Sheila T Angeles-Han1, Sarah Ringold2, Timothy Beukelman3, Daniel Lovell1, Carlos A Cuello4, Mara L Becker5, Robert A Colbert6, Brian M Feldman7, Gary N Holland8, Polly J Ferguson9, Harry Gewanter10, Jaime Guzman11, Jennifer Horonjeff12, Peter A Nigrovic13, Michael J Ombrello6, Murray H Passo14, Matthew L Stoll3, C Egla Rabinovich15, H Nida Sen16, Rayfel Schneider7, Olha Halyabar17, Kimberly Hays14, Amit Aakash Shah18, Nancy Sullivan19, Ann Marie Szymanski6, Marat Turgunbaev18, Amy Turner18, James Reston19. 1. Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio. 2. Seattle Children's Hospital, Seattle, Washington. 3. University of Alabama, Birmingham. 4. McMaster University, Hamilton, Ontario, Canada. 5. Children's Mercy Hospital, Kansas City, Missouri. 6. National Institutes of Health, Bethesda, Maryland. 7. The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada. 8. UCLA Stein Eye Institute, David Geffen School of Medicine at UCLA, Los Angeles, California. 9. University of Iowa Carver College of Medicine, Iowa City. 10. Children's Hospital of Richmond, Virginia Commonwealth University, Richmond. 11. BC Children's Hospital, Vancouver, British Columbia, Canada. 12. Columbia University Medical Center, New York, New York. 13. Brigham & Women's Hospital and Boston Children's Hospital, Boston, Massachusetts. 14. Medical University of South Carolina, Charleston. 15. Duke University, Durham, North Carolina. 16. National Eye Institute, National Institutes of Health, Bethesda, Maryland. 17. Boston Children's Hospital, Boston, Massachusetts. 18. American College of Rheumatology, Atlanta, Georgia. 19. ECRI Institute, Plymouth Meeting, Pennsylvania.
Abstract
OBJECTIVE: To develop recommendations for the screening, monitoring, and treatment of uveitis in children with juvenile idiopathic arthritis (JIA). METHODS: Pediatric rheumatologists, ophthalmologists with expertise in uveitis, patient representatives, and methodologists generated key clinical questions to be addressed by this guideline. This was followed by a systematic literature review and rating of the available evidence according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. A group consensus process was used to compose the final recommendations and grade their strength as conditional or strong. RESULTS: Due to a lack of literature with good quality of evidence, recommendations were formulated on the basis of available evidence and a consensus expert opinion. Regular ophthalmic screening of children with JIA is recommended because of the risk of uveitis, and the frequency of screening should be based on individual risk factors. Regular ophthalmic monitoring of children with uveitis is recommended, and intervals should be based on ocular examination findings and treatment regimen. Ophthalmic monitoring recommendations were strong primarily because of concerns of vision-threatening complications of uveitis with infrequent monitoring. Topical glucocorticoids should be used as initial treatment to achieve control of inflammation. Methotrexate and the monoclonal antibody tumor necrosis factor inhibitors adalimumab and infliximab are recommended when systemic treatment is needed for the management of uveitis. The timely addition of nonbiologic and biologic drugs is recommended to maintain uveitis control in children who are at continued risk of vision loss. CONCLUSION: This guideline provides direction for clinicians and patients/parents making decisions on the screening, monitoring, and management of children with JIA and uveitis, using GRADE methodology and informed by a consensus process with input from rheumatology and ophthalmology experts, current literature, and patient/parent preferences and values.
OBJECTIVE: To develop recommendations for the screening, monitoring, and treatment of uveitis in children with juvenile idiopathic arthritis (JIA). METHODS: Pediatric rheumatologists, ophthalmologists with expertise in uveitis, patient representatives, and methodologists generated key clinical questions to be addressed by this guideline. This was followed by a systematic literature review and rating of the available evidence according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. A group consensus process was used to compose the final recommendations and grade their strength as conditional or strong. RESULTS: Due to a lack of literature with good quality of evidence, recommendations were formulated on the basis of available evidence and a consensus expert opinion. Regular ophthalmic screening of children with JIA is recommended because of the risk of uveitis, and the frequency of screening should be based on individual risk factors. Regular ophthalmic monitoring of children with uveitis is recommended, and intervals should be based on ocular examination findings and treatment regimen. Ophthalmic monitoring recommendations were strong primarily because of concerns of vision-threatening complications of uveitis with infrequent monitoring. Topical glucocorticoids should be used as initial treatment to achieve control of inflammation. Methotrexate and the monoclonal antibody tumor necrosis factor inhibitors adalimumab and infliximab are recommended when systemic treatment is needed for the management of uveitis. The timely addition of nonbiologic and biologic drugs is recommended to maintain uveitis control in children who are at continued risk of vision loss. CONCLUSION: This guideline provides direction for clinicians and patients/parents making decisions on the screening, monitoring, and management of children with JIA and uveitis, using GRADE methodology and informed by a consensus process with input from rheumatology and ophthalmology experts, current literature, and patient/parent preferences and values.
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