Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
Catherine Burt Driver, MD, is board certified in internal medicine and rheumatology by the American Board of Internal Medicine. Dr. Driver is a member of the American College of Rheumatology. She currently is in active practice in the field of rheumatology in Mission Viejo, Calif., where she is a partner in Mission Internal Medical Group.
Biologic Response Modifiers, Glucocorticoids, Analgesics, and Nondrug Approaches
Biologic response modifiers are a newer, specialized type of immunosuppressive drugs.
These agents are carefully designed to block the actions of natural substances that are part of the immune response, such as tumor necrosis factor or interleukin-1. Therefore, these agents inhibit the autoimmune reaction that causes JRA.
Blocking these substances reduces joint inflammation and thus relieves symptoms and improves the child's overall condition.
There are several different versions of these agents, and in some children JRA will get better with one version and not another.
Although these agents slow down inflammation in a significant proportion of children with JRA, they do not usually lead to remission.
These agents are expensive.
It may take about two to three months to see whether a biologic agent is working in a specific individual.
Children with an infection (especially tuberculosis), cancer now or in the recent past, or certain types of nervous system disorders cannot take these agents.
These agents improve signs and symptoms and quality of life in many people with JRA.
Glucocorticoids ("steroids"), another group of immunosuppressive drugs, are very potent anti-inflammatory agents that block inflammation and other immune responses. All steroids work in the same way; they differ only in their potency and in the form in which they are given. They stop or slow joint damage and reduce symptoms.
These drugs can be given as pills by mouth, into a muscle (intramuscularly), into a vein (intravenously), or in some cases as an injection directly into a joint.
Steroids given in high doses can have many side effects. They tend to lose their effectiveness over time while still causing the same side effects. Furthermore, they can be given safely only for short periods
-- a few weeks or months. Therefore, these drugs are commonly used to bridge the gap while waiting for a DMARD to reach full effect.
These agents are not for everyone. Your child's health care professional will decide whether glucocorticoids are right for your child on the basis of his or her overall medical condition.
In children, these drugs are typically given at the lowest possible dose for the shortest possible time to avoid side effects.
It is very important not to stop taking a glucocorticoid
abruptly, as this can be dangerous. The only safe way to stop taking these
medications is to gradually lower (taper) the dose. If your child seems to be
having severe side effects, talk to his or her health care professional before stopping the drug.
Analgesics are drugs that reduce pain but do not affect inflammation, swelling, or joint destruction.
Acetaminophen is sometimes used for children with mild JRA who cannot take NSAIDs because of hypersensitivity, ulcers, liver problems, or interactions with other drugs. At very high doses, however, this drug also can harm the liver.
These agents usually are given only with other medications.
They should be given only under the supervision of your child's health care professional.
Nondrug approaches include the following:
Physical therapy helps preserve and improve range of motion, increase muscle strength, and reduce pain.
Hydrotherapy involves exercising or relaxing in warm water. Being in water reduces most of the weight on the joints. The warmth relaxes the muscles and helps relieve pain.
Relaxation therapy teaches techniques for releasing muscle tension, which helps relieve pain.
Both heat and cold treatments can relieve pain and reduce inflammation. Some children's pain responds better to heat and others to cold. Heat can be applied by ultrasound, microwaves, warm wax, or moist compresses. Most of these are done in the medical office, although moist compresses can be applied at home. Cold usually is applied by ice pack.
Occupational therapy teaches your child ways to use his or her body efficiently to reduce stress on the joints. It also can help the child learn to decrease tension on the joints through the use of specially designed splints. Your child's occupational therapist can help your child develop strategies for coping with daily life by adapting to his or her environment and using different assistive devices.