2026 PAFLAR指南：少关节型幼年特发性关节炎

Abstract

Objective To present updated evidence-based recommendations with a range of therapeutic options for children in Africa with oligoarticular juvenile idiopathic arthritis (JIA), adopting the treat to-target approach.

Methods This study was conducted by the Paediatric Society of the African League Against Rheumatism (PAFLAR) to reach a consensus for recommendations regarding diagnosis and management of oligoarticular JIA suitable for application among different African countries. The Delphi technique was used to reach a consensus of 15 key questions identified by the steering committee. According to the PICO (patient/population, intervention, comparison, outcome) approach, a voting process among 22 African and international clinicians and experts in the field of pediatric rheumatology was performed after intensive systematic review of literature.

Results A consensus was reached for 15 recommendations for diagnosis, monitoring, management of the disease, and its complications, intervention, and when to discontinue treatment of oligoarticular JIA patients with high level of agreement (ranging between 85 and 95%) who agreed or strongly agreed, and the response rate was 100%.

Conclusion These recommendations focus on the early diagnosis and multidisciplinary management of oligoarticular JIA and its complications with high levels of consensus and agreement, improving practice consistency among healthcare providers.

Key Points

* A panel of experts created a consensus about the early diagnosis of oligoarticular JIA * Consensus-based recommendations to the management of oligoarticular JIA * These guidelines emphasized on the oligoarticular JIA-specific characteristics, severity factors, and treatment alternatives

Keywords Arthritis · Guidelines · Juvenile · Oligoarticular · Treatment

Introduction

Juvenile idiopathic arthritis (JIA) is a chronic rheumatic disease characterized by synovitis of peripheral and axial joints, affecting children before the age of sixteen. The arthritis persists more than 6 weeks, and it is the most common pediatric rheumatic disease. According to the International League of Associations for Rheumatology (ILAR), JIA consists of seven heterogeneous subtypes with unique clinical patterns [1].

Oligoarticular is a peculiar JIA subtype that is defined as arthritis affects 4 or less joints with asymmetrical and large joint involvement as knees or ankles. It is the most prevalent subtype and usually affects young girls [2]. Arthritis that remains confined to 4 or less joints is classified as persistent oligoarticular subtype, while patients who develop 5 or more affected joints after 6 months are classified as extended oligoarticular [3]. About 70% of patients are antinuclear anti-body (ANA) positive who are at a greater risk for uveitis especially young girls [4].

The early diagnosis and immediate implementation of the best appropriate therapeutic approach are so

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fundamental to these growing children. The goals of treating oligoarticular JIA are to induce remission, control of the disease activity, improve joint function, prevent long-term joint damage, and preserve normal growth [5, 6].

The Paediatric Society of the African League Against Rheumatism (PAFLAR) updates the oligoarticular JIA practice guidelines especially with the recent improvements and accessibility of a wide variety of therapeutic options. These guidelines express the cross-cutting and evidence-based approach to manage oligoarticular JIA children.

Africa is a special continent with many low-income countries that limits the access to the best quality of care, experienced teams, and some unavailable biologics. This represents a strong impetus for developing specific standard of cares for children with oligoarticular JIA living in restricted-resources countries.

This study was conducted aiming at providing updated evidence-based recommendations with a variety of treatment alternatives for children with oligoarticular JIA, adopting the treat to-target approach. The treatment for associated uveitis and other disease complications was included in these guidelines as well.

Materials and methods

Design

The multi-step process was identified by PAFLAR for the development of the consensus guidelines for diagnosis and management of oligoarticular JIA suitable for different African countries with variable resources according to the available clinical data and scientific evidence.

Working group of pediatric and adult rheumatologists, with fair experience in the management of JIA, were selected to formulate a set of recommendations based on evidence derived from a systematic review of literature. The working group prepared a comprehensive list of questions to establish the different main aspects related to the screening, diagnosis, and management of oligoarticular JIA. Then, the available evidence for each question was identified from literature review using the methodology of PICO (patients, intervention, control, and outcome).

A steering committee, consisting of three pediatric rheumatologists, aided in defining the project's scope and in optimizing the PICO questions. These recommendations were subsequently discussed, amended, and voted on by a task force of 22 pediatric and adult rheumatologists (2 from Europe, 1 from Asia, and 19 representing different African regions) using the nominal group technique and Delphi method and helped refine the PICO

questions (Table 1). The steering committee identified 15 key questions that the guidelines should address (5 for diagnosis and 10 for management) that was approved by the voting group.

Literature review

Searches of the literature were performed through the databases of Pubmed, Embase, and Cochrane. The studies were selected with no limitations regarding the date of publication. Studies relevant to the diagnosis and management were ranked according to the evidence level of the study, and randomized controlled studies were evaluated using the Jadad scale. PRISMA flow diagram for studies selection is presented at Fig. 1.

Target audience

All healthcare professionals involved in diagnosis and management of oligoarticular JIA include pediatric and adult rheumatology physicians, general practitioners, family physicians, orthopedists, allied health services (particularly physiotherapists), and nurses.

Delphi process

A Delphi round was performed to reach a consensus regarding PAFLAR guidelines for oligoarticular juvenile idiopathic arthritis during the period from 19 December 2023 to 29 February 2024. Online survey was performed to complete the Delphi process. A score between 1 and 5 was assigned for each statement, where 1 meant “complete disagreement,” 2 meant “disagreement,” 3 meant “neutral,” 4 meant “agreement,” and 5 meant “complete agreement.” Essentially, disagreement was considered if the score is less than 3. The scientific committee assessed the comments that were added to each statement.

Voting process

Live online-delivered voting was carried out inone strictly time-limited round. All members of the task force were invited to participate and were informed in advance of the time of opening and closure for the round of votes. Access links were sent out for the round, and anonymous votes were gathered and processed. Comments on re-phrasing, potential ambiguity, and unidentified overlaps were gathered regarding each statement at the same time in the voting process. Only the members of this study had the right to vote on the statements.

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Table 1 The oligoarticular juvenile idiopathic arthritis PICO questions

Key questions

Recommendations for diagnosis

1. When should the practitioner suspect oligoarticular JIA and refer the patient to a pediatric rheumatologist? 2. What are the initial work up measures for oligoarticular JIA? 3. What is the classification criteria for oligoarticular JIA? 4. Should other causes of chronic arthritis be excluded before diagnosis? 5. How to manage uveitis and other disease complications? Recommendations for management 1. In children with oligoarticular JIA, what should be the treatment targets? 2. In children with oligoarticular JIA, what is the first-line treatment (also considers what is available)? 3. In children with oligoarticular JIA, what is second-line therapy and third-line (are there high-risk features that mandate second or third line)? 4. In children with oligoarticular JIA, what is the role of oral vs intraarticular steroids and which intraarticular steroids agents are recommended? 5. In children with oligoarticular JIA, is there any role for DMARDs/bDMARDs to modify evolution of extended oligo and uveitis? 6. In children with oligoarticular JIA, is there a role for biologics (other than uveitis)? 7. In children with oligoarticular JIA, what are recommendations for managing limb overgrowth? 8. In children with oligoarticular JIA, how disease activity, damage, and treatment response criteria assessed? 9. In children with oligoarticular JIA, when to consider treatment tapering or withdrawal? 10. In children with oligoarticular JIA, what are the non-pharmacological treatments and when to be considered?

JIA, juvenile idiopathic arthritis; DMARDs/bDMARDs, disease modifying antirheumatic drugs/biological disease modifying antirheumatic drugs

Fig. 1 PRISMA flow diagram of study selection


Results

Expert panel characteristics

The Delphi form was sent to the expert panel (n = 22), who participated in one round. Respondents were drawn from different continents (19 from Africa, two from Europe, and one from Asia. At the end of the survey, we had the final recommendations representing the answers of fifteen PICO questions. The response rate for rounds was 100%. Consensus was reached on the inclusion of clinical standards on 100% of the items (i.e., ≥ 75% of respondents strongly agreed or disagreed).

Section 1: diagnosis of oligoarticular JIA

When should the practitioner suspect oligoarticular JIA and refer the patient to pediatric rheumatologist? [1, 7]

Agreement percentage, 95.5%; agreement level, high When joint pain and swelling has persisted for 6 weeks or more and other causes of arthritis have been excluded. Age of onset of arthritis must be less than 16 years and the number of involved joints is less than 5 in the first 6 months from onset

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What are the initial work up measures for oligoarticular JIA? [8–10]

Agreement percentage, 91%; agreement level, high.

- Mainly clinical and the following work up to be considered:

Acute phase reactants: erythrocyte sedimentation rate (ESR), C reactive protein (CRP), ferritin; serology: Antinuclear antibody (ANA); radiology: plain radiograph, ultrasound, magnetic resonance imaging (MRI), and slit lamp examination.

What is the classification criteria for oligoarticular JIA? [1, 7]

Agreement percentage, 86.5%; agreement level, high Arthritis involving not more than 4 joints within the first 6 months of onset No constitutional symptoms Apart of uveitis, no other extra-articular manifestations

Should other causes of chronic arthritis be excluded before diagnosis? [8, 11, 12]

- Agreement percentage, 95.5%; agreement level, high

The diagnosis of oligoarticular juvenile idiopathic arthritis strongly requires the exclusion of the following conditions:

- Other categories of juvenile idiopathic arthritis

- Connective tissue diseases

- Malignancy especially acute lymphoblastic leukemia

- Infectious conditions: e.g., tuberculosis arthritis

- Postinfectious arthritis and acute rheumatic fever

- Pigmented villonodular synovitis

How to manage uveitis and other disease complications?

[9, 13, 14]

Agreement percentage, 91%; agreement level, high

- Patients with JIA are strongly recommended to undergo screening for uveitis at regular intervals (3 months) which should be more frequent in those with higher risk (Table 2)

- The goal of treatment of uveitis is strongly recommended of absence of cells in the anterior chamber and prevention of complications

- The management of JIA-associated uveitis should be strongly performed by close co-operation between ophthalmologist and pediatric rheumatologist

- Initial management using local steroid drops (prednisolone acetate) is strongly recommended for mild cases

- More severe cases strongly recommended to start systemic treatment as methotrexate and anti-TNF monoclonal antibodies

- Inadequate response to the first anti-TNF monoclonal antibody is conditionally recommended to change to another anti-TNF monoclonal antibodies

- Tocilizumab and abatacept is conditionally recommended to be considered as treatment option after failure of 2 anti-TNF monoclonal antibodies

- It is conditionally recommended to wait for at least 2 years of quiescent uveitis before attempting withdrawal.

Section 2: management of oligoarticular JIA

In children with oligoarticular JIA, what should be the treatment targets?

Agreement percentage, 91%; agreement level, high

The target of treatment is to achieve remission or low disease activity using clinical juvenile arthritis disease activity score (cJADAS) (conditionally recommended) [15, 16].

In children with oligoarticular JIA, what is the first-line treatment (also considers what is available)? [16-25]

Agreement percentage, 91%; agreement level, high Intra-articular steroid injection is strongly recommended as the initial therapy ± NSAIDs in non-risk

Table 2 Frequency of ophalmological examination of oligoarticular JIA patients according to the presence or absence of risk factors

|Oligoarticular JIA|Oligoarticular JIA|Oligoarticular JIA| |---|---|---| |Age of onset|<7 years|> 7 years| |ANA positive|Every 3 months|Every 6 months| |ANA negative|Every 6 months|Every 6 months| |General considerations|- Assessment of intraocular pressure especially in those taking local steroid eye drops - Assessment of the presence of cataract, posterior synechiae, or band keratopathy|| |ANA, antinuclear antibody|||

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oligoarticular JIA. Re-assess every 3 months and re-inject as needed.

If there is inadequate response, the need for more than 2 injections within 12 months in the same joint, or appearance of severe disease features managed as risk oligoarticular JIA.

The initial therapy for risk oligoarticular JIA: conventional synthetic DMARDs is strongly recommended. MTX is the preferred agent over other csDMARDs. It is conditionally recommended subcutaneous over oral administration. Re-assess every 3 months.

In children with oligoarthritis, what is second-line therapy and third-line (are there high-risk features that mandate second or third line)? [16–18, 26–36]

Agreement percentage, 91%; agreement level, high

Risk oligoarticular JIA (any one): arthritis of wrist, ankle, hip, and/or temporomandibular joint (TMJ), presence of imaging evidence of disease damage erosive disease, elevated inflammatory markers, extension to more than four joints, the presence of uveitis, or moderate /high disease activity by a validated disease activity measure (Table 3).

Biologic DMARDs are strongly recommended if there is inadequate response or intolerance to MTX and/or intra-articular steroid injections.

Biologic DMARDs are preferred over combining or switching to a different csDMARD. While the combination of csDMARDs can be used in case of biological therapy unavailability.

There is no preferred biologic DMARD. Although anti-TNF are the most commonly used agent, other bDMARDs of proven efficacy in the treatment of JIA may be used especially in the absence of head-to-head trials in oligoarticular JIA.

* Tocilizumab and abatacept are conditionally recommended as third-line therapy if there is a failure to respond to anti-TNF. JAK inhibitors can be used in dis-

ease extension. JAK inhibitors are FDA-approved for use in JIA patients who are 2 years of age or older.

Pre-commencement screening steps are strongly recommended for all cases:

* Infectious disease screening: Tuberculosis (TB): All patients new to biologics must be screened for active or latent TB. Hepatitis B and C: Testing for hepatitis B and C is necessary. * Immune status and vaccination: Vaccination policy: Live vaccinations are contraindicated while on biological agents. If live vaccinations are needed, they should be given at least 4 weeks before starting a biologic to ensure safety.

* Infection risk mitigation strategies

Monitoring: Regular monitoring for signs of infection, such as fever, cough, or sore throat, is critical.

Infection treatment: Prompt treatment of any new or worsening infections is crucial to prevent severe outcomes.

Dosing: Reducing the dosage, when possible and appropriate for the patient's condition, can help lower the risk of serious side effects like infections.

Patient-specific risk assessment: A thorough assessment of a patient's individual risk factors for infection should be conducted before initiating treatment.

In children with oligoarthritis, what is the role of oral vs intraarticular steroids and which IAI agents are recommended? [16–25, 37, 38]

Agreement percentage, 95.5%; agreement level, high

Table 3 Definitions of various risk factors associated with a worse prognosis of oligoarticular juvenile idiopathic arthritis patients

|Risk factor|Definition| |---|---| |Elevated acute phase reactant|ESR 20 mm/hr, CRP > 10 mg/l| |High disease activity|2.6-5 for moderate activity/>5 for high activity (using cJADAS)| |Certain joint involvement|Wrist/ankles/hip/TMJ affection| |Extended subtype|Extension for more than 4 joints after 6 months from disease onset| |Uveitis|The presence of uveitis is associated with higher disease activity and worse outcome| |Erosive disease|Evidence of radiographic erosions in early in the course of the disease|

ESR, erythrocyte sedimentation rate; CRP, C reactive protein; cJADAS, clinical juvenile idiopathic arthritis; TMJ, temporomandibular joint

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$\bullet$ Triamcinolone hexacetonide is strongly recommended as the preferred agent for local injection given its immediate action and long-term effect as compared to other preparations. However, triamcinolone hexacetonide was used in larger joints and methylprednisolone for smaller joints to avoid side effects of these long-acting agents as hypopigmentation or subcutaneous atrophy. Local injection can be performed under local anesthetic, sedation, or under general anesthetic. This decision will depend on the clinician, patient, and their family. $\bullet$ Particulate corticosteroids (e.g., triamcinolone hexacetonide, methylprednisolone acetate) remain in the joint longer than non-particulate soluble forms, offering a more extended anti-inflammatory effect (Table 4). $\bullet$ Oral glucocorticoids are conditionally recommended as part of initial therapy in risk oligoarticular JIA. Oral glucocorticoids are given to rapidly alleviate severe symptoms especially when local steroid injection is not available or feasible, or prior to the onset of DMARDs action; however, treatment should be limited to the lowest effective dose and for the shortest duration as possible.

In children with oligoarticular JIA, is there any role for DMARDS/BDMARDS to modify evolution of extended oligoarthritis and uveitis?

Agreement percentage, 91%; agreement level, high

Patients with persistent high to moderate disease activity are more likely to evolve to extended oligoarthritis. They strongly recommended to start biologic DMARDs if they continue to have high disease activity despite 6 months of synthetic DMARDs. Anti-TNF can be the first biologic due to high levels of TNF in this group [6, 39].

Methotrexate is associated with a reduced JIA-uveitis onset rate in patients with biological naïve JIA [40].

In children with oligoarthritis, is there any role for biologics (other than uveitis)?

Agreement percentage, 91%; agreement level, high

Biologic DMARDs are strongly recommended in oligoarticular if:

The patient has poor prognostic factors and continues to have moderate to high disease activity after 3 months of nonbiologic DMARDS. Poor prognostic factors are the following: involvement of the ankle, wrist, hip, sacroiliac joint and/or TMJ, presence of erosive disease or enthesitis, delay in diagnosis, elevated levels of inflammatory markers, symmetrical disease.

In patients with no poor prognostic factors, if they continue to have high disease activity after 6 months on synthetic DMARDs, there is no preferred biologic DMARD [6, 17].

In children with oligoarthritis, what are recommendation for managing limb overgrowth?

Agreement level: agreement percentage, 95.5%; agreement level, high

Chronic synovitis and the inflammatory process led to hyperemia in the area surrounding the growth plate, which can induce accelerated growth, length discrepancy, and axial deviation [41, 42]. The knee is the most affected since two-thirds of longitudinal growth occurs around this joint [43]. Limb-length discrepancies of less than 1 cm are not clinically significant [44].

In children with oligoarthritis, the recommendations for managing limb overgrowth are the following:

Early and continued use of intra-articular joint glucocorticoid injection may prevent limb-length discrepancies [45].

In children with mild limb-length discrepancy (1 to 2 cm), appropriate lift in the opposite shoe can maintain proper gait [43].

Surgical management (stapling or epiphysiodesis using temporary epiphyseal stapling) is conditionally recommended if the absolute discrepancy is greater than 2 to 2.5 cm [43].

- An orthopedist should perform this procedure in a child with an open physis [42].

|Joint|TH|TA|MP| |---|---|---|---| |Shoulder, knee, hip|1 mg/kg (max 40 mg)|2 mg/kg (max 80 mg)|| |Elbow, ankle|0.75 mg/kg (max 30 mg)|1.5 mg/kg (max 60 mg)|| |Wrist|0.5 mg/kg (max 20 mg)|1 mg/kg (max 40 mg)|| |Small hand and foot joint|||5-10 mg| |Subtalar and intertarsal|||20-40 mg|

TH triamcinolone hexacetonide, TA triamcinolone acetonide, MP methylprednisolone acetate

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- This technique corrects up to 3 cm in limb length discrepancy [42]. - Correction during the final growth period reduces the risk of recurrence of the deformity [42].

In children with oligoarthritic JIA, how disease activity, damage, and treatment response criteria assessed?

Agreement percentage, 91%; agreement level, high How disease activity criteria assessed?

Recommendation: In children with oligoarticular JIA, clinical juvenile arthritis disease activity score (cJADAS10) is conditionally recommended to assess disease activity during each visit and considered as the primary composite for oligoarticular JIA (level B) [6, 46–50]

Justifications:

The evidence from Finland indicates that cJADAS10 is equal to JADAS10 criteria in assessing disease activity. This suggests that cJADAS10 is a valid and reliable tool for assessing disease activity in JIA, including the oligoarticular subtype.

The American College of Rheumatology (ACR) recommendations define disease activity levels in JIA, and using validated tools like cJADAS10 aligns with these recommendations. It helps in categorizing disease activity accurately, which is important for making treatment decisions.

General cJADAS10 cut-offs

Inactive/remission: ≤1.0

Low disease activity: 1.1-2.5

Moderate disease activity: 2.6–5.0

> High disease activity: >5.0

The evidence also highlights the importance of accurate disease activity assessment in JIA, as different disease activity levels may require different treatment approaches. Using CJADAS10 scoring can help in more precise categorization, ensuring appropriate management.

How damage criteria assessed?

Recommendation: The juvenile arthritis damage index (JADI), which is composed of both the juvenile arthritis damage index-articular (JADI-A) and juvenile arthritis damage index-extra-articular (JADI-E), is conditionally recommended to assess long-term damage in children with oligoarticular JIA. The frequency of assessment should be individualized depending on the initial JADI score, disease activity, and treatment the patient is taking [51–54].

Justification:

The JADI is a comprehensive tool for evaluating damage in children with JIA. This demonstrates its suitability for assessing the long-term effects of the disease.

Long-term assessment of damage in JIA is crucial for monitoring the impact of the disease and treatment. The

JADI, with its dual components, provides a comprehensive evaluation that goes beyond joint damage to consider extra-articular effects, making it a valuable tool for assessing overall damage.

How treatment response criteria assessed?

Recommendation: In children with oligoarticular JIA on treatment, cJADAS10 scoring is conditionally recommended to assess treatment response by tracking changes in disease activity levels to determine improvement or flare [15, 46, 50].

Justification:

The cJADAS10 scoring is a reliable and validated tool for assessing disease activity in children with JIA, including those on treatment. This indicates its suitability for monitoring changes in disease activity over time.

Tracking changes in disease activity levels using cJADAS10 allows healthcare providers to determine whether a child is responding positively to treatment (improvement) or experiencing a worsening of symptoms (flare). This is crucial for making timely treatment adjustments and optimizing patient outcomes.

The use of cJADAS10 scoring aligns with the goal of personalized medicine in JIA management. It allows for tailored treatment decisions based on individual patient responses, ensuring that the treatment approach is optimized for each child's specific needs.

In children with oligoarticular JIA, when to consider treatment tapering or withdrawal?

Agreement percentage, 95.5%; agreement level, high

Recommendations:

If a child with oligoarticular JIA has had inactive disease for 12 months while on methotrexate monotherapy, gradual tapering of the methotrexate dose over 2 months to discontinue is conditionally recommended [55, 56].

For children with oligoarticular JIA who have had inactive disease for 12 months on methotrexate and etanercept or other biologic DMARD, physicians should first try to gradually reduce the methotrexate dose over 2 months until it is off methotrexate, then gradually increasing the interval between etanercept other biologic DMARD doses to discontinue it can be considered [55–62].

Children who started spaced dosing to discontinue biological therapy are strongly recommended to have their disease activity monitored every month for the first 3 months, then every 2 months for 6 months, and then every 3 months until 2 years have passed after discontinuation of the drug [59, 60, 63–65].

Biomarker triggers for re-escalation [66, 67]

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$\bullet$ Patients with a history of uveitis are more likely to flare and are also less likely to maintain remission after stopping therapy. $\bullet$ The presence of ANA at baseline has been associated with a higher risk of flare $\bullet$ Patients with persistently elevated inflammatory markers had a higher risk of flare $\bullet$ Ultrasound detected subclinical synovitis and positive power Doppler signal corresponds to increased risk of flare after treatment withdrawal

In children with oligoarticular JIA, what are the non-pharmacological treatments and when to be considered?

Agreement percentage, 95.5%; agreement level, high Recommendations:

In children with oligoarticular JIA, it is strongly recommended to incorporate exercise programs that emphasize strength, flexibility, and balance. These programs should include supervised or partially supervised training sessions conducted twice weekly, regardless of the pharmacologic treatment group [17, 63, 68–70].

Children diagnosed with oligoarticular JIA should be encouraged to maintain a healthy, age-appropriate diet. It is not recommended to impose specific dietary restrictions or preferences based on the disease [17].

The use of herbal supplements as either an adjunct to or a replacement for pharmacologic therapy in children with oligoarticular JIA should be discouraged [17].

A proposed treatment algorithm for oligoarticular JIA is shown in Fig. 2.

Discussion

Oligoarticular subtype is apparently a benign form of JIA; however, the delay in establishing its diagnosis results in joint damage, contractures, muscle atrophy, or limb deformities. Furthermore, the involvement of the hip or TMJ is considered as high-risk localization of JIA. Another problem in oligoarticular JIA is uveitis and its associated eye complications. These malicious features are considered as factors of poor prognosis and mandate to intensify the lines of management [17, 71].

JIA has been a field of recent research, with greater experience in understanding of the underlying pathogenesis and more treatment options are being available; hence, it was important to update the treatment recommendations to implement the best practice approach and accommodate new therapeutic lines [16, 72].

In the 2021 ACR guidelines for the treatment of oligoarticular subtype, the task force stated recommendations for initial and subsequent treatment of JIA with

![graph TD\n A1[Child diagnosed to have oligoarticular JIA -Screening for uveitis] -->|Yes| A2[local steroid drops for mild cases MTX and Anti-TNF monoclonal antibodies for more severe cases Inadequate responders: change to another Anti-TNF monoclonal tocilizumab and abatacept if failure of 2 Anti-TNF monoclonal Ab.]\n A1 -->|No| A3[First line of treatment NSAIDs Intra-articular steroid Methotrexate for risky patients with inadequate response to previous treatment]\n A3 -->|Target reached| A4[Continue treatment]\n A3 -->|Target not reached| A5[Second and third lines of treatment add Anti-TNF Biologics other than Anti-TNF （Inflectuzumab and abatacept） Combination of cDMARDs can be used in case of biological therapy unavailability]\n A4 -->|Remission for 12 months| A6[Discontinue MTX over 2 months]\n A5 -->|Target reached| A7[Continue treatment]\n A5 -->|Target not reached| A8[Shifting between biological DMARDs]\n A6 --> A5\n A7 -->|Remission for 12 months| A9[Discontinue MTX over 2 months then gradually tapering biologic DMARD]\n](1/parseimages/figure02810cc72bfd4a36983f9e9fea63c6a1_0_12.png) Fig. 2 Treatment algorithm for oligoarticular juvenile idiopathic arthritis

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oligoarticular and TMJ arthritis. Their recommendations provided qualified advice on treatment options in order to improve patient care in clinical practice [17].

Our study is in agreement with 2021 ACR guideline for the treatment of oligoarticular in many aspects. These guidelines were developed based on a standardized PICO process and consensus-based recommendations that provide a framework to help researchers in formulating rigorous and precise questions that can be answered in a systematic review, as well as to improve the specificity and conceptual clarity of clinical questions by breaking them down into smaller components that are easier to identify during the literature search process [16, 73].

However, the ACR committee considered TMJ arthritis is separate section and they did not include recommendations for uveitis associated with oligoarticular JIA, nor did focus in other disease complication, treatment targets, or treatment tapering/withdrawal strategy. Furthermore, the overall quality of evidence was very low, and most recommendations were conditional; nevertheless, these guidelines filled an important clinical gap in caring of oligoarticular JIA children [16, 17].

Our recommendations emphasized on the oligoarticular JIA-specific characteristics, severity factors, and disease complications that drive the treatment decisions. They are fairly unique compared with previously published recommendations, reflecting the challenges across our continent to access to special medications and experienced rheumatologists.

On previous clinical practice, NSAID use was considered as an adjuvant therapy to local steroid injection rather a mainstay of treatment to avoid any risk of chronic disability [17, 74]. Not all classes of biological therapy have been available in many countries across Africa because of high cost and lack of regular insurance system drug supply, forcing physicians to consider other alternatives, and these guidelines address this major unmet medical need.

These recommendations focus on the early diagnosis and multidisciplinary management of oligoarticular JIA and its complications with high levels of consensus and agreement, improving practice consistency among healthcare providers. However, these guidelines do not seek to provide full safety and usage information of pharmacological agents, and biosimilars were not addressed in these guidelines given the limited evidence assessing their use in oligoarticular JIA.

Author contribution All have read and agreed to the published version of the manuscript.

Funding PAFLAR convened the preparation of the guidelines and provided the meeting platform for the discussions. No funds were received from industries or any organization for this work.

Availability of data and material All data generated during this study are in this published article.

Declarations

Ethics approval and consent to participate Not applicable.

Consent for publication Not applicable.

Disclosures None.

References

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Authors and Affiliations

Waleed Hassan$^{1}$ D. Doaa Mosad Mosa$^{2}$ D. Ayodele Faleye$^{3}$ · Temesgen Teferi Libe$^{4}$ D. Elisa Palane$^{5}$ · Angela Migowa$^{6}$ D. Sulaiman Al Mayouf$^{7}$ D. Helen Foster$^{8}$ D. Mohammed Hassan Abu-Zaid$^{9}$ D. Soad Hashad$^{10}$ D. Wafa Hamdi$^{11}$ D. Hanene Lassoued Ferjani$^{11}$ D. Ahmed Seri$^{12}$ D. Hanna Lishan$^{13}$ D. Chafia Makhlouf Dahou$^{14}$ D. Yasmine Makhlouf$^{15}$ D. Yasmine Taha$^{16}$ D. Yaninga Halwani Fusseini$^{17}$ D. Wassila Messadi$^{18}$ D. Ali Sobh$^{19}$ D. Samah Ismail Nasef$^{20}$ D. Ourida Gecam$^{21}$ D. Madeleine Ngandeu$^{22}$ D. Francis Fredrick Furia$^{23}$ D. Samy Slimani$^{24}$ D. Christiaan Scott$^{25}$,$^{26}$ D. Djohra Hadef$^{27}$ D

☑ Doaa Mosad Mosa doaamosad@mans.edu.eg

Waleed Hassan waleed22101979@yahoo.com

Ayodele Faleye a.faleye2013@yahoo.com Temesgen Teferi Libe libe.temesgen.temesgen@gmail.com

Elisa Palalane elisa.palalane@gmail.com

Angela Migowa angela.migowa@yahoo.com

Sulaiman Al Mayouf almayoufsulaiman@yahoo.com

Helen Foster h.e.foster@newcastle.ac.uk Mohammed Hassan Abu-Zaid Drmhassan 113@yahoo.com

Soad Hashad soadashed@hotmail.com

Wafa Hamdi wafahandi6@yahoo.fr

Hanene Lassoued Ferjani lassouedferjanihanene@gmail.com

Ahmed Seri dr.seri@outlook.com

Hanna Lishan hanna.lishan@aau.edu.et

Chafia Makhloufi Dahou makhloufi-dahou@hotmail.com

Yasmine Makhlouf yasmine.mkhlouf@gmail.com

Yasmine Taha ytaha@doctors.org.uk

Ali Sobh ali.sobh@mans.edu.eg Samah Ismail Nasef dr.samah.ismaeel@gmail.com

Ourida Gacem gacemourida@yahoo.fr Madeleine Ngandeu ngandeum@yahoo.fr

Francis Fredrick Furia fredrick.francis78@gmail.com

Samy Slimani slimani@dr.com

Christiaan Scott christiaanscott@gmail.com Djohra Hadef d.hadef@univ-batna2.dz

1. Rheumatology and Rehabilitation Department, Benha University, Banha, Egypt 2. Department of Rheumatology & Rehabilitation, Mansoura University Hospitals, Faculty of Medicine, Mansoura University, Mansoura, Egypt

3. Pediatric Rheumatology Unit, Department of Pediatrics, Teaching Hospital, Lagos State University, Lagos, Nigeria

4 College of Health and Medical Sciences, Haramaya University, Dire Dawa, Ethiopia

5 Hospital Central de Maputo, Maputo, Mozambique

6 Department of Paediatrics and Child Health, Aga Khan University Hospital, Nairobi, Kenya

7 King Faisal Specialist Hospital and Research Center College of Medicine, Alfaisal University, Riyadh, Saudi Arabia

8 Population Health and Society Institute, Newcastle University, Newcastle Upon Tyne, UK

9 Rheumatology Department, Faculty of Medicine, Tanta University, Tanta, Egypt

10 University of Tripoli, Tripoli, Libya

$^{11}$ Department of Rheumatology, Kassab Institute UR17SP04, Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia

12 European Academy of Allergy and Clinical Immunology, Zurich, Switzerland

13 Addis Ababa University, College of Health Sciences, Addis Ababa, Ethiopia

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14 Department of Rheumatology, Faculty of Medicine of Algiers, Med Lamine Debaghine University Hospital, Bab El Oued, BD Said Touati, Algiers, Algeria 15 Mohammed Kassab Institute of Orthopaedics, Tunis, Tunisia 16 Ahmed Gasim Children's Hospital, Khartoum North, Sudan 17 Tamale Teaching Hospital, Tamale, Ghana 18 University Hospital of Issaad Hassani, Algiers, Algeria 19 Mansoura University Children's Hospital, Mansoura, Egypt 20 Suez Canal University, Ismailia, Egypt

21 Societe Algerienne de Pediatrie, Blida, Algeria 22 University of Yaounde, Soa, Cameroon 23 Department of Paediatrics and Child Health, School of Clinical Medicine, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania 24 Batna, Algeria 25 University of Ottawa, Ottawa, Canada 26 University of Cape Town, Cape Town, South Africa 27 Faculty of Medicine, Batna 2 University, Batna, Algeria