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Consensus Guidelines for Methotrexate in Juvenile Idiopathic Arthritis

A consensus panel was convened to develop consensus-based clinical and therapeutic recommendations for the use of methotrexate (MTX) in the management of Juvenile Idiopathic Arthritis (JIA) patients.  

The panel identified a total of 9 key clinical issues, and selected topics considered to represent clinically important issues facing clinicians caring for patients with JIA. They performed evidence-based, systematic, literature reviews to come up with a final 10 recommendations. 

The recommendations included the following (see paper for explanation and literature references): 

  1. MTX is recommended as the first-line treatment in oligoarthritis that persists despite nonsteroidal anti-inflammatory drugs (NSAIDs) and intraarticular steroid (IAS) therapy, and in polyarticular disease. MTX is also recommended in systemic arthritis with predominant joint inflammation, without active systemic features.
  2. Clinical and laboratory monitoring of MTX toxicity is recommended every 4-8 weeks initially, and then every 12-16 weeks, unless risk factors are present.
  3. The dose of methotrexate in juvenile idiopathic arthritis: 10-15 mg/m2/week is recommended.  Further increases in MTX dosage have not been associated with additional therapeutic benefit.
  4. MTX may be given orally or subcutaneously once a week. If high doses (15 mg/m2/week) are requested, the subcutaneous route is preferable due to increased bioavailability.
  5. Regarding tapering and discontinuation of methotrexate in juvenile idiopathic arthritis -MTX could be discontinued after 6 months of stable remission.
  6. Folic or folinic acid supplementation is recommended to prevent MTX side effects. The advised dose is approximately one third of the MTX dose, at least 24 hours after the weekly dose of MTX for folinic acid; for folic acid 1 mg/day skipping the day when MTX is administered.
  7. MTX is recommended for the treatment of JIA-related uveitis refractory to topical treatment.
  8. The combination of MTX with a TNF-α inhibitor is recommended in patients who had an inadequate clinical response to MTX alone.
  9. No recommendation is made regarding the use of biomarkers in current clinical practice.
  10. Vaccination with non-live vaccines is not contraindicated during MTX treatment.

These consensus recommendations provide balanced and evidence-based recommendations designed to have broad value for physicians and healthcare clinicians involved in the clinical management of patients with JIA.

Disclosures: 
The author has no conflicts of interest to disclose related to this subject

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