Group Offers Guide to Managing Juvenile Idiopathic Arthritis-Induced Uveitis

Australian- and New Zealand-based investigators have offered a consensus of recommendations for the evaluation and management of juvenile idiopathic arthritis (JIA)-linked anterior uveitis, as well as subsequent glaucoma and cataracts for patients in Australia and New Zealand.

A group of 29 ophthalmologists from the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) Uveitis Special Interest Group (SIG) participated in the Working Group, which involved uveitis specialists from various regions. First, the Working Group completed an online, 29-questionnaire practice pattern that focused on clinical evaluation and management of JIA-associated uveitis. Any patient younger than 16 years of age was categorized as a child. 

Items that achieved 75% or greater agreement were considered to have consensus. After completion of the questionnaire, the panel met in person, and the Delphi technique was used to reach consensus for any item with greater than 25% but less than 75% agreement. Consensus was reached for 18 statements related to the clinical evaluation of acute and chronic JIA-linked uveitis as well as treatment. 

The Working Group recommended that patients with active JIA-linked uveitis and anterior chamber cell grade above 1+ be reviewed at least every 2 weeks and that active cases could be treated via 1% prednisolone eye drops as often as 6 times per day, depending on the severity of inflammation, for up to 4 weeks before tapering. If a taper was not possible at the time, the Working Group recommended escalating to more aggressive therapy.

In the event that more aggressive therapy was required, the Working Group agreed that oral prednisolone would be useful at a maximum recommended dose of 1 mg/kg/day for a maximum duration of 16 weeks. 

The group also recommended methotrexate as the first-choice conventional immunosuppressive drug, with mycophenolate as the second choice; and adalimumab as the first choice biologic systemic immunosuppressive, with infliximab being the second choice. The group recommended that cessation of immunosuppressive therapy could be considered after inflammation had been inactive for 24 months.

In the event of cataract development, the Working Group recommended a 3-month quiescence period prior to cataract surgery and certain preoperative measures to reduce the risk of postsurgical inflammation. 

For glaucoma management, the Working Group recommended a medical therapy consisting of 4 topically delivered drugs including a beta-blocker, a carbonic anhydrase inhibitor, a prostaglandin analog, and an alpha-2 adrenergic agent but noted that individual adverse effects must be considered. 

Although there are several treatment and management guidelines for JIA-induced uveitis, most of these are tailored for the care of patients in Europe and in the United States. 

These recommendations were developed by expert consensus and not by a thorough review of the medical literature. Deviations from them may be appropriate for some patients. Finally, the Working Group notes that “the management of JIA-type uveitis is a fast-developing area….and it [is] important to periodically consider revision of these recommendations to address new advances.” 

Reference 

Smith J, Matthews J, Conrad D, et al. Recommendations for the management of childhood juvenile idiopathic arthritis-type chronic anterior uveitis. Clin Exp Ophthalmol. Published online January 10, 2021. doi:10.1111/ceo.13856.