Evidence and consensus based GKJR guidelines for the treatment of juvenile idiopathic arthritis

HELIOS Children's Hospital, Krefeld, Germany.
Clinical Immunology (Impact Factor: 3.67). 10/2011; 142(2):176-93. DOI: 10.1016/j.clim.2011.10.003
Source: PubMed


Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children and adolescents. Immunomodulatory drugs are used frequently in its treatment. Using the nominal group technique (NGT) and Delphi method, we created a multidisciplinary, evidence- and consensus-based treatment guideline for JIA based on a systematic literature analysis and three consensus conferences. Conferences were headed by a professional moderator and were attended by representatives who had been nominated by their scientific societies or organizations. 15 statements regarding drug therapy, symptomatic and surgical management were generated. It is recommended that initially JIA is treated with NSAID followed by local glucocorticoids and/or methotrexate if unresponsive. Complementing literature evidence with long-standing experience of caregivers allows creating guidelines that may potentially improve the quality of care for children and adolescents with JIA.

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    • "Moreover IACIs administered to the knee joints appear to be more efficacious than those administered to the small joints in the foot, where the response is less predictable [19]. Two other reviews of the overall medical management of JIA adopted systematic approaches to conduct their literature search, but their restrictive inclusion criteria retrieved only two small randomised studies concerning IACIs and only limited conclusions were drawn [10,20]. One other systematic review attempted to appraise the evidence for knee joint IACIs for a range of arthritis conditions including JIA, osteoarthritis (OA) and RA [21]. "
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    ABSTRACT: Background Juvenile Idiopathic Arthritis (JIA) commonly affects joints of the lower limb including the knee, ankle, subtalar and other foot joints. Intra-articular corticosteroid injections (IACIs) are considered to be effective for short-term relief of synovitis, however, there appears to be a significant lack of published evidence from comparative effectiveness studies. The aim of this study was to identify and critically appraise the evidence for the efficacy of lower limb IACIs in children/adolescents with JIA. Methods Studies were identified in databases Medline, Embase, CINAHL, AMED, PEDro, the Cochrane Library and TRIP, with no date restrictions. The primary search terms ‘juvenile idiopathic arthritis’, ‘lower limb’, ‘knee’; ‘ankle’, ‘foot’ and ‘intra-articular steroid injections’ and related synonyms were used to develop a comprehensive pragmatic literature search strategy. Included studies were quantitative longitudinal design such as randomised controlled trials, pseudo-randomised and non-randomised experimental studies, cohort studies, and case-control studies. All outcomes measures were subject to analysis. Quality assessment was conducted using the Cochrane Collaboration criteria with additional criteria for sample population representativeness, quality of statistical analysis and compliant intervention use and presence of co-interventions. Qualitative data synthesis was conducted for the outcome domains. Meta-analyses were not possible as multiple randomised controlled trials for outcome measures were not available. Levels of evidence were assigned to each outcome measure. Results The inclusion criteria were met by twenty-one studies. One study had high quality for internal validity and nine studies had high quality for external validity. No studies had high quality for both internal and external validity. Four outcome domains were identified. There was weak evidence for IACIs decreasing clinical signs and symptoms in the lower leg, improving joint range of motion, decreasing leg length discrepancy, and for imaging techniques detecting the effects of IACIs. Conclusions There is some weak evidence for the efficacy of IACIs improving certain outcome measures. However, there is also some inconclusive evidence due to a lack of quality studies. More high quality evidence is necessary to definitely determine the efficacy of IACIs for JIA in the lower leg.
    Full-text · Article · Jun 2014 · Pediatric Rheumatology
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    • "Introduction of disease-modifying anti-rheumatic drugs (DMARD) and, more recently, biologic agents such as TNF-antagonists, have significantly changed the treatment over the last two decades [4]. Various professional societies and groups have put considerable effort into developing recommendations and guidelines for the treatment of JIA [5,6]. "
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    ABSTRACT: Background Variations in the treatment of juvenile idiopathic arthritis (JIA) may impact on quality of care. The objective of this study was to identify and compare treatment approaches for JIA in two health care systems. Methods Paediatric rheumatologists in Canada (n=58) and Germany/Austria (n=172) were surveyed by email, using case-based vignettes for oligoarticular and seronegative polyarticular JIA. Data were analysed using descriptive statistics; responses were compared using univariate analysis. Results Total response rate was 63%. Physicians were comparable by age, level of training and duration of practice, with more Canadians based in academic centres. For initial treatment of oligoarthritis, only approximately half of physicians in both groups used intra-articular steroids. German physicians were more likely to institute DMARD treatment in oligoarthritis refractory to NSAID (p<0.001). Canadian physicians were more likely to switch to a different DMARD rather than a biologic agent in polyarthritis refractory to initial DMARD therapy. For oligoarthritis and polyarthritis, respectively, 86% and 90% of German physicians preferred regular physiotherapy over home exercise, compared to 14% and 15% in Canada. Except for a Canadian preference for naproxen in oligoarthritis, no significant differences were found for NSAID, intra-articular steroid preparations, initial DMARD and initial biologic treatment. Conclusions Treatment of oligo- and polyarticular JIA with DMARD is mostly uniform, with availability and funding obviously influencing physician choice. Usage of intra-articular steroids is variable within physician groups. Physiotherapy has a fundamentally different role in the two health care systems.
    Full-text · Article · Jan 2013 · Pediatric Rheumatology
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    ABSTRACT: Die juvenile idiopathische Arthritis (JIA) ist die häufigste chronisch-entzündliche Erkrankung im Kindes- und Jugendalter. In Deutschland liegt die Inzidenz bei etwa 4–7 pro 100.000 Kinder und Jugendliche unter 16 Jahren, die Zahl an Neukrankungen beträgt etwa 1000 pro Jahr. Bei der Diagnosestellung wird aktuell die ILAR-Klassifikation (ILAR: „International League of Associations for Rheumatology“) zugrunde gelegt. Demnach liegt eine JIA vor bei Arthritis eines oder mehrerer Gelenke, die für mindestens 6 Wochen anhält und vor dem 16. Geburtstag des Patienten beginnt. Andere Erkrankungen, die ähnliche Symptome verursachen können, müssen ausgeschlossen sein. Es werden 8 verschiedene Subgruppen der JIA unterschieden. Hieraus ergeben sich subgruppenspezifische Implikationen für mögliche Organbeteiligungen, Therapie und Prognose.Die vorliegende Handlungsempfehlung beruht auf der entsprechenden AWMF-Leitlinie (AWMF: Arbeitsgemeinschaft der wissenschaftlichen medizinischen Fachgesellschaften ...
    No preview · Article · Jan 2012 · Monatsschrift Kinderheilkunde
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