There are many different non-steroidal anti-inflammatory drugs (NSAIDs) which help control symptoms by reducing swelling (inflammation) and can help to reduce pain in the joints.

NSAIDs are the first choice. The amount given is worked out according to the weight and height of the child. Those approved for use in this country are: ibuprofen (brufen), naproxen (naprosyn), diclofenac (voltarol), piroxicam (feldene), and tolmetin. They have replaced aspirin, which was the usual drug for many years, as their side effects are less. Nevertheless all drugs can have side effects, so when your child is prescribed one of these drugs, it is important to note any loss of appetite or tummy pain and report it. Other problems include rashes, particularly on exposure to sun, while any tendency to wheeze can be increased.

Ibuprofen is generally well tolerated. There is a liquid preparation which can be used in young children 1 to 2 years old, provided they are over 7 kilos in weight. As it only works for about 6 hours it must be given in 3 or 4 doses every day. It is often useful in reducing fever - at such a time the dosage may be temporarily increased and reduced as the fever improves.

Junifen is available in any chemist shop for the relief of mild to moderate pain in children more than one year old. It contains ibuprofen and therefore should not be given to any child receiving anti-inflammatory drugs without talking to your doctor first. It can be used instead of ibuprofen syrup, and being a sugar-free preparation it is better for the teeth.

Naproxen is also available in liquid form. It’s advantage over ibuprofen is that it lasts for a longer time in the body and therefore needs to be given only twice a day. It is usually not prescribed until the child is about 4 years of age or more. Very occasionally naproxen suspension can cause diarrhoea. Sun sensitivity seems more common than with other drugs, beware of holidays in the sun - both abroad and in the UK!

Diclofenac is available in a suppository especially designed to relieve pain and fever in children. Although the suppository can help morning stiffness in children with arthritis, most people prefer something by mouth. This drug is available in a 50 (47.5)mg dispersible tablet, but as it needs to be given 3 times a day, it is important to follow the instructions given carefully. The 25mg tablet is small so that many older children have no trouble swallowing it. Slow acting tablets are also available, but the child needs to be 9 or 10 years old and to have reached a certain weight before these are used.

Piroxicam need only be given once a day as it lasts for 24 hours. There is a form which dissolves in water and another which melts in the mouth. It does seem however to cause a slightly higher incidence of tummy upsets than the other anti-inflammatory drugs.

Tolmetin is popular in the USA, but is not used widely in Great Britain as the smallest tablet available contains 200mg and is difficult to swallow. If essential it can be made up into liquid form for an individual child.

These are powerful drugs which reduce severe inflammation, but the exact way they work is not known. They are given by mouth or very occasionally by injection intravenously when a child is generally ill (systemic disease), for severe polyarthritis or general deterioration (e.g.anaemia, weight loss) with an increasing number of joints affected. Steroid drops are available for eye inflammation, and steroid ointments for rashes, while the development of special preparations which can be injected directly into the joints has been of great value. Here these damp down the inflammation locally without causing the general side effects seen when steroids are taken by mouth. This will allow the child to move the joint better. They are particularly valuable if children have just one or two joints affected (i.e. pauci-articular disease), or if they have one or two joints which are particularly troublesome. In young children the injection will be performed under a light general anaesthetic, while in an older child it may be possible to do the injection after giving them a sedative. Sometimes a splint will be put on straight away after the injection, especially if the joint such as a knee or a wrist has bent. Instructions will be given on how to use the splint. The parent and child will also be shown exercises and be told when to start them after the injection.

 Prednisone is an oral corticosteroid and is a very effective anti-inflammatory agent. When high doses have to be given every day or more than once in any one day, side effects can occur. Resistance to infection, e.g. pneumonia, is reduced and there is also a risk of an infection, such as chicken pox, being more serious in a child who has been on prednisone. Therefore it is vitally important that your doctor knows that your child is on prednisone. 
Longer term side effects of prolonged treatment with high dose prednisone can include the child becoming cushingoid. The term refers to a typical appearance of a round face. Such a child fails to grow normally, the bones can become thin and the skin bruises easily; very occasionally the blood pressure goes up. Another rare problem is the formation of cataracts in the eye.
To avoid complications, parents may be asked to give a single dose of prednisone (or equivalent) on alternate days in the morning or only a small dose on the second day. This way there is some improvement in the inflammation and the risk of the serious side effects are reduced.
However, when a child has systemic illness, particularly when there are complications such as inflammation of the covering of the heart (pericarditis), it will be necessary to give the drug on a daily basis. Indeed if a child is extremely ill, it may sometimes be necessary to introduce the drug by means of an intravenous drip (‘pulse’), so that it gets directly into the circulation. This may be repeated on several occasions. Sometimes a ‘pulse’ will cover a period of illness or infection so that the dosage by mouth does not need to be increased.

Deflazacort (Calcort) is a new form of corticosteroid which appears to have the advantage that in moderate dosage it may not cause as much thinning of the bones (osteoporosis), or make children so round faced, and may also allow them to continue to grow more normally.
Once a child has received corticosteroids and the inflammation appears to be getting better, withdrawal has to be gradual. Every case is individual and appropriate instructions will be given by your doctor.
To keep the steroid dose to a minimum, one of the anti-inflammatory drugs previously described will usually be given as well.

These drugs seem to reduce the overall activity of the arthritis, and therefore can sometimes be called ‘disease modifying anti-rheumatic drugs’ (DMARDs). If the arthritis persists they may be considered. Before any of these drugs are used, the doctor will discuss with you why this particular drug is being suggested and why your child has to have regular checks while taking it.

Methotrexate has been shown to be of particular value in younger children. This belongs to a group of drugs called anti-metabolites’, which interfere with cells dividing. Side effects can include nausea, ulcers in the mouth, skin rashes, thinning of hair, disturbance in the function of the liver and very occasionally interference with the white blood cells, platelets and red blood cells. It is given as a weekly dose either by mouth or by injection.
In the first month of therapy, before each dose, a blood test is necessary to check the blood count and liver function. Later this is done less often. If your child is having methotrexate you may be asked to give them folic acid between each dose of methotrexate, as it seems to protect against side effects. While good for the joints, it is still not clear whether methotrexate helps to damp down the fever and systemic illness.
Other drugs include gold (by injection), penicillamine and anti-malarials. In controlled trials these do not appear particularly helpful. However, in some children with polyarthritis, especially those who are positive for rheumatoid factor, gold injections (myocrisin) have been found to be useful. Side effects can be similar to methotrexate, i.e. mouth ulcers, rash and interference with the white blood cells and the platelets, but gold and penicillamine are different in that they can irritate the kidneys as well as the liver. Thus, in addition to regular blood checks a urine sample will be assessed before each gold injection. The injections are weekly at first. When a child has improved the dosage is not reduced, but the injections are given less often. Monthly checks on the urine are necessary with Penicillamine. Oral gold (auranofin) has been shown to be ineffective.

Sulphasalazine (salazopyrin) has been shown to be an effective drug in children whose arthritis has developed after the 9th or 10th birthday, particularly in children whose arthritis starts with a few joints involved, but then spreads. The majority of these are boys.
It is given by mouth and there is both a suspension and tablet form. It can cause nausea, loss of appetite, rash and temperature; and again regular blood tests looking at the white blood cells and liver function are required.

Anti-malarial drugs (plaquenil and chloroquine) are oral drugs which are occasionally used. Your doctor will explain why. These do not require regular blood tests, but must have eye checks.

Cyclosporin A is a well known drug in the field of kidney and liver transplants. Recently it has been suggested that children with systemic onset disease might benefit from suppressing their immune system early in their treatment. There is only limited information on this drug and presently it cannot be recommended for general use, and will only be used under trial conditions to compare with other drugs.

Chlorambucil is a cytotoxic cell-killing drug which is occasionally required to control inflammation if amyloidosis is present. Careful blood monitoring is essential.

.

Anaemia

Children with systemic arthritis are often anaemic because the body is not able to make haemoglobin satisfactorily while inflammation is present. Iron tablets will not help them. Occasionally children may become deficient in iron for a number of other reasons and then tablets will need to be prescribed.

Intravenous gammaglobulin

Controlled trials have shown this to be no better than placebo (dummy injections) in the majority of patients.
However, occasionally a child will be given intravenous gammaglobulin to try to control serious systemic illness, when the response to corticosteroids is poor.

Growth hormone

Why children with certain chronic diseases, including arthritis, do not grow is still not known and is the subject of intense investigation at present. Children with active disease do not grow normally and their growth can be further hindered by corticosteroids.
Those no longer on steroids, or only a small dose, may have their growth improved by a course of injections of new safe synthetic growth hormone preparations every day or at least 6 out of 7 days a week. Those whose disease is very active or are on high doses of steroid do not grow as well. These must be part of a study protocol as we still do not know the long term results or the puberty effects.
Studies in special centres continue so your paediatric rheumatologist can discuss this with you.

Diet and vitamin supplements

Drug therapy is only one part of the management of children with arthritis. General measures include a healthy diet making sure that the amount and type of food eaten will give enough calories and protein for growth, and calcium to keep the bones as strong as possible.
If your child is eating well there is no need to give vitamins. If the appetite is poor, there is no harm in giving a multivitamin preparation. Similarly, a single dose of cod liver oil each day may reassure parents that the child is getting enough vitamin D.
An extra supplement of calcium as well as vitamin D is necessary to minimise thinning of the bones in children on corticosteroids.