influences the treatment plan, but the overarching goal is to control inflammation, relieve pain, and prevent joint damage.

The Shift Away From Glucocorticoids

Glucocorticoids, often referred to as steroids, have long been used to quickly reduce inflammation in JIA flares. But, their use isn’t without drawbacks. In children, prolonged glucocorticoid exposure can hinder growth, increase the risk of osteoporosis, and contribute to weight gain, among other side effects. The updated guidelines, advocate for a more cautious approach, prioritizing DMARDs as the primary means of controlling the disease. DMARDs work by suppressing the immune system, addressing the underlying cause of the inflammation rather than just managing the symptoms.

“The new draft guidelines favor earlier DMARD therapy with much decreased reliance on glucocorticoids that have several side effects in growing children,” Shenoi stated in a report published in Medscape Medical News. This suggests a move towards a more proactive and preventative strategy, aiming to modify the disease course from the outset rather than simply reacting to flares.

What are DMARDs and How Do They Work?

Disease-modifying antirheumatic drugs (DMARDs) are a class of medications used to treat autoimmune diseases like JIA. They work by suppressing the immune system, which is overactive in these conditions. Notice conventional synthetic DMARDs (csDMARDs), such as methotrexate, sulfasalazine, and leflunomide, and biologic DMARDs (bDMARDs), which target specific parts of the immune system. Biologics include TNF inhibitors, IL-6 inhibitors, and others. The choice of DMARD depends on the type of JIA, the severity of the disease, and individual patient factors. Methotrexate is often the first-line DMARD used in JIA treatment.

The Importance of Early Intervention

The emphasis on early DMARD therapy stems from the understanding that early and aggressive treatment can improve long-term outcomes for children with JIA. By controlling inflammation early on, clinicians hope to prevent irreversible joint damage and maintain optimal function. This approach is particularly crucial in systemic JIA, a more severe form of the disease that can affect multiple organs. Susan Shenoi’s work at Seattle Children’s Hospital focuses, in part, on systemic juvenile idiopathic arthritis.

Guideline Development and Ongoing Research

It’s essential to note that these are draft guidelines, and the final recommendations may evolve as new evidence emerges. Guideline development typically involves a rigorous process of reviewing available research, assessing the quality of evidence, and formulating recommendations based on expert consensus. Organizations like the American College of Rheumatology (ACR) play a key role in developing these guidelines. Ongoing research continues to refine our understanding of JIA and identify more effective treatment strategies. A Cochrane review published in 2021 assessed the benefits and harms of short-term glucocorticoids used in conjunction with DMARD therapy for rheumatoid arthritis, acknowledging that longer-term glucocorticoid use will be addressed in separate reviews.

What This Means for Families

For families affected by JIA, these updated guidelines suggest a potential shift in treatment approaches. Parents and caregivers can expect their rheumatologist to discuss the benefits and risks of DMARD therapy in more detail, and to consider initiating DMARDs earlier in the course of the disease. It’s crucial to have an open and honest conversation with the healthcare team about any concerns or questions regarding treatment options. While glucocorticoids may still be used in certain situations, such as during severe flares, the goal is to minimize their use and prioritize long-term disease control with DMARDs.

Next Steps: Families should continue to work closely with their child’s rheumatologist to develop an individualized treatment plan that addresses their specific needs. The ACR will likely publish the finalized guidelines in the coming months, providing more detailed recommendations for clinicians. Continued research will further refine our understanding of JIA and lead to even more effective treatments in the future.