The aims of good management of JIA are to prevent joint destruction, and promote growth and development and management of complications. Effective management of JIA needs a multidisciplinary team approach with inputs from a pediatric rheumatologist, who will liaise with the local general pediatrician or general physician ophthalmologist, nurse specialist, physio-therapist, occupational therapist, orthopedic surgeon, podiatrist, clinical psychologist and social worker.
The medications used to treat JIA are divided into first-line agents, second-line agents, immunosuppressive agents, biologicals and steroids.
1. 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.
DMARD (Disease Modifying Anti Rheumatic Drugs) -
- Anti inflammatory agents (NSAIDS) – Nonsteroidal Anti-inflammatory Agents (NSAIDs) decrease inflammation by inhibiting the synthesis of prostaglandins Naproxen, Ibuprofen, Diclofenac sodium. Half of the children who respond to NSAIDs do so after 2 weeks and two thirds by a month; thus if a patient has minimal response, it may be advantageous to change to an NSAID of another chemical class after a month.
- Corticosteroids –. Steroids can be used either orally, by injections or direct administration in the joints depending on the severity of the condition. They are generally to be used when high fever is not responding to NSAID specially systemic JIA with pericarditis, severe uveitis or rapidly progressing JIA.
2. Supportive measures:
- Of current therapies, once a week low dose methotrexate has emerged as the therapeutic agent of choice for children who fail to respond to adequate administration of an NSAID. In the low doses used in the management of arthritis, the drug is an anti-inflammatory and probably a remittent or disease modifying drug. Its efficacy is usually evident 2-3 months after starting treatment. The child needs regular blood tests while on this medicine to screen for side effects.
- Biologic drugs, such as such as Etanercept, Infliximab, and related drugs that block high levels of proteins that cause inflammation can also be used.
- Cytotoxic drugs: Cyclophosphamide, azathioprine, can be used in intractable cases.
Rest and Exercise
3. Maintenance of joint function:
- Most children require 8 hours of sleep each night and often need one or more 30-minute rest periods during the day. Splints may be used to prevent contractures and deformities. Isometric exercise is the strengthening technique of choice in patients with active synovitis. Low impact activities, such as riding a bike and swimming, are also recommended. Physical and occupational therapists can assist in formulating and implementing a balanced regimen for each patient. Occupational therapy helps the child develop strategies for coping with daily life by adapting to his or her environment and using different assistive devices.
It is important for children to maintain lean body mass, because obesity places additional stress on joints, exacerbates inflammation. Studies using fish oil supplements to reduce inflammatory prostaglandins have reported encouraging data.
- Rest in bed. Use of splints to prevent contractures and deformities
- It is important for children with JRA to stay active and keep their muscles strong. Walking, bicycling, and swimming may be good activities. Children should learn to warm up before exercising.
- Physiotherapy – to maintain joint function and to prevent deformity.
Occasionally corrective surgical procedures and synovectomy (operation performed to remove partial or all the synovial membrane of a joint) may be required in severely involved joints.