Sheila T. Angeles-Han, MD, MSc, on the ACR/Arthritis Foundation Guideline for Managing Juvenile Idiopathic Arthritis–Associated Uveitis
The American College of Rheumatology (ACR) and the Arthritis Foundation have issued the first guideline for the treatment of children with juvenile idiopathic arthritis (JIA)–associated uveitis that includes recommendations about regular ophthalmic screening, new strategies to maintain control of uveitis to prevent vision impairment, and more.1
Rheumatology Consultant caught up with Sheila T. Angeles-Han, MD, MSc, an associate professor of pediatrics at Cincinnati Children’s Hospital Medical Center and the University of Cincinnati in Ohio, and lead author of the guideline, on what rheumatologists need to know about the treatment recommendations.
Rheumatology Consultant: This is the first guideline on the management of JIA–associated chronic anterior uveitis and acute anterior uveitis. Why has it taken an extended amount of time to develop the guideline, given that uveitis is a common extra-articular manifestation of JIA?
Sheila T. Angeles-Han: In general, there has been increased awareness that uveitis can occur in children with JIA, the prognosis of the condition, as well as the ocular complications that can occur. The potential for vision impairment has had the most influence on increased awareness. There has also been improved collaboration between ophthalmologists and rheumatologists over the last few years, which has prompted a need for management guidelines of uveitis among children. Most of the recommendations in the guideline had very low quality of evidence because of an overall lack of research in pediatric uveitis. More research is needed to determine the most effective and optimal treatments for children with uveitis. Knowledge of the risk factors that differentiate which children with JIA are at risk of developing uveitis and those who will experience a severe course with ocular complications such as vision loss is very important.
RHEUM CON: What is unique about this patient population that can make management more challenging?
SAH: What is difficult for these patients is that they require multiple visits with their rheumatologist and ophthalmologist, frequent blood draws for medication monitoring, and chronic immunosuppressive treatment which greatly impact their quality of life. The child has to see their rheumatologist regularly to monitor and evaluate the arthritis, and then they also need to see their ophthalmologist to screen for uveitis. If the child develops uveitis, then there is the burden of additional visits to monitor disease progression and medication response, which can be especially difficult for families. A multidisciplinary approach to management is crucial, which is why both ophthalmologists and rheumatologists were involved in developing the guideline. The collaboration and communication between both specialists are very important. The ophthalmologist screens for and monitors uveitis, whereas the rheumatologist is key for initiating and continuing therapy.
RHEUM CON: Which recommendations are critical for rheumatologists and ophthalmologists?
SAH: Screening and how to taper systemic treatment are the most important recommendations for clinicians. Regular screening of uveitis is important because most children have asymptomatic disease. I emphasize to my patients that even if their arthritis is controlled, arthritis and uveitis do not necessarily parallel each other in disease activity. The patient may have inactive arthritis but should continue regular screening with an ophthalmologist. The specific timepoint to initiate tapering of systemic treatment is when a child has had inactive uveitis, ideally without topical glucocorticoids, for at least 2 years. The message that a child has to be inactive for a longer period of time before attempting to taper treatment is important, especially since the disease can flare when tapering too quickly. Frequent ophthalmic monitoring is also a critical recommendation. There are general guidelines for screening, yet there is limited information on how to monitor children after they develop uveitis. The message of frequent monitoring, especially when a patient is changing therapy, is key.
RHEUM CON: Should every child with JIA undergo screening of uveitis every 3 months?
SAH: Screening frequency is based on the individual risk of uveitis. The risk of uveitis among children depends on several factors. Children with specific JIA categories, high antinuclear antibody (ANA) levels, those who are early in their JIA diagnosis, and those who are younger tend to be at increased risk of uveitis. Children with low ANA levels should undergo screening every 6 months. The American Academy of Pediatrics has a clinical report and guidelines on the frequency of screening.2
RHEUM CON: Are glucocorticoids a safe treatment option for patients?
SAH: It is possible to control a patient’s ocular inflammation from their uveitis with topical glucocorticoids alone, especially in children with acute anterior uveitis. However, there is a risk of adverse effects or ocular complications of the medication that causes concern. Long-term treatment with topical glucocorticoids is not recommended. If you have a patient who requires long-term topical glucocorticoids to control their eye disease, then it is time to begin systemic treatment. It is important for the clinician to know when to start systemic treatment.
References:
1. Angeles-Han ST, Ringold S, Beukelman T, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the screening, monitoring, and treatment of juvenile idiopathic arthritis–associated uveitis. Arthritis Care Res (Hoboken). 2019;71(6):703-716. doi:10.1002/acr.23871.
2. Cassidy J, Kivlin J, LindsleyC, Nocton J; the Section on Rheumatology and Section on Ophthalmology. Ophthalmologic Examinations in children with juvenile rheumatoid arthritis. Pediatrics. 2006;117(5):1843-1845. https://doi.org/10.1542/peds.2006-0421