Earlier, more aggressive treatment for JIA urged

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Earlier, more aggressive treatment for JIA urged



Oct 13, 2005



Janis

Cleveland, OH and Toronto, ON - 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 [1], 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 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.



" 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 pains

Hashkes 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.

http://www.jointandbone.org/viewArticle.do?primaryKey=576699