“If the two fail to bring down inflammation, we will quickly move to methotrexate,” says Edward H. Giannini, DrPH, professor of pediatrics at the Cincinnati Children’s Hospital Medical Center. 

If methotrexate, a disease-modifying antirheumatic drug (DMARD) fails to control inflammation, doctors prescribe a biologic drug such as etanercept (Enbrel) or infliximab (Remicade) that block an inflammatory protein called tumor necrosis factor (TNF). These drugs, commonly referred to as anti-TNF agents, are often effective at stopping or preventing joint damage and bringing the disease into remission.

“If the joints affected are large weight-bearing joints of the hips, knees or ankles, doctors may treat the disease more aggressively so that the child’s functional ability can be maintained – or regained,” says Giannini.

Another reason for treating aggressively would be if the child has severe uveitis, or inflammation of the eyes that can occur along with JIA and potentially lead to blindness.

Oral corticosteroids are rarely used in oligoarticular disease because of their risk of side effects, says Giannini.

“The idea is to avoid steroids, the more expensive drugs and the more aggressive drugs if you can,” he says.

Polyarticular

(five or more affected joints)

Because of the number of joints affected, injecting the individual joints with corticosteroids

is rarely an option for polyarticular disease. Often doctors begin treatment with NSAID, but if disease activity is high they may either start with methotrexate or quickly move to methotrexate, says Giannini.