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. . .so can methotrexate

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Methotrexate is invaluable for treating JIA, and its use should be continued, according to another review in the same series. The benefit that children derive outweighs the lack of evidence based RCTs, though these are needed to confirm long term effectiveness and safety.

There has been too little recognition of the transforming effect of methotrexate in one of the commonest chronic childhood disorders. In the UK, for example, it is not licensed for use in JIA. Elsewhere it is the first line treatment for polyarticular JIA, with or without steroids.

Just two short term RCTs have been done in children: one over a decade ago, showing significant clinical improvement in severe JIA, and the other more recently, confirming benefit for extended oligoarticular JIA. But a wealth of qualitative evidence exists from years of clinical use.

Modern treatment aims at securing early control of the disease and preventing joint damage, to maintain function and normal lifestyle. With standard treatment of weekly oral methotrexate 10–15 mg/m2 60–75% of recipients experience significant benefit after 4–6 months. Doses up to 20–25 mg/m2 by injection can be used without apparent harm.

Monitoring treatment to ensure optimum benefit and safety is an issue for children, their parents, and their health carers; all need to be educated accordingly. Side effects seem to be low, but routine monitoring is required to detect altered liver function or blood profile or a rash, mouth ulcers, or breathing difficulties or cough. All signal a need to interrupt treatment until these are resolved.