Juvenile idiopathic arthritis:: When and which DMARD and how long?

indication for a disease modifying antirheumatic drug (DMARD) in juvenile idiopathic arthritis (JIA) derives from the form of arthritis as well as its course. Oligoarthritis can often be treated with NSAIDs and intraarticular injections alone. A DMARD is indicated when the disease remains active for more than 6 to 12 months, when radiographic destructions appear or when problem joints like wrists or hips are involved. For polyarthritis and systemic JIA, an early start with DMARDs is important. Gold standard is methotrexate. Azathioprine or leflunomide can be alternatives if methotrexate is not well tolerated. We have good experience with antimalarials for ANA-positive oligoarthritis and sulfasalazine for enthesitis-related arthritis. Cyclosporin A is mainly used for severe uveitis. Not all DMARDs are licensed for use in children with chronic arthritis. Off-label use is therefore common in pediatric rheumatology. Combinations of DMARDs are also used in JlA, but there are no studies available. No reliable data exist for the length of DMARD therapy. Most pediatric rheumatologists treat their patients for at least one year after remission is achieved.