The ACR guidelines gave no specific recommendations on the use of these live vaccines but did recommended holding methotrexate for two weeks after flu vaccine to increase immunogenicity if possible.
Although she didn’t have time to cover them in detail, Dr. Ardoin also encouraged the audience to take a look at new practice guidelines pertaining to HLH/MAS, uveitis and quality measures in patients with JIA.6–8
Systemic JIA & Lung Disease
Dr. Ardoin turned next to systemic JIA and interstitial lung disease (ILD), noting, “Several publications this year added to our understanding of this very concerning complication.” Perhaps most useful was the development of a screening algorithm for lung disease in systemic JIA by investigators at Boston Children’s Hospital.9 If any of nine red flag features (e.g., eosinophilia or clubbing) are present, consider referral to pulmonary clinic and complete pulmonary function tests (spirometry, lung volumes, diffusing capacity and six-minute walk testing). Red flag features increase the risk of developing ILD.
Mental Health
Dr. Ardoin took care to mention two studies demonstrating the increased risk of mental health disorders in patients with JIA.10,11 “As you all know, we’ve had robust literature that has told us about the impact of mental health on people with lupus, but not as much in JIA,” she said. “I think these studies really demonstrate that we need more studies to make sure JIA patients are adequately cared for, too.”
Natural History
On a more upbeat note, comparison of two JIA inception cohorts (2005 to 2010, and 2017 to 2021) showed that we’re on the right track when it comes to treatment.12 “These data show that over 16 years, we have had significant improvements in the outcomes of our patients with the use of conventional and biologic disease modifying anti-rheumatic drugs.” The usage of these drugs increased, as did the amount of patients with minimally active or inactive JIA.
Musculoskeletal Ultrasound
Although she lacked time to go into detail, Dr. Ardoin gave a shoutout to colleagues focused on musculoskeletal ultrasound research. “They are really working diligently to develop protocols, a scoring system and an evidence base that will allow us to use this tool in the future to better characterize our patients,” she said. “There is also the potential to use musculoskeletal ultrasound findings as outcome measures in clinical trials.”13–15
Workforce Shortage & Access to Care
Dr. Ardoin closed with a study that confirms something that any rheumatologist, be it pediatric or adult, knows: not all rheumatology referrals are created equal. At a large pediatric referral center, only 23% of 2,638 new patient referrals were diagnosed with rheumatic disease, and of the positive anti-nuclear antibody (ANA) referrals, only 7% had rheumatic disease.16 “This information probably doesn’t come as a surprise,” Dr. Ardoin said. “In a time when we are facing a significant workforce shortage, data like these suggest that efforts to reduce unnecessary referrals by educating referring providers may help us increase access.”
