Side Effects of Juvenile Arthritis Treatments

When Zoe was 13 years old, the doctors told her she had juvenile arthritis, a diagnosis that could impact the rest of her life. For the year prior, her pain had been so severe she was walking with crutches and wearing two wrist braces. Today, she manages the condition with a combination of prescription drugs, diet, and thoughtful exercise. While physical activity is an important part of her routine, she recognized in high school that certain types—such as rowing and running—caused her more joint pain, so she switched to activities that were easier on her joints.

What Is Juvenile Arthritis?

Juvenile arthritis is arthritis in anyone under the age of 16. Adults may experience several types of arthritis such as osteoarthritis, a condition in which your bones and joints wear down over time, or rheumatoid arthritis, an autoimmune condition in which your immune system is overactive and ends up attacking joints. 

There are multiple types of juvenile arthritis, but, like rheumatoid arthritis, they all involve an overactive immune system, explains Jay Mehta, MD, a pediatric rheumatologist at the Children’s Hospital of Philadelphia.    

Symptoms of Juvenile Arthritis

Juvenile arthritis causes pain, swelling, and stiffness in the joints. It can affect a single joint or several joints, and symptoms may be worse in the morning hours. A child’s “main complaint may not be pain,” says Mehta. 

“It may be more stiffness and swelling,” that children mention, he says. Parents may notice their child limping, for example, when they wake up in the morning.

Treatments for Juvenile Arthritis and Their Side Effects

Juvenile arthritis is a chronic condition that cannot be cured. It often progresses into another type of arthritis, such as rheumatoid arthritis as the children age.

“My goal is for them to be able to do everything that any other kid their age does, including going to school playing sports, and participating fully in activities,” says Mehta. 

There are a few different treatment options for the condition:

Steroid Injections

If arthritis is only affecting one or two of the child’s joints, cortisone shots may be sufficient. These injections, which go directly into the affected area, reduce swelling, alleviate symptoms for several months, and tend to cause fewer side effects than corticosteroids taken orally because they don’t have to travel through your digestive system and entire body to reach the inflamed joint. 

The Mayo Clinic doesn’t recommend getting the shots more than three or four times a year, because, over time, they may break down the cartilage in a joint, which has very little ability to repair itself.

Other side effects of cortisone injections, according to the Mayo Clinic can include:

•   Joint infections
•   Temporary rise in blood sugar
•   Weakened tendons
•   Damaged cartilage or bone
•   Lightened skin around the injection.

Methotrexate (Rheumatrex, Trexall) and Side effects of juvenile arthritis treatments

Methotrexate is a chemotherapeutic drug often used for cancer treatment. It also works as an immunosuppressant for juvenile or rheumatoid arthritis. 

Given orally or as an injection, it is often the first disease modifying treatment prescribed to people newly diagnosed with the disease. While the term “chemotherapy” may conjure up images of patients with severe side effects such as vomiting, hair loss, and more, Mehta emphasizes that the doses used to treat juvenile arthritis are far smaller than those prescribed to treat cancer, and as a result, the side effects of the juvenile arthritis treatment are much milder. 

The doses for chemotherapy for cancer can be thousands of times higher than the doses used for arthritis.

Still, some patients do experience side effects. Some of the most common ones are:

•   Nausea
•   Fatigue
•   Liver irritation.

Some less common side effects are:

•   Mouth ulcers
•   Hair loss
•   A drop in white blood cells, leaving you vulnerable to infections.

To manage the side effects of this juvenile arthritis treatment, you can give your child folic acid supplements. A 2013 Cochrane Review of several studies suggested that people with rheumatoid arthritis who received folic acid along with their methotrexate experienced less nausea and liver irritation than those that only took methotrexate.

In some cases, you may be able to split the dose, giving half in the morning and the other half 12 hours later to reduce side effects. Additionally, when patients are given the drug weekly, Mehta recommends planning to give your child the medicine on Fridays, so that if they are tired or nauseous the next day, they don’t have to miss school. 

If a blood test shows your child has elevated liver enzymes, their levels generally go back to normal if they stop taking the drug and try a different treatment. Their doctor can monitor levels through testing during treatment.

TNF Inhibitors (Tumor Necrosis Factor Inhibitors)  

If your child’s symptoms don’t improve with corticosteroids or methotrexate, their healthcare provider may prescribe biologic TNF inhibitors such as Enbrel (etanercept) and Humira (adalimumab). These drugs block molecules that promote inflammation.

Some of the most common side effects of TNF inhibitors are:

•   Injection site reactions
•   Increased risk of infections

Some patients also developed irritable bowel syndrome, though researchers said it wasn’t clear whether digestive distress was a side effect of the medicine or a symptom of the illness.

The drugs contain a black box warning suggesting that they may raise your child’s risk of developing serious infections, due to the fact that the drugs weaken the immune response.

In 2008, the FDA started investigating 30 reports of cancer children who had been prescribed TNF inhibitors.  Shortly after, the agency added a box warning to the drugs warning of the risk of cancers, specifically lymphomas. However, more recent studies, such as a 2016 analysis of the medical records of more than 27,000 children with juvenile arthritis have concluded that the drugs did not raise the risk of cancer. 

“There’s been this unfortunate box warning about the risk of malignancy with TNF inhibitors and other biologics,” said Mehta. “The data has really not borne that out.” 

The most important way to minimize the impact of side effects with TNF inhibitors is vigilance. You should frequently monitor yourself (or your child) for signs of infection, such as fevers or redness at the injection site, and alert your healthcare provider right away.

Dietary Options 

There’s some evidence that following an anti-inflammatory diet, the Mediterranean diet, or a vegan diet may help reduce inflammatory markers in the bloodstream and minimize symptoms of juvenile arthritis or rheumatoid arthritis in adults.

When Angela, a young adult with rheumatoid arthritis, was prescribed methotrexate, she experienced nausea and dizziness. Blood tests showed her liver function was declining. 

Her doctor had her stop using the drug temporarily so her liver could heal. During that time, Angela says that avoiding gluten, sugar, dairy, and nightshade vegetables led to alleviating many of her rheumatoid arthritis symptoms entirely. She decided not to take methotrexate again.

“As long as the child is receiving adequate nutrition, I am completely supportive of them trying things like vegan diets, or the anti-inlammatory diet, or reducing sugar, dairy, or gluten,” says Mehta. “Some families do find that helpful.” 

The one caveat he adds is that typically if a child starts a diet like this, the whole family participates (either for support or just to make meal planning easier,) and it can be difficult for some families to maintain it long-term.

Physical Activity

“Physical therapy can be a valuable addition,” says Mehta. He explains that exercise can be especially helpful for children who lose some range of motion in their joints. It can also improve stiffness and pain. 

“Low-impact exercises like cycling, swimming, walking, tai chi, yoga, or stretching can help with pain control and overall mental and physical health,” says Jacob Hascalovici, MD, PHD, Chief Medical Officer of “Clearing,” an online pain treatment platform.

Other Lifestyle Tips

Using a symptom tracker can help you or your child discover and limit your exposure to foods, exercises, or other stressors that may trigger disease flare ups. They can also help you prepare for doctor’s appointments and keep track of how well treatments are working, as well as any new symptoms that could be side effects of the treatments.

Some advocacy groups, such as Creaky Joints, can provide support, and even produce caregiver guides for parents and guardians of children with rheumatoid arthritis that can help you navigate the challenges of long-term treatment.