Karen Onel, MD: Updates in JIA Treatment Guidelines, Unmet Needs in Pediatric Rheumatology

As recently reported in Rheumatology Network, the recent American College of Rheumatology (ACR) juvenile idiopathic arthritis (JIA) treatment and management guidelines emphasize changes regarding the treatment of oligoarthritis, systemic JIA (both with and without macrophage activation syndrome [MAS]), monitoring drug toxicities, immunizations, and radiographic imaging.

Karen Onel, MD, is Chief of the Division of Pediatric Rheumatology at the Hospital for Special Surgery (HSS), Professor of Clinical Pediatrics, and one of the lead investigators of the guidelines.

In our interview below, Onel discusses important updates, the benefits and harms of treating young patients with glucocorticoids, and the unmet needs in pediatric rheumatology.

Rheumatology Network: What prompted the ACR to update the guidelines for the treatment and management of JIA?

Karen Onel, MD: Changes within our field are occurring at an ever-increasing rate. When writing these guidelines, 3 new medications and a new vaccine became available to treat juvenile arthritis. Our practice has dramatically changed in the past 10 years and these guidelines have to reflect the challenges and advances in our field. We hope these guidelines position us well for best the clinical care and for the next update.

RN: What are the most important changes that have been made in the recent updates and what is the clinical significance?

KO: The guidelines stress the use of disease-modifying antirheumatic drugs (DMARDs) (both biologic and conventional) early in the course of disease. Long-term follow up studies show that juvenile arthritis often persists well into adulthood. The accumulation of damage over time, at least in part due to a wait and see approach,can be very hard on patients and could be avoided with more aggressive and proactive treatment early on. The clinical significance to this approach is clear: recent studies demonstrate that early, aggressive treatment leads to the best outcome for children with JIA.

RN: In your opinion, are glucocorticoids more helpful or harmful in treating rheumatic disease?

KO: They are both. Glucocorticoids were the original game changer for JIA and continue to be important. We use glucocorticoids all the time. Intraarticular glucocorticoid injections are a mainstay of treatment for oligoarticular JIA and intravenous steroids can be lifesaving for children with MAS. However, daily steroids are not a replacement for DMARDs when they are available and appropriate. We want to aim high and prevent damage so that these children live long, happy, wonderful lives.

Onel stresses that the unmet needs of this patient population continue to be developing medications that are more effective, a push to focus on mental health, education, and work disability, and, of course, a cure.

“As anyone who finished training in the last century could tell you, the progress that we have made is extraordinary,” Onel concluded. “This knowledge of where we were leads us forward to where we will be. I hope to see it.”