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On beyond methotrexate treatment of severe juvenile rheumatoid arthritis

C.A. Wallace

Division of Immunology and Rheumatology, Department of Pediatrics, University of Washington and Children’s Hospital and Regional Medical Center, Seattle, Washington, USA.

ABSTRACT
Juvenile rheumatoid arthritis (JRA) is not a difficult disease to treat initially. With time, however, it often becomes a challenging chronic illness in which the goal of prolonged remission seems to be a continuing quest for many patients and rheumatologists. The aim of treatment of juvenile rheumatoid arthritis is simple: prevention of joint destruction and promotion of growth and development. The attainment of these goals after the first few years of treatment becomes more and more difficult as medication after medication loses effectiveness and flares of disease occur.
The treatment of juvenile rheumatoid arthritis is hampered by our current lack of understanding of its etiology, what causes it to persist and why it recurs after periods of remission. Treatment is further complicated by the lack of available medications that can specifically alter the vaguely understood events and immunologic processes without significantly altering normal biological and immune functions. Other dilemmas that add to treatment difficulty are the lack of ability to predict which patients will have a more prolonged course with significant joint destruction and which medications are more likely to be effective in which types of patients.
This paper will explore treatment options for persistent, severe childhood chronic arthritis beyond the use of methotrexate but before a leap to transplant. These strategies fall into three main categories - combinations with methotrexate; familiar single agents; and novel new drugs.

Key words
Severe JRA, entancercept, leflunomide, combination therapy.

Please address correspondence and reprint requests to: Carol A. Wallace, MD, Associate Professor, Children’s Hospital and Regional Medical Center, 4800 Sand Point Way NE, P.O. Box 5371 CH-73, Seattle, Washington 98105-0371, USA.
E-mail: cwallace@u.washington.edu