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Medical Author:

William C. Shiel Jr., MD, FACP, FACR

William C. Shiel Jr., MD, FACP, FACR

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.

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Medical Editor:

Catherine Burt Driver, MD

Catherine Burt Driver, MD

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.

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Nonsteroidal anti-inflammatory drugs

• Ibuprofen (Advil, Ibuprin, Motrin)
• Naproxen (Aleve, Naprelan, Naprosyn)
• Diclofenac (Cataflam, Voltaren)
• Indomethacin (Indocin)
• Tolmetin (Tolectin)
• Oxaprozin (Daypro)
• COX-2 inhibitors -- Celecoxib (Celebrex), rofecoxib (Vioxx)

Disease-modifying antirheumatic drugs

• Methotrexate (Rheumatrex, Folex PFS): We do not know exactly how this drug works in treatment of inflammatory conditions. It relieves symptoms of inflammation such as pain, swelling, and stiffness. It may be given by injection if the oral form has little effect. Children taking methotrexate have to have regular blood tests to measure whether the drug is having any adverse effects on the liver or blood cells. It is the standard treatment for children with JRA in which joint damage is occurring.
• Sulfasalazine (Azulfidine): This drug decreases inflammatory responses by an effect similar to that of aspirin or NSAIDs.
• Gold salts (aurothiomalate, auranofin [Ridaura]): These compounds contain very tiny amounts of the metal gold. They can be taken by mouth or as injections. We do not know why they stop inflammation. Apparently the gold infiltrates into immune cells and interferes with their activities. Gold compounds, once widely used in JRA, are now rarely used in this disease.
• Azathioprine (Imuran): This drug stops production of cells that are part of the immune response that causes JRA. Unfortunately, it also stops production of some other types of cells and thus can have serious side effects. It very strongly suppresses the entire immune system and thus leaves the person vulnerable to infections and other problems. It is used only in very severe cases of JRA that have not gotten better with other DMARDs.
• Cyclosporin A (Neoral): This drug was developed for use in people undergoing organ transplantation. These people must have their immune system suppressed to prevent rejection of the transplant. Cyclosporin blocks an important immune cell and interferes with the immune response in several other ways. It is used most often in systemic JRA.
• Leflunomide (Arava): This drug blocks immune antibodies and reduces inflammation. It reduces symptoms and may even slow progression of JRA. This agent is not suitable for some people with kidney problems.

Biologic response modifiers

• Etanercept (Enbrel): This agent blocks the action of tumor necrosis factor, which in turn decreases inflammatory and immune responses. It is given by subcutaneous injection twice weekly.
• Infliximab (Remicade): This antibody blocks the action of tumor necrosis factor. It is usually used in combination with methotrexate in children whose JRA does not respond to methotrexate alone. It is given by intravenous infusion every six to eight weeks.
• Adalimumab (Humira): This is another blocker of tumor necrosis factor. It reduces inflammation and slows or stops worsening of joint damage in fairly severe JRA. This agent is used mainly for people whose JRA has not responded to at least two DMARDs. It is given by subcutaneous injection every other week.
• Anakinra (Kineret): This agent blocks the action of interleukin-1, which is partly responsible for the inflammation of JRA. This, in turn, blocks inflammation and pain. This agent usually is reserved for children whose JRA has not improved with DMARDs. It is given by subcutaneous injection daily.
• Clinical trials of the other biologic response modifiers are now being carried out to see whether these agents offer a benefit to children with JRA.

Glucocorticoids

• Prednisone (Deltasone, Meticorten, Orasone)
• Dexamethasone (Decadron)
• Methylprednisolone (Medrol)
• Betamethasone (Celestone)

Analgesics

• Acetaminophen (Tylenol, Feverall, Tempra)
• Tramadol (Ultram)

All medications have side effects, and the drugs used in JRA are no exceptions. Most studies of drug side effects are done in adults, and less is known about side effects in children. Side effects for a given drug may be much different in children than in adults. The medical professional who prescribes medication for a child with JRA should watch the child's response very carefully and adjust the dose accordingly. The goal is to find the proper balance between improving the child's condition and minimizing side effects.

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