Recently, a group of Canadian pediatric rheumatologists, pediatric ophthalmologists and patients and parents have been working together to develop standardized approaches for monitoring and treating children with uveitis associated with JIA .  It was felt important to develop standardized approaches because there is some variability in how children with JIA uveitis are managed. In both the Canadian and similar United States guidelines that are being developed in children with JIA and uveitis who are starting treatment other than eye drops for uveitis, using injection of methotrexate is recommended over oral methotrexate.

In general, evidence suggests that injection of methotrexate works better for both arthritis and uveitis.  Thus, if the child was on oral methotrexate before the injection and the switch was made to achieve better control of the JIA and/or uveitis, then switching back to oral methotrexate might or might not result in a flare.  The decision the doctors might have to consider is not when to switch to back to oral methotrexate but when to try to discontinue methotrexate entirely.  Deciding when to stop methotrexate would depend on how severe the uveitis was, how difficult it was to control, and if the child is on other medications. In the guidelines that are being developed, in children with uveitis that is well controlled on a medication such as methotrexate with or without other therapy,  it is recommend that there be at least 2 years of well-controlled disease before tapering and then discontinuing the therapy.

So, in a child with at least 2 years of inactive disease one might soon consider beginning a slow taper of current medications rather than switching to oral methotrexate.  But again, this depends a lot on the individual patient’s characteristics and treatments now and in the past. Studies are underway to gather evidence that will help guide when medications can be safely stopped without risking flare ups.