Treatments

+ Medications

Biologics used to treat ERA include adalimumab (Humira or biosimilar), etanercept (Enbrel or biosimilar) and infliximab (Remicade or biosimilar). Some patients with ERA have another associated condition like uveitis or inflammatory bowel disease. In these cases, this would affect which biologic you would select in discussion with your health care team.

At this time, most of the research for peptide-based therapies has been in animal models of rheumatoid arthritis with some promising results. More studies are needed in humans to determine whether these are feasible and effective treatments. Typically novel therapies are developed and tested in adults before they are studied in pediatric patients.

Yes, there are a new class of biologics that are oral, called JAK inhibitors. This includes a medication called tofacitinib (Xeljanz) that has been studied in children with polyarticular JIA. These medications will become more commonly used in a variety of diseases, and hopefully more available to children and teens.

At present, it is not known what factors- symptoms, lab tests, or disease type- put a patient at higher risk of flare off medication. Your doctor is the best to evaluate whether the symptoms you describe are due to active inflammation, or perhaps due to other issues.

We do not know if taking a biologic treatment for a longer period will influence the chance of a long lasting remission of disease. Each patient is very individual, and other factors, such as type of disease and previous flares, likely have influence over chance for disease remission off medications.

University life can make it easy to prioritize school over your health, but staying consistent with medications and listening to your body is important. Missing doses or pushing through fatigue can sometimes lead to flare-ups, increased symptoms, or burnout.

Helpful strategies may include:

• Keeping a consistent medication schedule
• Tracking symptoms or side effects to discuss with your doctor
• Coordinating prescriptions with a nearby pharmacy before starting school
• Researching student accommodation services early

Many universities offer supports such as exam accommodations, note-taking assistance, deadline extensions, or typing instead of handwriting during exams. Connecting with accessibility services early can make balancing school and health much easier.

Both biologics and biosimilars are created in living cells. Biosimilars are drugs that are highly similar to an originator biologic that has already been approved by for use by regulatory bodies. This means that there cannot be any meaningful differences between the biosimilar and the reference drug with respect to effectiveness and safety. In order to establish biosimilarity, extensive analytical testing confirms matching of structure and function of the drug, followed by limited but targeted clinical trials in a patient population to demonstrate the same efficacy and safety. For approval of a biosimilar, it is not necessary to repeat studies in all the conditions for which the drug is used, as extrapolation is used for the other conditions for which the reference biologic is approved.

The information we have to date on use of biologic treatments in adolescents do not indicate that there should be any concern that these treatments affect puberty or development in any way. As your teen goes into his growth spurt, his doctors may change his doses to account for weight increase.

Both males and females should avoid pregnancy while taking MTX as if it is taken at the time of conception or during pregnancy it can cause birth defects and/or miscarriage.
Individuals should be stop taking MTX for 3-6 months before trying to conceive. The available evidence suggests that MTX does not have any long-term effects on the female or male reproductive system or fertility.

The main risk of mixing MTX with alcohol is that both of these can irritate the liver and thus together could lead to higher risk of liver problems. This is particularly true if one is binge-
drinking while taking MTX. In contrast, liver toxicity with naproxen is rarer.

There is no evidence to recommend vitamin B12 supplementation to help ease nausea or other side effects of methotrexate.

Pediatric rheumatologists usually prescribe folic acid or folinic acid (leucovorin) supplementation, which helps reduce some of the methotrexate side effects, such as stomach upset, nausea and liver toxicity. There are many ways of prescribing folic acid or folinic acid (leucovorin). Some patients take it every day whereas others take it once a week. Your pediatric rheumatologist will discuss the best regime for you.

There are many ways to help reduce nausea caused by methotrexate. Reducing the dose, changing its route of administration (pills versus subcutaneous injections), and splitting the dose if given orally, may be proposed by your pediatric rheumatology care team. Other suggestions may include giving it at bedtime during the weekend so it does not affect school participation. Pediatric rheumatologists often prescribe medications to relieve nausea (for
example; dimenhydrinate, and ondansetron). These measures will usually help the majority of children dealing with this side effect.

Sometimes, if nausea becomes significant and non-responsive to the measures listed above, the pediatric rheumatologist may decide to stop methotrexate and discuss other therapeutic options with the parent/child. We would suggest speaking with your pediatric rheumatology care team about your concerns.

Methotrexate is prescribed either in pill form or in subcutaneous injections given every week. The most common side effects of methotrexate are stomach upset, nausea and
fatigue. These side effects usually manifest themselves within 24 hours of taking methotrexate and may last up to 24-48 hours. If these symptoms are present every day of the week or occur far away from the time of methotrexate administration, it is unlikely that methotrexate is the cause and you may be dealing with something else. If you are unsure, we would suggest speaking with your pediatric rheumatology care team about your concerns.

Pediatric rheumatologists may prescribe various classes of medications to treat juvenile idiopathic arthritis. Each medication or class of medication has its own side effect profile.
Some side effects may be prevented or reduced in various ways (for example: by reducing the dose, changing the administration schedule, or prescribing additional medication). If you believe you/your child has side effect(s), we would suggest speaking with your pediatric rheumatology care team about your concerns.

Methotrexate (MTX) is considered a mild immunosuppressing medication. It works by decreasing the activity of certain types of white blood cells (WBCs). WBCs are also a part of our body’s immune defense against infections, thus by definition MTX does suppress the immune system to a mild degree. However, WBCs are overactive in autoimmune diseases such as Juvenile Idiopathic Arthritis (JIA) and by suppressing their activity, MTX helps to control the disease.

The term “immunomodulating” refers to a drug or substance that modifies the response of the immune system in any way, which may include increasing or decreasing its function.

The dose of methotrexate is generally prescribed by a child’s weight, with the dose calculated based on a calculated body surface area. Your pediatric rheumatologist will suggest dosing changes in your child’s medication depending on several factors including having a reasonable trial of a new medication, such as Humira that your child just started. It may take several months to see best benefit from Humira. Talk to your pediatric rheumatologist to get an idea of how they will make decisions like changing the methotrexate dosing or administration
method.

In some cases, your pediatric rheumatologist may suggest splitting the methotrexate dose in this way; this may be an attempt to avoid stomach upset from the methotrexate.

Many children with JIA will take Naproxen and methotrexate together. Naproxen is a medication with pain relieving properties, and has some anti-inflammatory effect as well when taken regularly. Methotrexate is not a pain relieving medication, but works to control inflammation in a very different way from Naproxen. Many children have good disease control with this combination. Although sometimes parents are told by a pharmacist that one should not take these medications together, in children and teens there is ample evidence that this combination is safe as well as effective.

Both methotrexate and leflunomide have been shown to have efficacy in treating active polyarticular JIA, in clinical trial testing. Methotrexate has been tested more extensively, has slightly higher efficacy and the advantage of being able to adjust the dose more easily as well as administer it through an injection when needed. It is known to have good efficacy in patients with uveitis, whereas leflunomide has not been tested in this situation. Most commonly, methotrexate is the first second-line, or disease modifying agent recommended, and leflunomide is recommended when methotrexate is not tolerated.