Department of Family Medicine (Dr. Momah) and Department of Pediatric Rheumatology (Dr. Ray), University of Mississippi Medical Center, Jackson tmomah@umc.edu
The authors reported no potential conflict of interest relevant to this article.
When treatment of JIA fails with a given drug, options include increasing the dosage; switching to another agent in the same drug class; switching to a different class; and combining an NSAID with a csDMARD or a biologic agent.32 In class-specific JIA cases, a change in a drug regimen is warranted on the basis of the evidence-based historical clinical response rate.32
What is the prognosis?
Treatment of JIA with novel agents, such as biologics, has opened up the possibility that JIA patients can live not just with suppressed symptoms but immunologically inactive disease. This is the result of better understanding of the pathogenesis of JIA and the mechanism of action of targeted drugs, and identification of biomarkers that are helpful in predicting prognosis, adverse effects, and response to treatment.
On average, it takes 3 visits to a physician, over the course of about 3 months, before definitive diagnosis of JIA is made.
JIA is often a lifelong disease; one-third of patients continue to exhibit symptoms into adulthood.4 If their disease is properly managed, however, these patients do not develop typical features of rheumatoid arthritis, including hand, limb, and spine deformities. Last, patients with JIA who have only intermittent disease tend to do better over the long term than those whose disease is continual.32
The mortality rate of JIA has dropped: from 1% to 4% in the mid-1970s to 0.3% to 1% today4—an improvement in life expectancy that is echoed in enhanced quality of life for patients. According to the 4-level Steinbrocker functional classification scale33 (used to rate the extent of physical disability), 15% of JIA patients were Class III (limited to few or no activities of the patient’s usual occupation) or Class IV (bedridden with little or no self-care) in the period from 1976 to 1994—a percentage that had declined to 5% by 2002.34
The family physician plays pivotal role in JIA care
For the family physician, appropriate initial intervention in the management of JIA is imperative. This includes ordering imaging (whether plain films or MRI), laboratory tests as described earlier (although not to make the diagnosis), and the use of NSAIDs, intra-articular steroids, and other induction agents. Once the diagnosis is made, and a drug regimen is put in place, you will need to monitor for adverse effects. This monitoring will need to occur when a patient is escalated to csDMARDs, biological agents, or systemic steroids; is maintained on an NSAID; or is placed on a combination regimen.
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