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The use of non-steroidal anti-inflammatory drugs in paediatric rheumatic diseases
1Rheumatology Department, Southmead Hospital, Bristol.
Insights
Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective for juvenile idiopathic arthritis (JIA). While generally well-tolerated in children, specific NSAIDs are recommended for fever or joint symptoms, with careful monitoring for potential toxicities.
Area of Science:
- Pediatric Rheumatology
- Pharmacology
- Clinical Therapeutics
Background:
- Juvenile idiopathic arthritis (JIA) management differs significantly from adult arthritis due to pediatric-specific pharmacokinetics and assessment challenges.
- Fewer nonsteroidal anti-inflammatory drugs (NSAIDs) are available or indicated for pediatric use compared to adults.
- Children may underreport pain, influencing assessment and treatment strategies for arthritis.
Purpose of the Study:
- To review the distinct indications, uses, pharmacokinetics, and available NSAIDs for managing arthritis in children.
- To compare the efficacy and safety profiles of different NSAIDs for fever and joint symptom control in pediatric arthritis.
- To highlight potential toxicities, drug interactions, and optimal therapeutic trial duration for NSAIDs in children.
Main Methods:
- Literature review focusing on NSAID use in pediatric arthritis.
- Comparison of efficacy and tolerance data for salicylates, indomethacin, ibuprofen, diclofenac, tolmetin, and naproxen.
- Analysis of safety data, including gastrointestinal, renal, and hepatic toxicities, and drug interactions.
Main Results:
- For systemic JIA fever, salicylates, indomethacin, and ibuprofen are used.
- Diclofenac, ibuprofen, tolmetin, and naproxen show equal efficacy and tolerance for joint symptoms; salicylates and indomethacin are less effective and more toxic.
- Children generally tolerate NSAIDs well, with fewer gastrointestinal issues reported than in adults, though evidence on endoscopic changes is conflicting. Renal toxicity is rare, but specific NSAIDs carry risks (tolmetin: pseudoproteinuria, naproxen: pseudoporphyria). Liver toxicity is a concern in systemic JIA.
Conclusions:
- NSAIDs are a cornerstone in managing pediatric arthritis, with specific agents favored for different symptoms.
- While generally safe, careful consideration of potential toxicities and drug interactions is crucial for optimal pediatric NSAID therapy.
- An 8-week therapeutic trial is recommended for NSAIDs in children with arthritis, necessitating vigilant monitoring.
Abstract:
The use of NSAIDs for arthritis differs in children from adults in their indications, uses and pharmacokinetics, and fewer are available. Children with arthritis are assessed differently, as they complain less of pain. Salicylates, indomethacin and ibuprofen are used for the fever of systemic JCA. For control of joint symptoms, diclofenac, ibuprofen, tolmetin and naproxen are equal in their efficacy and tolerance:salicylates and indomethacin are no more effective but more toxic. Children tolerate NSAIDs well. Gastrointestinal symptoms appear to be less common than in adults, but the evidence regarding endoscopic changes in conflicting. Renal toxicity is rare. Tolmetin can cause pseudoproteinuria and naproxen pseudoporphyria. The liver in systemic JCA is vulnerable to drug toxicity. A therapeutic trial of an NSAID should continue for 8 weeks. Interactions with methotrexate and carbonic anhydrase inhibitors for glaucoma complicating iridocyclitis may occur.