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Stories for Reprint
Treatment of Children with Arthritis is Changing, Researchers Say
By Petya Eckler, MARRTC Staff
Treatment of juvenile rheumatoid arthritis (JRA) has changed dramatically over the past 10 years and children with the disease are now in better shape than ever, researchers say.
The study involved 960 children with the disease from 21 medical centers in the United States and Canada. Two groups of children were compared - one group was diagnosed between 1996 and 1999, and the other was diagnosed between 2001 and 2005. Researchers observed the children's condition during the course of their disease without intervening as children were receiving one of three disease-modifying treatments, which slow down the disease and limit joint damage. Those treatments were the disease-modifying drug, methotrexate, other disease-modifying antirheumatic drugs (DMARDs) or biologic response modifers.
JRA is arthritis that causes chronic joint inflammation and stiffness in children 16 years old or younger. It can affect any joint and mobility may become limited. The Centers for Disease Control and Prevention estimate that 285,000 children in the United States have the disease.
Biologic response modifiers (brand names Humira, Enbrel and Remicade) block a cell protein which causes inflammation in RA. Biologic therapy can help reduce pain, morning stiffness and joint tenderness in one or two weeks and halts disease progression. Methotrexate and other DMARDs also slow down the disease and limit joint damage but they take weeks to months to start working and are often prescribed together with nonsteroidal anti-inflammatory drugs (NSAIDs), which ease the pain and inflammation. Biologic therapy can help reduce pain, morning stiffness and joint tenderness within weeks and also halt disease progression.
Researchers found that children diagnosed since 2001 were started on methotrexate or the other DMARDs sooner than children diagnosed between 1996 and 1999 and had less active disease and fewer swollen joints.
"It used to be that we were hesitant and would give them [children with JRA] more time on NSAIDs before we added the other medications, primarily because we were concerned about side effects and we didn't think it was necessary to use second-line medications quickly. Now we have learned that side effects are minimal and outcomes are better if we start sooner," said Dr. Beth Gottlieb, chief of the division of pediatric rheumatology at Schneider Children's Hospital in New Hyde Park, NY.
Gottlieb says side effects in children with JRA are the same as in adults with RA but some of the factors that may contribute to side effects are different. Methotrexate, for example, can affect the liver but children's livers aren't burdened by drinking, diabetes and other risk factors and so liver toxicity is less of a concern than in adults, Gottlieb says. In addition, methotrexate in children is often used in higher doses because they have a faster metabolism, she says.
Researchers also looked at how biologic therapy compared with methotrexate and the other DMARDs. They found that children taking biologics had a more severe disease and some had more swollen joints than children on the other medication. This is because biologic therapy is often prescribed for children who fail all other therapies and those who go on biologics have a more sever form of JRA. So to assess the drugs' effectiveness, researchers looked at the amount of change, Gottlieb said.
"They improved greater than the children on methotrexate," she said.
The introduction of biologics has changed the treatment of JRA dramatically and children are reaping the benefits, Gottlieb said.
"There're many more options now. If a child fails one treatment, there're others," she said. "The other big change is the method of treatment ... We're treating with higher dosage, faster and with more medicine available, now that biologics are here."
Because of their short history on the market, the long-term effects of biologics are still unknown, but Gottlieb says the results witnessed so far are that children are functioning better in their day-to-day activities.
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