Understanding How Doctors Treat JIA
Approaches may vary, but the ultimate goal is always the same: Remission.
By Mary Anne Dunkin
Juvenile arthritis (JA) is one of the most common childhood diseases in the United States, affecting nearly 300,000 children. JA is actually an umbrella term for the various autoimmune and inflammatory conditions that affect children 16 years or younger, the most common form being juvenile idiopathic arthritis (JIA), which replaces the term “juvenile rheumatoid arthritis.”
For a child diagnosed with JA today, the prognosis is better than at any time in history. The advent of new drugs in recent years and years of experience with the older ones make it possible for the vast majority of children to live healthy, active lives, and in most cases avoid the joint damage that was common a generation ago, says Yukiko Kimura, MD, chief of pediatric rheumatology at Joseph M. Sanzari Children’s Hospital, Hackensack University Medical Center, in New Jersey.
Dr. Kimura is a co-author of the American College of Rheumatology Guidelines for Treatment of Juvenile Idiopathic Arthritis (JIA). The guidelines serve as an outline doctors can follow to help guide their treatment choices for children with JIA, she says.
While the new guidelines offer recommendations, they don't dictate treatment, which varies depending on a number of factors, primarily the type of arthritis your child has, says Dr. Kimura.
“JIA is not one disease, but many different diseases,” she says. “The kind of medications you choose depends on the type of JIA the child is diagnosed with, so the first step is to establish the type of arthritis the child has.”
The Goals of Treatment
Remission – inactive disease – is the ultimate goal of treatment for JA. With the variety of treatments available and the aggressive use of therapies as necessary, doctors are now, more than ever, able to achieve this goal.
“Even though this has always been our goal, we didn’t achieve it a lot of the time maybe 10 or 15 years ago. Now it is the norm rather than the exception,” says Dr. Kimura.
(four or fewer joints affected)
Because oligoarticular JIA affects few joints, treatment is usually less aggressive than for the other forms of the disease. Doctors often being treatment with injections of corticosteroids – man-made drugs similar to cortisol produced naturally by the body – directly into the affected joints, sometimes along with a nonsteroidal anti-inflammatory drug such as ibuprofen (Advil, Motrin) or naproxen (Aleve, Anaprox, Naprosyn).
“If the two fail to bring down inflammation, we will quickly move to methotrexate,” says Edward H. Giannini, DrPH, professor of pediatrics at the Cincinnati Children’s Hospital Medical Center.
If methotrexate, a disease-modifying antirheumatic drug (DMARD) fails to control inflammation, doctors prescribe a biologic drug such as etanercept (Enbrel) or infliximab (Remicade) that block an inflammatory protein called tumor necrosis factor (TNF). These drugs, commonly referred to as anti-TNF agents, are often effective at stopping or preventing joint damage and bringing the disease into remission.
“If the joints affected are large weight-bearing joints of the hips, knees or ankles, doctors may treat the disease more aggressively so that the child’s functional ability can be maintained – or regained,” says Giannini.
Another reason for treating aggressively would be if the child has severe uveitis, or inflammation of the eyes that can occur along with JIA and potentially lead to blindness.
Oral corticosteroids are rarely used in oligoarticular disease because of their risk of side effects, says Giannini. “The idea is to avoid steroids, the more expensive drugs and the more aggressive drugs if you can,” he says.
(five or more affected joints)
Because of the number of joints affected, injecting the individual joints with corticosteroids is rarely an option for polyarticular disease. Often doctors begin treatment with NSAIDs, but if disease activity is high they may either start with methotrexate or quickly move to methotrexate, says Giannini.
If disease activity is low, however, the doctor may continue to watch the disease for six months before moving onto methotrexate. If methotrexate fails to control the disease after a few months, your child’s doctor will likely recommend an anti-TNF agent.
If, after four months or so,TNF agents are not effective, your doctor may switch to another biologic agent such as abatacept (Orencia) with a different mode of action.
“The idea then is to shut off the disease as quickly as possible with as aggressive a therapy as you need to,” says Giannini.
The treatment for systemic disease is often more complicated than oligoarticular or polyarticular disease because children with systemic JIA essentially have two diseases: joint disease and systemic disease, says Dr. Kimura. “You have to look at the two different parts and treat to ameliorate the symptoms of each of those.”
For mild disease with few involved joints and the absence of serious systemic manifestations, such as pericarditis (inflammation of the pericardium, the sac-like covering around the heart), doctors often begin treatment with an NSAID. If the systemic disease is active, your child’s doctor may begin treatment with an oral corticosteroid such as prednisone to get inflammation quickly under control.
If corticosteroids alone fail to control disease activity, the doctor may that prescribe one of two biologic agents: anakinra (Kineret), which blocks a protein called interleukin 1(IL-1), or tocilizumab (Actemra), which blocks interleukin 6 (IL-6).
“It all depends on how they do and how long you are willing to stick with therapy before escalating to the next level,” says Giannini. “Also, if you go to a biologic, you may still use steroids and NSAIDs if you need them.”
If your child has active arthritis, her doctor may prescribe methotrexate or an anti-TNF agent; however, doctors never prescribe two biologics together due to their prohibitive cost and the possibility of complications, says Giannini.