What are the current first-line treatment options for managing JIA in primary care?

First-line treatment options for managing juvenile idiopathic arthritis (JIA) in primary care primarily involve symptom control and supportive care, as initiation of disease-modifying treatments is typically managed by specialists.

In primary care, initial management includes the use of non-steroidal anti-inflammatory drugs (NSAIDs) at the lowest effective dose for the shortest possible duration to control pain and inflammation. Oral NSAIDs such as ibuprofen or naproxen may be used, considering the patient's risk factors and monitoring requirements.

Glucocorticoids may be used as short-term bridging therapy to rapidly reduce inflammation during flares, either via intra-articular injections if expertise is available, intramuscular injections, or a short reducing course of oral steroids while awaiting specialist assessment.

Conventional disease-modifying anti-rheumatic drugs (cDMARDs) such as methotrexate, sulfasalazine, or leflunomide are the mainstay of first-line pharmacological treatment but are usually initiated and monitored by rheumatology specialists rather than in primary care.

Primary care's role includes supporting the patient with symptom management, monitoring for adverse effects, ensuring vaccinations are up to date, and facilitating rapid referral to specialist care for diagnosis, initiation of DMARDs, and management of flares or complications.

Therefore, the first-line treatment in primary care focuses on NSAIDs and short-term glucocorticoids for symptom relief, with cDMARDs started and overseen by specialists under shared care agreements.

This approach aligns with the management principles for inflammatory arthritis in children, extrapolated from adult rheumatoid arthritis guidelines and spondyloarthritis management, as specific UK guidelines for JIA pharmacological treatment initiation are specialist-led.

Summary:

• NSAIDs for symptom control at lowest effective dose and shortest duration.
• Short-term glucocorticoids (intra-articular, intramuscular, or oral) for flares.
• Referral to and shared care with specialists for initiation and monitoring of cDMARDs like methotrexate.

These recommendations are consistent with the UK NICE and CKS guidance on inflammatory arthritis management, emphasising specialist initiation of DMARDs and primary care's role in symptom control and monitoring ¹,²,³,⁴.