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Juveniele idiopathische artritis (JIA)

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Startpagina - Juveniele idiopatische artritis (JIA)

Beoordeeld: 11-04-2018

Waar gaat deze richtlijn over?

De behandeling van de patiënt met juveniele idiopathische artritis (JIA) is multidisciplinair en gericht op het volledig onderdrukken van ziekteactiviteit met behoud van de normale groei en ontwikkeling van het kind. Hoewel paramedische behandeling en psychosociale ondersteuning essentieel zijn bij de behandeling van kinderen met JIA valt een systematisch overzicht van indicaties en uitvoeringswijze van deze behandelingen buiten het focus van de richtlijn. In deze richtlijn worden de verschillende medicamenteuze behandelstrategieën voor JIA uitgewerkt.

In geval van JIA en bijkomende uveitis wordt verwezen naar de Richtlijn Uveitis  (www.oogheelkunde.org/richtlijn/uveitis)

 

1. Medicamenteuze therapie bij JIA. Aanbevelingen betreft:

  • Effectiviteit en veiligheid van corticosteroïden (intra-articulair en systemisch) en conventionele systemische DMARDS (csDMARDs) bij JIA
  • Effectiviteit en veiligheid van biologische DMARDs (bDMARDS) bij JIA
  • Stroomdiagrammen JIA behandeling en startindicatie DMARDs bij verschillende categorieën van JIA. De behandeling van JIA is complex door de heterogeniteit van de ziekte. Voor de huidige Nederlandse richtlijn heeft de werkgroep schematische overzichten (stroomdiagrammen) voor de behandeling van JIA opgesteld welke worden toegelicht.
  • Leidraad doseringen medicatie bij behandeling JIA, met vermelding van dosering per gewicht, toedieningsvormen en meest voorkomende bijwerkingen 
  • Wanneer en met welke afbouwstrategie is er de minste kans op flare van ziekteactiviteit bij JIA
  • Effectiviteit en veiligheid van methotrexaat bij JIA sacroiliïtis
  • Effectiviteit en veiligheid van maagbescherming (protonpompremmers) bij gebruik van NSAIDs en/ of systemische glucocorticoïden en effectiviteit en veiligheid Coxibs (celecoxib, etoricoxib) bij JIA
  • Effectiviteit en veiligheid van specifieke medicatie bij JIA: startdosering csDMARDs, hydroxychloroquine, biosimilars, combinatie therapie van csDMARDs

 

2. Complicaties van de therapie. Aanbevelingen betreft:

  • Screening voor starten en monitoring bij behandeling met DMARDs: DMARDs onderdrukken (delen van) het eigen immuunsysteem. Daardoor kunnen infecties ernstiger verlopen, verminderde symptomen geven, en ook kunnen opportunistische infecties de kans krijgen zich te manifesteren in kinderen met JIA die behandeld worden met deze middelen. Daarnaast kunnen ernstige bijwerkingen optreden zoals beenmergdepressie en hepatotoxiciteit.
  • Vaccinaties bij kinderen met JIA en gebruik DMARDs: Door de effecten van DMARDs op het immuunsysteem kan ook verandering optreden in de respons op vaccinaties.
  • Beleid rondom operaties t.a.v. het voortzetten/ stoppen van NSAIDs en DMARDs: Door de effecten van DMARDs op het immuunsysteem kan dit ook consequenties hebben voor operaties en het postoperatieve beloop. Er zal daarbij een afweging gemaakt moeten worden t.a.v. het opvlammen van de ziekte met een mogelijk ongunstig effect op herstel en het risico op postoperatieve infecties.
  • Beleid rondom antistofvorming (ADA) bij gebruik bDMARDs: Bij het gebruik van biologicals (bDMARDs) kan antistofvorming (anti-drug-antibodies: ADA) optreden waardoor de het effect van het geneesmiddel kan worden geneutraliseerd. Van sommige biologicals kan een spiegel / titer van antistoffen worden bepaald.
  • Beleid rondom MTX-intolerantie. Methotrexaat (MTX) is een effectief middel voor het verminderen van ontstekingsactiviteit bij JIA. Bij een deel van de patiënten gaat het gebruik van MTX gepaard met (hevige) bijwerkingen en kunnen patiënten een MTX-intolerantie ontwikkelen.

 

3. Organisatie van zorg. Aanbevelingen:

Aandachtpunten Eerste Lijn: Een goede communicatie tussen de behandelaren van de patiënten met JIA en de eerste lijn is essentieel voor goede zorg. Het chronisch gebruik van DMARDs door JIA patiënten heeft consequenties waar de eerste lijn mee geconfronteerd kan worden. DMARDs onderdrukken (delen van) het eigen immuunsysteem. Daardoor kunnen infecties ernstiger verlopen en kan de symptomatologie van infecties anders zijn tijdens het gebruik van immunosuppressiva: symptomen kunnen milder zijn (bv geen tekenen van koorts tijdens een infectie en anti-TNF-alfa of tocilizumab gebruik) of symptomen kunnen juist heel heftig zijn (bijvoorbeeld ernstige disseminatie en superinfectie bij varicella en MTX-gebruik). Ook bekendheid van de interacties tussen de medicatie voor JIA en andere in de eerste lijn voorgeschreven medicatie is van groot belang.

 

Voor wie is deze richtlijn bedoeld?

Deze richtlijn is bedoeld voor kinderarts-reumatologen en reumatologen of kinderartsen met aandachtsgebied kinderreumatologie en beschrijft aanbevelingen voor de dagelijkse praktijk om de behandeling van kinderen en jongeren met juveniele idiopatische artritis (JIA) (leeftijd 0-18 jaar) te stroomlijnen. Daarnaast kunnen andere zorgverleners die betrokken zijn bij de behandeling van kinderen met JIA zoals, huisartsen, kinderartsen, oogartsen, (kinder)revalidatie-artsen, verpleegkundigen, verpleegkundig specialisten, apothekers, fysiotherapeuten en patiënten (en hun ouders), hun voordeel doen met de informatie in deze richtlijn.

 

Voor patiënten

Jeugdreuma (juveniele idiopatische artritis; JIA) is een verzamelnaam voor allerlei vormen van artritis (gewrichtsontsteking) die ontstaan bij een kind voor de 16e verjaardag, en waarbij de artritis meer dan 6 weken aanhoudt en er geen bekende oorzaak voor de artritis wordt gevonden. De behandeling van JIA is er op gericht elke vorm van ziekteactiviteit in het lichaam (zoals gewrichtsontsteking, koorts, peesontsteking, oogontsteking) te onderdrukken en daarmee gewrichtsschade of oogschade op lange termijn te voorkomen. De behandeling richt zich daarnaast ook op het verminderen van pijn, vermoeidheid en op het kunnen (blijven) deelnemen aan normale activiteiten zoals naar school gaan, sporten en afspreken met vrienden. De paramedische behandeling en psychosociale ondersteuning die van groot belang kunnen zijn bij JIA, vallen, evenals de behandeling van uveitis, buiten de focus van deze richtlijn. In de huidige richtlijn staat de medicamenteuze behandeling van JIA beschreven, dat wil zeggen dat deze richtlijn zich beperkt tot alle aspecten die te maken hebben met het zo effectief en veilig mogelijk gebruik van anti-reumatische medicatie (ook wel DMARDs genoemd). Werking en bijwerkingen van medicatie, (laboratorium) controles tijdens behandeling, aspecten van vaccinaties, operaties, en aandachtspunten voor de eerste lijn (huisarts), worden besproken. Ook worden in verschillende behandelschema's de mogelijke stappen beschreven tijdens het eerste jaar van de behandeling.

 

Hoe is de richtlijn tot stand gekomen?

Het initiatief voor deze richtlijn is afkomstig van de Nederlandse Vereniging voor Kindergeneeskunde. Voor de ontwikkeling van deze richtlijn is een werkgroep geformeerd waarin gemandateerde vertegenwoordigers van de belangrijkste beroepsverenigingen die te maken hebben met de behandeling van JIA zitting hebben. Om het ouder-/patiëntenperspectief te waarborgen participeren vertegenwoordigers van de Jeugdreuma Vereniging Nederland in de werkgroep. De werkgroep wordt procedureel en methodologisch ondersteund door twee epidemiologen (Nederlandse Vereniging van Kindergeneeskunde en PROVA). De projectleider van de internationaal ontwikkelde SHARE-richtlijn heeft tevens zitting in de werkgroep. Daarnaast zijn er meelezers / consulenten gemandateerd.

De ontwikkeling van deze richtlijn is gefinancierd door een projectsubsidie van de Stichting Kwaliteitsgelden Medisch Specialisten (SKMS). Gedurende de periode 1 maart 2015 tot 1 maart 2018 is aan de ontwikkeling van de richtlijn gewerkt door leden van de werkgroep.

Na vaststelling van de conceptrichtlijn door de werkgroep, werd de richtlijn naar de meelezers gestuurd ter becommentariëring. Na verwerking van alle suggesties, startte de commentaarfase en werd de richtlijn voorgelegd aan de volgende partijen: Nederlandse Vereniging voor Kindergeneeskunde, Nederlandse Vereniging Kinderreumatologie, Nederlands Oogheelkundig Gezelschap, Nederlandse Orthopaedische Vereniging, Nederlandse Vereniging voor Radiologie, Nederlandse Vereniging van Revalidatieartsen, Koepel Artsen Maatschappij en Gezondheid - AJN Jeugdartsen Nederland, Nederlands Huisartsen Genootschap, Nederlandse Vereniging van Ziekenhuis Apothekers, Koninklijk Nederlands Genootschap voor Fysiotherapie, V&VN Beroepsvereniging Verpleegkundigen en Verzorgenden Nederland, Zorgverzekeraars Nederland en Jeugdreumavereniging Nederland.

De definitieve richtlijn is ter autorisatie, dan wel goedkeuring, aangeboden aan alle in de werkgroep vertegenwoordigde secties en verenigingen: Nederlandse Vereniging voor Kindergeneeskunde, Nederlandse Vereniging Kinderreumatologie, Nederlands Huisartsen Genootschap, Nederlandse Vereniging van Ziekenhuis Apothekers en Jeugdreumavereniging Nederland.

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Volgende:
Conventionele DMARDs bij JIA