Medications

Medications

The aim of medical treatment is to improve the arthritis as quickly as possible in all the affected joints.  This is often done with several medications initially and then once the joints are better some medications can be stopped. Always consult your child’s Paediatric Rheumatologist if any of your child’s medication is changed or stopped.

Medication will reduce pain and stiffness in the joints.  This will also prevent damage to the joints. The child is then able to participate in an active exercise programme which keeps the muscles around the joint strong, keeps the joint moving, and reduces the tendency of thinning of the bones. What medication is chosen for that particular child will depend on the pattern of the arthritis.

 

Non-steroidal Anti – inflammatory Drugs (NSAIDs)

There are many different non-steroidal anti-inflammatory drugs (NSAIDs) which help control symptoms such as pain and stiffness in the joints.

NSAIDs are often used initially as they work quickly and are well tolerated. The amount given is worked out according to the weight of the child. NSAIDs reduce inflammation and help control the symptoms caused by JIA, such as stiffness and swelling.

They can make your child feel better but they don’t cure JIA.

These may be: ibuprofen (Brufen), naproxen (Naprosyn), celecoxib (CELEBREX), indomethacin (INDOMETACIN). Nevertheless, all drugs can have side effects, so when your child is prescribed one of these drugs, it is important to note any loss of appetite or tummy pain and report it to your child’s Doctor. Other problems include rashes, particularly on exposure to sun, and sometimes headaches.

Do not give your child any additional over-the-counter NSAIDs, only those prescribed.

Ibuprofen is generally well tolerated. There is a liquid preparation which can be used in young children. As it only works for about 6 hours it must be given in 3 or 4 doses every day. It is often useful in reducing fever – at such a time the dosage may be temporarily increased and reduced as the fever improves.

Naproxen is also available in liquid form although sometimes hard to obtain. It’s advantage over ibuprofen is that it lasts for a longer time in the body and therefore needs to be given only twice a day. Very occasionally naproxen suspension can cause diarrhoea. Sun sensitivity seems more common than with other drugs, beware of holidays in the sun.

Disease modifying Anti – rheumatic drugs (DMARDs)

DMARDs such as Methotrexate, can slow or stop the progression of JIA by reducing the activity of the immune system, which is overactive in JIA. They are often used in combination with an NSAID. These medicines can take several months to reach their maximum effectiveness.

DMARDs reduce the activity of the immune system, some children are more likely to catch infections, because of this, consult your Paediatric Rheumatologist when giving live vaccinations e.g. oral polio, varicella (chicken pox), measles, mumps and rubella.

Corticosteroids (Steroids)

These are powerful drugs which reduce severe inflammation, but the exact way they work is not known. They are given by mouth or by injection intravenously when a child is generally ill (systemic disease), for severe polyarthritis or general deterioration (e.g. anaemia, weight loss) with an increasing number of joints affected. Steroids that are injected directly into the joints under general anaesthetic or Entonox (laughing gas sedation) are an excellent way of treating the inflammation in the joints and the preferred way especially in treating oligo-arthritis, and do not have the side effects of steroids by mouth. This will allow the child to move the joint better and far quicker than other treatments. The parent and child will also be shown exercises and be told when to start them after the injection. Steroid drops are available for eye inflammation.

Prednisolone is an oral corticosteroid and is a very effective anti-inflammatory agent. When high doses have to be given every day or more than once in any one day, side effects can occur. Resistance to infection can be reduced and there is also a risk of an infection, such as chicken pox, being more serious in a child who has been on prednisone. Therefore, it is vitally important that your doctor knows that your child is on prednisone.

Longer term side effects of prolonged treatment with high dose prednisone can include the child becoming cushingoid. The term refers to a typical appearance of a round face. Such a child fails to grow normally, the bones can become thin and the skin bruises easily; very occasionally the blood pressure goes up. Another rare problem is the formation of cataracts in the eye.

When a child has systemic illness, particularly when there are complications such as inflammation of the covering of the heart (pericarditis), it will be necessary to give the drug on a daily basis. Indeed, if a child is extremely ill, it may sometimes be necessary to introduce the drug by means of an intravenous drip (‘pulse’), so that it gets directly into the circulation. This may be repeated on several occasions. Sometimes a ‘pulse’ will cover a period of illness or infection so that the dosage by mouth does not need to be increased.

Steroids must never suddenly be stopped.

Biological Treatment (biologics)

Biological Therapies is a name for some newer very effective drugs. Etanercept, Adalimumab, and Tocilizumab are funded for JIA in New Zealand. Biologics slow down the progress of arthritis, and reduce pain, swelling and stiffness. Like DMARD’s they work by suppressing the immune system and inhibiting the body’s over production of inflammatory substances such as Tumour Necrosis Factor (TNF) alpha.

Biologics (Anti-TNF Treatment), blocks Tumour Necrosis Factor (TNF), a chemical in the body that mediates arthritis. These are given by injection and are given by subcutaneous injection once or twice a week, infliximab given by infusion in hospital. Adalimumab is given once a fortnight by subcutaneous injection. These are generally reserved for patients where methotrexate has not been effective or have developed side effects from methotrexate. There are usually few side effects compared to other treatments but infections can sometimes occur more often.

Pain relievers (analgesics)

Pain relievers include paracetamol (Panadol).  Other stronger pain relievers are also available and can be prescribed by the child’s GP or Specialist. Pain relievers do not reduce inflammation, and can be used with other dugs like NSAIDs.

Always follow the prescribed amount, do not overdose the child.

Diet and Vitamin Supplements

Drug therapy is only one part of the management of children with arthritis. General measures include a healthy diet making sure that the amount and type of food eaten will give enough calories and protein for growth, and calcium to keep the bones as strong as possible.

If your child is eating well there is no need to give vitamins. If the appetite is poor, there is no harm in giving a multivitamin preparation. Similarly, a single dose of cod liver oil (Omega-3) each day may reassure parents that the child is getting enough vitamin D.

An extra supplement of calcium as well as vitamin D may be necessary to minimise thinning of the bones in children on corticosteroids. Taking calcium and vitamin D can help build strong bones.

The vitamin B9 (Folic acid) is usually prescribed when taking Methotrexate, it helps to reduce side effects. It is normally prescribed to be taken on a different day to Methotrexate.

Some supplements that adults take may help children too. These include curcumin, a substance found in turmeric, and omega-3 fish oil supplements, which may help with joint pain and stiffness.

Keeping a child’s gut bacteria healthy is also important. Kid friendly probiotic foods include plain yogurt, kefir, kombucha drink – it contains probiotics, which are healthy bacteria for the gut and fermented vegetables like raw sauerkraut.

Always discuss supplements and vitamins with the child’s doctor. Some may cause side effects and interact with other medications.