American College of Rheumatology – Pediatric Rheumatology

View all recommendations from this society

Released October 27, 2013

Don’t perform methotrexate toxicity labs more often than every 12 weeks on stable doses.

Laboratory abnormalities in JIA patients taking methotrexate are usually mild and rarely prompt significant changes in management. Screening low-risk children every 1–2 months may lead to unnecessary interruptions in treatment. More frequent monitoring may be required in the first six months after methotrexate initiation or dose escalation and in patients with risk factors for toxicity including obesity, diabetes, renal disease, psoriasis, systemic JIA, Down syndrome and use of alcohol or other hepatotoxic or myelosuppressive medications.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

The American College of Rheumatology (ACR) used a multi-stage process combining consensus methodology and literature reviews to arrive at its Pediatric Rheumatology Top 5 list. Items were generated by a group of practicing pediatric rheumatologists using the Delphi method. Items with high content agreement and perceived prevalence advanced to a survey of ACR members who listed pediatric rheumatology as their specialty. Based on member input related to content agreement, impact and item ranking, candidate items advanced to literature review. The ACR Special Committee on Pediatric Rheumatology discussed the items in light of their relevance to rheumatology, level of evidence to support their inclusion in the final list and the member survey results, and drafted the final pediatric rheumatology Top 5 list. The list was reviewed and approved by the ACR Board of Directors.

ACR’s disclosure and conflict of interest policy can be found at www.rheumatology.org.

ACR Special Committee on Pediatric Rheumatology

  • Polly Ferguson, MD, Chair – University of Iowa Carver College of Medicine, Iowa City, IA
  • Stacy Ardoin, MD – Ohio State University, Columbus, OH
  • Mara Becker, MD – Children’s Mercy Hospital, Kansas City, MO
  • Ashley Cooper, MD – University of Texas Southwestern Medical School, Dallas, TX
  • Leonard Dragone, MD, PhD – National Jewish Hospital, Denver, CO
  • Anna Huttenlocher, MD – University of Wisconsin Medical School, Madison, WI
  • Karla Jones, RN, MS, CPNP – Nationwide Children’s Hospital, Columbus, OH
  • Karen Kolba, MD – Pacific Arthritis Center, Santa Maria, CA
  • Lakshmi Moorthy, MD, MS – Robert Wood Johnson Medical School, New Brunswick, NJ
  • Peter Nigrovic, MD – Brigham and Women’s Hospital, Boston, MA
  • Kelly Rouster-Stevens, MD – Emory Children’s Center, Atlanta, GA
  • Jennifer Stinson, RN, PhD, CPNP – The Hospital for Sick Children, Toronto, ON, CA

American College of Rheumatology Pediatric Rheumatology Core Membership Group*

* Members of the Core Membership Group included: Robert Colbert, MD, PhD, Randy Cron, MD, PhD, Peter Dent, MD, Melissa Elder, MD, PhD, Don Goldsmith, MD, Roger Hollister, MD, Norman Ilowite, MD, Yukiki Kimura, MD, Marisa Klein-Gittelman, MD, MPH, Erica Lawson, MD, Murray Passo, MD, Ross Petty, MD, PhD, Marilynn Punaro, MD, Egla Rabinovich, MD, MPH, Andreas Reiff, MD, David Sherry, MD, Larry Zemel, MD.

Sources

Beukelman T, Patkar NM, Saag KG, Tolleson-Rinehart S, Cron RQ, DeWitt EM, Ilowite NT, Kimura Y, Laxer RM, Lovell DJ, Martini A, Rabinovich CE, Ruperto N. 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: initiation and safety monitoring of therapeutic agents for the treatment of arthritis and systemic features. Arthritis Care Res. 2011;63(4):465–82.

Saag K, Teng G, Patkar N, Anuntiyo J, Finney C, Curtis JR, Paulus HE, Mudano A, Pisu M, Elkins-Melton M, Outman R, Allison JJ, Suarez Almazor M, Bridges SL Jr, Chatham WW, Hochberg M, MacLean C, Mikuls T, Moreland LW, O’Dell J, Turkiewicz AM, Furst DE; American College of Rheumatology. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Care Res. 2008;59(6):762–84.

Lahdenne P, Rapola J, Ylijoki H, Haapasaari J. Hepatotoxicity in patients with juvenile idiopathic arthritis receiving longterm methotrexate therapy. J Rheumatol. 2002;29:2242–5.

Kocharla L, Taylor J, Weiler T, Ting TV, Luggen M, Brunner HI. Monitoring methotrexate toxicity in juvenile idiopathic arthritis. J Rheumatol. 2009;36:2813–8.

Ortiz-Alvarez O, Morishita K, Avery G, Green J, Petty RE, Tucker LB, Malleson PN, Cabral DA. Guidelines for blood test monitoring of methotrexate toxicity in juvenile idiopathic arthritis. J Rheumatol. 2004;31:2501–6.