Drugs

NSAIDS, DMARDs, Corticosteroids And Other Drugs Commonly Prescribed For Juvenile Arthritis

(NSAID) Ibuprofen
A review of the medications commonly used as part of a treatment plan for juvenile arthritis. Derrick Coetzee

Although the word literally means joint inflammation, 'arthritis' is a complex family of musculoskeletal disorders consisting of more than 100 different diseases or conditions that destroy joints, bones, muscles, cartilage, and other connective tissues. Similarly, juvenile arthritis (JA) is a basket term used to describe the many autoimmune and inflammatory conditions that can develop in children ages 16 and younger. JA affects the joints, yet it may also involve the eyes, skin, and gastrointestinal tract.

Many approaches to treating juvenile arthritis exist, but underlying any therapeutic plan is a desire to control inflammation, relieve pain, prevent or control joint damage, and maximize a child's functional abilities. Exercise, healthy diet, eye care, and dental care typically feature as components in the initial strategy for treating juvenile arthritis. Drug therapy is a usual second step.

Medication

The occasional use of pain relievers may be the only drug therapy necessary for some children. Yet, juvenile arthritis can advance rapidly and persistently so other children may require a stronger and more consistent course of medication. As the aim of any drug therapy is to reduce swelling, relieve pain, and restore or maximize your child's ability to do things, often more than one drug at a time may be prescribed to treat your child. Beyond any immediate benefits of pain relief, medications are intended to prevent disease progression and destruction of bone, cartilage, and soft tissues, such as muscles, tendons, and joint capsules. 

The following medications, with an individual dosage determined by your child's doctor according to height and weight of your child, have been used to treat juvenile arthritis as well as related conditions. (The descriptions are digested from the work of the Mayo Clinic and the Arthritis Foundation.)

Analgesics

Analgesics are drugs designed specifically to relieve pain. Acetaminophen (for example, Tylenol) is the first level of analgesic and is available without a prescription. Some products combine acetaminophen with an opioid analgesic for added relief. Opioid (also known as 'narcotic') analgesics are usually very effective against pain, but they also carry a greater risk of side effects than acetaminophen. Opioid analgesics work by binding to receptors on cells mainly in the brain, spinal cord, and gastrointestinal system.

Doctors once reserved opioids for treating severe acute pain, such as that from surgery or a broken bone; however, in recent years, they have prescribed opioids increasingly for chronic pain, such as that which results from arthritis. Narcotic analgesics are not appropriate for everyone, and if your child's doctor prescribes an opioid analgesic, be sure you know how to take it. If your child stops taking it abruptly, withdrawal symptoms like anxiety, sweating, nausea, and insomnia may result.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs, such as ibuprofen (for example, Advil and Motrin) and naproxen (Aleve), may reduce pain and inflammation for patients with JA. Outside of arthritis treatment, NSAIDs are used to lower fevers, ease tooth aches, and relieve muscle aches from strenuous physical activity or the flu.

NSAIDs provide sufficient relief for many people, though they are not for everyone. Although some are available without a prescription, they are serious medicines with side effects that may include stomach upset and liver problems. An NSAID may also cause an increased risk of blood clots, heart attacks, and stroke — a risk that may increase with higher doses and longer use. NSAIDs also may cause gastrointestinal bleeding. For these reasons, regular checkups, including blood counts and checking liver enzymes, are important.

All NSAIDs work by blocking prostaglandins, which are involved in pain and inflammation as well as many other bodily functions, including protecting the stomach lining from its own digestive fluids. Traditional NSAIDs block prostaglandins, which are hormone-like substances, by inhibiting two enzymes, cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2). On the other hand, Celecoxib (Celebrex) blocks only the COX-2 enzyme, which is responsible for pain and inflammation, without affecting COX-2, which plays a role in stomach protection. For that reason, it is less likely to cause damage to the stomach.

Disease-modifying Antirheumatic Drugs (DMARDs)

Doctors prescribe DMARDS when NSAIDs alone fail to relieve symptoms of joint pain and swelling. They quell inflammation that can cause permanent damage to the joints and organs and when prescribed early enough, DMARDs may prevent irreparable damage from occurring. Commonly used DMARDs for children include methotrexate (Trexall) and sulfasalazine (Azulfidine). Side effects may include nausea and liver problems.

Their exact mechanisms differ, but most DMARDs work by suppressing the immune system, which in the case of JA is mistakenly attacking parts of the body (the joints, skin and internal organs, for example). Because they work slowly, doctors often prescribe an additional drug, such as a corticosteroid or an NSAID, to help control pain and inflammation. Once a DMARD takes effect, though, the other medications can be tapered or even stopped completely. While your child is taking DMARDs, you should watch him or her for signs of infection, such as chills, fever, sore throat, or cough; it is also necessary to inform your doctor before your child is vaccinated. 

Tumor Necrosis Factor (TNF) Blockers

TNF blockers, such as etanercept (Enbrel) and adalimumab (Humira), may help reduce your child's pain, morning stiffness, and swollen joints. Such drugs, though, may increase the risk of infections and may also mildly increase your child's chance of getting some cancers, such as lymphoma.

TNF blockers literally 'block' or impede a protein called tumor necrosis factor, which is made by white blood cells and promotes inflammation of joint damage. They are a form of 'biologics' and so are genetically engineered from a living organism, such as a virus, gene, or protein, to simulate the body's natural response to infection and disease. Biologics are usually reserved for people whose disease has not responded well to other medications, such as NSAIDs or DMARDs. The body naturally produces small amounts of these agents, but when produced in large amounts in the laboratory and given by injection or infusion, biologics can interfere with different inflammatory substances, cells, or pathways responsible for the symptoms and damage of arthritis.

Biologics will not cure JA, but for many children they can induce remission. A clinical remission is defined as fewer than 15 minutes of morning stiffness and no tender or swollen joints for at least three months. If your child has a serious or recurrent infection or requires live vaccination, your doctor should not start a course of biologics.

Immune Suppressants

Because juvenile rheumatoid arthritis is caused by an overactive immune system, medications that suppress the immune system may be prescribed. Examples include abatacept (Orencia), rituximab (Rituxin), anakinra (Kineret) and tocilizumab (Actemra). They work by blocking white blood cells, called B-cells, which make antibodies and are produced excessively in some forms of arthritis; by blocking interleukin-1 (IL-1) or interleukin-6 (IL-6), two proteins involved in joint inflammation; or by inhibiting the activation of white blood cells called T-cells, thereby preventing the chain reactions that result in inflammation.

Another form of biologics, immune suppressants may increase the risk of infections and, rarely, some types of cancer.

Corticosteroids

Medications, such as prednisone, may be used until a DMARD takes effect to control symptoms of JA or to prevent complications, such as pericarditis, an inflammation of the sac around the heart. Corticosteroids are man-made drugs that simulate the effects of the hormone cortisol, which is produced naturally by the adrenals to play a number of roles in the body. Doctors prescribe these drugs to quickly suppress inflammation that can damage the joints and/or internal organs in people with many forms of arthritis and related conditions.

They may be administered by mouth or by injection directly into a joint. When taking oral corticosteroids, it is important not to stop taking them too quickly because taking the drugs more than a couple of weeks can cause your adrenal glands to slow or even stop their own cortisol production. Thus, stopping quickly could lead to a dangerous cortisol deficiency. Gradually decreasing, or tapering, the dosage, however, gives your own adrenal glands time to resume their normal function. Your doctor will give you specific instructions on how to taper your dose.

Corticosteroids can interfere with normal growth and increase susceptibility to infection, so generally they are used for the briefest possible duration.

 

Source: Arthritis Today's Drug Guide. The Arthritis Foundation. 2013.

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