Treatment Options
How is JSpA Treated?
Treatment of JSpA is individualized according to how severe the disease is, what joints are affected, and whether there are complications. Pediatric rheumatologists are trained in the diagnosis and management of kids with JSpA. However, if one is not available, an adult rheumatologist may be appropriate, particularly when the patient is older.
Although there is no known cure, the good news is that there is much that can be done to help. To that end, it is very important to have a correct diagnosis made as quickly as possible. This is the role of the pediatric rheumatologist, who is a physician with special training in rheumatic diseases (including arthritis) in children. In order to make a diagnosis, he or she will evaluate the history of symptoms, perform a complete physical exam and do laboratory tests, and then decide upon a course of treatment that will sometimes involve bringing in other medical experts. These can include an eye doctor (ophthalmologist), bowel doctor (gastroenterologist), and sometimes a skin doctor (dermatologist).
In general, a four-part approach is used for treatment.
Children with JSpA and their families must understand that there is no cure for this disease, but that treatments continue to improve. Also, the disease symptoms may wax and wane over time, and can sometimes be mild. This makes it very difficult to evaluate the effectiveness of treatments. It is also important for patients with JSpA and their families to understand the risks and potential complications of treatment. Finally, it is important to anticipate and evaluate the psychological effects of the illness on the child and the family. Families may over protect children with JSpA and treat them as more ill than necessary.
The first type of medication used for patients with JSpA is usually a non-steroidal anti-inflammatory drug (NSAID). These drugs include naproxen (Naprosyn), ibuprofen (Advil), tolmetin (Tolectin), and in older patients, indomethacin (Indocin) or diclofenac (Voltaren); other NSAIDS are sometimes used as well. Most pediatric rheumatologists agree that indomethacin is a particularly effective NSAID for JSpA. However, its side effects can include headaches, dizziness, stomachaches, or other nervous system effects, and therefore it may not be suitable for younger children and may not be tolerated even in teenagers. It is generally safe for children age 14 and older who recognize these adverse symptoms, and can stop taking the medication if they occur. All NSAIDS may cause gastrointestinal discomfort or pain, and occasionally ulcers when taken chronically. Children seem less susceptible to these problems than adults, but still should be closely watched and have routine blood tests. These medications should be taken with food in order to minimize stomach distress. Medications that help protect the gastrointestinal tract (such as ranitidine or proton pump inhibitors) can be prescribed if needed
to control symptoms.
Biologics medications block the effects of TNF-a., a chemical the body produces that increases inflammation. Known as TNF inhibitors, this class of medication has been shown to be highly effective in reducing or sometimes even eliminating the symptoms of SpA. We also know that they are relatively safe medications in children because they have been used for decades now in children with JIA, as well as more recently in JSpA. The main risk for people taking a biologic is that they will develop a serious infection. This makes it important for doctors to screen for certain infections before starting a biologic.
Other medications that are sometimes effective include methotrexate and sulfasalazine, and their derivatives. Oral corticosteroids like prednisone are rarely used in JSpA, although they may be needed to control eye inflammation. Topical steroids are used to treat the eye disease of JSpA (iritis). Injection of steroids into an inflamed joint that has not responded to NSAID therapy may be highly effective.
Youth with JSpA must strive to maintain range of motion in affected joints and strengthen weakened muscles in the back, abdomen, and limbs. The well designed therapy program will involve daily activities designed to promote normal function. The three areas of emphasis are stretching, posture, and regular daily exercise. Basic stretching exercises for range of motion in the chest, back and other joints may be prescribed depending upon the specific joints and ligaments affected.
Rounding of the shoulders may develop over time with the head being gradually thrust forward. Attention to posture will keep the head, shoulders, and back well aligned, reduce pain and fatigue, and promote effective breathing patterns.
Both kids and teens with JSpA should be encouraged to participate in physical activities appropriate for their age. Regular daily activities such as walking, bicycle riding, and swimming should be encouraged, but it is important to know that these activities are not a substitute for prescribed physical therapy, particularly when the disease has already affected mobility. Decisions to pursue contact sports should be made after consultation with a pediatric rheumatologist and physical therapist.
Some with JSpA can also benefit from special equipment. For example, shoe inserts may help relieve heel and foot pain, and splints for affected joints help prevent and/or treat joint contractures.
If NSAIDs and other anti-inflammatory medications are not adequate for pain relief, often heat and/or acetaminophen can be beneficial. Stronger pain medications are only rarely needed. In addition, because youth with back arthritis may experience muscle spasm, massage may be useful, and occasionally muscle relaxants. Acupuncture is not usually recommended for kids.
How Will This Affect Day-to-Day Life?
Even in its mild forms, JSpA can affect normal daily routines. It’s important to keep daily life as normal as possible to prevent any undue emotional stress.
It’s important for parents to inform teachers and school of the young person’s condition, and make them aware of any special needs they might have such as seating and the need to periodically get up and stretch.
Prior to meeting with your child’s school care team, download and customize this JSpA medical information guide for your child (Download here). This will help guide your meeting and provide school staff details of your child’s medical condition, and how it affects them at school.
Whenever possible, kids and teens should participate in gym and other physical activities. Remaining active will help youth stay involved with peers and lead a normal life. Before returning to a physical activity, make teachers and coaches aware of any mobility limitations. Low impact sports are more favorable than sports that produce high joint stress. However, it is not always necessary to avoid high impact sports. Consult the pediatric rheumatologist on what are safe activities and sports.