First Medications for JIA

By Robyn Abree

If your child was recently diagnosed with juvenile idiopathic arthritis (JIA), take comfort in knowing that today’s treatments are good at preventing long-term joint damage and putting kids in remission. The first medication your child takes depends on various factors, including disease severity, type of JIA and the number of joints affected. But most children will be prescribed one of the following types of medication first.

Methotrexate

Methotrexate (MTX) is one of the most common first drugs kids with JIA receive, and it’s been used for more than 20 years to treat the condition. MTX is a conventional disease-modifying antirheumatic drug (DMARD). DMARDs are powerful drugs that fight the inflammation that can destroy joint cartilage and affect other organs.

Methotrexate is widely considered one of the safest and most effective drugs for children with arthritis. Some parents have concerns about the popular drug , in part because it is also used to treat cancer. But the dose used to treat cancer is significantly higher than the dose used to treat JIA. Experts stress that the benefits of taking methotrexate to help control disease activity greatly outweigh the risks.

Many of the side effects from methotrexate, such as nausea, fatigue and mouth sores, can be managed with a folic or folinic acid supplement or other complementary therapies. Rarely, MTX can affect your child’s liver and bone marrow. So, your child’s doctor will do regular blood tests to assess the liver and blood counts. Doctors and parents should also talk to teens about the risks associated with taking methotrexate and drinking alcohol, since both can affect the liver. It is also important to discuss safe sex practices, as methotrexate can cause birth defects in fetuses.

Methotrexate can be given orally, through pills or liquid, or by injection. You, your child and your child’s doctor will decide the best form to try first.

It can take two to three months for your child to feel the full benefit of MTX.  Your child’s doctor may also prescribe other medications in the meantime. These include nonsteroidal anti-inflammatory drugs (NSAIDs) , such as ibuprofen (Advil, Motrin) and naproxen (Aleve), to ease pain and inflammation. Some doctors may also use corticosteroids , which act on the immune system to calm inflammation. In patients with few joints involved, it’s more common to use intra-articular steroids, which are injected directly into the joint. In severe cases where the patient has significant pain or dysfunction, the doctor may opt for oral corticosteroids while waiting for the medication to kick in.

Biologics

Some children may start with a more aggressive medication if they have more severe disease or systemic JIA (SJIA). Biologics are another type of immunosuppressive medication that target specific parts of the immune system that fuel inflammation. They are more powerful than conventional DMARDs. There are five FDA- approved biologics for children: abatacept, adalimumab, canakinumab, etanercept and tocilizumab. Your child’s doctor may prescribe one of these or prescribe another biologic not yet approved for children, such as infliximab. This practice is common and is called off-label use. If your child’s doctor prescribes a drug approved for adults, he or she will likely adjust the dosage for your child’s body weight. Because biologics are harder to make and cost more to produce, insurers often won’t cover the costs until your child has tried MTX first. But if your doctor believes strongly that your child should try a biologic first, he or she can make a special appeal.

Biologics are given at a doctor’s office through IV infusion or at home by injections. Burning, itching or redness at the needle site may occur, but there are ways to make shot time easier for your child.  Biologics can also increase your child’s risk of infection , so it’s important to take measures that protect them from getting sick. Though uncommon, your child will be screened for tuberculosis before being put on a biologic - these drugs may cause a reactivation of the disease.

A Positive Outlook

If your child doesn’t improve right away, don’t lose hope. Kids with JIA are in a much better place now than they were twenty years ago. Doctors have much more experience working with these medications and have other options for your child if the first medication isn’t working. Help your child take the medication exactly as prescribed. Don’t be afraid to ask questions or raise concerns with your child’s doctor. You may also find it helpful to talk to other parents about their experiences finding the right medication for their child. Connect at arthritis.org/liveyes.