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Juvenile Arthritis (cont.)

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What is the treatment for juvenile idiopathic arthritis (JIA)/juvenile rheumatoid arthritis (JRA)? What medications treat JIA/JRA?

While there currently is no cure for JIA, an integrated and coordinated approach has been shown to be helpful in lessening the morbidity (nonlethal side effects) of JIA. Goals include lessening pain, joint contractures, and growth disturbances (see above). Monitoring for the development of iritis and aggressive treatment are also paramount. Often patients are best served at a pediatric teaching hospital where access to pediatric rheumatologists, physical and occupational therapists, pharmacologists, and social support providers may allow "one stop shopping."

Therapies for JIA patients include the following:

1. Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used as the first line of therapy due to their positive effect of reducing inflammation in arthritis and relatively few side effects. Medications such as ibuprofen (Advil, Motrin), naproxen (Aleve), and indomethacin (Indocin) are examples of this class of therapy.

2. Steroids are another common class of medications for those experiencing moderate to severe arthritis or nonarthritis inflammatory consequences of JIA. These medications may be administered orally (prednisone [Deltasone], prednisolone [Pediapred]), intravenously (methylprednisolone [Solu-Medrol], dexamethasone [Decadron], hydrocortisone [Solu-Cortef]), or injected directly into an involved joint (methylprednisolone [Depo-Medrol], triamcinolone [Kenalog]). Side effects of steroids may be considerable, and pediatric rheumatologists strive to use the lowest possible dosage. Side effects are most commonly seen at dosages over 20 mg/day and may include immune system depression, increased appetite resulting in weight gain, acne, mood changes, osteoporosis, bruising, cataracts, glaucoma, and diabetes.

3. Antirheumatic medications (also known as disease-modifying antirheumatic drugs or DMARDs) are needed in approximately two-thirds of children to control the joint changes and prevent damage of JIA. These medications are generally considered when the medications previously described are not providing effective control of the illness. Medicines in this category include methotrexate (Trexall), now considered the "gold standard" for JIA, sulfasalazine (Azulfidine), azathioprine (Imuran), cyclosporine (Sandimmune, Neoral), and others. These medications are administered orally or intravenously. Antirheumatic medications are more potent in effect but also can have significant side effects. All of these medications require regular blood testing to monitor for side effects. Problems include immune suppression, which may cause an increased risk of infection, certain cancers, bone marrow toxicity, pulmonary toxicity, liver function abnormalities, abdominal pain, and decrease in appetite.

4. Biologic agents can lessen the morbidity for children with JIA. These agents are administered either by superficial injection under the skin or intravenously. Their general chemical classification is that of "monoclonal antibodies" that work by accurately targeting various mechanisms of the immune system that are overactive and misdirected in JIA. They are associated with an increased risk of infections and (rarely) development of certain malignancies. As such, close clinical monitoring and various laboratory studies are required. Examples of biologics used in the treatment of JIA include etanercept (Enbrel), anakinra (Kineret), adalimumab (Humira), tocilizumab (Actemra), and abatacept (Orencia).

5. Autologous stem cell transplantation is reserved only for those children with JIA who have failed the above therapeutic options. This procedure requires hospitalization and is a two-step process. The initial goal is utilization of high-dose immune suppression medications to remove the patient's lymphocytes (a type of white blood cell) that are attacking the patient's joint(s). Once removed, new stem cells from the patient (autologous) that were previously harvested and treated are introduced back into the patient's body via the bloodstream. This process requires expertise found only in a few pediatric referral centers.

Medically Reviewed by a Doctor on 9/14/2016



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