A generation ago, children with
arthritis faced a lifetime of
pain and disability. Today, there are a multitude of treatment options, including a variety of biologics targeting key
cytokines and other inflammatory mediators. While non-steroidal anti-inflammatory drugs and
corticosteroids were once the mainstay of
therapy, they are now largely used as bridge or adjunctive
therapies. Among the conventional disease-modifying
anti-rheumatic drugs,
methotrexate remains first-line
therapy for most children with
juvenile idiopathic arthritis (JIA) due to its long track record of safety and effectiveness in the management of peripheral
arthritis.
Sulfasalazine and
leflunomide may also have a secondary role. The
tumor necrosis factor inhibitors (TNFi) have shown tremendous benefit in children with polyarticular JIA and likely in enthesitis-related
arthritis and psoriatic JIA as well. There may be additional benefit in combining TNFi with
methotrexate.
Abatacept and
tocilizumab also appear to benefit polyarticular JIA; the role of
rituximab remains unclear. For the treatment of systemic JIA, while the TNFi are of less benefit, blockade of
interleukin-1 or
interleukin-6 is highly effective. Additionally,
interleukin-1 blockade appears to be effective treatment of
macrophage activation syndrome, one of the most dangerous complications of JIA; specifically,
anakinra in combination with
cyclosporine and
corticosteroids may obviate the need for cytotoxic approaches. In contrast,
methotrexate along with the TNFi and
abatacept are effective agents for the management of
uveitis, another complication of JIA. Overall, the biologics have demonstrated an impressive safety record in children with JIA, although children do need to be monitored for rare but potentially dangerous adverse events, such as
tuberculosis and other
infections; paradoxical development of additional
autoimmune diseases; and possibly an increased risk of
malignancy. Finally, there may be a window of opportunity during which children with JIA will demonstrate most optimal responses to aggressive
therapy, underscoring the need for rapid diagnosis and initiation of treatment.