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  • Review Article
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Management of juvenile idiopathic arthritis: hitting the target

Nature Reviews Rheumatology volume 11, pages 290–300 (2015)Cite this article

Subjects

Key Points

  • The development of biologic DMARDs has revolutionized the therapeutic management of juvenile idiopathic arthritis (JIA)

  • A treat-to-target approach combined with tight control, in which patients are frequently reassessed, can help improve disease outcomes and achieve disease remission off medication

  • Initiating intensive therapy early in the course of JIA (during the window of opportunity) is likely to improve long-term disease outcomes, and is a focus of ongoing clinical trials

  • Guidelines and consensus protocols have been pivotal in improving the management of children with JIA, but further development and investigator-led clinical trials are required, including by multinational collaborations

  • Optimal management strategies for patients with JIA can be achieved by combining guideline-led care and personalized treatment approaches, and by focusing efforts on targeted treatment

Abstract

The treatment of juvenile idiopathic arthritis (JIA) is evolving. The growing number of effective drugs has led to successful treatment and prevention of long-term sequelae in most patients. Although patients with JIA frequently achieve lasting clinical remission, sustained remission off medication is still elusive for most. Treatment approaches vary substantially among paediatric rheumatologists owing to the inherent heterogeneity of JIA and, until recently, to the lack of accepted and well-evidenced guidelines. Furthermore, many pertinent questions related to patient management remain unanswered, in particular regarding treatment targets, and selection, intensity and sequence of initiation or withdrawal of therapy. Existing JIA guidelines and recommendations do not specify treat-to-target or tight control strategies, in contrast to adult rheumatology in which these approaches have been successful. The concepts of window of opportunity (early treatment to improve long-term outcomes) and immunological remission (abrogation of subclinical disease activity) are also fundamental when defining treatment methodologies. This Review explores the application of these concepts to JIA and their possible contribution to the development of future clinical guidelines or consensus treatment protocols. The article also discusses how diverse forms of standardized, guideline-led care and personalized treatment can be combined into a targeted, patient-centred approach to optimize management strategies for patients with JIA.

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Figure 1: The armamentarium of antirheumatic drugs available for the treatment of JIA.
Figure 2: Matching evidence-based guidance to individual disease courses in clinical practice.
Figure 3: Target definition and achievement in JIA management.
Figure 4: Optimization of JIA management in clinical practice.

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Acknowledgements

F.G. is supported by the European Union Seventh Framework Programme for Research and Technological Development (FP7) grant EUTRAIN (European Translational Training for Autoimmunity & Immune Manipulation Network, ref. 289903). D.F. is supported by the FP7 grant MIAMI (Monitoring Innate Immunity in Arthritis and Mucosal Inflammation project, ref. 305266) and by a Clinical Research Award (CRA-04) from the Interdisciplinary Centre of Clinical Research (IZKF), Münster, Germany.

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  1. Department of Paediatric Rheumatology and Immunology, University Children's Hospital Münster, Albert-Schweitzer-Campus 1, Building W30, D-48149, Münster, Germany

    Claas Hinze, Faekah Gohar & Dirk Foell

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Correspondence to Dirk Foell.

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C.H. declares that he has received lecture fees from Novartis. D.F. declares that he has received lecture fees from Chugai, Novartis, Pfizer, Roche and Swedish Orphan Biovitrum. F.G. declares no competing interests.

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Hinze, C., Gohar, F. & Foell, D. Management of juvenile idiopathic arthritis: hitting the target. Nat Rev Rheumatol 11, 290–300 (2015). https://doi.org/10.1038/nrrheum.2014.212

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