Methotrexate for juvenile rheumatoid arthritis

Methotrexate reduces inflammation caused by juvenile rheumatoid arthritis (JRA).

Most experts believe the potential benefits of methotrexate in children with JRA are greater than the risks of serious side effects, and methotrexate has become the preferred second-line medicine for children with JRA. It is generally reserved for children who do not respond to nonsteroidal anti-inflammatory drugs (NSAIDs). However, some children with JRA, especially those with polyarticular JRA, gain significant benefit from early methotrexate treatment. Methotrexate decreases symptoms and may slow joint damage.¹

Methotrexate may also be used for resistant chronic inflammatory eye disease (uveitis) in children with JRA.²

Methotrexate should not be used in children with chronic liver disease. Some children with kidney disease can take methotrexate, but they require an adjusted dose and careful monitoring.

Methotrexate appears to be effective for juvenile rheumatoid arthritis.¹ Methotrexate may improve the:

• Number of joints that are pain-free with motion.
• Severity of pain.
• Number of joints with limited motion.
• Results of the erythrocyte sedimentation rate test (ESR, or sed rate).

Serious but rare side effects of methotrexate include:

• Reduced white blood cell, red blood cell, or platelet counts.
• Inflammation of the lungs (allergic pneumonitis).
• Liver inflammation (abnormal liver enzyme blood tests or hepatitis) or mild to moderate scarring (fibrosis). Liver inflammation or fibrosis seems to be less common and less severe in children than in adults.
• Severe liver damage (severe scarring or cirrhosis). Cirrhosis is not reversible, but it is rare and is most often seen in patients with underlying liver disease, diabetes, or alcohol abuse.

Minor side effects include:

• Stomach and intestinal symptoms (nausea, vomiting, diarrhea, or stomach upset). If your child becomes severely dehydrated from vomiting or diarrhea, methotrexate should be stopped until the symptoms resolve.
• Mouth sores.
• Hair thinning.

None of these side effects are permanent. Folic acid supplements may decrease the severity of side effects.

Effects on blood cells and liver inflammation can be detected early by regular blood tests (every 1 to 2 months) and almost always return to normal when methotrexate is discontinued. Regular blood tests may help detect liver inflammation. In very rare cases, inflammation can lead to more serious liver scarring (fibrosis or cirrhosis).

Anyone taking methotrexate must avoid alcohol use to prevent significant drug interactions.

Women taking methotrexate should avoid becoming pregnant, as the drug causes miscarriage and possibly birth defects.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

Children who are taking methotrexate should not take other medicines without the approval of the health professional who is treating their JRA. Methotrexate interacts dangerously with certain other medicines.

Frequent blood monitoring for blood cell counts and liver function enzymes should be done during methotrexate therapy.

Methotrexate may increase the risk of developing certain infections, such as shingles and pneumonia.

Methotrexate has been shown to be safe for long-term use in most children, but it is still usually tapered off and discontinued about 1 year after remission.¹

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Citations

1. Giannini EH, Brunner HI (2005). Treatment of juvenile rheumatoid arthritis. In WJ Koopman, LW Moreland, eds., Arthritis and Allied Conditions, 15th ed., vol. 1, pp. 1301–1318. Philadelphia: Lippincott Williams and Wilkins.

2. Hollister JR (2005). Rheumatic diseases. In WW Hay Jr et al., eds., Current Pediatric Diagnosis and Treatment, 17th ed., chap. 26, pp. 846–854. New York: McGraw-Hill.