Juvenile Idiopathic Arthritis (JIA)

Prescribing Notes:

For children at high risk of gastro-intestinal adverse events:

• First choice would be to avoid a NSAID. Second choice, prescribe a NSAID + omeprazole.
• Children at ‘high risk’ of developing serious gastro-intestinal adverse events include:
  • Children with previous peptic ulcer
  • Children with previous GI bleed
  • Children receiving systemic corticosteroids
  • Children receiving anticoagulants
  • Children requiring very high dose NSAIDs [greater than 120% average daily dose]

• Consider whether an NSAID is required; regular dosing of paracetamol is often adequate for pain.
• All long-term use of NSAIDs in children should be under the guidance of a specialist.
• Relative contra-indications to NSAIDs include heart failure, hypertension, renal impairment, history of gastro-intestinal bleeding, coagulation defects; absolute contra-indications include proven hypersensitivity to aspirin or any NSAID.
• NSAIDs may worsen asthma; they are contra-indicated if aspirin or any other NSAID has precipitated attacks of asthma, although this rarely occurs in children.
• Naproxen is an alternative NSAID which combines good efficacy with a low incidence of side-effects.
• Naproxen is associated with a 10% risk of blistering skin rash in blonde, blue eyed, non-tanning children.
• Diclofenac e/c tablets are only suitable for children who are able to swallow tablets whole. Naproxen oral suspension may be a suitable alternative preparation for patients who cannot swallow tablets. For those patients in whom naproxen is not a suitable choice the rheumatology team will advise.
• If other therapy is successful in controlling arthritis, then consider withdrawing NSAIDs especially in children receiving conventional DMARDs and drugs affecting the immune system (see DMARD and biologic pathways).

Prescribing Notes:

• Corticosteroids should ideally only be commenced after liaison with a rheumatologist, and a steroid card given in every case.
• Patient/parent/carer should be provided with written information (e.g. the Versus Arthritis leaflet on steroids) and given the opportunity to discuss the benefits and risks of long-term corticosteroids before treatment is commenced.
• Further weekly doses of intravenous methylprednisolone sodium succinate may be required for some patients on the advice of a specialist.
• The requirement for prophylactic bone protection in children is uncertain. However, this should be considered for children receiving long-term corticosteroids.
• Long-term steroids should be withdrawn gradually.
• Prednisolone oral solution and soluble tablets are restricted to use in patients who are unable to swallow tablets. These preparations are considerably more expensive than the standard tablets.
• The British Society for Paediatric and Adolescent Rheumatology (BSPAR) and Scottish Paediatric and Adolescent Rheumatology Network (SPARN) websites include useful supporting information. However, some of the treatment guidelines are due for update and/or may not have had pharmacist peer review. Locally, specialists refer to the current edition of the Paediatric Rheumatology (Oxford Specialist Handbook in Paediatrics). Please consult up to date BNFc and product literature for full information.

Prescribing Notes:

• Intra-articular steroids should be used judiciously and ideally any one joint should not be injected more than 4 times in 1 year.
• Children requiring joint injections may require general anaesthesia or sedation. Factors to consider include: patients age, the number and the type of joints affected. In children> 5 years Entonox may be considered for some patients. Older children can be administered intra-articular injections with a topical local anaesthetic, e.g. Emla cream.

Prescribing Notes:

• Risks/benefits of DMARDS and drugs affecting the immune response should be discussed with the patient/parent/carer before commencing using a written information sheet available from the Versus Arthritis website or RHSC.
• Methotrexate is appropriate for a shared care agreement to facilitate the seamless transfer of individual patient care from secondary care to general practice.
• The MHRA has received reports of prescription and dispensing errors for methotrexate that have resulted in serious and fatal adverse reactions. Tablet strength, indication, dose and frequency should be carefully explained to the patient/parent/carer to avoid confusion between 2.5mg and 10mg tablets.
• Methotrexate must only be administered once weekly. The dispensing label must clearly show the dose and frequency.
• For oral methotrexate, only 2.5mg tablet strength or 10mg/5mL solution strength should be prescribed / dispensed.
• Folic acid may be prescribed for patients with evidence of intolerance to methotrexate or where the dose of methotrexate is 15mg/m2 or more. Where indicated, folic acid 5mg should be prescribed weekly, typically 24 hours after methotrexate to reduce toxicity. It should not be taken on the same day as methotrexate. Calcium folinate (folinic acid) 15mg orally or by injection may be an alternative for children who are unwilling to take folic acid due to gastro-intestinal intolerance or its unpalatability.
• All children must be adequately monitored (typically monthly blood tests for the first three months, then 3 monthly thereafter if the patient is stable on a standard dose; tests include: liver function, urea and electrolytes and cell counts). The child or their carer should be warned to report immediately the onset of any feature of blood disorders (e.g. sore throat, bruising, and mouth ulcers), liver toxicity (e.g. nausea, vomiting, abdominal discomfort, and dark urine), and respiratory effects (e.g. shortness of breath).
• Providing monitoring procedure is followed, NSAIDs may be prescribed with methotrexate. However, the need for NSAID therapy should be reviewed once methotrexate becomes effective.
• Subcutaneous methotrexate should only be given by individuals trained to administer methotrexate competently.
• Methotrexate is the first choice in the majority of rheumatic diseases but in certain conditions other agents may be preferred first e.g. lupus.
• Azathioprine is sometimes used as an adjunct to infliximab.
• Concurrent use of ciclosporin and corticosteroids is common and advantageous but be alert for any evidence of increased ciclosporin and corticosteroid adverse effects.

Prescribing Notes:

• Biologic therapies may be initiated by rheumatologists in patients who have not responded to conventional DMARDs in line with NICE technology appraisal for abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis (JIA) NICE TA373. Infliximab may be initiated by rheumatologists in line with local unit protocol.
• Monitoring guidance for individual agents is included in patient correspondence.
• Etanercept is avoided in patients with uveitis.
• Fatal infections have been reported in patients prescribed tocilizumab. Extra vigilance is required as signs and symptoms of acute inflammation may be lessened. The effects of tocilizumab on C-reactive protein (CRP), neutrophils and signs and symptoms of infection should be considered when evaluating a patient for a potential infection. Patients and parents/guardians should be instructed to contact their healthcare professional immediately when any symptoms suggesting infection appear, in order to assure rapid evaluation and appropriate treatment.
• In Lothian the brand of adalimumab prescribed depends on the clinical speciality. First choice in paediatrics is Amgevita.