Table 3 Summary of the guidelines

Recommendation 1: Polyarticular JIA should be suspected, and the child should be referred to a pediatric rheumatologist if child was presented with chronic arthritis affecting 5 or more joints

IIb

90% (High)

Recommendation 2: Plain X-rays, MSUS, and MRI are important radiological investigations which help in the diagnosis of polyarticular JIA

IIb

90% (High)

Recommendation 3: Diagnosis of polyarticular JIA is based on diagnosis of expert pediatric rheumatologist after clinical examination and using laboratory and radiological evaluation guided by the 2001 ILAR Classification Criteria for JIA in children who have arthritis affecting 5 or more joints during the first 6 months of disease

III b

100% (High)

Recommendation 4: Polyarticular JIA should be differentiated from other inflammatory and non-inflammatory arthropathies in children

IIb

100% (High)

Recommendation 5: Uveitis may occur in RF-negative poly arthritis especially in ANA positive children

I b

85% (High)

Recommendations for management

Recommendation 1: The main treatment target is to achieve clinical and/or ultrasound remission, with the alternative target of low disease activity is recommended

III b

85% (High)

Recommendation 2: Non-pharmacologic interventions could be used to optimize supportive care in JIA patients using physical therapy, occupational therapy nutrition, and surgical intervention

IV C

95% (High)

Recommendation 3: NSAIDs could be used as first-line for pain relief and symptom management, and corticosteroids could be used in polyarticular JIA as a bridge therapy, intra-articular injection in resisted joints, or as IV infusion (in severe resisted cases)

II b

85% (High)

Recommendation 4: Starting with csDMARDs (MTX is the first choice) should be considered as first-line in patients with polyarticular JIA

II b

85% (High)

Recommendation 5: The choice of second-line management depends on disease activity, response to initial treatments, individual patient characteristics and prognostic factors. Escalation of MTX dose or using combined csDMARDs should be considered, biological therapy could be used as second line of treatment in presence of poor prognostic factors

IV b

85% (High)

Recommendation 6: Biological DMARDs should be adopted as third-line management after failure of csDMARDs as mono or combined therapy

II b

95% (High)

Recommendation 7: In moderate or severe active polyarticular JIA who do not respond to csDMARDs, biological therapy is recommended in the form of: anti-TNFs, tocilizumab, abatacept and tofacitinib. The usage of biosimilars in African countries provides an important opportunity to treat more JIA children with biologic drugs due to lower cost and similar efficacy

IV b

90% (High)

Recommendation 8: High-risk polyarticular JIA patients who should proceed to 2nd line or 3rd line immediately are those who have poor prognostic factors

III b

95% (High)

Recommendation 9: The child should be assessed clinically, radiographically, and functionally to assess disease activity and response to treatment

III b

95% (High)

Recommendation 10: Stop or withdraw medication depends upon response to the medication, tolerance of the administration regimen, and other patient factors

IV C

85% (High)