Gold serum levels in children with juvenile rheumatoid arthritis

Medical management of children with juvenile rheumatoid arthritis

One of the most important and changing areas of research in paediatric rheumatology is the optimum approach to the treatment of children with chronic arthritis. Until recently all medications for children with arthritis were nonspecific in terms of our understanding, albeit poor, of the pathogenesis of these diseases. Of current therapies, low dose, once-a-week methotrexate has emerged as the therapeutic agent of choice for children who fail to respond adequately to administration of a nonsteroidal anti-inflammatory drug. Thereby, it has displaced the more traditional slower acting anti-rheumatic drugs, although one or more of them are often combined with methotrexate in the polypharmaceutical approach to childhood arthritis. Better and more specific agents are needed, especially for systemic onset disease, unremitting polyarticular involvement, and certain complications such as resistant chronic uveitis. At this time the introduction of the cyclo-oxygenase 2 inhibitors and etanercept (soluble tumour necrosis factoralpha.p75 fusion protein) may herald an era of more specific and effective therapy.

In vitro activity of nonsteroidal anti-inflammatory agents, phenotiazines, and antidepressants against Brucella species

The in vitro antimicrobial activity of streptomycin, rifampicin, tetracycline, seven nonsteroidal anti-inflammatory agents (acetyl-salicylic acid, piroxicam, indomethacin, ibuprofen, ketoprofen, sulindac, and diclofenac), and eight phenotiazine derivatives and antidepressant agents (clorpromazine, fluphenazine, amitryptiline, clomipramine, imipramine, maprotiline, sertraline, and diazepam) against 62 strains of Brucella spp. was tested. Diclofenac was the most active of the anti-inflammatory agents (MIC90 = 16 micrograms/ml). The activity of the phenotiazines and antidepressants was heterogeneous, with MIC90s ranging from 16 micrograms/ml for sertraline and 32 micrograms/ml for fluphenazine and clomipramine to > 512 micrograms/ml for diazepam. When the six most active anti-inflammatory agents and the six most active psychiatric drugs were tested at pH 5 and pH 4, the MICs remained unchanged except for those of fluphenazine; the MIC50 and MIC90 of this agent increased by one dilution.

Comparative efficacy and safety of advanced drug therapy in children with juvenile rheumatoid arthritis

Results from three randomized placebo-controlled trials were combined in a meta-analysis to compare the clinical utility of four advanced drug therapy agents used to treat juvenile rheumatoid arthritis (JRA): D-penicillamine (10 mg/kg/d), hydroxychloroquine (6 mg/kg/d), auranofin (oral gold, 0.15 to 0.20 mg/kg/d), and two low dose levels of methotrexate [5MTX, 5 mg/M2/wk; 10MTX, 10 mg/M2/wk]. A total of 520 children with JRA were enrolled into these trials. Only 10MTX resulted in significantly greater improvement than placebo in variables that assess effectiveness: physician's global assessment, a composite index, and erythrocyte sedimentation rate. Treatment effect sizes were the largest in the 10MTX group for all articular disease indices. The short-term safety profiles were similar across all treatment groups. It is concluded that the current trend among pediatric rheumatologists to use oral methotrexate as the first advanced drug therapy in JRA is appropriate and that the minimum effective dose is 10 mg/M2/wk.

Pharmacotherapy of juvenile rheumatoid arthritis

Salicylate is the drug of first choice in the initial treatment of juvenile rheumatoid arthritis. In therapeutic dosage it will adequately control joint symptoms in the majority of patients. For children who do not respond to or are intolerant of salicylate, a change to one of the other nonsteroidal anti-inflammatory agents is appropriate. In progressive polyarthritis unresponsive to the above agents, the addition of gold, antimalarials, or penicillamine is indicated, preferably in that order. Corticosteroid therapy should be reserved for selected patients meeting specific criteria. Pharmacotherapy of juvenile rheumatoid arthritis should always be individualized. For optimal treatment of the whole child it must be combined with both physical and educational measures.

Gold therapy in the management of juvenile rheumatoid arthritis

Gold therapy for 6 months was shown to be efficacious in reducing the severity of articular manifestations in 32 (63%) of 51 juvenile rheumatoid arthritis patients reviewed retrospectively. Similarly, reductions in the total number of involved joints were seen in 25 (49%) patients. Patients in whom a favorable response to therapy was noted had more severe joint involvement at the start of therapy than did nonresponders. In general, patients who responded experienced considerable improvement. Duration of disease prior to gold therapy initiation and disease onset type were not related to the probability of favorable response. Incidence of adverse side effects was low. Gold has recently been approved by the Food and Drug Administration for use in children.

Metacarpal cortical bone mass in patients with mandibular pain and dysfunction

Sixty consecutive patients with mandibular pain and/or dysfunction were divided in three groups; one group with temporomandibular joint (TMJ) crepitation, another with tenderness on palpation of the TMJ and a reference group without any of these signs. The TM joints of the patients were exposed radiographically in oblique lateral and transmaxillary projections. The hands were exposed in the dorsovolar projection. The metacarpal index of Barnett & Nordin (2) (Formula: see text) was determined from the hand radiographs as well as the Exton-Smith (II) index (Formula: see text) Radiographic abnormalities in the TMJ and hand joints were recorded and quantified in indices as well as clinical abnormalities in the masticatory system. The index of Barnett & Nordin was significantly lower in the group of patients with palpatory tenderness of the TMJ than in the reference group. The Exton-Smith index was significantly and negatively correlated to the radiographic index of hand joint but not TMJ disease. A statistically significant positive correlation was found between the Exton-Smith index and the size of the TMJ condyle. The results of the present study indicate that patients with palpatory tenderness of the TMJ, probably of inflammatory origin, have a smaller second metacarpal cortical bone mass than reference patients, as have patients with radiographic signs of hand joint disease.