Juvenile Rheumatoid Arthritis

How is it Treated?

Medications

The immediate goal of drug therapy is to reduce inflammation, relieve pain and swelling, and maximize function. Long-range goals are to alter the progress of the disease and the prevent damage to bone, cartilage and soft tissues such as muscles, tendons and joint capsules. It must be remembered that medication dosages in children must be carefully calculated based on their weight and body size. Medication doses should be adjusted regularly as the child grows to make sure the proper dosages are used. In addition, it is well known that children metabolize some medications differently than do adults. Therefore, drug dosages may be much higher than one would expect based just on the child's smaller body size. Side effects may be different in children, or occur rarely compared to adults taking the same medication. 

The following medications may be used to treat children with arthritis and related conditions.

NSAIDs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first line of medication used in juvenile arthritis and are the mainstay of the initial therapy. NSAIDs must be taken for at least three to four weeks to tell whether they are helping control pain and inflammation. Laboratory tests may be done a few times a year to monitor medication side effects. These medications come in liquid or pill form and are taken from one to four times per day, depending on the drug prescribed. Some common NSAIDs on the market approved for children include: ibuprofen, naproxen, tolmentin, aspirin, choline magnesium trisalicylate and indomethacin. 

Possible side effects of NSAIDs include: occasional stomach pain, nausea and vomiting; anemia; headache; and uncommonly, blood in the urine; fluid retention; thinning and scarring of the skin (especially with naproxen); difficulty concentrating; and rarely, stomach ulcer. 

Aspirin

Aspirin is a rarely prescribed NSAID these days. If chosen by your doctor, it may be used to control joint pain and swelling and to reduce fever just like the other NSAIDs. It is prescribed in large amounts and is given three or four times a day. Young children should not suck or chew on the aspirin because this may damage the chewing surfaces of the teeth and irritate the gums. Instead, try crushing the dose and having the child swallow it in a small amount of a favorite food such as applesauce or yogurt.

Possible side effects of aspirin include stomach pains or stomach bleeding; toxic reactions can occur from too a high dose built up in your child's system (rapid or deep breathing, ringing in the ears, decrease in hearing, drowsiness, nausea, vomiting, irritability, unusual behavior and black stools). A rare complication called Reye's syndrome can occur in children who have the chicken pox or the flu and are taking aspirin. Symptoms include frequent vomiting, very painful headaches, unusual behavior, extreme tiredness and confusion. The different NSAIDs should never be combined together without your doctor's instructions.

Slow Acting Anti-Inflammatory Drugs

These drugs do not relieve pain or inflammation right away; instead, they are given to change the progress of joint disease (such as joint erosions or cartilage and bone destruction) weeks to months after therapy is begun. Therefore, they are referred to as slow-acting anti-rheumatic drugs (SAARDs) or disease modifying anti-rheumatic drugs (DMARDs). These drugs are often used in combination with NSAIDs. Because they are more powerful medications, children will need to have more frequent laboratory tests for monitoring of possible side effects. Some of these medications are described below.

Hydroxychloroquine

Hydroxychloroquine (Plaquenil) is a pill used to control joint pain and swelling. It may take 3 to 6 months to work. While not helpful in all cases, it may be useful when methotrexate or gold have not been completely effective and can be used alone or in combination with other drugs.

Side effects of hydroychloroquine include upset stomach, skin rash and a rare complication, eye damage. A child who takes this drug should have his/her eyes examined at least every six months by an ophthalmologist familiar with this medication.

Sulfasalazine

Sulfasalazine (Azulfadine) is given in pill form. This medication helps the joint pain, stiffness and swelling. It can sometimes have more side effects in children with systemic onset JRA, so should be used with caution in this type of JRA. It takes 6-12 weeks to work. 

Side effects may include stomach upset, achiness, diarrhea, dizziness, headache, light sensitivity, itching, appetite loss, liver abnormalities, lowered blood count, nausea, vomiting or rash. Blood work is checked within a few weeks of starting this medication then every few months to check for these changes.

Gold Compounds

Gold compounds (Auranofin, Ridaura, Myochrysine and Solganol) are used to ease morning stiffness and control joint swelling and pain. The oral form is taken daily. Injections are usually given every week for five or six months, then one or twice a month for as long as necessary. These medications are only occasionally used in JRA any more. They take 3-6 months to work. 

Side effects may include skin rash, mouth sores, kidney problems, a low blood count or anemia. Blood and urine tests are checked every 1 to 4 weeks while taking gold compounds.

Penicillamine

Penicillamine (DePen and Cuprimine) is given in pill form. This medication is rarely used for JRA but more often for scleroderma, an arthritis-related condition. It takes up to 6 months to work.

Side effects include diarrhea, skin rash, hives or itching, low blood counts, mouth sores, nausea or vomiting, stomach pain, loss of taste or appetite, swollen glands, unusual bleeding or bruising, or weakness.

Immune System Medications

Methotrexate

Methotrexate (Rbeumatrex) is given weekly either orally as a liquid or in pill form, or by injection. It is one of the most commonly prescribed SAARDs for children with JRA. It can help the arthritis as well as the systemic illness in many children. It can help control uveitis in more severe cases. It takes 4-8 weeks to work.

Few side effects have been reported at the low doses at which methotrexate is usually prescribed (typically 7.5 to 25 mg a week), but regular laboratory monitoring is still important. Blood tests are usually checked every month at first then every 6-8 weeks later on. This is also a cancer chemotherapy drug but the dosages used in children with JRA are much lower. Therefore, the side effects are less frequent. 

Side effects may include nausea, mouth sores, moodiness, diarrhea, low white blood cell count, lung irritation, infections and liver irritation. Avoid all alcohol intake and smoking while on this medication.

Azathioprine

Azathioprine (Imuran) is given in pill form. This is an immune system suppressing medication. It is not commonly used to treat JRA. It is saved for children that have failed or cannot take methotrexate. It takes about 3 months to work.

Side effects can include cough, fever and chills, loss of appetite, nausea or vomiting, skin rash, unusual bleeding or bruising, unusual tiredness or weakness, or possibly, sterility.

Cyclophosphamide

Cyclophosphamide (Cytoxan) is given in pill form daily or intravenously in a single dose, usually monthly. This drug is rarely used for JRA but often given in children with systemic lupus erythematosus, an arthritis-related condition. It may take several months to work.

Side effects include blood in the urine or burning on urination, confusion or agitation, cough, dizziness, fever and chills, infertility, loss of appetite, nausea or vomiting, unusual bleeding or bruising, unusual tiredness or weakness, and an increased risk for cancer.

Cyclosporine

Cyclosporine (Sandimmune) is given in liquid or pill form. This drug helps the joint inflammation as well as the systemic symptoms of systemic onset JRA. It may take a 1-2 months to work. Blood levels are often checked to determine the best dosage for your child.

Side effects include bleeding, tender or enlarged gums; fluid retention; high blood pressure; increased hair growth; kidney problems; loss of appetite; or trembling or shaking of hands.

Biologic Agents

Biological agents are a new class of medications made of synthetic proteins. These drugs may be made of antibodies that block high levels of inflammatory proteins in patients with arthritis. The drugs available include etanercept (Enbrel) which blocks the protein TNF, and was approved in 1998 by the FDA for RA treatment in adults, and in 1999 for the treatment of JRA. Infliximab (Remicade) is another anti-TNF medication that is approved to treat RA and has begun testing in JRA. 

Intravenous immunoglobulin (IVIG) is used to treat several childhood rheumatic diseases. It is usually given intravenously once a month. It is sometimes used as part of the treatment of systemic JRA. Side effects include the risk of allergic reactions, headaches, stomachache and flu-like symptoms. 

Researchers are developing other experimental biologic therapies that are aimed at specific proteins to control a variety of different diseases.

Glucocorticoid Drugs

Glucocorticoid medications (Dexamethasone, Methylprednisolone, Cortef, Prednisolone and Prednisone) are the most potent anti-inflammatory agents. These drugs are used to treat a variety of rheumatic diseases when the disease is severe or has not responded to other drugs. Sometimes glucocorticoids are used for a few weeks until other slower medications can become effective in controlling the arthritis. 

Because of their many side effects, glucocorticoids must be used with caution. If these drugs are prescribed, the lowest possible dose should be used for the shortest length of time. Usually the drug is given by mouth as a pill or liquid. It can also be given as an injection into the joint itself, or into a muscle, or vein (IV).

Possible side effects of these medications include high blood pressure, osteoporosis (brittle bones), Cushing's syndrome (weight gain, moon face, thin skin, muscle weakness) cataracts, slowed growth rate, reduced resistance to infection, sudden mood swings, increased appetite and weight gain, or increased risk for ulcers. Many of these side effects occur only when the dose is more than 7.5 to 10 mg a day (dose for an average size adult who is taking prednisone).

Glucocorticoids should never be stopped suddenly if they have been taken for more than a month. Your child's own natural gluco-corticoids may not be produced enough after using these drugs for a month or more. A schedule to slowly discontinue or taper these medications will be given to you by your doctor and will prevent this problem. A child taking glucocorticoids should wear a medical alert bracelet or necklace. This will alert emergency medical personnel to give extra medication if the child has surgery or is seriously injured.

Analgesics

Analgesics (acetaminophen [Tylenol, Panadol], tramadol [Ultram]) do not relieve inflammation, but provide pain relief. They should be taken only under a physician's advice in conjunction with other medications. Acetaminophen has few side effects when taken in small doses; very high doses (overdoses) can cause liver damage. Side effects of tramadol may include dizziness, nausea, constipation, headache and sleepiness.

Medications | Exercise | Splints/Surgery | Eye & Dental Care/Diet