What does an adult rheumatologist need to know about juvenile idiopathic arthritis?

What have we learned from long-term studies in juvenile idiopathic arthritis? - Prediction, classification, transition

BACKGROUND

Research and management of juvenile idiopathic arthritis (JIA) are challenging due to its heterogeneous nature, chronicity, and unpredictable, multidimensional long-term outcomes.

MAIN BODY

Long-term studies have consistently shown that a majority of children with JIA reach adulthood with ongoing disease activity, on medication, or with recurrent flares. The heterogeneity is evident both between and within the present JIA categories based on The International League of Associations for Rheumatology (ILAR) JIA classification system. Several baseline predicting factors are known, but prediction modelling is only in the initial phase, and more models need to be tested in independent cohorts and possibly also supplemented with new biomarkers. Many have criticized the ILAR classification system, but new or updated classification systems have not yet been validated and proved their superiority. The lack of prediction possibilities for long-term outcomes and the limited alignment between JIA classification categories and adult rheumatic conditions are challenges for research, may limit the accessibility to treatment, and hamper a smooth transition to adult care.

CONCLUSION

We need more prospective, long-term studies based on unselected JIA cohorts with disease onset in the biologic era that can aid decision-making for individualized early treatment, suggest intervention studies, and ensure our patients the best possible transition to adulthood and the best likelihood of optimal health and quality of life.

Systemic juvenile idiopathic arthritis and adult-onset Still's disease are the same disease: evidence from systematic reviews and meta-analyses informing the 2023 EULAR/PReS recommendations for the diagnosis and management of Still's disease

OBJECTIVES

To analyse the similarity in clinical manifestations and laboratory findings between systemic juvenile idiopathic arthritis (sJIA) and adult-onset Still's disease (AOSD).

METHODS

Three systematic reviews (SR) were performed. One included cohort studies comparing sJIA versus AOSD that described clinical and biological manifestations with at least 20 patients in each group (SR1). The second identified studies of biomarkers in both diseases and their diagnostic performance (SR2). The last focused on diagnostic biomarkers for macrophage activation syndrome (MAS, SR3). Medline (PubMed), Embase and Cochrane Library were systematically searched. The risk of bias was assessed with an adapted form of the Hoy scale for prevalence studies in SR1 and the Quality Assessment of Diagnostic Accuracy Studies-2 in SR2 and SR3. We performed meta-analyses of proportions for the qualitative descriptors.

RESULTS

Eight studies were included in SR1 (n=1010 participants), 33 in SR2 and 10 in SR3. The pooled prevalence of clinical manifestations did not differ between sJIA and AOSD, except for myalgia, sore throat and weight loss, which were more frequent in AOSD than sJIA because they are likely ascertained incompletely in sJIA, especially in young children. Except for AA amyloidosis, more frequent in sJIA than AOSD, the prevalence of complications did not differ, nor did the prevalence of biological findings. Ferritin, S100 proteins and interleukin-18 (IL-18) were the most frequently used diagnostic biomarkers, with similar diagnostic performance. For MAS diagnosis, novel biomarkers such as IL-18, C-X-C motif ligand 9, adenosine deaminase 2 activity and activated T cells seemed promising.

CONCLUSION

Our results argue for a continuum between sJIA and AOSD.

PROSPERO REGISTRATION NUMBER

CRD42022374240 and CRD42024534021.

A lifelong journey: Long-term perspectives on Juvenile Idiopathic Arthritis

Juvenile Idiopathic Arthritis (JIA) represents a diverse group of chronic inflammatory conditions that begin in childhood or adolescence and continue into adulthood, with varying severity and outcomes. This review discusses the complexities of transitioning JIA patients emphasizing that inadequate transition from pediatric to adult care leads to loss of follow-up, treatment discontinuation, and increased disease activity. Furthermore, challenges in disease classification hinder continuity of care across lifespan. It is also pointed out that predicting long-term outcomes in JIA remains complex due to heterogeneity and evolving phenotypes. Factors such as disease category, joint involvement, and treatment influence disease activity, functional disability, and quality of life. Despite advancements in treatment strategies, a substantial proportion of patients experience long-term disability and joint damage. Finally, it is underscored that optimising long-term outcomes in adults with JIA requires a multifaceted approach encompassing structured transition processes, personalised treatment strategies, and comprehensive management of comorbidities. Further research is needed to refine predictive models, enhance disease monitoring tools, and understand the complex interplay between disease activity, treatment response, and long-term outcomes.

Relapses of juvenile idiopathic arthritis in adulthood: A monocentric experience

INTRODUCTION

Our aim was to describe a monocentric cohort of young adult patients with juvenile idiopathic arthritis (JIA), assessing the risk of relapse after transition to adult care.

METHODS

We conducted a retrospective study and collected clinical, serological, and demographic data of young adult patients (18-30 years old) referred to the Transition Clinic of a single Italian centre between January 2020 and March 2023. Patients with systemic-onset JIA were excluded. Primary outcome was disease relapse, defined by Wallace criteria. Risk factors were analysed by Cox proportional hazards regression.

RESULTS

Fifty patients with age 18-30 years old were enrolled in the study and followed for a median 30 months. The median disease duration at transition was 15 years. Twenty (40%) patients were on conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and 38 (76%) were on biological DMARDs through adulthood. Twenty-three patients relapsed after transitioning to adult care for a median 9-month follow-up (IQR 0-46.5). Most relapses involved the knees (69.6%). The univariate analysis identified monoarthritis (HR 4.67, CI 1.069-20.41, p value = 0.041) as the main risk factor for relapse within the first 36 months of follow-up. Early onset, ANA positivity, past and ongoing treatment with csDMARDs or bDMARDs, therapeutic withdrawal, and disease activity within 12 months before transition did not significantly influence the risk of relapse.

CONCLUSION

In JIA patients, the risk of relapse after transitioning to adult care remains high, irrespective of disease subtype and treatment. The main risk factor for the early occurrence of articular activity is monoarticular involvement.

Juvenile idiopathic arthritis in an adult Filipino female: A case report

INTRODUCTION

Juvenile idiopathic arthritis (JIA) is a family of arthritic conditions that occurs in childhood. If untreated, the disease may result in poor quality of life and complications, such as long-term joint damage, that may affect patients their entire lives.

METHODS

A case of a 23-year-old Filipino female presenting with persistent joint pain in both knees, ankles, wrists, and multiple fingers and toes since childhood was investigated. Bilateral eye pain and redness with associated headache, nausea, and vomiting, prompted consultation at the emergency room. Physical examination revealed deformity, erythema and swelling of multiple joints. Ophthalmologic exam revealed poor visual acuity of both eyes (20/100, both eyes). C-reactive protein was elevated, and rheumatoid factor (RF) was negative. The patient underwent glaucoma drainage device (Ahmed valve) insertion on both eyes and was treated on an out-patient basis with adalimumab, methotrexate, prednisone, folic acid, and prednisolone acetate eye drops.

CONCLUSION

JIA is a complicated disease which begins early in life and affects patients even in adulthood. These patients may suffer from arthritis with permanent joint deformities and uveitis, among other disabilities that make daily tasks impossible, impacting patients both mentally and socially.

Patients with psychiatric diagnoses have lower quality of life than other patients with juvenile rheumatic disease: a prospective study

Objectives

Transition of adolescents with chronic diseases from paediatric healthcare to adult care requires attention to maintain optimal treatment results. We examined changes in health-related quality of life (HRQoL) and disease activity among JIA patients with or without concomitant psychiatric diagnoses after transfer to an adult clinic.

Methods

We prospectively followed 106 consecutive patients who were transferred from the New Children’s Hospital to the Helsinki University Hospital Rheumatology outpatient clinic between April 2015 and August 2019 and who had at least one follow-up visit. HRQoL was measured using 15D, a generic instrument.

Results

The patients’ median age at transfer was 16 years and disease duration 4.0 years. Patients were followed for a median of 1.8 years. Disease activity and overall HRQoL remained stable, but distress (dimension 13 of 15D) increased during follow up (P=0.03). At baseline, patients with at least one psychiatric diagnosis had lower overall 15D scores [mean 0.89 (s.d. 0.14) vs 0.95 (s.d. 0.05), P <0.01] and higher disease activity [DAS28mean 1.88 (s.d. 0.66) vs 1.61 (s.d. 0.31), P = 0.01] than patients without psychiatric diagnoses. The difference in overall 15D persisted over the study period.

Conclusion

Transition-phase JIA patients with psychiatric diagnoses had lower HRQoL than other JIA patients. Despite reduced disease activity and pain, HRQoL of patients with psychiatric diagnoses remained suboptimal at the end of follow-up. Our results highlight the necessity of comprehensive care and support for transition-phase JIA patients.

Improving musculoskeletal health for children and young people - A 'call to action'

This chapter describes the musculoskeletal (MSK) context in children and young people as an important contributor to the global non-communicable disease burden. Through selected MSK conditions, we describe the impact on patients, families and communities and highlight the challenges that need to be addressed. We focus on opportunities for better working together and describe exemplar initiatives to raise awareness, workforce capacity building, models of care and research agendas to have a greater global context.

Comparison of Adults With Polyarticular Juvenile Idiopathic Arthritis to Adults With Rheumatoid Arthritis: A Cross-sectional Analysis of Clinical Features and Medication Use

BACKGROUND/OBJECTIVE

Many individuals with juvenile idiopathic arthritis (JIA) have persistent disease into adulthood. Polyarticular JIA (pJIA) is often mislabeled as rheumatoid arthritis (RA) in adult rheumatology clinics, and treatment for adult pJIA patients is not well defined. We aimed to describe clinical features and medication use in the adult pJIA population in relation to an RA control cohort.

METHODS

We performed a cross-sectional study of 45 adults with pJIA and 94 with RA seen from 2013 to 2017. Clinical characteristics including RA classification criteria were compared using χ and McNemar tests. Medication use was analyzed focusing on tumor necrosis factor inhibitor (TNFi) survival, and an accelerated failure-time model was developed for time to methotrexate initiation.

RESULTS

Polyarticular JIA patients were less likely to be rheumatoid factor or cyclic citrullinated peptide antibody positive; fewer than half of pJIA subjects met the RA 2010 American College of Rheumatology/European League Against Rheumatism Classification Criteria. Time from diagnosis to methotrexate initiation was associated with longer disease duration in both groups (p < 0.01). Current TNFi use was more prevalent in pJIA patients (49% vs. 18%, p < 0.01), and TNFi use, particularly for etanercept, was sustained longer with a median drug survival of 4.41 years compared with 0.70 years in RA patients (p < 0.01).

CONCLUSIONS

Although often considered together in adult rheumatology practice, adults with pJIA are distinct from patients with RA. Medication use markedly differed between the 2 populations with greater prevalence and duration of TNFi use in pJIA patients. Further study is needed to improve outcomes in this unique population.

Disease activity, treatment and long-term prognosis of adult juvenile idiopathic arthritis patients compared with rheumatoid arthritis patients

Objective: To evaluate the difference between adult juvenile idiopathic arthritis (JIA, starting at <16 years) and rheumatoid arthritis (RA).Methods: Data on 128 adult JIA patients were from the National Database of Rheumatic Diseases in Japan (NinJa), 2014, divided into 4 groups by period of disease onset (Group 1: 2000-2013, n = 32; Group 2: 1981-1999, n = 32; Group 3: 1966-1980, n = 31; Group 4: ∼1965, n = 33). Disease activity, treatment and long-term prognosis of adult JIA patients were compared with RA patients matched for sex- and disease duration in each era.Results: In Groups 1 and 2, adult JIA patients had significantly lower clinical disease activity indices (CDAI) (Group 1: adult JIA 1.5 [0.4-6.9]-vs-RA 5.3 [2.5-10.3], p = .001, Group 2: 2.6 [0.6-9.0]-vs-6.9 [3.5-11.0], p = .001, shown as median [quartile range], p-value, respectively), and had higher CDAI remission rates than RA patients (Group 1: 54.8%-vs-28.2%, p = .002, Group 2: 51.7%-vs-17.0%, p < .001). More adult JIA than RA patients in Group 1 used biologics (62.5%-vs-24.7%, p < .001). However, there were no adult JIA-vs-RA differences in joint destruction and physical function in any group.Conclusions: Adult rheumatologists must recognize that adult JIA patients are different from RA patients even when disease duration is the same.

Transition from child to adult care in an outpatient clinic for adolescents with juvenile idiopathic arthritis: An inductive qualitative study

AIM

The aim of this study was to investigate experiences and needs in the transition from child to adult care in an outpatient clinic from the perspective of adolescents with juvenile idiopathic arthritis and their parents focusing on which aspects in the transition could ease the process.

DESIGN

A qualitative design with an inductive approach.

METHODS

Inductive content analysis was used to analyse individual interviews with three parents and three adolescents from a rheumatology clinic in Denmark.

RESULTS

Three descriptive categories emerged: "Information during transition," "Personalized care" and "A change of roles." The comparative analysis of the categories revealed two explanatory themes: "To move from something known to something unknown" and "To develop and change." We found that preparation for transition, information of organisational and procedural changes when entering adult care, continuity and relationships with health professionals characterised by trust as well as involvement of adolescents and parents will ease the process of transition.

Transition to adult rheumatology care is necessary to maintain DMARD therapy in young people with juvenile idiopathic arthritis

OBJECTIVE

To evaluate the outpatient health service utilisation of young people (YP) with juvenile idiopathic arthritis (JIA) during transfer from paediatric to adult care in Germany.

METHODS

Based on claims data of a large German statutory health fund (BARMER GEK) we conducted a cohort study of 2008-2014. Insured YP with diagnosis of JIA (ICD: M08 or M09.0) in two quarters at the age of 16 and continuous insurance until the age of 20 were included. Outpatient health care utilisation, prescribed antirheumatic drugs and diagnosis maintenance were analysed over four consecutive years for all YP with JIA and for the subgroup on disease-modifying antirheumatic drugs (DMARDs) at the age of 16.

RESULTS

A total of 256 YP with JIA (67% female) were followed during the transfer period, 115 of them received (DMARDs) at the age of 16. At the age of 20, 30% of all 256 YP utilised adult specialty care, 59% still had a JIA diagnosis and 30% were treated with DMARDs. Of those 115 YP, treated with DMARDs at the age of 16 and in need of follow-up, 49% had visited an adult rheumatologist at the age of 20, 75% had a JIA diagnosis and 56% were on DMARDs. Those 49% YP with successful transfer to adult specialty care had a JIA diagnosis in 93% and were treated with DMARDs in 80%. YP, who were only seen by general practitioners, had a JIA diagnosis in 54% and received DMARDs in 27%.

CONCLUSIONS

One in two YP with JIA and a clear need for ongoing follow-up do not utilise adult rheumatologic care. The maintenance of JIA diagnosis and DMARD therapy depend on the utilisation of specialised care services.

Joint hypermobility and oligoarticular juvenile idiopathic arthritis: What relationship?

AIM

Oligoarticular onset juvenile idiopathic arthritis (oJIA) is characterised by a prevalent lower limb involvement, antinuclear antibodies (ANA) positivity and high risk of anterior uveitis. As we observed that oJIA patients frequently present with joint hypermobility (JH), we investigated whether there was a relationship between oJIA and JH.

METHODS

Our series consisted of children with oJIA, as defined by the International League of Associations for Rheumatology criteria, for whom complete clinical data of at least 2 years' duration were available. Clinical and laboratory data, collected at disease onset and at the last follow-up, included: sex, age, presence of JH according to the Beighton score, disease activity, presence of uveitis, ANA, treatment and outcome.

RESULTS

A total of 274 oligoarticular JIA patients (224 female, 50 male; mean age: 11.5) followed on average for 6.6 years, entered the study. The mean age at disease onset was 4.9 years, ANA were positive in 83.9% and uveitis occurred in 20.8%. JH was present in 70.8% of cases at onset, in 44.5% at the last evaluation. JH was more frequent in females (73.7%) than in males (58.0%) (P = 0.028). Uveitis was less frequent in hypermobile children both at diagnosis (17.5 vs. 28.7%, P = 0.037) and during overall disease course (23.7 vs. 36.3%, P = 0.034). Of 163 subjects with at least 5-year follow-up, the full clinical remission rate was significantly higher in JH patients (50.5%) than in those without JH (42.3%; P = 0.042).

CONCLUSION

In patients with oligoarticular JIA, JH is more frequent than in healthy subjects, uveitis less frequent and the long-term outcome better.

[Transition from pediatric to adult rheumatological care]

Childhood onset rheumatic and musculoskeletal diseases often continue into adulthood. These diseases are associated with a high risk of permanent disability and impairment in the quality of life of people affected. Adolescence and young adulthood represent a particular risk phase for an unfavorable long-term outcome. During this challenging and future health-determining phase at least one in three patients stops seeking regular specialized healthcare and the health status of these people deteriorates after having left pediatric care. The key principles of transitional care have been defined, are generally accepted and are presented in this article. There is emerging evidence of the effectiveness of transitional care programs. The implementation of a structured transition into the routine care of adolescents and young adults with rheumatic diseases is necessary.

Juvenile arthritis: current concepts in terminology, etiopathogenesis, diagnosis, and management

The latest change in terminology from juvenile rheumatoid arthritis (JRA) to juvenile idiopathic arthritis (JIA), established by the International League of Associations for Rheumatology (ILAR), has resulted in some confusion for OMFS and other treating clinicians. JIA comprises a group of systemic inflammatory diseases that result in the destruction of hard and soft tissues in a single or multiple joints. In a significant number of patients, one or both temporomandibular joints (TMJ) are also involved. TMJ disease may be accompanied by pain, swelling, and limitation of motion, as well as mandibular retrognathism, open bite, and asymmetry. The purpose of this article is to provide a review, for the oral and maxillofacial surgeon, of the terminology, etiopathogenesis, diagnosis, and management of children with JIA.

Looking through the patient lens - Improving best practice for young people with juvenile idiopathic arthritis transitioning into adult care

We describe a qualitative study to establish the emerging needs of young people with juvenile idiopathic arthritis (JIA) as they go through the transition process, identifying which elements are valued and where support gaps exist. Qualitative interviews with healthcare professionals, young people with JIA and their parents explored the lived experience of transition to care in an adult rheumatology clinic. Perspectives of the experience and reflections of the process of transitioning were captured along with the young people's views of optimal support. Service provision in the clinical environment varied. Service design for this particular patient group has an impact on how young people optimise management of, and engagement with, their condition during young adulthood. Two specific themes emerged that had the greatest impact on defining a positive user experience of transitioning care: tailored service provision within the clinical environment and support for those living with JIA beyond the clinic doors (we have termed these the lived experience). Factors of importance to young people with JIA were grouped into key domains, namely: day-to-day life with JIA, emotional and developmental factors and a desire for independence. The young people and healthcare professionals interviewed in this small qualitative study highlighted some common themes considered critical in the development and organisation of an excellent care pathway from paediatric to adult healthcare. Aligning the clinical process with young people's individual needs and lifestyle creates stronger beginnings in adult care.