Monitoring

The American College of Rheumatology (ACR) recommends infection surveillance of tuberculosis (TB) screening prior to starting a biological therapy and when there is a concern for TB exposure. Exposure is broad and includes contact with someone with active TB, travel to locations where TB is endemic, contact with high-risk individuals (e.g., prisoners, visitors from TB-endemic areas), or living in communities with a higher frequency of TB. However, in an urgent clinical scenario (i.e., in active systemic JIA and macrophage activation syndrome), it would be appropriate to initiate treatment without delay.[70]

Patients are usually actively managed by paediatric rheumatologists until their disease achieves remission. Once in remission, they can be followed up by their primary care providers.

Diet should be optimised and where necessary, a calcium and vitamin D supplement should be used, particularly if patients are on long-term corticosteroids.[126]

Full blood count (FBC), serum creatinine, and liver enzymes should be checked every 3 to 4 months during treatment with methotrexate.[70] Elevation of aspartate aminotransferase or alanine aminotransferase above 2 times the upper limit justifies temporary suspension of methotrexate, which can be re-started following normalisation of serum liver enzyme levels.[59]

Ultrasound and MRIs are useful to monitor activity in joints that are clinically difficult to assess in the early stages (temporomandibular joints, subtalar joints, hips). Subtle growth abnormalities can occur insidiously over time, so it is important to monitor for leg length discrepancy, scoliosis, and temporomandibular joint asymmetry.

Regular ophthalmic examinations for signs of anterior uveitis are essential. The ACR recommends screening every 3 months for children at high risk of uveitis, and screening every 6 to 12 months for children at lower risk.[123] High-risk features are oligoarticular JIA, rheumatoid factor-negative polyarticular JIA, psoriatic arthritis, undifferentiated arthritis with positive antinuclear antibodies, age younger than 7 years at JIA onset, and duration of JIA 4 years or less.[123]

The British Society for Paediatric and Adolescent Rheumatology guidelines state initial screening must be within 6 weeks of diagnosis, and for those most at risk every 2 months thereafter for 6 months. When patients go into remission and stop immunosuppressive treatment, screening should be re-started at 2-monthly intervals for 6 months before reverting to previous screening arrangements.[57]

The ACR recommends baseline laboratory testing prior to treatment initiation, for all medications.[70] This should include FBC with differential cell count and liver function tests (e.g., alanine aminotransferase and aspartate aminotransferase), plus renal function tests (e.g., urea, creatinine, and urinalysis) for patients being treated with methotrexate, sulfasalazine, or non-steroidal anti-inflammatory drugs (NSAIDs) and lipid profiles for patients being treated with tocilizumab and tofacitinib. It provides recommendations for regular laboratory monitoring to detect medication toxicity, and the risk of adverse events pertaining to specific medications or medication classes. If a child is receiving >1 medication, a more frequent schedule for laboratory testing is recommended.[70]

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