This post has been inspired by people who suffer from a condition, not commonly found or have a common condition but to not respond to medicines. Common diseases are easy to treat as you know giving a particular medicine or treatment will help. But when the individual does not respond to tried and tested medicines, often doctors find themselves at a dead end. A similar case presented itself to me a couple of days back.

Katie Horn: I have JRA in both knees and ankles, and No matter what medicine my Dr puts me on, I can’t get into remission! I am on Naproxen 500mg/2x a day, 50mg Enetracept sub-q injection once a week, Methotrexate 20mg injection once a week and intensive physical therapy. My rhuematologist said i will already need full joint replacements by the time i’m 30. I am seeing one of the best pediatric rheumatologists in the USA at AI DuPont Children’s Hospital, but he has hit a dead end. Any ideas of other treatments that might help?

As per her condition and approved medications, she is getting the best treatment. However, there is no remission.

I would suggest her the following options: Try medicines which are already in use for adult population,
1. Ramicade trial,
2. Tocilizumab,
3  Rituximab,
4. other DMARDs such as Leflunomide, gold, penicillamine,
5. If they also do not work other medicines such as Cyclosporine, Cyclophosphomide, azathioprine can also be tried to control your disease.
Please find references or reasons for the options I’ve listed above. Ignore, if it just sounds medical jargon. I wish all the very best to Katie. Just have a positive outlook in all circumstances.
Crux of the matter is this that your disease has to be controlled. And it is the responsibility of a doctor not to give up but find a solution to give you relief. So, as a patient please do not lose hope yourself and consider other avenues and keep searching for the right solution. You never know what comes your way.

References:
Biologic agents for the treatment of juvenile rheumatoid arthritis: Current status
Levinson Chair of Pediatric Rheumatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio 45229, USA. Daniel. [email protected]

Erratum in:

  • Paediatric Drugs. 2005;7(2):136. Carrasco, Ruy [added]; Smith, Judith A [added].

Abstract
Biologic therapies, primarily anticytokine therapies, are being increasingly used in patients with juvenile rheumatoid arthritis (JRA). Levels of a variety of proinflammatory cytokines have been shown to be elevated in the peripheral blood and synovial fluid and tissue in children with JRA. In a blinded, randomized, controlled trial in children with severe, long-standing, polyarticular-course JRA not responsive to standard therapies, etanercept showed a statistically significantly greater response rate than placebo. Approximately 75% of these children responded to etanercept. Etanercept has been efficacious in 50-60% of children with active systemic JRA in open clinical trials with acceptable tolerance. Adverse events seen in children treated with etanercept have been similar in type and frequency to those reported in adults. Infliximab has been studied in several open clinical trials in both polyarticular and systemic JRA and found to, overall, have demonstrated efficacy in approximately 60% of patients. Approximately 3-5% of patients have demonstrated infusion reactions or frank allergic reactions and 9% developed new autoantibodies. Anakinra has been studied in children with polyarticular JRA. Approximately 65% of patients developed injection-site reactions and 68% demonstrated a response to the medication. Anakinra may have increased efficacy in systemic JRA. Interleukin (IL)-6 is highly related to the systemic disease manifestations in systemic JRA and two patients treated with a monoclonal antibody to the IL-6 receptor have demonstrated significant improvement with prolonged clinical control with continued treatment. A particular pediatric concern is the effect of immunosuppressive biologics in children who are exposed to or develop varicella. These children should be treated, both in terms of prophylaxis and aggressive antivaricella treatment, as for other immunosuppressed children. Anticytokine biologics have demonstrated great promise in the treatment of JRA and a variety of other pediatric rheumatic diseases, although at this time the randomized, placebo-controlled data are limited only to etanercept in children with polyarticular JRA. Randomized trials are ongoing to better define both the efficacy and safety of these novel treatments for children with JRA and other rheumatic diseases.
PMID: 15170361 [PubMed – indexed for MEDLINE]
B Cell Depletion: On the Rise References

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