From the Guidelines
The management of juvenile idiopathic arthritis (JIA) should prioritize a multidisciplinary approach, focusing on controlling inflammation, relieving pain, preserving joint function, and promoting normal growth and development, with the most recent guidelines from 2022 1 recommending a stepped approach to treatment.
Treatment Approach
The treatment typically begins with nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen or ibuprofen to reduce pain and inflammation. For patients who don't respond adequately to NSAIDs, disease-modifying antirheumatic drugs (DMARDs) like methotrexate are often the next step, as recommended by the 2019 American College of Rheumatology guideline 1.
- Key considerations include:
- The use of biologic agents targeting specific inflammatory pathways for more severe cases or those unresponsive to conventional DMARDs.
- Intra-articular corticosteroid injections for persistent joint inflammation.
- Physical and occupational therapy to maintain joint mobility and muscle strength.
- Regular eye examinations to monitor for uveitis, a common complication.
Nonpharmacologic Therapies
The 2021 American College of Rheumatology guideline for the treatment of JIA recommends the use of physical therapy and occupational therapy interventions, as well as a healthy, well-balanced, age-appropriate diet 1.
- Additional recommendations include:
- Medication monitoring and immunizations.
- Imaging studies as needed to assess disease activity and joint damage.
Therapeutic Approaches
The 2021 American College of Rheumatology guideline for the treatment of JIA provides recommendations for therapeutic approaches for oligoarthritis, temporomandibular joint arthritis, and systemic JIA, including the use of DMARDs and biologic agents 1.
- Key points to consider:
- The importance of shared decision-making between the physician, parents, and patient.
- The need for regular assessment of disease activity and adjustment of treatment as needed.
- The potential benefits and risks of different treatment options, including the use of biologic agents.
Disease Management
Effective management of JIA requires a comprehensive approach, including pharmacologic and nonpharmacologic therapies, as well as regular monitoring and assessment of disease activity, as outlined in the Childhood Arthritis and Rheumatology Research Alliance consensus treatment plans for new-onset polyarticular JIA 1.
- Important aspects of disease management include:
- Controlling inflammation and relieving pain.
- Preserving joint function and promoting normal growth and development.
- Preventing long-term morbidities, such as joint damage and visual impairment.
- Addressing the emotional and psychological impact of chronic disease on the child and family.
From the FDA Drug Label
Naproxen suspension is recommended for juvenile rheumatoid arthritis in order to obtain the maximum dosage flexibility based on the patient's weight
HULIO is indicated for reducing signs and symptoms of moderately to severely active polyarticular juvenile idiopathic arthritis in patients 2 years of age and older. HULIO can be used alone or in combination with methotrexate.
The recommended subcutaneous dosage of HULIO for patients 2 years of age and older with polyarticular juvenile idiopathic arthritis (JIA) is based on weight as shown below.
Pediatric Weight (2 Years of Age and older) Recommended Dosage 15 kg (33 lbs) to less than 30 kg (66 lbs) 20 mg every other week 30 kg (66 lbs) and greater 40 mg every other week
The management of juvenile rheumatoid arthritis includes the use of:
- Naproxen: recommended for juvenile rheumatoid arthritis to obtain maximum dosage flexibility based on the patient's weight
- Adalimumab (HULIO): indicated for reducing signs and symptoms of moderately to severely active polyarticular juvenile idiopathic arthritis in patients 2 years of age and older, and can be used alone or in combination with methotrexate. The recommended dosage of HULIO is based on the patient's weight, with 20 mg every other week for patients weighing 15 kg to less than 30 kg, and 40 mg every other week for patients weighing 30 kg or greater 2 2 3
From the Research
Management of Juvenile Rheumatoid Arthritis
The management of juvenile rheumatoid arthritis (JRA), also known as juvenile idiopathic arthritis (JIA), involves a combination of pharmacological and non-pharmacological approaches. The primary goals of treatment are to suppress inflammation, achieve remission, relieve pain, and maintain function with minimal toxicity 4.
Pharmacological Approach
The pharmacological approach includes the use of:
- Nonsteroidal anti-inflammatory agents (NSAIDs) for mild disease 4
- Intra-articular steroid injections, commonly used in patients with oligoarticular JIA 4
- Disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate, which have demonstrated efficacy and safety 5, 6, 4
- Biologic agents, including:
Non-Pharmacological Approach
The non-pharmacological approach includes:
- Physiotherapy to restore normal joint function 7
- Herbs as adjuvants, which have the benefit of no side effects 7
Treatment Modalities
Treatment modalities may vary depending on the subtype of JIA and the individual patient's response to therapy. The treatment of JIA patients involves teamwork, including an experienced pediatric rheumatologist, an ophthalmologist, an orthopedist, a pediatric psychiatrist, and a physiotherapist 6.
Recent Advances
Recent advances in the therapeutic field have created a more hopeful present and future for patients with JIA. International institutions, such as the American College of Rheumatology, have released recommendations and guidelines for rheumatologists for optimal JIA management 8. The use of biologic therapies has contributed to the preservation of functional activity, control of pain, avoidance of joint damage, and extra-articular manifestations 8.