New JIA Guideline Draft Emphasize Earlier, Aggressive Therapy, With Susan Shenoi, MD, MS

The American College of Rheumatology (ACR)'s new juvenile idiopathic arthritis (JIA) draft guidelines represents a meaningful shift in how pediatric rheumatologists should approach treatment — moving decisively toward combination biologic therapy early in the disease course, away from NSAIDs as initial monotherapy, and incorporating new evidence in uveitis management that has accumulated since the last iteration.

Rheumatology Live spoke with Susan Shenoi, MD, MS, Professor at the University of Washington and Clinical Director of the Pediatric Rheumatology Division at Seattle Children's Hospital and Research Center in Seattle, at the 2026 Rheumatology Winter Clinical Symposium, held in Maui, Hawaii, on February 11–14, where she gave a talk centering on the new guidelines.

Shenoi, alongside Karen Onel, MD, Daniel Horton, MD, MS, Sheila Angeles-Han, MD, MSc, and Rich Vehe, MD, served as a core member of the guideline development committee. The updated guidelines have grown substantially in scope — systemic JIA recommendations expanded from nine in 2021 to 15 in 2025, while non-systemic JIA now carries more than 50 recommendations, with over half representing new directions — reflecting both the rapid accumulation of trial data and increasing recognition of disease heterogeneity across JIA subtypes.

The central theme running through the update is the primacy of early, effective intervention. Data from CARRA studies, the STOP-JIA study, and European JAKI trials have reinforced that the window of opportunity for disease control is real and consequential — and the guidelines now reflect that by strongly recommending IL-1 or IL-6 inhibitors as initial therapy for systemic JIA patients without macrophage activation syndrome, while explicitly recommending against NSAIDs as initial monotherapy. For systemic JIA with MAS — which remains a life-threatening complication — IL-1 or IL-6 inhibitors are similarly strongly recommended, with emapalumab available as an additional option for Still's disease–associated MAS. For non-systemic JIA, TNF inhibitors are conditionally recommended as first-line biologics across polyarthritis, oligoarthritis, and TMJ arthritis, with JAK inhibitors held back from first-line use due to limited safety data.

In uveitis, the guidelines now conditionally recommend against intraocular and periocular glucocorticoids in children, push for early combination therapy with methotrexate plus TNF agents without a waiting period before systemic treatment initiation, and conditionally recommend above-standard dosing of TNF inhibitors — a notable shift supported by several randomized controlled trials that have emerged since 2019. On deprescribing, the guidelines strongly recommend tapering rather than abrupt cessation for patients achieving clinical inactive disease, and CARRA JIA registry data indicate approximately 70% of systemic JIA patients recapture disease control after flaring from medication discontinuation.

In this conversation, Shenoi stressed that earlier guideline-concordant treatment depends on earlier referral — noting that recognition of pediatric rheumatic disease remains inadequate among primary care providers, and that directing the right patients to specialists promptly is as critical to outcomes as any treatment decision made in the rheumatology clinic.

“We have a few randomized control trials now, since the last iteration of the guidelines, which was 2019, and there's a bigger push to start again, combination therapy, early biologic therapy, and use them at adequate doses, which in uveitis tends to be higher than standard doses,” Shenoi said.

Shenoi’s related disclosures include Novartis.

References

1. Shenoi S. Evidence based medicine: New developments in Pediatrics for adult rheumatologists. Presented at: RWCS 2026, held February 11-14 in Maui, Hawaii.

2. Panelists Explain ACR’s Expanding JIA Guidelines. News release. ACR. November 14, 2025. https://www.acrconvergencetoday.org/panelists-explain-acrs-expanding-jia-guidelines/