`
`DMARDs for Juvenile Idiopathic Arthritis - National Library of Medicine - PubMed Health
`
`PubMed Health. A service of the National Library of Medicine, National Institutes of Health.
`
`Comparative Effectiveness Review Summary Guides for Consumers [Internet]. Rockville (MD): Agency
`for Healthcare Research and Quality (US); 2005-.
`This publication is provided for historical reference only and the information may be out of
`date.
`
`DMARDs for Juvenile Idiopathic Arthritis
`A Review of the Research for Parents and Caregivers
`
`John M. Eisenberg Center for Clinical Decisions and Communications Science.
`
`Baylor College of Medicine, Houston, Texas
`
`Created: September 26, 2011.
`
`Is This Information Right for Me?
`
`Yes, if
`
`A doctor said your child has “juvenile idiopathic arthritis” (JIA) (formerly known as “juvenile
`rheumatoid arthritis” or JRA).
`Systemic arthritis
`Oligoarthritis
`Psoriatic arthritis
`Enthesitis-related arthritis
`Undifferentiated arthritis
`Polyarthritis—rheumatoid factor negative
`Polyarthritis—rheumatoid factor positive
`The doctor suggested a type of medicine called a “disease-modifying anti-rheumatic drug” (DMARD).
`
`No, if
`
`Your child is over the age of 16.
`Your child has joint pain, but a doctor has not said that it is JIA.
`The doctor has not suggested a DMARD.
`
`What does this summary cover?
`This summary describes the research about the effectiveness and safety of DMARDs to treat JIA. It explains
`what research shows about how DMARDs help children with JIA, their side effects, and how much they cost.
`It is written to help you talk with your doctor when deciding if a DMARD is best for your child.
`
`Where does the information come from?
`This information comes from a report that reviewed 56 research studies on DMARDs to treat JIA. The report
`was funded by the Agency for Healthcare Research and Quality (AHRQ), a Federal government research
`agency, and reviewed by clinicians, researchers, experts, and the public. You can read the report at
`www.effectivehealthcare.ahrq.gov/dmardsjia.cfm.
`
`Understanding Your Child's Condition
`
`What is JIA?
`Juvenile Idiopathic Arthritis (JIA) is a chronic (ongoing) disease that causes children to have swelling, pain,
`and stiffness in their joints. The ankles, knees, hips, elbows, jaw, and joints in the wrists, hands, and feet
`are most often affected. JIA occurs before the age of 16.
`
`JIA affects each child differently. Symptoms range from mild to severe, and the number of joints
`affected may be different for each child.
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`DMARDs for Juvenile Idiopathic Arthritis - National Library of Medicine - PubMed Health
`JIA can also cause fever, rash, swollen glands, and eye inflammation. Pain, sensitivity to light, or
`blurry vision can be signs of eye inflammation, but often it has no symptoms.
`Rarely, JIA can also cause irritation around the heart and lungs.
`Some children with JIA may develop destructive joint disease. JIA can cause life-long pain and
`disability
`The growth of some children with JIA may be delayed or slowed. Also, the bones around their joints
`may grow at different rates, causing their arms or legs to be different lengths.
`
`How common is JIA?
`Although JIA is rare, it is the most common childhood joint disease. About 1 in 1,000 children have JIA. It
`affects children of all races.
`
`What causes JIA?
`The immune system normally protects the body from disease by destroying bacteria or viruses. In children
`with JIA, the immune system targets and destroys healthy tissue in their joints. Doctors are not sure why this
`happens.
`
`What else should I know about JIA?
`
`JIA is not usually life threatening. Although there is no cure for JIA, there are medicines that can
`control the symptoms of the disease and help prevent long-term disability.
`Children with JIA may go through periods with no joint pain or swelling, called “remission.” While
`some children achieve long periods of remission, others will have their symptoms come back or “flare.”
`The goal of treatment is to keep children in remission and minimize flares.
`Most children with JIA can play sports and exercise when their symptoms are not flaring.
`Your child's primary care physician or pediatrician may suggest you take your child to a doctor who
`specializes in treating children with joint problems. This type of doctor is called a “pediatric
`rheumatologist” (pronounced roo-mah-TOL-o-jest).
`
`Understanding Your Options
`
`How is JIA treated?
`Before any treatment is started, the doctor will ask many questions to understand your child's symptoms and
`activities. Sometimes doctors use questionnaires to collect this information. Doctors and nurses use this
`information to decide what kind of medicines will be best for your child and to measure the success of
`treatment.
`The doctor may recommend medicines that help your child by:
`
`Lessening the pain and swelling when these symptoms “flare.”
`Reducing the number of times the child has symptoms, with the goal of taking away all symptoms for
`long periods of time (“remission”).
`Preventing long-term painful joint damage.
`
`The way JIA is treated depends on how severe your child's symptoms are and how well your child responds to
`the different treatments that are available. Most children with JIA will start with one or both of these
`medicines that treat pain and inflammation:
`
`Nonsteroidal anti-inflammatory drugs (NSAIDs).
`Corticosteroids injected into the painful joint or sometimes taken by mouth.
`
`For some children, NSAIDs and corticosteroids will be all that is needed to relieve the symptoms of JIA and to
`reduce the risk of long-term problems. Other children may need a third kind of drug called a “disease-
`modifying anti-rheumatic drug,” or DMARD.
`
`What are DMARDs?
`DMARDs are a family of medicines that slow or stop the immune system from destroying the joints. Several of
`these medicines have been approved by the United States Food and Drug Administration (FDA) for use in
`children with JIA.
`There are two types of DMARDs — nonbiologic and biologic. Nonbiologic DMARDs are produced from
`chemicals, like most drugs. Biologic DMARDs are antibodies that are similar to those made in the body but
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`these antibodies are created in laboratories.
`
`The most common DMARD given to children with JIA is a nonbiologic called “methotrexate”
`(pronounced meth-oh-TREK-sate). Many doctors prescribe methotrexate as standard treatment for
`JIA.
`Both nonbiologic and biologic DMARDs can be added to standard treatment for children with more
`severe symptoms of JIA or when they are not getting enough relief from their symptoms. DMARDs
`may be taken with each other and with NSAIDs and corticosteroids.
`
`What's the difference between nonbiologic and biologic DMARDs?
`
`Nonbiologic DMARDs can be given as pills or as shots. Biologic DMARDs must be given through an
`IV (intravenous) tube or as a shot. The IV treatment must be given in a clinic or doctor's office, but the
`shot may be given in a clinic or doctor's office or at home.
`Because nonbiologic and biologic DMARDs work in different ways, they have different safety
`concerns. There is not enough research yet to know what all of the differences may be or how
`important they are.
`
`Brand Name
`Generic Name
`Nonbiologic DMARDs
`®
`®
`Azathioprine
`Azasan ; Imuran
`®
`®
`Cyclosporine A Neoral ; Gengraf
`®
`®
`Penicillamine
`Depen ; Cuprimine
`®
`Leflunomide
`Arava
`Methotrexate* Methotrexate LPF
`®
`®
`Sulfasalazine*
`Azulfidine ; Sulfazine
`Biologic DMARDs
`Abatacept*
`Orencia
`Adalimumab* Humira
`Anakinra
`Kineret
`®
`Etanercept*
`Enbrel
`®
`Infliximab
`Remicade
`®
`®
`®
`®
`Intravenous
`BayGam ; Carimune NF; Flebogamma 5% DIF; Gammagard S/D;
`®
`®
`®
`®
`immunoglobulin
`Gammagard Liquid 10%; Gammar-P ; Gamunex 10%; Iveegam EN ;
`(IVIG)
`®
`®
`®
`®
`®
`Octagam 5%; Panglobulin ; Polygam S/D; Privigen 10%;Vivaglobin
`®
`Actemra
`
`®
`
`® ® ®
`
`Tocilizumab
`
`All of the medicines in this list have been studied on children with JIA. Those followed by an * have been approved by the United
`States Food and Drug Administration (FDA) for treating JIA. This list of DMARDs may not include newer medicines that are
`being studied and used for JIA. Ask your doctor about the names of other DMARDs that may be available to you.
`
`What does the research say about the benefits of DMARDs?
`Researchers know much more about using DMARDs in adults than they know about using them in children.
`For this reason, researchers cannot say with much certainty how well these drugs work for children with JIA.
`Researchers found that:
`
`Adding the nonbiologic DMARD methotrexate to treatment works better than NSAIDs and
`corticosteroids alone to improve the symptoms of JIA.
`Biologic DMARDs can improve the symptoms of JIA and reduce flares in some children.
`
`A very small amount of research found:
`
`Children who took DMARDs had some improvement to their quality of life and abilities, but there is
`not enough research to know this for sure.
`Nonbiologic DMARDs may reduce symptoms and improve the health of children with JIA, but there is
`not enough research to know this for sure.
`
`There is not enough research to know if:
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`DMARDs for Juvenile Idiopathic Arthritis - National Library of Medicine - PubMed Health
`Any one of the nonbiologic or biologic DMARDs works better than any other to reduce pain and
`swelling or to protect against joint damage.
`
`What does the research say about the side effects of DMARDs?
`
`The FDA warns that certain biologic DMARDs may rarely lead to the development of unusual
`infections like tuberculosis (called “TB”) and fungal infections like yeast. Children are usually tested
`for these infections before starting biologic DMARDs.
`Serious infections were seen most often in children taking methotrexate and the biologic DMARD
`infliximab at the same time.
`The FDA warns that certain biologic DMARDs called “TNF-alpha blockers” — adalimumab
`®
`®
`®
`), and infliximab (Remicade ) — have been associated with cancer in
`(Humira ), etanercept (Enbrel
`children, but this is rare. The cancer that usually occurs is lymphoma (cancer in the lymph glands,
`which are part of the immune system).
`There is not enough research to know if the side effects are different among DMARDs.
`
`Making a Decision
`
`What else should be considered when making a decision?
`
`Your child's symptoms can help you decide what treatment is best. Be sure to talk about all of your
`child's symptoms and your concerns when answering the doctor's questions. Also tell the doctor about
`the activities your child wants to be able to do.
`In reviewing all the treatment choices with your doctor, you may want to talk about the “trade-offs”
`between the benefits of certain treatments and the risks of possible side effects. In these discussions,
`you want to understand from your doctor the risk of crippling or destructive joint disease if your child is
`not treated or is not treated enough.
`
`What are the costs of DMARDs?
`The cost to you for these medicines depends on:
`
`The type of health insurance you have.
`The dose (amount) of medicine your child needs to take.
`Whether the medicine comes in a generic form.
`
`The most commonly used nonbiologic DMARD is methotrexate. This drug comes in both generic and brand
`forms.
`The cost of methotrexate can range widely, depending on the weight of your child. The average wholesale
`price of the medicine for a 65-pound child is around $60 a month for generic methotrexate (tablets), around
`®
`®
`$187 a month for the brand Rheumatrex , and around $76 a month for the brand Trexall
`.
`
`The cost of biologic DMARDs can range widely, depending on the weight of your child and the type of
`DMARD. For a child who weighs about 88 pounds, the cost of a 1-month supply of a biologic DMARD is
`between $750 and $2,500.
`
`Ask Your Doctor
`
`What do you think about the research on DMARDs?
`Given my child's symptoms, which treatment option is best?
`What are the short-term and long-term side effects of the medicines?
`Is my child at risk for developing infections or cancer if he or she takes these medicines?
`What should I expect will happen to my child if no treatment is given?
`
`Other questions for your doctor
`_________________________________________________________________
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`_________________________________________________________________
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`_________________________________________________________________
`_________________________________________________________________
`
`Write the answers here
`_________________________________________________________________
`_________________________________________________________________
`_________________________________________________________________
`_________________________________________________________________
`_________________________________________________________________
`_________________________________________________________________
`_________________________________________________________________
`_________________________________________________________________
`
`Source
`The information in this summary comes from the report Disease-Modifying Antirheumatic Drugs
`(DMARDs) in Children With Juvenile Idiopathic Arthritis (JIA). It was produced by the Duke University
`Evidence-based Practice Center with funding by the Agency for Healthcare Research and Quality (AHRQ).
`For a copy of the report, or for more information about AHRQ and the Effective Health Care Program, go to
`www.effectivehealthcare.ahrq.gov/dmardsjia.cfm. Additional information for this summary came from
`®
`MedlinePlus Web site, a service of the U.S. National Library of Medicine and the National Institutes of
`Health. This site is available at www.nlm.nih.gov/medlineplus.
`This summary was prepared by the John M. Eisenberg Center for Clinical Decisions and Communications
`Science at Baylor College of Medicine, Houston, TX.
`
`Copyright Notice
`
`PMID: 22091483
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