With the increased recognition that radiologic joint and cartilage damage occurs earlier in the course of juvenile idiopathic arthritis (JIA) than originally thought, a literature review in the October 5, 2005, issue of the Journal of the American Medical Association¹ underlines the importance of taking a customized approach to treatment of the disease. However, despite treatment advances, researchers argue that there is no evidence-based consensus on the optimal treatment regimen for several subtypes of JIA.
 
"The development of new therapies has markedly increased the ability to effectively treat children with JIA, and the future appears promising," write study authors Philip J. Hashkes, MD, MSc, a pediatric rheumatologist at the Cleveland Clinic Foundation in Cleveland, Ohio, and Ronald M. Laxer, MD, a rheumatologist at the Hospital for Sick Children in Toronto, Ontario, Canada.

"However, there is still a lack of evidence-based medicine in the treatment of some JIA subtypes, [and] the efficacy of early aggressive therapy on the disease course, including the potential use of combination induction therapy, has not been studied," the authors conclude.

Few oligoarthritis patients respond to NSAID therapy

According to the 34 clinical trials included in the analysis, only 25% to 33% of pediatric patients with oligoarthritis respond to nonsteroidal anti-inflammatory drugs (NSAIDs). For patients who do not respond to NSAID therapy after 4 to 6 weeks or who present with flexion contractors or leg length discrepancies, intra-articular corticosteroid injections may be effective, Drs. Hashkes and Laxer point out.

While methotrexate (MTX) is effective for patients with extended oligoarthritis and polyarthritis, it is less effective for systemic arthritis, according to the new review article. For patients with systemic arthritis, sulfasalazine and leflunomide can be used in place of MTX. Anti-tumor necrosis factor-alpha (TNF-α) drugs may also be highly effective for polyarticular-course JIA that does not respond to MTX, but these biologics are less effective in systemic arthritis. According to the review article, there is a lack of consensus on the optimal treatment of systemic and enthesis-related arthritis, and no treatment studies exist for children with psoriatic arthritis.

Furthermore, there are no controlled studies on the use of the interleukin-1 blocker anakinra (Kineret®) in the treatment of JIA, nor are there JIA studies involving the new medications found to be effective in rheumatoid arthritis (RA), such as rituximab (Rituxan®) and abatacept (Orencia®).

Stem cell transplantation still experimental

Autologous stem cell transplantation (ASCT) is believed by many to be the future of refractory autoimmunity, but when it comes to JIA, many questions exist as to ASCT protocol. "Therefore, ASCT must still be regarded as an experimental procedure for patients with severe and unremitting disease," the authors write.

New article offers much-needed guidance

Calling the new study an "excellent review of the available literature on arthritis treatment for kids," Yukiko Kimura, MD, chief of the division of pediatric rheumatology at Hackensack University Medical Center in Hackensack, New Jersey, tells CIAOMed that "these guidelines are important because [they] give the nonpediatric rheumatologist an idea of the evidence for various treatments, [and remind] the pediatric rheumatologist of the existing evidence for the treatments that we use day to day."

For Dr. Kimura, editor of the forthcoming textbook Arthritis in Children and Adolescents: Juvenile Idiopathic Arthritis, the guidelines don't really change the way she treats patients. "I try to use treatments that are evidence-based for the most part, [and] of course, when you have a very severe and refractory patient, these guidelines may not be all that helpful," she says.

However, she continues, "[they] may change the way that adult rheumatologists practice, which is good. Adult rheumatologists often end up caring for children with arthritis by default because of the unfortunate paucity of pediatric rheumatologists, and most are very conservative when treating children because they are afraid to be aggressive, which results in these children being woefully undertreated," she says, adding that "this can result in very poor outcome for these kids, which is a shame in this age of biologic therapies."
 
 Reference

1. Hashkes PJ, Laxer RM. Medical treatment of juvenile idiopathic arthritis. JAMA. 2005;294:1671-1684.