From the Guidelines
Juvenile idiopathic arthritis (JIA) typically follows a relapsing-remitting course with potential for joint damage if inadequately treated, requiring a stepwise treatment approach. Initial therapy begins with NSAIDs like naproxen (10-20 mg/kg/day divided twice daily) or ibuprofen (30-50 mg/kg/day divided three to four times daily) for pain and inflammation, as recommended by the 2019 American College of Rheumatology guideline for the treatment of JIA 1. For patients with persistent symptoms or polyarticular disease, methotrexate is the cornerstone DMARD, started at 10-15 mg/m² weekly (oral or subcutaneous) with folic acid supplementation, as supported by the guideline 1.
Key Treatment Considerations
- Intra-articular corticosteroid injections (triamcinolone hexacetonide) may be used for oligoarticular disease.
- For inadequate response to methotrexate after 3-6 months, biologic agents are added, with TNF inhibitors (etanercept 0.8 mg/kg weekly, adalimumab 20-40 mg every other week based on weight) being first-line biologics, as recommended by the guideline 1.
- Alternative biologics include IL-6 inhibitors (tocilizumab), T-cell costimulation modulators (abatacept), or IL-1 inhibitors (anakinra, canakinumab) for systemic JIA.
- Systemic JIA specifically may require systemic corticosteroids (prednisone 0.5-1 mg/kg/day) during flares.
- Regular ophthalmologic screening is essential due to the risk of uveitis, particularly in ANA-positive patients.
- Physical and occupational therapy are crucial adjuncts to maintain joint function and prevent contractures.
Treatment Goals
- Achieving clinical remission
- Preventing joint damage
- Maintaining normal growth and development
- Minimizing medication side effects
The disease course varies widely, with some patients achieving permanent remission while others require lifelong therapy, necessitating regular monitoring of disease activity, growth, and medication side effects, as emphasized by the Childhood Arthritis and Rheumatology Research Alliance consensus treatment plans for new-onset polyarticular JIA 1.
From the FDA Drug Label
- 7 Clinical Trials Experience in Polyarticular Juvenile Idiopathic Arthritis Patients Treated With Subcutaneous ACTEMRA (ACTEMRA-SC) The safety of ACTEMRA-SC was studied in 52 pediatric patients 1 to 17 years of age with PJIA who had an inadequate clinical response or were intolerant to methotrexate
- 8 Clinical Trials Experience in Systemic Juvenile Idiopathic Arthritis Patients Treated with Intravenous ACTEMRA (ACTEMRA-IV) The data described below reflect exposure to ACTEMRA-IV in one randomized, double-blind, placebo-controlled trial of 112 pediatric patients with SJIA 2 to 17 years of age who had an inadequate clinical response to nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids due to toxicity or lack of efficacy.
The clinical course and treatment of Juvenile Idiopathic Arthritis (JIA) involves the use of tocilizumab (IV), with the following key points:
- Polyarticular JIA: Tocilizumab can be used in patients who have an inadequate clinical response or are intolerant to methotrexate.
- Systemic JIA: Tocilizumab can be used in patients who have an inadequate clinical response to nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids.
- Treatment: The treatment involves the administration of tocilizumab (IV), with a dose of 8 or 12 mg per kg based on body weight.
- Adverse events: Common adverse events include upper respiratory tract infection, headache, nasopharyngitis, and diarrhea.
- Serious infections: The rate of serious infections was 11.5 per 100 patient years in the controlled phase and 11.4 per 100 patient years in the open-label extension.
- Macrophage Activation Syndrome (MAS): There were a few cases of MAS reported, but the incidence does not appear to be elevated in the tocilizumab (IV) clinical development experience 2.