45953032 Juvenile Rheumatoid Arthritis JRA
-
Upload
bima-andika-pratama -
Category
Documents
-
view
220 -
download
0
Transcript of 45953032 Juvenile Rheumatoid Arthritis JRA
-
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
1/36
Juvenile rheumatoidarthritis (JRA)
-
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
2/36
BACKGROUND
Chronic Arthritis in Childhood ischaracterized as
Juvenile Rheumatoid Arthritis
(JRA)Age of onset < 16 years of age.
-
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
3/36
BACKGROUND
Pathogenesis and Etiology of JRA: Multi-factorial
Genetic, Hormonal, Immunologic Pathogenesis
Characterized by chronic inflammation of thesynovium;
Presence of articular cartilage damage;
Accompanied by extra-articular systemicmanifestations.
Heterogeneity of JRA
At least 3 primary types of onset of JRA:
Pauciarticular (Oligoarticular)
Polyarticular and
Systemic
-
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
4/36
BACKGROUND
Pathogenesis (Continued)
Genetic Basis of immune distinction between self and non-
self is the major histocompatibility complex (MHC)that in humans is called the human leukocyteantigen (HLA).
HLA system comprises a family of polymorphicgenes located on the short arm of chromosome 6.
Polymorphisms of JRA suggest a non-mendelianinheritance.
Hormonal Factors Differences in the sex ratio of JRA subtype onset Pre-adolescent or post-adolescent peaks
-
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
5/36
BACKGROUND Immune Mechanisms
Disease process involves loss of tolerance towardsauto-antigens chronic synovitis;
Production of auto-antibodies:
Anti-nuclear antibodies (ANA): associated with
increased risk of iridocyclitis (eye inflammation); Rheumatoid factors (RF): auto-antibodies directed
against the Fc fragment of IgG (associated with~10% of polyarticular JRA);
Complement activation by circulating immunecomplexes may also contribute to the diseaseprocess.
-
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
6/36
BACKGROUND
Immune Mechanisms (Continued)
Cytokines: act on the immune system and other cellsto initiate and sustain inflammation:
Intercellular mediators: Interleukin-1 (IL-1), IL-6,and tumor necrosis factor-alpha (TNF-);
Immunomodulatory cytokines produced by T-cells Interferon gamma (IFN-), IL-4, IL-2.
-
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
7/36
CLASSIFICATION OF JRA
ACR (American College of Rheumatology)Criteria Age at onset: < 16 years of age; Arthritis - swelling or effusion or the presence of 2 or more
of the following signs: Limitation of range of motion, Tenderness or pain on motion and
Increased heat in one or more joints; Duration of disease > 6 weeks;
Onset type is defined by the type of disease in the first 6
months: Oligoarticular (Pauciarticular) < 5 inflamed joints; Polyarticular: > 5 inflamed joints; Systemic onset: arthritis with characteristic fever.
Exclusion of other forms of childhood arthritis.
-
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
8/36
General history of JRA includes the following: Disease onset is either insidious or abrupt, with morning
stiffness and arthralgia during the day. Their abilities to participate in physical education classes
may reflect severity of the disease.
Limping may be observed in individuals with more severe
JRA; however, the presence of limping also raises thepossibility of trauma or another orthopedic problem.
A preceding illness raises the possibility of infectious triggerof JRA or postinfectious arthritis.
Very severe joint pain raises isnt typical for JRA and showsthe possibility of acute rheumatic fever (also suggested bymigratory but not additive arthritis, with fevers).
Weight loss without diarrhea may be observed in individuals
with active JRA and sometimes associated with anorexia.
-
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
9/36
CLINICAL MANIFESTATIONS of JRA
-
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
10/36
Characteristic
% Cases (F:M)
# Joints
Age at onset
Systemicinvolvement
Chronic Uveitis
RF/ANA
Prognosis
Polyarticular
30 (3:1)
> 5
Thruchildhood,peak 1-3 yr
Mild;unremitting
articularinvolvement
5%
10%/40-50%
Guarded tomoderately
good
Pauciarticular
60 (5:1)
< 4
Earlychildhood,peak 1-2 yr
None;uveitis (++)
5-15%
Rare/75-85%
Excellentexcept for
eyesight
Systemic
10 (1:1)
Variable
Thruchildhood,
no peak
Systemic self-limited; chronic
destructivearthritis ~50%
Rare
Rare/10%
Moderate topoor
JRA by the Type-of-Onset
-
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
11/36
Extra-Articular Manifestations of JRA
FeverRheumatoid rash
Rheumatoid nodulesHepatosplenomegalyLymphadenopathyChronic uveitisPericarditisPleuritisAbdominal pain
Polyarticular
30%2
101055511
Pauciarticular
0%0
000
20000
Systemic
100%95
585701
352010
-
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
12/36
Systemic-onset JRAis characterizedby spiking fevers, typically occurring severaltimes each day
Evanescent salmon-pink rash, often linear, is foundon the trunk and the extremities; this rash is worsewith fever.
Hepatosplenomegaly. Lymphadenopathy.
Muscle tenderness to palpation.
Ocular: Photophobia, in uveitis (usually
asymptomatic on onset), and synechiae (irregulariris perimeter resulting from postinflammatoryadhesions of iris to lens) may be found
Cardiovascular: myocarditis occurs in individuals
with systemic JRA.
-
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
13/36
Pauciarticular formis characterized by arthritisaffecting 4 or fewer joints.
Typically, large weight-bearing joints, knees, and
ankles are affected.
Involvement of a few small joints in the hands isatypical and suggests eventual development of
polyarticular JRA. Muscle atrophy, often of extensor muscles
(vastus lateralis, quadriceps when knee affected)is found.
Flexion contractures in the knees and, lesscommonly, the wrists are found.
-
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
14/36
Picture 1. Patient with active pauciarticular disease. (significantsuprapatellar swelling (effusion), loss of natural contour medial tothe patella).
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25652565Img00013.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25652565Img00013.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
15/36
Polyarticular formaffects at least 5 joints
Both large and small joints can be involved,often in symmetric bilateral distribution.
Severe limitations in motion are usuallyaccompanied by weakness and decreased
physical function.
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25652565Img00013.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25652565Img00013.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25652565Img00013.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25652565Img00013.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25652565Img00013.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25652565Img00013.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25652565Img00013.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25652565Img00013.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25652565Img00013.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25652565Img00013.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
16/36
Picture 2. Patient with active polyarticular arthritis. (swelling of allproximal interphalangeal joints, boney overgrowth, lack of distalinterphalangeal joint involvement. The patient has interosseusmuscle wasting and subluxation and ulnar deviation of the wrists
are present).
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25652565Img00013.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25652565Img00013.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25652565Img00013.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25652565Img00013.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25652565Img00013.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
17/36
Laboratory studies should include the following:
o Erythrocyte sedimentation rate (ESR)
o
CBC with differential and platelet counto Alanine aminotransferase (ALT) test
o Urinalysis with microscopic examination
o Antinuclear antibody
o Rheumatoid factor
o Total protein, albumin, fibrinogen, D-dimer (forsystemic JRA)
o
Imaging Studies: radiography of affectedjoints, bone scanning, MRI, CT scanning oflong bones, echocardiography
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
18/36
Picture 3. Wrist radiographs of the patient with active polyarticular arthritis shownin Image 2. (severe loss of cartilage in the intercarpal spaces and the radiocarpalspace of the right wrist, large erosion is present in the articular surface of theulnar epiphysis. The view of the left wrist shows boney ankylosis involving the
lateral 4 carpal bones with sparing of the pisiform. Erosions are present in thedistal radius and ulna.
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26092609Img00007a.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
19/36
PROGNOSIS OF JRA
Pauciarticular JRA
Boys may be affected in older childhood oradolescence; this may represent an earlymanifestation of a spondyloarthropathy.
Leg length discrepancy from asymmetric knee
synovitis and bone growth may cause flexioncontractures, gait abnormalities and long-term growthabnormalities.
Eye involvement as anterior uveitis, may lead to
scarring or blindness in ~ 15-20% of children. Active arthritis into adulthood in 40% to 50% of
patients.
Radiographic joint damage within 5 years.
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
20/36
PROGNOSIS OF JRA
Polyarticular JRA and Systemic JRA Active arthritis into adulthood: 50% to 70% of polyarticular
or systemic onset JRA;
Long-term disabilities: 30% to 40% of children
Unemployment: 25% to 50% of adult JRA patients;
May need major surgery(joint replacement).
Radiographic joint damage within 2 years;
Mortality rate: 0.4% to 2% (greater risk with systemic JRAthan with polyarticular JRA).
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
21/36
Traditional Approach to theTreatment of JRA
Cytotoxic Drugs
Disease Modifying
Anti-Rheumatic Drugs(DMARDs)
Intra-Articular/Oral Corticosteroids
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Before the 1990s Pyramid Approach
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
22/36
Treatments with Indications for JRA
Non-Selective NSAIDs
Aspirin, tolmetin sodium, ibuprofen, naproxen Naproxen [Tablets and Suspension]
Indicated for patients 2 years and older with juvenilearthritis.
Daily dose: approximately 10 mg/kg/day as a BIDdose (5 mg/kg given twice-a-day). Total daily dose isnot to exceed 15 mg/kg/day.
Adverse events: gastrointestinal, central nervous
system (headache, dizziness, drowsiness, vertigo),rash (ecchymoses, purpura), pruritus, sweating,special senses (tinnitus, visual disturbances, hearingdisturbances), cardiovascular (edema, palpitations)prolonged bleeding times.
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
23/36
Treatments with Indications for JRA
Non-Selective NSAIDs/COX-2 Selective Inhibitors
MOBIC (meloxicam) [Tablets and Suspension] Indicated for the relief of the signs and symptoms of
pauciarticular and polyarticular course JRA in patients 2 yrsand older.
0.125 mg/kg once daily up to a maximum of 7.5 mg.
Adverse events: abdominal pain/upper, vomiting, diarrhea,headache, infection (rhinitis), cough, pyrexia, rash. urticaria,slight increases in systolic blood pressure.
VIOXX (rofecoxib)[Tablets and Suspension]
Withdrawn from the global market September 2004. Indicated for the relief of the signs and symptoms of juvenile
rheumatoid arthritis in patients 2 years and older.
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
24/36
Treatment of JRA
Corticosteroids
Used for uncontrolled or life-threatening systemicdisease; Treatment of chronic uveitis as local ophthalmic
drops; or Intra-articular agents (Pauci- and polyarticular JRA)
Intermediate-acting corticosteroids: Prednisone;methyl-prednisolone (Intravenous pulse therapy forseverely active JRA). Prednisone low-dose as 0.1 to 0.2 mg/kg; higher-
dose 0.25 to 1.0 mg/kg/day (maximum single dose
40 mg) Adverse events: hypertension, iatrogenicCushings syndrome, growth suppression,fractures, cataracts, increased susceptibility toinfection.
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
25/36
Treatment of JRA DMARDs and Biologic DMARDs
Methotrexate (MTX): used when NSAIDs fail to bringrelief. Indicated for polyarticular JRA. MTX is the most
widelyused DMARD for JRA treatment. Starting dose 7.5 mg/m2 per week; maximum dose of
15 mg/m2 per week. Methotrexate compared to leflunomide (Lef): 240 JRA
pts, 16-week DB + 6 mo Ext + optional 30 mo Ext inJRA; JRA Definition of Improvement > 30% (JRA DOI> 30): 89% MTX compared to 68% Lef.
Adverse events: stomatitis, leukopenia, nausea/abdominal pain, gastrointestinal bleeding, anorexia,malaise, fatigue, chills and fever, headache, alopecia,rash, decreased resistance to infection, elevatedhepatic enzymes.
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
26/36
Treatment of JRA
DMARDs and Biologic DMARDs (Continued)
Sulfasalazine Indicated for polyarticular JRA who have responded
inadequately to salicylates or other non-steroidalanti-inflammatory drugs.
Children 6 yrs and older: 40 - 60 mg/kg/day dividedinto 3 to 6 doses.
Maintenance dose: 30 mg/kg/day divided into 4doses.
Adverse events: anorexia, headache, vomiting,gastric distress, rash, urticaria, hemolytic anemia.
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
27/36
Treatment in JRA
DMARDs and Biologic DMARDs (Continued)
ENBREL (etanercept): a cytokine antagonist Indicated for moderate to severe polyarticular course JRApatients 4 to 17 years of age who had an inadequate responseto one or more DMARDs.
Dosage: 0.4 mg/kg/week (maximum 25 mg/ dose given twice
weekly) as subcutaneous injection pre-filled syringe, 72-96 hrs.apart.
Adverse events: headache, nausea, abdominal pain, andvomiting. Infection was reported in 43 of 69 (62%) of JRApatients during the 3-month (open-label phase). Serious AEs
reported in the study: varicella, gastroenteritis, depression/personality disorder, cutaneous ulcer, esophagitis/ gastritis,group A streptococcal septic shock, Type 1 diabetes, soft tissueand post-operative wound infection.
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
28/36
Treatment in JRA
DMARDs indicated for RA without an indication for JRA
Hydroxychloroquine, injectable gold, leflunomide andd-penicillamine.
Other Immunomodulatory or Cytotoxic Drugs
Indicated in RA without a JRA indication:
Azathioprine
Cyclosporine A
Without a RA or a JRA indication:
Chlorambucil
Thalidomide
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
29/36
Treatment of JRA in 2008
Pauciarticular 25% to 33% will respond to NSAIDs;
Patients not responsive to NSAIDS after 4 - 6 weekswith flexion contractures or leg length discrepancy
intra-articular corticosteroids. Patients with extended pauciarticular JRA or small
joint involvement treat as polyarticular JRA.
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
30/36
Treatment of JRA in 2008
Polyarticular
RF (-) or (+), NSAID (symptom control) alone is usuallynot as effective as a NSAID + DMARD.
NSAID trial for several weeks add oral MTX.
If oral MTX is not effective parenteral route MTX.
If NSAID + MTX (oral or parenteral) is not effective anti-TNF medication.
No current evidence whether a combination of MTX +anti-TNF medication are more effective than only anti-
TNF medication.
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
31/36
Treatment of JRA in 2008
Systemic
NSAIDs 2 to 3 weeks with caution risk ofDisseminated Intravascular Coagulation (DIC),(macrophage activation syndrome);
Intravenous pulse methylprednisolone;
Oral corticosteroids
Lowest effective dose;
Steroid sparing immunomodulatory approach isunder evaluation for steroid sparing effects.
omp cat ons:
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
32/36
omp cat ons: Systemic-onset JRA
Pericarditis Hemolytic anemia Disseminated intravascular coagulopathy. Macrophage activation syndrome Endarteritis resulting in circulatory compromise of the digits
with threatened autoamputation
Pauciarticular JRA Knee flexion contractures: Uveitis (Picture 7). Leg length discrepancy (can result from neovascularization
of growth plates of an affected knee)
Polyarticular JRA Skeletal abnormalities - (Picture 5-6). Cervical spine involvement
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
33/36
Picture 5. Patient with inactive polyarticular arthritis. Long-term sequelae ofpolyarticular disease includes joint subluxation (note both wrists and thumbs),
joint contractures (at proximal interphalangeal joints and distal interphalangealjoints), boney overgrowth), and finger deformities (swan-neck or boutonniere
deformities).
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2610REVD26102610jra-xray-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25102510Img00028.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25102510Img00028.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
34/36
Picture 6. Hand and wrist radiographs of the patient with inactive polyarticulararthritis shown in Image 5. Long-term sequelae of polyarticular disease includesperiarticular osteopenia, generalized increase in the size of epiphyses,accelerated bone age, narrowed joint space, boutonniere deformities (at left third
and fourth interphalangeal joints), and medial subluxation of the firstmetacarpophalangeal joints bilaterally.
Pi t 7 S l f h i t i iti N t th t i hi
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25102510Img00028.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25102510Img00028.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25102510Img00028.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25102510Img00028.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25102510Img00028.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25102510Img00028.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/25102510Img00028.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2615REVD26152615jra-xray5-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2615REVD26152615jra-xray5-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2615REVD26152615jra-xray5-lr.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
35/36
Picture 7. Sequelae of chronic anterior uveitis. Note the posterior synechiae(weblike attachments of the pupillary margin to the anterior lens capsule) of theright eye secondary to chronic anterior uveitis. This patient has a positiveantinuclear antibodies and initially had a pauciarticular course of her arthritis.
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2615REVD26152615jra-xray5-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2615REVD26152615jra-xray5-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2615REVD26152615jra-xray5-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2615REVD26152615jra-xray5-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/2615REVD26152615jra-xray5-lr.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26192619261917.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/ped/images/Large/26192619261917.jpg&template=izoom2 -
7/31/2019 45953032 Juvenile Rheumatoid Arthritis JRA
36/36