DEAR DOCTOR K:
My young granddaughter has juvenile rheumatoid arthritis. I worry about the effects of the powerful medications she has to take.
Modern medicine has created real miracles. We have been smart enough to create treatments that relieve suffering and prevent premature death beyond what was previously possible. But we are not yet smart enough to create tests and treatments that are free of side effects.
The treatment of arthritis, in adults and in children like your granddaughter, is an example. Powerfully effective treatments are available today that were not available in the past. Your granddaughter’s suffering has a better chance of being relieved than ever before.
But you’re also right to worry: Medications used to treat juvenile rheumatoid arthritis can cause serious problems. That’s why treating children with this condition is a delicate balance. It’s true the treatment can cause immediate side effects and there can be long-term risks. However, doctors want to do everything they can to promptly relieve their young patients’ suffering and to protect them against long-term bone damage.
With juvenile rheumatoid arthritis, the lining of the joint becomes inflamed and enlarged, limiting movement and causing pain and tenderness. Enzymes released by the inflamed membranes erode the bone and cartilage. This joint and bone damage can cause problems in a growing child; bones may develop abnormally in shape or size.
Medications help to control inflammation to stop further joint damage. They also control pain and inflammation.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are usually the first medications used to relieve joint inflammation. But NSAIDs can cause ulcers. COX-2 inhibitors may be safer for the stomach.
In more severe cases, doctors may use corticosteroids, which are fast-acting, anti-inflammatory agents. But they can cause weakened bones, increased susceptibility to infections and stunted growth. They usually are prescribed for only a short time.
Drugs known as DMARDs often provide relief if other medications have failed. The most widely used is methotrexate. These drugs can cause liver damage or other complications. Doctors carefully monitor children taking DMARDs.
Over the past 30 years, medical scientists have made major advances in understanding the chemical signals that cause inflammation, called cytokines. In the past 15 to 20 years, scientists have developed drugs that block these signals and reduce inflammation. These powerful newer treatments, including adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade) and others, can be highly effective. But they also have the potential for serious side effects, particularly the reactivation of bacterial and fungal infections that lie dormant inside some people.
Encourage your granddaughter to maintain as normal a life as possible — for example, to engage in usual play and sports activities. Tutoring may help if she misses school due to illness, and counseling might help her deal with the emotional aspects of having a long-lasting illness.
Finally, take heart. For many children, symptoms of juvenile rheumatoid arthritis gradually lessen or disappear as they enter adulthood.