Background

Adult Inflammatory Arthritis

Inflammatory arthritis (IA) is characterised by abnormal inflammation in the joints, ligaments and tendons, resulting in pain, stiffness, swelling and loss of function. Uncontrolled inflammation may result in irreversible joint damage.

There are many types of IA including rheumatoid arthritis (RA), spondyloarthritis (SpA), psoriatic arthritis (PsA), crystal arthritis (including gout and pseudogout) and autoimmune connective tissue diseases such as systemic lupus erythematosus (SLE). New approaches to management (including 'treat-to-target') and a rapid expansion in available disease-modifying antirheumatic drugs (DMARDs) have improved outcomes for many people living with IA.

Juvenile Idiopathic Arthritis

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in childhood. JIA is an umbrella term for a heterogeneous group of disorders that manifest as early onset arthritis. JIA typically manifests with arthritis, although extra-articular symptoms such as fever, constitutional symptoms and ocular inflammation can also occur.

The cause of JIA is not completely understood but is probably due to a combination of genetic and environmental factors. It affects approximately 1–4 per 1,000 children under the age of 16. Girls are more commonly affected than boys in an overall ratio of approximately 3:2 but the ratio varies significantly between JIA subtypes. It is a heterogeneous condition with varied long-term outcomes.

Disease-Modifying Anti-Rheumatic Drugs (DMARDs)

DMARDs are the cornerstone of pharmacologic treatment for inflammatory arthritis. They control inflammation and thus reduce symptoms and prevent joint damage. DMARDs are categorised according to their structure and mechanisms of action:

Conventional Synthetic DMARDs (csDMARDs)

Do not target a specific molecular structure.

Examples: methotrexate, sulfasalazine, hydroxychloroquine

Targeted Synthetic DMARDs (tsDMARDs)

A newer class of medications designed to target a specific molecular structure.

Examples: tofacitinib, baricitinib

Biologic DMARDs (bDMARDs)

Derived biologically and designed to target specific cells or proteins involved in the inflammatory response. As the complex structure of biologically derived proteins cannot be reproduced exactly, bDMARDs are further classified into bio-originator and biosimilar DMARDs.

Examples: adalimumab, etanercept, rituximab

Living Guidelines Approach

The increasing rate of production of new evidence regarding treatment means that recommendations based on current evidence are likely to become outdated quickly as new studies are published. The living evidence approach facilitates rapid updating of recommendations. By frequently incorporating the most up-to-date evidence, these methods ensure that the currency of each recommendation remains high.

Understanding Recommendations

Each recommendation in these guidelines is graded according to its strength, which reflects the panel's confidence in the balance between benefits and harms. The guidelines consist of two layers: the recommendation itself and the supporting information.

Recommendation Strength

⊕⊕

Strong Recommendation For

Given when there is high-certainty evidence showing that the overall benefits of the intervention are clearly greater than the disadvantages. This means that all, or nearly all, patients will want the recommended intervention.

⊖⊖

Strong Recommendation Against

Given when there is high-certainty evidence showing that the overall disadvantages of the intervention are clearly greater than the benefits. Also used when the examination of the evidence shows that an intervention is not safe.

⊕

Conditional Recommendation For

Given when the benefits of the intervention are considered greater than the disadvantages, or the available evidence cannot rule out a significant benefit while assessing that adverse effects are few or absent. Also used when patient preferences vary.

⊖

Conditional Recommendation Against

Given when the disadvantages of the intervention are judged greater than the benefits, but where this is not substantiated by strong evidence. Also used where there is strong evidence of both beneficial and harmful effects, but where the balance between them is difficult to determine.

≈

Consensus Recommendation

Can be given for or against an intervention. Used when there is not enough evidence to give an evidence-based recommendation, but the panel still regards it as important to provide guidance.

Supporting Information

Click on any recommendation card to access detailed supporting information. Each recommendation includes multiple tabs with additional context:

Recommendation
The recommendation text, any remarks or qualifications, and the rationale explaining how the panel weighed the evidence to arrive at the recommendation.
Evidence to Decision
The panel's assessment across seven domains: benefits and harms, certainty of evidence, patient values and preferences, resource use, equity, acceptability, and feasibility.
Practical Info
Implementation guidance, special patient considerations, and links to relevant resources such as patient information sheets and PBS criteria.
Data
The clinical question (PICO) and links to evidence summaries including systematic search results and updates.
More Info
Panel members who contributed to the recommendation, meeting dates, and update history.

Certainty of Evidence

The certainty (or quality) of the evidence reflects how confident we are that the estimated effects are close to the true effects. This is assessed using the GRADE approach:

High We are very confident that the true effect is close to the estimated effect.
Moderate We are moderately confident in the estimated effect. The true effect is probably close to this, but there is a possibility that it is significantly different.
Low We have limited confidence in the estimated effect. The true effect may be significantly different from the estimated effect.
Very Low We have very little confidence in the estimated effect. The true effect is likely to be significantly different from the estimated effect.

Providing Feedback

We welcome feedback on the guideline recommendations. Each recommendation includes a "Suggest feedback" link that allows you to submit comments or suggestions directly to the guideline team.

The grading of evidence quality and recommendation strength is based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE). For more information, visit the GRADE Working Group website or read the article 'Understanding GRADE: an introduction' by Goldet & Howick (J Evid Based Med 2013;6(1):50-4).