2025 PANLAR Recommendations: Treatment of Polyarticular Juvenile Idiopathic Arthritis (pJIA)

Source: Pan‑American League of Associations for Rheumatology (PANLAR), Reumatología Clínica, 2025. Panel: Latin‑American paediatric rheumatology experts. GRADE methodology; Delphi voting; context for limited‑resource settings across Latin‑AmericaPMC. Population: RF‑positive / RF‑negative polyarticular JIA, children ≤ 16 years old, arthritis ≥ 5 joints. 4 overarching principles, 11 formal recommendations; treat‑to‑target (T2T) framework. ⚠️ For academic note‑taking only; not substitute for original article.

Keywords: polyarticular juvenile idiopathic arthritis; PANLAR; treat‑to‑target; biologic DMARD; resource‑limited setting

Overarching Principles

1. Treat‑to‑target goal: primary target is inactive disease; if unattainable, accept low‑disease‑activity (LDA). Use validated tools: JADAS‑10 / cJADAS‑10 for assessment. Evaluation every 4‑8 weeks during active disease.
2. Minimise glucocorticoid exposure; avoid long‑term systemic steroids. Prioritise steroid‑sparing agents, intra‑articular corticosteroid injections.
3. Care must adapt to local drug accessibility, affordability, and regional infection risks (TB, hepatitis B, endemic infections).
4. Multidisciplinary care: paediatric rheumatology, ophthalmology (uveitis screening), physiotherapy‑rehabilitation, mental‑health support; shared decision‑making with caregivers and patients.

Baseline Assessment

• Clinical: joint count, functional status, growth and pubertal development.
• Laboratory: CBC, ESR, CRP, LFT, RF, anti‑CCP, ANA.
• Screening: slit‑lamp ophthalmology screening for uveitis (especially ANA‑positive patients).
• Imaging: joint ultrasound preferred for synovitis; radiographs for structural damage.
• Infection screening prior to biologic initiation: TB, HBV, HCV, endemic regional infections.

11 Formal Recommendations

Rec 1. NSAIDs

NSAIDs may be used for symptomatic pain/inflammation control. NSAIDs alone cannot prevent joint damage; never use as monotherapy for polyarticular JIA. Do not combine two NSAIDs. Gastro‑protection for high‑risk children.

Rec 2. Initial csDMARD therapy

Methotrexate (MTX) is first‑line csDMARD for all pJIA. Start early after diagnosis, weight‑based dosing, folate supplementation.

• Leflunomide is an alternative for MTX intolerance.
• Sulfasalazine is secondary option; limited efficacy for polyarticular involvement.

Triple csDMARD combination is not preferred over MTX monotherapy as initial treatment.

Rec 3. Glucocorticoids

• Short‑course low‑dose systemic glucocorticoids may be used only as temporary bridge therapy.
• Goal: discontinue systemic glucocorticoids as soon as feasible.
• Intra‑articular steroid injections are strongly recommended for persistent mono‑/oligo‑joint synovitis, to avoid raising systemic immunosuppression.

Rec 4. Patients with moderate‑high activity despite adequate MTX (≥3 months)

Add a bDMARD to ongoing MTX, rather than switching to a second csDMARD. Preferred options:

1. TNF‑α inhibitors (etanercept, adalimumab) – best accessibility across Latin‑America.
2. Abatacept or tocilizumab as alternatives.

JAK‑inhibitors (tsDMARD): conditional recommendation, for cases failing ≥1 bDMARD; consider safety profile, cardiovascular risk, and local regulatory status.

Rec 5. RF‑positive polyarticular JIA

RF‑positive phenotype carries higher risk of structural joint damage. If moderate‑high activity under MTX: early bDMARD addition is favoured, do not delay escalation.

Rec 6. Uveitis‑associated pJIA

For patients with confirmed uveitis: prefer TNF‑α inhibitors (adalimumab); coordinate management with paediatric ophthalmology.

Rec 7. Treatment in resource‑limited settings

If bDMARDs are unavailable/unaffordable: optimise MTX dose; intra‑articular steroids; consider leflunomide. When biologics become accessible, do not withhold them from high‑risk patients.

Rec 8. Monitoring during therapy

• Active phase: every 4‑8 weeks: JADAS, clinical joint assessment, safety labs.
• Inactive disease: follow‑up every 3‑6 months; periodic slit‑lamp surveillance.
• For biologics: monitor for infection signs; TB surveillance.

Rec 9. Reaching inactive disease: maintenance strategy

Once sustained inactive disease ≥ 6‑12 months: maintain therapy. Tapering may be considered gradually. Do not rapid abrupt discontinuation, risk of flare. MTX usually continues before tapering biologic.

Rec 10. Disease flare

Upon flare: reassess adherence, rule‑out infection. Escalate therapy according to baseline activity; return to prior effective regimen. Re‑evaluate target.

Rec 11. Non‑pharmacological management

Physiotherapy‑occupational therapy for joint mobility, muscle strength. Psychosocial support, vaccination update (complete live vaccines before starting biologics). Growth and bone‑health surveillance; vitamin D and calcium supplementation.

Distinction vs PRES / CARRA 2025 JDM‑T2T & ACR JIA guidelines

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Disclaimer: summary derived from PANLAR consensus framework. Clinical decisions must reference full original publication.