Disease-modifying anti-rheumatic drugs (DMARDs) for JIA

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When other treatments cannot control your joint inflammation, your doctor may give you disease-modifying anti-rheumatic drugs (DMARDs). They can help manage the inflammation. They can also stop any permanent joint damage.

What are DMARDS?

DMARDs are used to get JIA under better control. These are “slow acting” drugs. They work well against inflammation but can take from several weeks to six months to work.

How do DMARDs work?

DMARDS help to stop or reduce the cells in the immune system that cause inflammation. They are often used in combination with NSAIDs, corticosteroids or joint injections.

Types of DMARDs

Drugs in this group include methotrexate, sulfasalazine, hydroxychloroquine, and leflunomide. Sometimes one DMARD will work while another might not. You may need to try different DMARDS to find which one works best for you. Several DMARDS may be combined together to get JIA under control.

Treatment with DMARDs must be continued for a long time. Often they must be taken for months to years. Treatment will continue even after the disease is controlled. This is done to keep JIA from coming back.

Each DMARD has its own possible side effects. They require careful monitoring with regular physical exams and lab tests. Your health care team will go over these with you carefully.

The following are DMARDS commonly used to treat young people with JIA.

Methotrexate

Generic nameMost common brand nameHow it is givenHow the medication comesSide effects
MethotrexateRheumatrexBy mouth or injection under the skin, once weeklyPill, liquid, injection

Common side effects:

  • Feeling unwell for 24 to 48 hours

Less common side effects:

  • Nausea, vomiting, stomach ache
  • Mouth sores
  • Low white blood cell counts
  • Abnormalities in liver function
  • Breathing problems

Safety Issues to Consider When Taking Methotrexate

  • Before you start methotrexate, your doctor will do a blood test to make sure that your liver is working properly. He or she will also check your complete blood count: your white blood cells, red blood cells, and platelets.
  • You will need to have regular blood tests to make sure there are no side effects. Your doctor will tell you how often you need to have this done.
  • Methotrexate is taken once a week. You should take methotrexate on the same day every week. Speak to your nurse or doctor if you need to change the day.
  • If you have a fever, chills, or other symptoms of infection, see your doctor as soon as possible. If you have an infection that requires you to take an antibiotic, you may need to hold off taking your methotrexate until you complete your antibiotic medications and have cleared the infection.
  • Do not take antibiotics that contain sulfamethoxazole/trimethoprim. This drug may reduce blood counts along with methotrexate.
  • You should not receive live vaccines (MMR, varicella, nasal flu shot) while receiving methotrexate.
  • You should be vaccinated against, or already have had, chicken pox before starting treatment with methotrexate.
  • If you have not had chicken pox and have been around people with chicken pox, contact your doctor as soon as possible.
  • You may need to take a vitamin called folic acid or folinic acid either every day (low dose) or once a week (high dose). It may reduce many of the side effects of methotrexate. Talk to your doctor about this.
  • Females should not get pregnant while on methotrexate. If a female takes methotrexate while pregnant, the fetus could be harmed. Both males and females on methotrexate need to use birth control or barrier devices if they plan to be sexually active when they are on this drug. Talk to your nurse or doctor about this. They will be able to give you advice.
  • Teenagers taking methotrexate should avoid drinking alcohol.

Tips to manage the side effects of methotrexate

Some young people find it helpful to take their methotrexate on the weekend so they don’t miss school due to feeling unwell. Others take their methotrexate right before bedtime so that they can sleep through most of the side effects. Talk to your family and doctor about finding a convenient time to take your methotrexate that minimizes any disruption to your schedule or activities.

If the nausea is unbearable, speak to your doctor. There are anti-nausea medications that your doctor might be able to prescribe for you.

Sulfasalazine

Generic nameMost common brand nameHow it is givenHow the medication comesSide effects
SulfasalazineSalazopyrinBy mouth, 2 times dailyLiquid or pill

Common side effects:

  • Stomach upset, nausea, vomiting
  • Headache, dizziness
  • Skin rash, sun sensitivity

Rare side effects:

  • Low red blood cell and white blood cell counts
  • Abnormalities in liver function

Safety Issues to Consider When Taking Sulfasalazine

  • Avoid this medication if you have an allergy to sulfa (as it is contained in this medication).
  • Before starting sulfasalazine, your doctor will do a blood test to make sure that your liver is working properly. The doctor will also check your complete blood count: white blood cells, red blood cells, and platelets. You will need to have regular blood tests to make sure there are no side effects. Your doctor will tell you how often you need to have this done.

Hydroxychloroquine

Generic nameMost common brand nameHow is it givenHow the medication comesSide effects
HydroxychloroquinePlaquenilBy mouth, once dailyPill

Rare side effects:

  • Stomach upset, nausea
  • Rash, sun sensitivity
  • Hair bleaching
  • Low blood counts
  • Blind spot on back of the eye or altered coloured vision (rare)

Safety issues to consider when taking hydroxychloroquine

  • You will need to have regular blood tests to make sure there are no side effects. Your doctor will tell you how often you need to have this done.
  • Regular eye checks by an eye doctor once a year are required. If any problems are detected, the drug will be stopped well before any changes to your vision.

Leflunomide

Generic nameMost common brand nameHow it is givenHow the medication ComesSide effects
LeflunomideAravaBy mouth, once dailyPill

Common side effects:

  • Nausea and diarrhea

Rare side effects:

  • Skin rash
  • Thinning hair
  • High blood pressure
  • Abnormalities in liver function
  • Low platelet count

Safety issues to consider when taking leflunomide

  • Before you start lefunomide, your doctor will do a blood test to make sure that your liver is working properly. The doctor will also check your complete blood count: white blood cells, red blood cells, and platelets.
  • You will need to have regular blood tests to make sure there are no side effects. Your doctor will tell you how often you need to have this done.
  • If you have a fever, chills, or other symptoms of infection, see your doctor as soon as possible. If you have an infection that requires you to take an antibiotic, you may also need to hold off taking your leflunomide until you complete your antibiotic medications and have cleared the infection.
  • You should not receive live vaccines (MMR, varicella, nasal flu shot) while receiving leflunomide.
  • You should be vaccinated against, or already have had, chicken pox before starting treatment with lefunomide.
  • If you have not had chicken pox and have been around people with chicken pox, contact your doctor as soon as possible.
  • Females should not get pregnant while on leflunomide. If a female takes leflunomide while pregnant, the fetus could be harmed. Both males and females on leflunomide need to use birth control or barrier devices if they plan to be sexually active when they are on this drug. Talk to your nurse or doctor about this. They will be able to give you advice.
  • Teenagers taking leflunomide should avoid drinking alcohol.

Other DMARDs

Other DMARDs may be used to treat some forms of JIA in young people. These include cyclosporine (Neoral), azathioprine (Imuran), or cyclophosphamide (Cytoxan). They would only be used if other agents cannot control the JIA.

Important safety points to remember about all DMARDs

  • If you are taking methotrexate or leflunomide, do not drink alcohol. Methotrexate, leflunomide and alcohol can affect your liver. You could develop serious liver problems.
  • If you are sexually active, use birth control or barrier devices while taking methotrexate or leflunomide. These drugs can cause miscarriage or birth defects in the unborn baby.
  • You might want to be vaccinated against other common infections, such as chicken pox, before starting DMARDs. Talk with your doctor about this.

A story of hope

"I’ve had juvenile rheumatoid arthritis since I was seven. The medications I was taking had made my symptoms disappear completely for about three years. I was in heaven

Last fall, I signed up to play volleyball on a competitive school team. We were 15 girls, and the coach had to select 12 of us. The selection process lasted a month. After a week of training, my ankles started to hurt. I knew right away that it was JIA pain. My ankles were swollen, painful, and hot. I had trouble walking. At home I had to go down the stairs on my rear end, but when I got to the gym, I would run for 10 minutes, jump, etc. When I got back home, I wanted to chop my legs off.

There was no way I was going to tell the coach, because I wanted to be on the team. The doctor at The Montreal Children’s Hospital told me that I should stop running for two to three weeks to allow the medications to start working. I was so discouraged! Finally, my parents called the coach and explained the situation. He met with me and agreed to have me do other types of exercises when the rest of the team did running and jumping.

Now, three months later, I’m on higher doses of medication, and I take anti‑inflammatories regularly. I have very little pain, and I’M ON THE TEAM!!!"

-Hélène, age 14


Last updated: January 31st 2017