Recommendations for managing JIA-associated uveitis published
medwireNews: The SHARE initiative has developed consensus evidence-based recommendations for the management of uveitis associated with juvenile idiopathic arthritis (JIA).
JIA “is the most common rheumatic disease in children and uveitis is possibly its most devastating extra-articular manifestation,” say the guideline authors, led by Athimalaipet Ramanan (University of Bristol, UK).
They add that evidence-based guidelines for the management of this condition are “sparse,” as a result of which “treatment practices differ widely, within and between nations.”
As reported in the Annals of the Rheumatic Diseases, the SHARE (Single Hub and Access point for pediatric Rheumatology in Europe) committee, comprising nine experts in pediatric rheumatology and three experienced ophthalmologists, developed draft recommendations using a systematic literature review approach. The proposals were then discussed by a committee, and recommendations were accepted if more than 80% of the taskforce, including all of the ophthalmologists, were in agreement.
In all, 22 recommendations related to diagnosis, measurement of disease activity, treatment, and future research were accepted.
The three recommendations on diagnosis and screening emphasize that all patients with a probable diagnosis of JIA should be screened for uveitis, and that those with a confirmed JIA diagnosis who stop immunosuppressive treatment should undergo screening at least every 3 months for a minimum of 1 year.
Ramanan and colleagues observe that there is currently “no widely accepted definition” of inactive disease for JIA-associated uveitis, in addition to a lack of validated markers to monitor disease activity, and their five recommendations on disease activity include the need to develop outcome measures to help guide treatment decisions.
All of the experts agreed that active uveitis in patients with JIA “usually requires immediate treatment.” The 12 treatment recommendations advocate first-line therapy with topical corticosteroids for anterior uveitis, and methotrexate for patients who require systemic immunosuppression, with escalation to biologic treatment if needed.
The authors stress the importance of effective communication between healthcare providers to ensure correct diagnosis, monitoring, and treatment of JIA-associated uveitis, with 100% of the committee agreeing that pediatric rheumatologists and ophthalmologists should work together.
This sounds very simple, but in this day and age of “go-go-go,” it can be difficult to find time.
Although there was a high level of agreement between members of the taskforce – all of the final recommendations were endorsed by at least 92% of the experts – Ramanan and colleagues note that the level of evidence supporting the guidelines was “quite low.” Indeed, only two of the recommendations were based on level 1 evidence, and the majority (59%) were based on level 3 or 4 evidence.
“This highlights the need for more research in this clinical setting where a number of new therapies, particularly biological agents, have been introduced in recent years,” writes the taskforce.
In their two recommendations for future research, the authors underline the need for controlled clinical trials and validated outcome measures for JIA-associated uveitis.
And they conclude: “In a disease setting where the evidence base is limited by small numbers of patients, and which is developing rapidly, these expert recommendations should help specialists with the evidence-based advice to provide optimal care for their patients.”
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