Adult therapies that may be considered for juvenile rheumatoid arthritis

Children who have severe and persistent juvenile rheumatoid arthritis (JRA), during or even after treatment, may be considered for therapies that have been proven to be safe and effective for adult rheumatoid arthritis or other autoimmune disease but have yet to be fully studied for juvenile rheumatoid arthritis. Examples of such therapies include:

• Cyclosporine A. This is a cytotoxic medicine, which destroys certain cells. Cyclosporine A has been used extensively in people who have had organ transplants to prevent their bodies from rejecting the transplanted organ. Cyclosporine is not often used to treat children with JRA; it may be used to treat inflammatory eye disease, which is sometimes caused by JRA.¹ The most common side effects are kidney damage, tremors, headache, high blood pressure, and excessive hair growth.
• Azathioprine (Imuran). This cytotoxic medication has been used to treat very few children with JRA. In a small study, some children also receiving nonsteroidal anti-inflammatory drug (NSAID) and corticosteroid treatment showed a small improvement in symptoms, compared with those who received NSAID, corticosteroid, and placebo treatment.¹ Because little is known about risks of treatment and its effectiveness is not well-established, azathioprine should only be used in life-threatening illness that has not responded to other therapies.
• Intravenous immunoglobulin (IVIG). This therapy has been helpful in the treatment of some immune system diseases. Small studies of IVIG have shown no effect in treating systemic JRA but some short-term effectiveness in treating 75% of children with polyarticular JRA. Because this therapy is very costly and carries some risks, however, it is not considered a practical treatment option for most children.¹
• Leflunomide (Arava). This medicine blocks production of white blood cells, which are needed to cause inflammation in the joints, and thus interferes with disease progression. Studies show leflunomide to be effective in treating adults with rheumatoid arthritis. Leflunomide's side effects include diarrhea, liver inflammation, rash, and hair loss.² Side effects will probably continue to limit leflunomide's use for JRA.¹

Citations

1. Giannini EH, Brunner HI (2005). Treatment of juvenile rheumatoid arthritis. In WJ Koopman, LW Moreland, eds., Arthritis and Allied Conditions, 15th ed., vol. 1, pp. 1301–1318. Philadelphia: Lippincott Williams and Wilkins.

2. Ilowite NT (2002). Current treatment of juvenile rheumatoid arthritis. Pediatrics, 109(1): 109–115.