When other treatments cannot control joint inflammation, your child's doctor may give your child disease-modifying anti-rheumatic drugs (DMARDs). They can help manage the inflammation. They can also stop any permanent joint damage.
What are DMARDS?
DMARDs are used to get JIA under better control. These are “slow acting” drugs. They work well against inflammation but can take from several weeks to six months to work.
How do DMARDs work?
DMARDS help to stop or reduce the cells in the immune system that cause inflammation. They are often used in combination with NSAIDs, corticosteroids or joint injections.
Types of DMARDs
Drugs in this group include methotrexate, sulfasalazine, hydroxychloroquine, and leflunomide. Sometimes one DMARD will work while another might not. Your child may need to try different DMARDS to find which one works best for them. Several DMARDS may be combined together to get JIA under control.
Treatment with DMARDs must be continued for a long time. Often, they must be taken for months to years. Treatment will continue even after the disease is controlled. This is done to keep JIA inflammation from coming back.
Each DMARD has its own possible side effects. They require careful monitoring with regular physical exams and lab tests. The health care team will go over these with you and your child carefully.
The following are DMARDS commonly used to treat young people with JIA.
Methotrexate
Most common brand name: Methotrexate
How it is given: By mouth or injection under the skin once weekly
How the medication comes: Pill, liquid, injectable
Side effects
Common side effects:
- Feeling unwell for 24 to 48 hours
Less common side effects:
- Nausea, vomiting, stomach ache
- Mouth sores
- Low white blood cell counts
- Abnormalities in liver function
- Breathing problems
Here are some safety issues to consider when taking methotrexate:
- Before your child starts methotrexate, your child's doctor will do a blood test to make sure that their liver is working properly. The doctor will also check your child's complete blood count: white blood cells, red blood cells, and platelets.
- Your child will need to have regular blood tests to make sure there are no side effects. The doctor will tell you how often your child needs to have this done.
- Methotrexate is taken once a week. Your child should take methotrexate on the same day every week. Speak to the nurse or doctor if your child needs to change the day.
- If your child has a fever, chills, or other symptoms of infection, see their doctor as soon as possible. If your child has an infection that requires antibiotics, they may need to hold off taking their methotrexate until they complete the antibiotic medications and have cleared the infection.
- Do not give antibiotics that contain sulfamethoxazole/trimethoprim. This drug may reduce blood counts along with methotrexate.
- Your child should not receive live vaccines (MMR, varicella, nasal flu shot) while receiving methotrexate.
- Your child should be vaccinated against, or already have had, chicken pox before starting treatment with methotrexate.
- If your child has not had chicken pox and has been around people with chicken pox, contact their doctor as soon as possible.
- Your child may need to take a vitamin called folic acid or folinic acid either every day (low dose) or once a week (high dose). It may reduce many of the side effects of methotrexate. Talk to your child's doctor about this.
- Females should not get pregnant while on methotrexate. If a female takes methotrexate while pregnant, the fetus could be harmed. Both males and females on methotrexate need to use birth control or barrier devices if they plan to be sexually active when they are on this drug. You or your teen can talk to the nurse or doctor about this. They will be able to give you advice.
- Teenagers taking methotrexate should avoid drinking alcohol.
Here are some tips to help manage the side effects of methotrexate:
Some children and teens find it helpful to take their methotrexate on the weekend so they don’t miss school due to feeling unwell. Others take their methotrexate right before bedtime so that they can sleep through most of the side effects. Talk to child and their doctor about finding a convenient time to take your methotrexate that minimizes any disruption to your child's schedule or activities.
If the nausea is unbearable, speak to your child's doctor. There are anti-nausea medications that the doctor might be able to prescribe for them.
Sulfasalazine
Most common brand name: Salazopyrin
How it is given: By mouth, twice daily
How the medication comes: Liquid or pill
Side effects
Common side effects:
- Stomach upset, nausea, vomiting
- Headache, dizziness
- Skin rash, sun sensitivity
Rare side effects:
- Low red blood cell and white blood cell counts
- Abnormalities in liver function
Here are some safety issues to consider when taking sulfasalazine:
- Your child should avoid this medication if they have an allergy to sulfa (as it is contained in this medication).
- Before starting sulfasalazine, your child's doctor will do a blood test to make sure that the liver is working properly. The doctor will also do a complete blood count: white blood cells, red blood cells, and platelets. Your child will need to have regular blood tests to make sure there are no side effects. The doctor will tell you how often your child needs to have this done.
Hydroxychloroquine
Most common brand name: Plaquenil
How it is given: By mouth, once daily
How the medication comes: Pill
Side effects
Rare side effects:
- Stomach upset, nausea
- Rash, sun sensitivity
- Hair bleaching
- Low blood counts
- Blind spot on back of the eye or altered coloured vision (very rare)
Here are some safety issues to consider when taking hydroxychloroquine:
- Your child will need to have regular blood tests to make sure there are no side effects. The doctor will tell you how often your child needs to have this done.
- Regular eye checks by an eye doctor once a year are required. If any problems are detected, the drug will be stopped well before any changes to your child's vision.
Leflunomide
Most common brand name: Arava
How it is given: By mouth, once daily
How the medication comes: Pill
Side effects
Common side effects:
- Nausea and diarrhea
Rare side effects:
- Skin rash
- Thinning hair
- High blood pressure
- Abnormalities in liver function
- Low platelet count
Here are some safety issues to consider when taking leflunomide:
- Before your child starts lefunomide, their doctor will do a blood test to make sure that the liver is working properly. The doctor will also check their complete blood count: white blood cells, red blood cells, and platelets.
- Your child will need to have regular blood tests to make sure there are no side effects. The doctor will tell you how often your child needs to have this done.
- If your child has a fever, chills, or other symptoms of infection, see their doctor as soon as possible. If your child has an infection that requires antibiotics, they may need to hold off taking leflunomide until they complete their antibiotic medications and have cleared the infection.
- Your child should not receive live vaccines (MMR, varicella, nasal flu shot) while receiving leflunomide.
- Your child should be vaccinated against, or already have had, chicken pox before starting treatment with lefunomide.
- If your child has not had chicken pox and has been around people with chicken pox, contact their doctor as soon as possible.
- Females should not get pregnant while on leflunomide. If a female takes leflunomide while pregnant, the fetus could be harmed. Both males and females on leflunomide need to use birth control or barrier devices if they plan to be sexually active when they are on this drug. You or your teen can talk to the nurse or doctor about this. They will be able to give you advice.
- Teenagers taking leflunomide should avoid drinking alcohol.
Other DMARDs
Other DMARDs may be used to treat some forms of JIA in young people. These include cyclosporine (Neoral), azathioprine (Imuran), or cyclophosphamide (Cytoxan). They would only be used if other agents cannot control the JIA.
Important safety points to remember about all DMARDs
- If your child is taking methotrexate or leflunomide, they should not drink alcohol. Methotrexate, leflunomide and alcohol can affect the liver. They could develop serious liver problems.
- If your teenager is sexually active, they should use birth control or barrier devices while taking methotrexate or leflunomide. These drugs can cause miscarriage or birth defects in an unborn baby.
- Your child might want to be vaccinated against other common infections, such as chicken pox, before starting DMARDs. Talk with their doctor about this.