Earlier, more aggressive treatment for JIA urged

Juvenile idiopathic arthritis (JIA) should be treated early and aggressively to prevent significant structural damage, and clinicians should not assume that symptoms will resolve as the patient ages, say the first specific JIA treatment guidelines which were published in the October 5, 2005 issue of the Journal of the American Medical Association. The guidelines are the result of a massive review by Drs Philip J Hashkes (Cleveland Clinic Foundation, OH) and Ronald M. Laxer (Hospital for Sick Children, Toronto, ON) of data from more than 279 clinical studies conducted between 1966 and 2005 and covering treatment of the five most common types of JIA.

“The most important lesson is to treat JIA aggressively early in the disease course by using methotrexate for polyarthritis and biologic-modifying medications for those not responsive to methotrexate. Use intra-articular steroids for oligoarthritis. Also, we know that NSAIDs are not disease modifying and thus should be used more as a symptomatic medication and that systemic steroids should be used as sparingly as possible,” Hashkes tells rheumawire.Not just growing painsHashkes says that this review was undertaken because although JIA (previously called juvenile rheumatoid arthritis) is the most common rheumatic disease of childhood, no carefully vetted treatment guidelines had previously been developed. Perhaps in consequence, he notes that most affected children do not achieve long-term remission and that the attendant burden on patient, family, and society is large.The investigators define JIA as “persistent arthritis for more than six weeks with an onset at less than 16 years of age, after excluding other causes.” The five most common types are:- Oligoarthritis (accounting for more than half of all cases and affecting fewer than five joints). – Polyarthritis (swelling of more than five joints). – Systemic arthritis (high fevers, rash, and swelling of other organs in addition to joints). – Enthesitis-related arthritis (occurring at the point of attachment of skeletal muscle to bone and often affecting the spine and hips). – Psoriatic arthritis.The main recommendations in the guidelines are based on the 36 controlled studies identified. The conclusions based on analysis of those data are that:- Methotrexate is effective for extended oligoarthritis and polyarthritis and less effective for systemic arthritis. – Sulfasalazine and leflunomide may be good alternatives to methotrexate. – TNF inhibitors are highly effective for methotrexate-resistant polyarticular JIA but less effective for systemic arthritis.The authors comment, “There is a lack of evidence for the optimal treatment of systemic and enthesitis-related arthritis.” “It is important that parents and caregivers not assume that the symptoms of arthritis are simply growing pains.”The review puts into high relief the importance of early and accurate diagnosis of JIA occurrence and subtype. Laxer added, “It is important that parents and caregivers not assume that the symptoms of arthritis are simply growing pains.” Hashkes notes that studies from the 1960s through 1980s assumed a 70% to 80% remission rate by adulthood, but in fact between 50% and 70% of children with systemic arthritis or polyarthritis and 40% to 50% of children with oligoarthritis continue to have active disease into adulthood. “Between 30% and 40% of patients have significant long-term disabilities, including unemployment, and between 25% and 50% need major surgery, including joint replacement,” the authors write.Some part of this outcome might reflect undue reliance on NSAIDs for treatment of children with arthritis. Hashkes tells rheumawire that pattern is beginning to change, however. He says that studies in 1999 and 2000 found that rheumatologists were prescribing NSAIDs for about 77% of JIA patients, but he notes an emerging trend among rheumatologists toward the use of more effective agents in pediatric patients.This review also revealed a number of knowledge gaps that would benefit from research attention. Hashkes’s top priority for clinical trials would be a study designed to determine whether combination induction therapy (as is used in cancer chemotherapy) with methotrexate and a biologic-response modifier with or without early steroids and begun immediately after diagnosis would improve remission rates and reduce radiologic joint damage compared with traditional therapy (as outlined in this paper) followed by maintenance therapy. He would also like to see controlled studies in systemic JIA addressing both the systemic component and the arthritis. “The most promising drugs [for systemic JIA] appear to be anti-IL-1 and anti-IL-6 medications. Systemic JIA is the most severe type of JIA and the type most associated with mortality and morbidity. Another important study in systemic JIA would be to compare various ways of giving systemic steroids (daily vs every other day vs intermittent IV pulse),” Hashkes says. Finally, Hashkes would like to see a controlled study comparing methotrexate or sulfasalazine with TNF inhibitors for enthesitis-related arthritis. (Source: Hashkes PJ, Laxer RM. Medical treatment of juvenile idiopathic arthritis. JAMA 2005; 291:1671-1684″; Pubmed: Rheumawire: Joint and Bone: October 2005.)