Update on Canadian Rheumatology Association guidelines for JIA-associated uveitis

The occurrence of asymptomatic anterior uveitis in children with juvenile idiopathic arthritis
(JIA) is around 20% with morbidity including permanent vision loss. Appropriate screening,
detection, and treatment of ocular inflammation are vital for preventing further
complications. Now, a group of Canadian researchers have put forth the recommendations for
the management of JIA-associated uveitis based on the Grading of Recommendations
Assessment, Development, and Evaluation (GRADE)-ADOLOPMENT framework. The
recommendations have been published in the recent issue of Pediatric Rheumatology.

The expert panel comprising rheumatologists and ophthalmologists in the management of
uveitis, methodologists, and caregivers has reviewed recent American College of
Rheumatology (ACR)/Arthritis Foundation (AF) recommendations. They developed
evidence-to-decision tables and finalized the adaptation of 5 recommendations, removal of 2
recommendations, and development of 1 de novo. They also discussed controversial topics
such as the timing of eye examination, screening frequency, utilization of systemic and
biologic therapy, and nonbiologic therapy.

The revised recommendations include the need for ophthalmic screening every 3 months in
JIA patients with a high risk of developing chronic anterior uveitis. The experts
recommended the addition of systemic therapy to taper glucocorticoids in patients who
receive prednisolone acetate. There are recommendations for the revision of systemic
therapy, and the use of methotrexate as a first-line disease-modifying anti-rheumatic drug and
dual therapy over methotrexate monotherapy. For patients who have limited response to
tumor necrosis factor inhibitors, standard JIA dosing is recommended over switching to
another monoclonal antibody.

The 2019 ACR/AF recommendation developed by Angeles-Han and co-researchers has also
used the GRADE framework to develop guidelines for treating JIA-associated uveitis. In
addition to regular ophthalmic screening, the guidelines were focused on the use of topical
glucocorticoids, methotrexate, and monoclonal antibody tumor necrosis factor inhibitors for
controlling inflammation and managing uveitis. In JIA patients with a higher risk of vision
loss, experts recommended the adoption of uveitis control using biologic and nonbiologic

The updated Canadian Rheumatology Association guidelines fill the gap in the guidance on
JIA-associated uveitis management to ensure equitable access and transparency in clinical

1. Berard R, Ng HY, Human A, Piskin D, Dhalla M, Gottlieb C, et al. Canadian
Rheumatology Association Recommendations for the Screening, Monitoring, and
Treatment of Juvenile Idiopathic Arthritis-Associated Uveitis. The Journal of
Rheumatology. 2023 Mar 1;50(3):390–9.
2. Angeles-Han ST, Ringold S, Beukelman T, Lovell D, Cuello CA, Becker ML, et al. 2019
American College of Rheumatology/Arthritis Foundation Guideline for the Screening,
Monitoring, and Treatment of Juvenile Idiopathic Arthritis-Associated Uveitis. Arthritis
Care Res (Hoboken). 2019 Jun;71(6):703–16.