Screening, Monitoring, and Treatment of Juvenile Idiopathic Arthritis Associated Uveitis in the Canadian Context: Adolopment of the American College of Rheumatology/Arthritis Foundation Guidelines

Authors: Chloe Gottlieb, Roberta Berard, David Piskin, Honyan Ng, Jordi Pardo, Glen Hazlewood, Deborah Levy.

Abstract Title:

Screening, Monitoring, and Treatment of Juvenile Idiopathic Arthritis Associated Uveitis in the Canadian Context: Adolopment of the American College of Rheumatology/Arthritis Foundation Guidelines

Abstract Body:

Purpose: In 2019, the ACR/AF published guidelines for the screening, monitoring and treatment of JIA-associated uveitis.  JIA-associated uveitis has significant morbidity; thus it is important to have Canadian guidelines for rheumatologists and ophthalmologists.  The ACR/AF guidelines used GRADE methodology; therefore, we used the adolopment method to consider Canadian contextual differences, including differences in patients’ preferences, cost/resource considerations, and feasibility of implementation.  This work represents the first CRA guideline to apply this method which combines adoption, adaptation and, as needed, de novo development of recommendations.

Study Design: Systematic literature review, development of evidence-to-decision tables (EtDs) and recommendations considered using a table of equity filters.

Methods: A working group was assembled, an updated systematic literature review performed (Oct 13, 2017 to Feb 6, 2020) and summary tables were produced.  Members reviewed two ACR/AF recommendations, working in pairs to develop EtDs tables.  Recommendations and EtDs were circulated and a detailed survey distributed to assess agreement and issues requiring group discussion.  A virtual meeting was held in August 2020. EtDs with candidate recommendations were presented, discussed and voted upon to produce the final set of recommendations. Each recommendation was considered using a table of equity filters developed by the CRA Quality Care Committee that included indigenous, rural/remote, refugee and low socioeconomic status.

Results: The working group comprised 20 physicians from across Canada (14 pediatric rheumatologists, 6 ophthalmologists with expertise in pediatric uveitis) along with 2 advisors from the CRA Guidelines Committee and Cochrane MSK group and 2 parent/patient representatives.  All 19 ACR/AF recommendations for JIA-associated uveitis care encompassing screening (4) glucocorticoid use (4) DMARD and biologic use (4), education (2) and tapering of therapy (2) were reviewed. Following the survey, a virtual meeting was held to review the process, health equity considerations, and discuss in depth 6 of the 19 recommendations that required significant revision. In addition to 15/20 working group members, patient/parent representatives and facilitators attended the meeting to discuss Canadian-specific (and potentially controversial) topics including the frequency of ophthalmic screening and by whom performed, initial use of biologics, use of subcutaneous versus oral methotrexate, and role of alternative biologic and non-biologic therapies for patients failing methotrexate and anti-TNF therapies. Equity issues related to access to advanced therapeutics across provinces and territories were highlighted.

Conclusions: We applied a novel epidemiologic method to efficiently evaluate and modify the ACR/AF guidelines for JIA-associated uveitis to be applicable in the Canadian context with a lens for cost, equity and access.