Juvenile Rheumatoid Arthritis (cont.)

Medical Treatment

The aim of treatment is to stop or slow down the progress of inflammation, thus relieving symptoms, improving function, and preventing joint damage and other complications. Specific objectives are to reduce joint swelling, stiffness, and pain; maintain full range of motion of all joints; and identify and treat complications early, when they can be stopped or reversed. The success of treatment is checked by regular physical examinations and interviews.
 
Medication is the foundation of treatment in JRA. The medications that work best in JRA reduce inflammation, which in turn reduces symptoms. Aggressive, early treatment is the best way to stop or slow the disease over the long run. Various classes of medications used in JRA are described here. 
 
Nonsteroidal anti-inflammatory drugs (NSAIDs) reduce inflammation, swelling, and pain. They work by blocking an enzyme called cyclo-oxygenase (COX), which promotes inflammation.

• These drugs are used to treat all types of JRA and are usually the first choice of treatment.
  
  
• An NSAID alone may be adequate in pauciarticular disease and mild cases of polyarticular disease.
  
  
• Children with more severe disease often require a second drug to be added to the NSAID. This is usually a drug from another class, since taking more than one NSAID does not help the disease and may cause severe side effects.
  
  
• It usually takes at least 4 weeks to see whether treatment with a specific NSAID is going to work.
  
  
• Aspirin is no longer a first choice in JRA because of its side effects. The side effects can be (but rarely are) serious, especially those in the digestive tract and liver.
  
  
• A newer generation of these drugs is called the COX-2 inhibitors. These drugs are much less likely than other NSAIDs to cause digestive side effects in adults. Rofecoxib (Vioxx) is a COX-2 inhibitor that was recently approved by the United States Food and Drug Administration (FDA) for treating JRA. However, on September 30, 2004, Merck & Co, Inc, announced a voluntary withdrawal of rofecoxib (Vioxx) from the US and worldwide market because of its association with an increased rate of cardiovascular events (including heart attacks and strokes) compared to that of placebo.
  
  
• Predicting which children will respond to a particular NSAID is impossible. Children who show no improvement after 1-2 months of treatment may benefit from changing to a different NSAID.
  
  
• Common side effects include nausea and vomiting, stomach pain, and anemia. Other side effects depend on the NSAID.

Disease-modifying antirheumatic drugs (DMARDs) are not a single class of drugs. Rather, they are a wide variety of different drugs that act in many different ways. Their main similarity is that they interfere in the immune processes that cause inflammation and JRA. DMARDs can slow or stop the progression of JRA and thus joint damage and disability.

• DMARDs may be given alone or in combination with other types of drugs. On the other hand, successful DMARD therapy may eliminate the need for other anti-inflammatory or analgesic medications.
  
  
• Many, but not all, work by stopping the autoimmune response; they are called “immunosuppressive drugs.”
  
  
• These drugs do not work for everyone with JRA, but they give substantial relief to many.
  
  
• DMARDs may not reach their full effect for several months. It is important that the child keeps taking the medication for at least that long before you decide that it is not working. Until the full action of a DMARD takes effect, your child’s health care provider may prescribe anti-inflammatory or analgesic medications as “bridging therapy” to reduce pain and swelling.
  
  
• These drugs have many potential side effects (which vary by drug). Children taking some of these drugs require regular blood tests to check for side effects.
  
  
• The immunosuppressive drugs impair the immune system’s ability to fight infections. Anyone taking one of these drugs must be very vigilant to watch for early signs of infection, such as fever, cough, or sore throat. Early treatment of infections can prevent more serious problems.
  
  
• These drugs have been shown to improve signs and symptoms (as well as quality of life) in most children with JRA.

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 2-3 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 provider 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 provider before stopping the drug.

Analgesics are drugs that reduce pain but do not affect inflammation, swelling, or joint destruction.

• Acetaminophen/paracetamol, tramadol, codeine, opiates, and a variety of other analgesic medications can be employed to reduce pain.
  
  
• 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 provider.

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.