Management of a child with juvenile idiopathic arthritis (JIA) is directed toward treating the underlying inflammation, preventing complications (e.g. joint damage, loss of function) and decreasing pain. Treatment is aimed at inducing and maintaining remission with the least toxic medications. The mainstays of JIA therapy represent drugs that suppress the inflammatory and immune responses, and include non-steroidal anti-inflammatory drugs (NSAID), corticosteroids, disease-modifying antirheumatic drugs (DMARDs) and biologic agents.
Systemic corticosteroids are the most potent anti-inflammatory agents and still have an important role especially as an initial treatment in certain JIA subtypes such as systemic JIA, severe forms of polyarthritis with functional impairment and for chronic uveitis unresponsive to topical therapy. Indications for corticosteroids use in systemic JIA include uncontrolled fever, symptomatic serositis, severe anemia and macrophage activation syndrome, while in patients with polyarthritis corticosteroids are usually used as a low-dose and short term bridging therapy before the full therapeutic efficacy of DMARD. Injections of long-acting corticosteroid directly into inflamed joints is a standard therapy in children with oligoarthritis and are sometimes given also in patients with polyarticular disease while awaiting response to DMARD.
The goal of treatment with DMARDs is to achieve and maintain inactive disease and then stop other treatments such as NSAIDs and corticosteroids. Methotrexate is safe and effective drug for treatment of JIA and is the most frequently prescribed DMARD. It has the greatest efficacy in patients with extended oligoarthritis and polyarthritis, and may also have a disease-modifying effect to slow down the radiologic progression of the disease. The disease flare will occur in as many as 60% of the patients after stopping methotrexate and it is not firmly established when a patient can stop taking the drug.
Tumor necrosis factor (TNF)-α antagonists are the most often used biologic therapy in patients with JIA. In general, biologics are indicated in JIA patients who have had an inadequate response to 3 months of methotrexate at the maximum tolerated typical dose or who have not tolerated methotrexate. Since biologic agents have a more rapid onset of action and appear to be more efficacious than methotrexate, treatment with biologics may also be considered before or concurrent with methotrexate, particularly in patients with severe polyarthritis or cervical spine involvement. At present, there is no clear evidence for how long JIA patients should be treated and when to discontinue treatment with biologics. In general, it is advised that the biologic treatment should be slowly tapered and it is not recommended to completely discontinue all therapy (e.g. patients should stay at least on methotrexate). Current evidence suggests that up to 70% of children with JIA that achieved clinical remission on medication will have a disease flare within three years off their medication.
Disclosure of Interest None declared