Disease Modifying Drug Treatment in Juvenile Idiopathic Arthritis

Combination of cyclosporin (CyA) with the prevailing therapy was studied in 32 children with severe and refractory juvenile idiopathic arthritis (JIA). Although blood erythrocyte sedimentation rate (ESR) and the serum concentration of the C-reactive protein (CRP) improved significantly (p<0.05 and <0.001, respectively), the hospitalization days, oral dose of prednisolon and intra-articular injections did not decrease. CyA may have a place in the treatment of uveitis in patients with JIA. The effect of hydroxychloroquine (HCQ) on the serum concentration of methotrexate (MTX) in children with JIA was studied in 34 children receiving concomitant HCQ and MTX, and in 40 children with only MTX. No differences were seen in the serum concentration of MTX between the two groups. It was concluded that contrary to an earlier report, concomitant HCQ does not reduce the bioavailability of MTX. The hepatotoxicity of long-term MTX treatment was studied in 34 children with JIA by blood transaminase concentrations and by histology of liver biopsy specimens. All patients with a weekly MTX dose lower than 20 mg/body surface square meter, evinced no signs of liver pathology. Out of ten patients on a higher MTX dose, four had mild pathological changes and one had markedly elevated blood transaminases. No irreversible changes were seen. The efficacy and costs of a new antirheumatic drug, etanercept, were studied in 31 patients with severe and refractory JIA. Etanercept was combined with the prevailing drug therapy, which in 27 children also included MTX. The dose of etanercept was 0.4 mg/kg twice a week for 12 months. Significant improvements were seen in all parameters studied: daily dose of prednisolon (P<0.001), number and dose of diseasemodifying antirheumatic drugs (DMARDs) (p<0.001) and number of intraarticular injections of glucocorticoids (p<0.001), and level of ESR (p<0.01) and CRP (p<0.05). In two patients the treatment was discontinued because of adverse effects and in two because of lack of efficacy. Etanercept increased the total annual costs of treatment by 2 716 US dollars per patient (10% of the total costs). This must be viewed against the background of reduced inflammatory activity in the joint disease and the probable reduction of lifetime pain and disability produced by the disease.