How is it treated and managed?
The effective management of JIA requires early diagnosis and a multidisciplinary team approach as well as education of the patient and family. The goals of treatment are the control of inflammation, pain relief, prevention or control of joint damage and to maximise function. For children with severe arthritis or a rapid progression of symptoms, the use of two more modalities (methods of treatment) appears to alter the disease course.
Pharmacological management
1. NSAIDs
Non-steroidal anti-inflammatory drugs (NSAIDs) are used to help control pain and inflammation. Common NSAIDs include: ibuprofen, naproxen, and indomethacin.
Side effects of concern are gastric irritation, liver and kidney toxicity or other evidence of drug sensitivity that require stopping the use of these drugs. However, children are much less likely to suffer such side effects than adults.
2. Analgesics
Analgesics like paracetamol (Panadol) and tramadol provide pain relief.
3. DMARDs
Disease modifying anti-rheumatic drugs (DMARDs), reduce the activity of JIA. These drugs are often used in combination with NSAIDs. They require frequent monitoring blood tests. Some of these medications are listed below:
Methotrexate is the most commonly prescribed DMARD and has made a significant difference in the management of JIA. It can help the arthritis, as well as the systemic illness including control of uveitis. It starts to work quickly in most cases, but can take up to 4 weeks to take effect. It is given weekly either orally as a liquid or in pill form, or, more usually, by injection. Regular laboratory monitoring is important as it can affect the blood count as well as causing nausea, mouth ulcers, and more rarely liver and lung problems, although it is usually tolerated very well by children.
Other DMARDs used in JIA are: Hydroxychloroquine (Plaquenil) Sulfasalazine (Salazopyrin); Gold injections (Myocrisin); Penicillamine; Azathioprine (Imuran); Cyclophosphamide and Cyclosporin A.
4. Biological Agents
Biological agents are a newer class of medications made of synthetic proteins that block the inflammatory proteins in patients with arthritis. These drugs include:
- Etanercept (Enbrel) - a self-injectable drug given twice weekly.
- Infliximab (Remicade) IV - infusion every two months.
- Adalimumab (Humira) - a self-injectable drug.
5. Steroids
Steroid treatment is reserved to treat more severe features of illness. They may also be injected in to joint space to treat a single troublesome joint. Steroid eye drops are used to treat Uveitis. Although effective in decreasing inflammation, they have significant long-term side effects when taken orally. Prolonged steroid use may cause growth problems, weak bones and decreased resistance to infections.
The usual preparation used is prednisolone.
Non- Pharmacological management
Splints
Splints help keep joints in the correct position and relieve pain. They may be used for a variety of joints, from the knee to the wrist and fingers. Often worn at night, they may be used to treat or prevent contractures. The child is usually under the care of a specialist occupational therapist or physiotherapist.
Exercise
Therapeutic exercise can improve joint flexibility and build muscles. It helps to keep joints mobile; keep muscles strong; regain lost motion or strength in a joint or muscle. Crucially, it makes everyday activities like walking, eating and dressing easier. A therapist instructs on how to perform these exercises at home. Hydrotherapy may be of benefit to strengthen muscles and improve range of motion of joints.
Eye Care
Frequent eye examinations in at-risk children can identify inflammatory problems early and reduce the potential for serious eye complications. Eye inflammation may occur even when the joint disease is inactive, therefore periodic examination is essential.
Dental Care
Problems with jaw movement can make brushing and flossing their teeth difficult. Various toothbrush handles, electric toothbrushes and rinses can be used to maintain healthy teeth and gums.
Surgery
Surgery is used as a last resort in children that have responded poorly to medication and other measures. ‘Release’ operations may be needed to loosen tight muscles and tendons and increase range of movement. In order to fix deformed bones, an operation called an osteotomy may need to be performed to reset the bones. Total hip and knee replacements may relieve pain and restore function in a functionally disabled child with debilitating disease.
