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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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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 four 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 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 U.S. and worldwide market because of its association with an increased rate of cardiovascular events (including heart attacks and strokes in adults) compared to that of placebo. Another COX-2 inhibitor, celecoxib (Celebrex), is widely available in the United States.
• Predicting which children will respond to a particular NSAID is impossible. Children who show no improvement after one to two 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 prevent 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 professional 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.

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