pediatrics
Juvenile Idiopathic Arthritis (JIA)
Treatment of JIA
Drugs that slow disease progression (particularlymethotrexate, tumor necrosis factor [TNF] inhibitors, and interleukin [IL]-1 inhibitors) Intra-articular corticosteroid injections Sometimes nonsteroidal anti-inflammatory drugs (NSAIDs) for symptom relief ), have dramatically changed the therapeutic approach ( Treatment references , Methotrexateis useful for oligoarticular, psoriatic, and polyarticular forms of JIA. Adverse effects are monitored as in adults. Bone marrow depression and hepatic toxicity are monitored with complete blood count, aspartate aminotransferase (AST), alanine aminotransferase (ALT), andalbumin. Occasionally,sulfasalazineis used, especially in cases of suspected spondyloarthritis. TNF inhibitors are used ifmethotrexateis not effective.Etanerceptis used most commonly at doses of 0.8 mg/kg subcutaneously (up to 50 mg) once a week.Adalimumabandinfliximabare other TNF inhibitors that have been shown to be effective. The IL-1 inhibitorsanakinraandcanakinumabare particularly effective for systemic JIA.Tocilizumab, an IL-6 receptor antagonist, is also indicated for the treatment of systemic JIA and polyarticular JIA.Abatacept, a T-cell costimulation inhibitor, andtofacitinib, a Janus kinase inhibitor, are also options for the treatment of polyarticular JIA. Except for severe systemic disease, systemic corticosteroids can usually be avoided. When necessary, the lowest possible dose is used (eg, range for oralprednisone, 0.0125 to 0.5 mg/kg 4 times a day, or the same daily dose given once or twice a day). Growth retardation, osteoporosis, and osteonecrosis are the major hazards of prolonged corticosteroid use in children. Intra-articular corticosteroid injections can be given. The dosage for children is adjusted based on weight. Some children may need to be sedated for intra-articular injection, especially if multiple joints require injection. Symptoms of juvenile idiopathic arthritis may be reduced with NSAIDs but they do not alter long-term joint disease or prevent complications. NSAIDs are most useful for enthesitis.Naproxen5 to 10 mg/kg orally 2 times a day,ibuprofen5 to 10 mg/kg orally 4 times a day, andindomethacin0.5 to 1.0 mg/kg orally 3 times a day are among the most useful. Iridocyclitis is treated with ophthalmic corticosteroid drops and mydriatics and may require systemicmethotrexateand anti-TNF therapy, and, occasionally, surgery. Physical therapy, exercises, splints, and other supportive measures may help prevent flexion contractures. Adaptive devices can improve function and minimize unnecessary stresses on inflamed joints. 1.Ringold S, Angeles-Han ST, Beukelman T, et al: 2019 American College of Rheumatology/Arthritis Foundation guideline for the treatment of juvenile idiopathic arthritis: Therapeutic approaches for non-systemic polyarthritis, sacroiliitis, and enthesitis.Arthritis Rheumatol71(6):846–863, 2019. doi: 10.1002/art.40884 2.Ringold S, Weiss PF, Beukelman T, DeWitt EM, et al: 2013 update of the 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: Recommendations for the medical therapy of children with systemic juvenile idiopathic arthritis and tuberculosis screening among children receiving biologic medications.Arthritis Rheum65(10):2499–2512, 2013. doi: 10.1002/art.38092.2013 3.Mehta J, Beukelman T: Biologic agents in the treatment of childhood-onset rheumatic disease.J Pediatr189:31–39, 2017. doi: 10.1016/j.jpeds.2017.06.041 