Juvenile Rheumatoid Arthritis: Treatment Overview

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Treatment Overview

The goals of medical treatment for juvenile rheumatoid arthritis (JRA) are to reduce your child's joint pain and to prevent disability. Physical therapy and medicine are the basis of medical treatment for JRA, also called juvenile idiopathic arthritis (JIA) or juvenile chronic arthritis.

Treatment is determined by the type and severity of JRA. Even when JRA is uncomplicated, an affected child still needs many years of medical treatment. To make sure your child's care is appropriate for the stage of disease, work closely with the medical team. Learn as much as you can about your child's disease and treatments, and stay on schedule with medicine and exercise.

Because pain, stiffness, and swelling can change from day to day, it is important to learn how to assess your child's condition. It can be hard to know if children are having pain. Some children are not able to say what they feel, while others are afraid to say they feel pain if they think they will have to go to the doctor or think they will make their parents upset. Children also simply learn to cope with pain by sleeping or playing. To know a child is in pain, you may need to look for changes such as stiff movements, rubbing a joint or muscle, or avoiding movement.⁸ You may also notice your child is irritable or easily upset.

Initial treatment

Treatment for juvenile rheumatoid arthritis (JRA) usually begins after your doctor has eliminated other causes for your child's symptoms. A good indicator of JRA is if your child's pain, swelling, and stiffness in the joints have persisted for at least 6 weeks. Your doctor may set up a treatment team, often including a pediatrician, rheumatologist, and physical and/or occupational therapist.

Physical exercise is a crucial part of treatment for a child with JRA. Your child's physical and occupational therapists can teach you and your child exercises to do at home to prevent contractures and maintain joint range and muscle strength. Moving your child's arthritic joints regularly through their full range of motion helps prevent stiffening or deformity. Many children with JRA don't want to move painful joints and need to be encouraged to continue with daily physical therapy.

Medicine will likely be an important factor in your child's treatment.

• Unless your child's condition is life-threatening or involves severe eye or joint inflammation, nonsteroidal anti-inflammatory drugs (NSAIDs) are likely to be the first line of medication treatment to reduce inflammation and any pain. If you see no improvement after 6 weeks, your doctor may try a different NSAID. Some children gain relief from one NSAID but not another.
• In cases of severe JRA, your doctor may prescribe medicines referred to as disease-modifying antirheumatic drugs (DMARDs) or slow-acting antirheumatic drugs (SAARDs). DMARDs/SAARDs that may be prescribed for JRA include methotrexate, either alone or in combination with other medicines, and/or a newer DMARD called etanercept (Enbrel), which is a tumor necrosis factor (TNF) inhibitor.
• A corticosteroid injection into a joint also may be used to reduce inflammation, particularly if your child has pauciarticular JRA (oligoarthritis).

Pain relief techniques can help you and your child control pain caused by JRA. Your child's doctor can work with you to set up a pain management plan, which might include heat treatments, exercise, and cognitive-behavioral therapy. Breathing and relaxation techniques can be an effective way to reduce pain intensity.⁸

Inflammatory eye disease may develop in children with JRA. Because this form of eye disease generally has no symptoms and can lead to a permanent decrease in vision or blindness, part of your child's treatment plan should be regular checkups with an ophthalmologist. Most children who develop eye disease are treated with corticosteroids and prescription eyedrops called mydriatics.⁹

Home treatment to help your child function as normally as possible should include and address activities in the home, school, and community.

• Range-of-motion exercises, done twice daily with the assistance of an adult, will help to maintain joint range and muscle strength and prevent contractures.
• Balancing rest and activity may mean extra naps or quiet times during the day, mixed with frequent activity to keep muscles from stiffening and weakening.
• Assistive devices can help your child hold onto, open, close, move, or do things more easily. Doorknob extenders, Velcro fasteners, and canes are all assistive devices.
• Partnering with school staff to develop creative ways of dealing with JRA-caused limitations can help your child make the best of his or her abilities.

Ongoing treatment

After your child's initial treatment for juvenile rheumatoid arthritis (JRA), it is likely that he or she will require ongoing treatment throughout childhood. Many children with JRA will outgrow their disease and lead normal adult lives, while others will have some disability and will need continued treatment as adults. Physical exercise and medicines will be the basics of treatment throughout the disease's course.

Physical therapy is a vital component of the successful ongoing management of JRA. Help your child understand the importance of physical therapy exercises and help him or her keep an upbeat attitude about twice-or-more daily stretching and strengthening sessions. Working closely with a pediatric physical therapist can be especially helpful.

If your child doesn't respond to NSAID treatment (first-line treatment) after 2 or 3 months, additional medicine (second-line treatment) will be necessary to manage symptoms and inflammation. Methotrexate has been found to be the most effective second-line medicine for children with JRA.⁹ Children who don't respond well to methotrexate can be offered similar medicines, sometimes referred to as disease-modifying antirheumatic drugs (DMARDs) or slow-acting antirheumatic drugs (SAARDs).

Inflammatory eye disease can develop as a complication in children with JRA. Regular eye examinations with an ophthalmologist need to be included in your child's treatment plan. Most children who develop eye disease are treated with corticosteroids and prescription eyedrops called mydriatics. More severe or continuing eye disease may require other medicines such as methotrexate.⁹

Treatment if the condition gets worse

If your child develops a severe type of juvenile rheumatoid arthritis (JRA), your child's treatment team will initiate treatments for more aggressive disease.

Physical therapy will be an important part of treatment if your child is experiencing severe JRA. Regular physical exercise will help maintain joint range and muscle strength and prevent contractures. If your child is 4 years old or younger, an adult will need to move the child's joints through the range-of-motion exercises. Range-of-motion exercises may be painful during a flare-up of arthritis, so it is very important to be gentle. The physical therapist can help set up an exercise program for your child, either for the child to do alone or to do with help from an adult. Exercises should be done every day and periodically reviewed by the physical therapist.⁹ The therapist will be sure the exercises are being done correctly and decide whether any exercises should be added, dropped, or changed.

Combination therapy—using methotrexate with other medicines such as sulfasalazine, hydroxychloroquine, or etanercept—may be used to treat children with severe JRA.

Biological therapy is a new option to treat JRA, particularly polyarticular JRA, that does not respond to other treatments. The biological agent etanercept, which is a tumor necrosis factor (TNF) inhibitor, has had some success in relieving symptoms and decreasing the number of flare-ups. Other TNF inhibitors, such as infliximab, are also used.¹⁰

Surgery may be used in a very small number of children with JRA who have severe joint deformity, loss of movement, or pain.

Inflammatory eye disease can develop as a complication in children with JRA. Regular eye examinations with an ophthalmologist need to be included in your child's treatment plan. Most children who develop eye disease are treated with corticosteroids and prescription eyedrops called mydriatics. More severe or continuing eye disease may require other medicines such as methotrexate. If eye disease does not respond to these treatments, either, cyclosporine or TNF inhibitors such as etanercept may help.⁹

What To Think About

Some children with JRA suffer a loss of appetite severe enough that malnutrition becomes a medical concern. If your child has little appetite for food, consult a nutritionist for help with your child's basic nutritional needs.

Most children with JRA do not go on to have adult rheumatoid arthritis or other long-term problems related to JRA. Children with pauciarticular JRA (4 or fewer affected joints) have a good long-term outlook but an ongoing risk of developing eye disease. Children with polyarticular JRA (5 or more joints) tend to have more problems long-term.

Very few children with JRA have joint damage that requires surgery. If at all possible, joint reconstruction is delayed until childhood bone growth is complete (about 18 years of age).⁵

Last updated:	June 25, 2008
Author:	Shannon Erstad, MBA/MPH
Reviewed By:	Michael J. Sexton, MD - Pediatrics, Stanford M. Shoor, MD - Rheumatology
Editors:	Kathleen M. Ariss, MS, Pat Truman, MATC