Glucocorticoids in juvenile idiopathic arthritis

Glucocorticoid (GC) drugs are a potent and rapidly effective therapeutic option for the treatment of juvenile idiopathic arthritis (JIA). These medications are mainly used for the management of the extra-articular features of systemic-onset disease. A course of low-dose prednisone may be considered for achieving a rapid disease control in patients with severe polyarthritis refractory to other therapies or while awaiting the full therapeutic effect of a recently initiated disease-modifying antirheumatic drug or biologic agent. Short-term systemic GC administration may also be indicated for chronic iridocyclitis unresponsive to topical therapy. The general objective of GC therapy is to limit the maximum dose and exposure to the highest doses to what is needed to achieve disease control, and then to gradually taper the dose until the minimum level sufficient to maintain disease quiescence over time is reached. High-dose intravenous 'pulse' methylprednisolone administration is sometimes chosen to treat the most severe or acute disease manifestations of systemic JIA, particularly macrophage activation syndrome. Intra-articular GC injection is a safe and rapidly effective treatment for synovitis in children with chronic arthritis. Triamcinolone hexacetonide is the optimal GC preparation for pediatric patients. Local injection therapy is used most frequently to treat oligoarthritis, but the strategy of performing multiple injections to induce disease remission, while simultaneously initiating therapy with second-line or biologic agents, has also been proposed for children with polyarticular JIA. Administration of GCs is associated with potentially deleterious adverse effects, some of which can be irreversible. This highlights the need of a judicious use of these medications and careful monitoring of their toxicity. The recently published recommendations for the management of JIA provide useful guidance to the clinicians for the administration of GCs in children with chronic arthritis.