ORADE Report – Michelle Batthish, ACR 2018, Chicago
Thank you to the ORA for providing me with the funding to attend the 2018 American College of Rheumatology Annual Meeting in Chicago, Illinois. The meeting had a number of educational sessions that provided me with the opportunity to review and discuss the latest clinical treatments and scientific research relevant to the field of pediatric rheumatology, especially Juvenile Idiopathic Arthritis (JIA).
Treatment recommendations for JIA
In this session, the recent ACR update and expansion of the Recommendations for the Treatment of JIA were presented by Dr. Beukelman (University of Alabama at Birmingham). The updated guidelines focused on newly approved treatments for polyarthritis as well as an increased emphasis on sacroiliitis and enthesitis. For example, in patients with moderate or high disease activity after the first TNF inhibitor, a switch to a non-TNF inhibitor biologic is conditionally recommended over a switch to a second TNF inhibitor. Furthermore, for active sacroiliitis despite NSAID therapy, TNF inhibitor therapy is strongly recommended over NSAID monotherapy and methotrexate monotherapy is strongly recommended against. It is worth noting that most of these recommendations were conditional and had a low quality of supporting evidence. Higher quality evidence and a greater understanding of patients’ preferences are needed to optimize treatment outcomes in JIA.
Biologic classification of JIA
Drs. Yeung (The Hospital for Sick Children, University of Toronto) and Nigrovic (Brigham and Women’s Hospital, Harvard Medical School) reviewed novel concepts in the classification of JIA. Computer modeling of large clinical and biological data sets can help with pattern recognition in childhood arthritis, redefining JIA subtypes into five new cohorts that only partially overlap with ILAR subtypes. Using genetic, demographic and clinical features may be also be able to define different patient clusters, some of which overlap significantly with adult RA groups. Pediatric and adult arthritis represents a continuum that should not be divided by an arbitrary age cutoff and genetic data will be important to redefine disease categorization.
Ultrasound vs MRI in JIA
The rationale for the use of ultrasound and MRI in the assessment and implementation of a treat to target (T2T) approach for JIA were hotly debated in this session, given by Drs. Roth (Children’s Hospital of Eastern Ontario, University of Ottawa) and Malattia (Instituto Giannina Gaslini, University of Genoa). Ultrasound can be an important measurement tool in T2T and can help to determine subclinical disease activity for most joints. However, it is not sufficient for all joints and has to be embedded in the overall clinical assessment. More longitudinal studies and definitions of disease activity are needed. On the other hand, MRI is valuable in early diagnosis, monitoring and prognosis but feasibility and access is a challenge with MRI. The use of any imaging modality in a T2T context will need to be better defined so that either ultrasound or MRI can be integrated into the clinical workflow.