Oligoarticular juvenile idiopathic arthritis

Australian clinical guidelines for oligoarticular juvenile idiopathic arthritis (oligoarticular JIA), including diagnosis, uveitis screening and management, intra-articular corticosteroid injection, systemic treatment, and follow-up in Australian primary care and paediatric rheumatology practice.

Introduction and Overview

Oligoarticular juvenile idiopathic arthritis (oligoarticular JIA) is the most common subtype of JIA, accounting for approximately 50% of all cases. It is defined by arthritis affecting four or fewer joints during the first 6 months of disease in a child under 16 years of age. Oligoarticular JIA predominantly affects young females (F:M ratio approximately 3:1) with a peak onset between 1 and 5 years of age. Despite being the most common subtype, oligoarticular JIA carries a significant risk of uveitis — the leading preventable cause of blindness in children with JIA. While most children with oligoarticular JIA have a favourable joint prognosis, sight-threatening uveitis can occur silently and requires systematic ophthalmological surveillance.

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Australian Context: Oligoarticular JIA is the most commonly diagnosed JIA subtype in Australian paediatric rheumatology centres. ANA positivity (present in ~70% of cases) is the strongest predictor of uveitis risk and drives ophthalmology surveillance frequency. Intra-articular triamcinolone hexacetonide (THK) injection, available in major paediatric hospitals, remains the standard of care for initial joint management. Methotrexate and biologics (including adalimumab for uveitis) are PBS-listed when required. ATSI children require urgent exclusion of reactive arthritis and rheumatic fever before commencing immunosuppressive therapy.

Feature	Persistent Oligoarticular	Extended Oligoarticular
Definition	≤4 joints throughout entire disease course	≥5 joints after first 6 months
Frequency	~75% of oligoarticular JIA	~25% of oligoarticular JIA
Prognosis (joints)	Generally favourable; most enter remission	More similar to polyarticular JIA; higher disability risk
Uveitis risk	High (especially ANA+, young onset)	High (similar to persistent)
Treatment	IAC ± MTX; biologic if refractory	MTX; TNF inhibitor if MTX fails

Pathophysiology

Oligoarticular JIA pathogenesis involves dysregulated adaptive immunity with T cell-driven synovial inflammation, but the precise triggers remain unknown. The disease has a strong genetic predisposition through HLA associations.

Immunological Mechanisms

HLA class II associations — HLA-DR8 and HLA-DR5 (DRB1*08 and DRB1*11) confer susceptibility; HLA-DR4 is protective (inverse association)
T cell dysregulation — CD4+ Th1 and Th17 cells drive synovial inflammation; TNF-α, IL-17, and IL-6 are key cytokines in the synovial microenvironment
ANA and uveitis — ANA positivity (titre ≥1:40) occurs in ~70% of oligoarticular JIA and strongly correlates with uveitis risk; the specific autoantigen(s) driving ANA in JIA remain undefined; ANA titre does not reflect disease activity
Intra-articular pathology — synovial hypertrophy with mononuclear cell infiltration; pannus formation with cartilage erosion can occur in long-standing untreated disease; local over-growth from synovial hyperaemia causes leg length discrepancy and joint enlargement

Uveitis Pathogenesis

Chronic anterior uveitis — non-granulomatous, bilateral (50–70%), and characteristically asymptomatic (no red eye, no pain, no photophobia in early disease)
T cell-mediated inflammation of the anterior chamber — leukocytes, flare (protein), and posterior synechiae develop insidiously; band keratopathy (calcium deposition in cornea), cataract, and glaucoma develop from chronic uncontrolled uveitis
Risk factors for uveitis — ANA positive, age at onset <7 years, female sex, oligoarticular subtype, early disease (highest risk in first 4–7 years after diagnosis)

Clinical Presentation

Oligoarticular JIA typically presents in a toddler or preschool-aged girl with swelling of one or more joints (most commonly the knee), morning stiffness or altered gait, and often without significant pain complaint. Systemic features are absent.

Articular Features

Knee — the single most commonly affected joint; unilateral or bilateral asymmetric swelling; warm but not erythematous; effusion palpable; child may limp or refuse to run
Ankle — second most common; periarticular swelling; limping; hindfoot involvement affects gait
Wrist and small joints of hands — less common than lower limb; wrist synovitis may be subtle on examination
Hip involvement — uncommon in oligoarticular JIA; hip pain with limited internal rotation; urgent investigation to exclude septic arthritis if acute; sustained hip involvement suggests ERA
Growth disturbance — leg length discrepancy from unilateral knee hyperaemia is common; the affected leg typically grows longer than the unaffected side; overgrowth of affected joints causes bone enlargement
Morning stiffness — described as gelling — child wakes stiff, improves after 30–60 minutes; young children may be carried by parents until stiffness resolves or refuse to walk

Uveitis — The Silent Complication

Asymptomatic in early stages — no red eye, no pain, no visual complaint; detected only on slit-lamp examination by an ophthalmologist
Prevalence — uveitis develops in 20–30% of oligoarticular JIA patients during the disease course; risk is highest in the first 7 years after JIA diagnosis
Late presentations — visual impairment, white pupil (band keratopathy), reduced visual acuity; these represent late-stage complications of missed/uncontrolled uveitis

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Uveitis is Asymptomatic Until Late: Parents and GPs should be aware that JIA uveitis causes NO symptoms in early stages. A child with oligoarticular JIA and a red, painful eye most likely has a different diagnosis (e.g., conjunctivitis). JIA uveitis is identified only through scheduled slit-lamp examination. Failure to attend ophthalmology appointments is the leading cause of preventable JIA blindness in Australia.

Investigations

Oligoarticular JIA is a clinical diagnosis supported by laboratory findings. Investigations primarily serve to exclude septic arthritis, reactive arthritis, and malignancy, and to classify risk for uveitis.

Essential
FBC, ESR, CRP
Elevated ESR/CRP in active disease; thrombocytosis common. FBC: mild normocytic anaemia of chronic disease. Leukocytosis is uncommon — marked leukocytosis or neutropenia should prompt consideration of alternative diagnoses (infection, malignancy). Leukopenia or thrombocytopenia raises concern for malignancy (leukaemia) and requires urgent bone marrow evaluation.
Essential
ANA (antinuclear antibody)
ANA positive in ~70% of oligoarticular JIA. Titre ≥1:40 on indirect immunofluorescence is considered positive. High-titre ANA (≥1:160) confers higher uveitis risk. ANA is the most important uveitis risk stratification tool and determines ophthalmology surveillance frequency. ANA must be checked at diagnosis and does not need repeating during disease course.
Essential
RF and anti-CCP
RF is negative in oligoarticular JIA by definition. RF positive on 2 occasions ≥3 months apart reclassifies to RF-positive polyarticular JIA. Anti-CCP also negative. Testing is essential to confirm correct subtype classification.
Essential
Synovial fluid analysis (first presentation monoarthritis)
Joint aspiration is essential when single-joint presentation is indistinguishable from septic arthritis. JIA: yellow-clear, WBC 5,000–50,000/μL, predominantly lymphocytes, negative Gram stain and culture. Septic arthritis: WBC >50,000/μL (often >100,000), PMN predominance, positive Gram stain/culture in 50–70% of cases. Do not delay arthrocentesis and antibiotics if septic arthritis is suspected.
Essential
Joint X-ray (affected joints)
Baseline X-ray of affected joints; assess for periarticular osteopaenia, soft tissue swelling, leg length, growth disturbance. Joint space narrowing and erosions are late findings. X-ray may be normal in early disease. Leg length films (scanogram) if clinical leg length discrepancy noted.
Recommended
Joint ultrasound
Confirms synovial hypertrophy and effusion; guides arthrocentesis and intra-articular injection. Useful for hip assessment (difficult to clinically assess). Power Doppler assesses active synovitis. Can demonstrate synovitis in clinically uninvolved joints (subclinical disease).
Recommended
Slit-lamp examination (ophthalmology)
Not a laboratory test, but essential at diagnosis and at regular intervals based on uveitis risk. Cannot be replaced by any other investigation. Must be performed by an ophthalmologist skilled in paediatric uveitis assessment. Slit-lamp frequency determined by ANA status, age at onset, sex, and disease duration.

Risk Stratification

Risk stratification in oligoarticular JIA encompasses both articular disease severity and uveitis risk. These are independent dimensions — a child may have mild joint disease but high uveitis risk.

Articular Disease Severity

MILD

1‑2 Joints, Controlled

1‑2 joints affected, minimal functional limitation, inflammatory markers mildly elevated or normal

NSAIDs ± single intra-articular corticosteroid injection (IAC); monitor 3‑6 monthly

MODERATE

3‑4 Joints or Refractory

3‑4 joints, significant functional limitation, or recurrence within 3 months of IAC

Methotrexate SC 10–15 mg/m²/week; reassess at 3‑6 months; ophthalmology per risk

EXTENDED

≥5 Joints (Extended Oligo)

Spread to ≥5 joints after month 6; treat as polyarticular JIA; erosive potential higher

MTX; TNF inhibitor if MTX fails; adalimumab if uveitis present

Uveitis Risk Classification (ACR/AF 2019 Guidelines)

Risk Category	Criteria	Slit-Lamp Frequency
Highest risk	Oligoarticular or psoriatic JIA + ANA positive + age ≤6 years at onset	Every 3 months
High risk	Oligoarticular or psoriatic JIA + ANA positive + age 7–10 years at onset	Every 6 months
Moderate risk	Oligoarticular or psoriatic JIA + ANA negative, or ANA positive + age >10 years at onset	Every 6–12 months
Lower risk	Disease duration >7 years and no prior uveitis; or age >10 years + ANA negative	Every 12 months (continue until 5 years disease remission)

Pharmacological Management

Treatment of oligoarticular JIA is stepwise, guided by joint count, disease trajectory, and uveitis status. The goal is clinical remission (inactive disease) to prevent joint damage and uveitis complications.

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Intra-articular triamcinolone hexacetonide (THK)

Lederspan® | First-line for oligoarticular JIA joint management

DoseKnee: 1 mg/kg (max 40 mg); ankle/wrist: 0.5–1 mg/kg (max 20–30 mg); small joints: 5–10 mg; performed under GA or conscious sedation in young children

PBS Status✓ PBS: Corticosteroid injection; specialist/hospital procedure

NotesTHK preferred over triamcinolone acetonide — longer duration of action (months to >1 year in some cases). Ultrasound guidance improves accuracy. Subcutaneous fat atrophy (localised) is a known side effect. Limit to 2–3 injections per joint per year to minimise tendon/cartilage risk. Response is often dramatic.

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NSAIDs

Naproxen / Ibuprofen | Adjunct symptom control

DoseNaproxen: 10–15 mg/kg/day in 2 divided doses (max 1000 mg/day); Ibuprofen: 30–40 mg/kg/day in 3‑4 divided doses (max 2400 mg/day)

PBS Status✓ PBS: General benefit

NotesNSAIDs reduce pain and stiffness but do not prevent uveitis or joint damage. Naproxen: risk of pseudo-porphyria (photo-distributed blistering rash, especially in fair-skinned children) — cease if occurs. Take with food. Prolonged NSAID monotherapy is insufficient for active synovitis.

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Methotrexate (MTX)

Various generics | DMARD for refractory or extended oligoarticular JIA

Dose10–15 mg/m²/week SC or oral (max 25 mg/week); SC route preferred for doses >15 mg or with GI intolerance; once weekly only

PBS Status✓ PBS: Polyarticular-course JIA; paediatric rheumatologist or rheumatologist initiation

NotesIndicated when: oligoarticular disease is refractory to IAC (≥2 injections without sustained remission); extended oligoarticular course; active uveitis requiring systemic steroid-sparing. Folic acid 5 mg once weekly (not on MTX day). Monitor FBC and LFTs monthly until stable, then 3-monthly. MTX significantly reduces uveitis activity and is first-line systemic therapy for JIA uveitis.

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Adalimumab

Humira® | TNF inhibitor — preferred biologic for JIA-associated uveitis

Dose20 mg SC fortnightly (<30 kg); 40 mg SC fortnightly (≥30 kg)

PBS Status✓ PBS: Chronic anterior uveitis associated with JIA, refractory to MTX; Authority required; paediatric rheumatologist and ophthalmologist initiation

NotesSuperior to etanercept for JIA uveitis — etanercept lacks ocular efficacy and should NOT be used for uveitis. Adalimumab + MTX combination reduces immunogenicity (anti-drug antibodies). Screen for latent TB (IGRA) and HBV before commencing. Continue for minimum 2 years after uveitis remission. Monitor for injection site reactions and infection.

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Etanercept

Enbrel® | TNF inhibitor — for extended oligoarticular/polyarticular joint disease ONLY

Dose0.4 mg/kg SC weekly (max 25 mg) or 0.8 mg/kg SC fortnightly (max 50 mg)

PBS Status✓ PBS: Active polyarticular JIA failing MTX; paediatric rheumatologist initiation

NotesEffective for synovitis in extended oligoarticular/polyarticular disease. NOT effective for JIA-associated uveitis — may worsen ocular inflammation. Use adalimumab instead if uveitis present or high uveitis risk. Latent TB screening mandatory before commencement.

Directed Therapy: Uveitis Management

JIA-associated uveitis (JIAU) requires a stepwise approach coordinated between paediatric rheumatology and ophthalmology. The goal is to achieve uveitis remission (zero cells in anterior chamber on slit-lamp) and prevent structural complications.

Step 1 — Topical Therapy (Ophthalmologist-Led)

Topical prednisolone acetate 1% eye drops — initial treatment for active uveitis; frequency determined by anterior chamber cell grading; taper under ophthalmologist guidance to minimise steroid-induced cataract and glaucoma
Mydriatics (cyclopentolate, atropine) — prevent posterior synechiae; relieve ciliary spasm; used adjunctively with topical steroids
Topical steroids alone are insufficient for chronic uveitis — systemic therapy must be added promptly when uveitis is recurrent or chronic

Step 2 — Systemic Steroid-Sparing (Methotrexate)

MTX 10–15 mg/m²/week SC — first-line systemic agent for chronic or steroid-dependent uveitis; allows tapering of topical steroids; improvement may take 3‑6 months
Short courses of oral prednisolone (0.5–1 mg/kg/day) may be required for acute uveitis flares while awaiting systemic DMARD effect; taper rapidly

Step 3 — Biologic Therapy (Adalimumab)

Adalimumab — PBS-listed for JIA uveitis refractory to MTX; significantly reduces uveitis flare frequency; combine with MTX to reduce immunogenicity
Abatacept — second-line biologic for uveitis refractory to adalimumab; evidence emerging from observational studies
Periocular triamcinolone injection — for acute uveitis flares requiring rapid control; administered by ophthalmologist; risk of glaucoma and cataract with repeated use

Treatment of Structural Uveitis Complications

Band keratopathy — calcium deposition in cornea from chronic uveitis; treated by ophthalmology with topical EDTA chelation
Cataract — from chronic uveitis or steroid use; surgical extraction with appropriate timing; risk of re-uveitis with surgery requires perioperative immunosuppression intensification
Glaucoma — from uveitis or topical steroid use; medical and surgical management by paediatric ophthalmologist

Non-Pharmacological Management

Non-pharmacological management is integral to joint preservation and functional recovery in oligoarticular JIA.

Physiotherapy

Range of motion exercises — prevent joint contracture; particularly important for knee flexion contracture (common in active oligoarticular JIA)
Quadriceps strengthening — knee arthritis leads to quadriceps wasting and instability; targeted strengthening essential
Hydrotherapy — low-impact exercise with buoyancy; excellent for maintaining mobility and fitness without joint loading during active disease
Orthotics — ankle-foot orthosis for ankle/hindfoot involvement; heel raise for leg length discrepancy (>1 cm); early referral to orthotist

Occupational Therapy

Joint protection education — activity modification during active disease; avoidance of high-impact loading
Splinting — resting splints for wrist involvement to prevent flexion contracture; worn at night
School and play accommodations — letter to school regarding modified PE, rest breaks, and adaptations during flares

Ophthalmology Co-management

Regular slit-lamp examinations — mandatory at frequency determined by uveitis risk; cannot be delegated to non-ophthalmologist
Shared care plan — rheumatologist and ophthalmologist communicate regarding treatment changes; if MTX or biologic commenced for uveitis, ophthalmologist must be informed and monitor response

Monitoring Parameters

Monitoring in oligoarticular JIA covers disease activity (joint and eye), treatment toxicity, and growth. Frequency depends on treatment and disease activity phase.

Parameter	Frequency	Indication
FBC, LFTs, UEC	Monthly on MTX (first 3 months); then 3-monthly when stable	MTX myelosuppression, hepatotoxicity
ESR, CRP	Each specialist visit (3‑6 monthly)	Disease activity assessment; guide treatment decisions
Slit-lamp examination	Every 3–12 months based on uveitis risk category	Asymptomatic uveitis detection; monitor known uveitis
Height and weight	Every 3‑6 months	Growth monitoring; corticosteroid growth impact
Leg lengths	6–12 monthly if asymmetric knee disease	Leg length discrepancy from knee hyperaemia; guide orthotics
JADAS score	Each specialist visit	Quantify disease activity; guide treatment escalation/de-escalation
Latent TB (IGRA) + HBV serology	Before biologic; annually on biologic	Biologic safety; reactivation prevention

When to Refer Urgently

Septic arthritis: Acute hot, exquisitely tender joint — WBC >50,000/μL on aspiration, fever, raised CRP/WCC; orthopaedic and paediatric emergency
Visual symptoms in JIA: Any complaint of blurred vision, halos, or photophobia in a child with known JIA — urgent ophthalmology (note: most JIA uveitis is asymptomatic, but symptoms indicate advanced disease)
Missed uveitis screening: Child overdue for slit-lamp examination by >3 months — arrange urgent ophthalmology appointment

Special Populations

Specific patient groups with oligoarticular JIA require tailored management approaches.

Very Young Children (Under 2 Years)

Diagnosis in toddlers is challenging — presenting as refusal to walk, limping, or being carried; parents may attribute symptoms to injury or growing pains
Exclude leukaemia — all children with unexplained joint symptoms, particularly if accompanied by bone pain, constitutional symptoms, or cytopenias, require FBC and blood film; bone marrow biopsy if leukaemia suspected
Intra-articular injection under GA — standard for this age group; outpatient procedure at paediatric centre

Adolescents and Transition

Persistent uveitis risk — uveitis risk decreases with increasing disease duration and age but does not disappear; continue ophthalmology surveillance for at least 5 years after disease remission
MTX and contraception — MTX is teratogenic (category X); adolescent females on MTX must use effective contraception; counsel appropriately
Transition to adult care — approximately 30–40% of oligoarticular JIA patients have active disease at age 18; ensure ophthalmology and rheumatology transfer in adult services

Hip Involvement

Hip involvement in oligoarticular JIA is uncommon — when present, suggests ERA or sJIA subtype and requires re-evaluation of diagnosis
Hip arthritis MRI — superior to plain films for detecting synovitis, acetabular cartilage damage, and early erosions; arrange if clinical hip involvement

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Oligoarticular JIA in Aboriginal and Torres Strait Islander (ATSI) children requires careful differential diagnosis, given the significantly higher rates of acute rheumatic fever, reactive arthritis, and septic arthritis in this population. Misdiagnosis of these conditions as JIA — or vice versa — carries serious consequences. Access to paediatric rheumatology and regular ophthalmology for uveitis surveillance presents major geographic and logistical challenges for ATSI families in remote settings.

Acute Rheumatic Fever Exclusion

In any ATSI child presenting with arthritis, acute rheumatic fever must be excluded before diagnosing JIA. ARF arthritis is migratory, painful, responds rapidly to aspirin/NSAIDs, and is associated with fever and elevated ASO/anti-DNase B titres. JIA arthritis is typically non-migratory and persistent. Obtain ASO titre, anti-DNase B, throat swab, ECG, and echocardiogram in all ATSI children with arthritis. Untreated ARF causes rheumatic heart disease — a major cause of preventable cardiac death in ATSI Australians. RHD Australia guidelines should be followed for ARF management and secondary prophylaxis.

Infection Screening Before Immunosuppression

Screen all ATSI children for strongyloides serology, IGRA (not TST in BCG-vaccinated individuals), hepatitis B, and hepatitis C before commencing MTX, biologics, or corticosteroids. Strongyloides hyperinfection syndrome with corticosteroids or immunosuppression is potentially fatal and preventable with pre-treatment ivermectin. Latent TB reactivation on biologic therapy is a serious risk and requires prophylactic isoniazid if IGRA positive before biologic commencement.

Ophthalmology Access for Uveitis Surveillance

JIA uveitis is asymptomatic and can only be detected by slit-lamp examination. Remote ATSI communities generally do not have access to slit-lamp ophthalmology. ATSI children with oligoarticular JIA at high uveitis risk (ANA+, young onset) require 3-monthly slit-lamp examinations — an extraordinary burden for remote families. Coordinate with state ophthalmology outreach services, RFDS (Royal Flying Doctor Service), and Aboriginal Community Controlled Health Services to establish a sustainable surveillance schedule. Teleophthalmology (retinal photography) is not a substitute for anterior chamber slit-lamp examination.

Paediatric Rheumatology Access and Follow-up

Paediatric rheumatology centres are in capital cities. Telehealth rheumatology for ongoing management is now standard of care and has been widely implemented since 2020. Aboriginal Health Workers and community nurses are critical partners for medication support, blood test monitoring, and recognition of flares. Intra-articular injections require travel to a centre with GA capability — coordinate in advance with the family and integrate with other hospital appointments to minimise travel burden. Written treatment plans in plain English (with visual aids if needed) help families recognise relapse symptoms.

Appropriate Use of Medicine and Stewardship

Stewardship in oligoarticular JIA focuses on uveitis surveillance adherence, appropriate biologic choice, steroid minimisation, and infection screening before immunosuppression.

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Common Stewardship Issues in Oligoarticular JIA:

Using etanercept when uveitis is present or at high risk: Etanercept is ineffective for JIA-associated uveitis and may worsen ocular inflammation. Adalimumab must be used when uveitis is the primary indication for biologic therapy.
Missed ophthalmology appointments: Many children are permanently visually impaired from JIA uveitis because surveillance was inconsistent. GPs should actively facilitate ophthalmology attendance and alert families that JIA uveitis has no symptoms until severe. Every missed appointment is a potential missed diagnosis.
Repeat oral steroids for flares: Oral corticosteroids are not appropriate for ongoing oligoarticular JIA management due to growth suppression and other toxicities. Intra-articular injection and DMARDs are the preferred approaches. Oral steroids may be used briefly for acute uveitis flares under specialist guidance only.
Delaying MTX for uveitis: Methotrexate should be commenced promptly when uveitis is chronic or recurrent, even if joint disease is mild. Delaying systemic therapy risks progressive ocular damage from chronic anterior uveitis.

GP Role in Oligoarticular JIA Management

Diagnosis trigger — joint swelling persisting >6 weeks in a child under 16 years; exclude septic arthritis; urgent paediatric rheumatology referral
Uveitis surveillance — actively facilitate and remind families of ophthalmology appointments; educate parents that JIA uveitis has no symptoms in early stages
Monitoring — FBC and LFTs monthly on MTX (then 3-monthly when stable); blood pressure and glucose if on systemic steroids; growth monitoring 3‑6 monthly
Immunisation — annual influenza vaccination; avoid live vaccines if on biologic; complete all vaccinations before biologic initiation; co-ordinate with rheumatology team

Follow-up and Prevention

Oligoarticular JIA requires long-term follow-up for disease activity monitoring, uveitis surveillance, and treatment optimisation. Approximately 30–40% of patients achieve sustained remission off medication; others require ongoing treatment into adulthood.

Diagnosis

Paediatric rheumatology referral; ANA, RF, FBC, ESR; NSAID commencement; ophthalmology referral for uveitis surveillance; physiotherapy; family education on asymptomatic uveitis risk.

Months 1‑3

Intra-articular THK injection if joint active; slit-lamp review; JADAS assessment; FBC/ESR. Methotrexate commencement if NSAID/IAC insufficient or recurrent disease.

Months 3‑6

MTX response assessment; FBC/LFTs; ophthalmology per risk schedule. Biologic commencement (adalimumab) if uveitis not controlled with MTX, or etanercept if extended oligo without uveitis and MTX fails.

Every 3‑6 months (stable)

JADAS; FBC; slit-lamp per risk; leg length assessment; growth monitoring; steroid review; adherence check; school support letter if needed.

Remission (inactive disease)

Trial of medication tapering after ≥6–12 months of sustained remission, under specialist guidance. Continue ophthalmology surveillance for ≥5 years after remission. Transition to adult services if disease persists to age 18.

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