Medications

Most children with juvenile rheumatoid arthritis (JRA) need to take medicine to reduce inflammation and control pain and to help prevent increasing damage to the joints. When inflammation and pain are controlled, a child is more willing and able to do joint exercises to improve joint strength and prevent loss of movement.

Many different medicines are used to treat JRA. No single medicine works for every child. It may take some time to find the right medicine or combination of medicines that best controls your child's symptoms. Treatment is individualized for each child by his or her doctor and parents while considering effectiveness, side effects, cost, and the type and severity of the disease.

Medication Choices

Although treatment varies depending on the needs of the individual child, certain medications are often tried first (first-line medications), while others are often saved to try later if they are needed (second-line medications).

First-line medication. Nonsteroidal anti-inflammatory drugs (NSAIDs) are usually the first medicines tried to control JRA inflammation and symptoms. Naproxen sodium is the most frequently used NSAID treatment for JRA. Doctors choose naproxen based on its low incidence of side effects compared to its effectiveness.⁹ Ibuprofen is an effective alternative. But in general, less than one-third of children will have significant relief from NSAIDs.⁴

Corticosteroids may also be used as a first-line medicine, especially as injections, for children who have pauciarticular (oligoarthritis) with shortening of the muscles around the joints (contractures). Oral or injected corticosteroids are often used for polyarticular disease with joint pain and swelling, and sometimes intravenous (IV) corticosteroids are used for systemic JRA.¹¹

Second-line medication. If symptoms are not well-controlled with NSAIDs or corticosteroids, stronger medicines such as methotrexate are often used successfully.¹¹ Methotrexate, sulfasalazine, and other second-line medications are sometimes referred to as disease-modifying antirheumatic drugs (DMARDs). Some experts prefer to call them slow-acting antirheumatic drugs (SAARDs).

Some children with JRA gain significant benefit from early methotrexate treatment. Although there is no definitive way of knowing which children are the best candidates for early methotrexate treatment, this practice is becoming more common in an effort to prevent joint and eye damage. Early treatment with methotrexate is often used for polyarticular JRA.⁴

Biological therapy is a newer option to treat JRA (particularly polyarticular JRA) that does not respond to other treatments. The biological agent etanercept, which is a tumor necrosis factor (TNF) inhibitor, has had some success in relieving symptoms and decreasing the number of flare-ups. Other TNF inhibitors, such as infliximab, are also used.¹⁰

Medications used to treat JRA

First-line

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Corticosteroids

Second-line

Corticosteroids

Methotrexate

TNF inhibitors such as:

• Etanercept (Enbrel)
• Infliximab (Remicade)
• Adalimumab (Humira) and abatacept (Orencia), other medicines similar to etanercept and infliximab

Other second-line medications used less often

Sulfasalazine

Antimalarials (such as hydroxychloroquine sulfate [Plaquenil])

Adult therapies, such as cytotoxic (cell-destroying) drugs and intravenous human immunoglobulin, that may be used for rheumatoid arthritis in adults but are not yet proved to be safe and effective for children with JRA

Gold salts were one of the first treatments used for joint inflammation, and you may still hear about them. But injected gold salts have been replaced by methotrexate for the treatment of JRA. Gold salts taken by mouth (oral) have not been shown to be effective for JRA.⁹

Medications used to treat inflammatory eye disease

Corticosteroid eyedrops

Methotrexate and cyclosporine A

Mydriatics, which are eyedrops that dilate the pupil and keep the iris from sticking to the cornea or lens

Tumor necrosis factor (TNF) inhibitors. These medicines are biological agents known as anti-TNF agents because they reduce inflammation by blocking the TNF protein. Etanercept is an example of these medicines.

What To Think About

Annual flu shots are recommended for children who are on long-term aspirin therapy. Children on long-term aspirin therapy who get chickenpox or influenza (flu) are at risk for getting Reye's syndrome. Although there is a risk, Reye's syndrome is very rare. Very few cases of Reye's syndrome have been reported in children with chronic arthritis who were being treated with aspirin. If your child has been exposed to chickenpox or flu, talk to the doctor about giving your child acetaminophen to control pain and relieve fever until the incubation period, or the illness itself, has passed.

Combination therapy—such as using methotrexate with sulfasalazine, hydroxychloroquine, or etanercept—has been used on a limited basis to treat JRA. Most medical experience with combination therapy is with adults. Only children with severe JRA that has not improved with methotrexate or sulfasalazine are considered for combination treatment.

It is impossible to predict whether a child will improve with a certain medicine. Several different medicines may be tried before one is found that controls symptoms and doesn't cause side effects. It can also take weeks to months for a medicine to show effect, and symptoms may continue during that time.