The misconception that arthritis only affects the elderly

In the UAE, one in 10 adults suffer from arthritis. With its high prevalence, there is a common misconception that arthritis is a condition that only affects the elderly and adults. This isn’t the case though. Juvenile idiopathic arthritis (JIA) can affect children that are as young as six months old, up to the age of 16. Some children can experience the symptoms for a few months and others can have the symptoms for the rest of their lives. Globally, JIA affects around one in 1,000.

Dr Anand Gorva, Specialist Paediatrics Orthopaedics, Medcare Orthopaedics & Spine Hospital, says that JIA, like rheumatoid arthritis, is autoimmune-related and causes inflammation and pain and stiffness in the joints. “JIA is an autoimmune disease or it is when the immune system malfunctions against the lining of the joints, called the synovial membrane.”

Dr Gorva says that although the exact cause of the condition is unknown, it is associated with a number of factors. “It is genetic disorder and risk factors include exposure to environmental factors, such as pollution.” He says that smoking, infections, a lack of exercise and a poor diet can also be risk factors.

Dr Ajith Jose, Specialist Orthopaedics, Aster Hospital, Qusais, says that the majority of cases of JIA aren’t inherited. “Most cases of JIA are sporadic, which means they occur in people with no history of the disorder in their family. A small percentage of cases of JAI have been reported to run in families, although the inheritance pattern of the condition is unclear.

“A sibling of a person with juvenile idiopathic arthritis has an estimated risk of developing the condition that is about 12 times that of the general population. Dietary and emotional factors do not appear to play a role in the development of JIA. Researchers have also identified changes in several genes that may influence the risk of developing JAI.”

Lack of awareness

Dr Gorva says that people’s lack of awareness about JIA means that it is often diagnosed late or missed. “Most people assume that arthritis is an adult disorder and can’t happen in children therefore they present late to the doctors. This lack of awareness delays the presentation time when compared to adults. Schools need to be informed and encourage the child to participate in extra-curricular activities as normal as possible. Occupational therapists should liaise with school-based therapists for the continuation of care for these children.”

He says that diagnosing JIA at an early stage means that the child is more likely to be receptive to the treatment and less likely to face complications. “If the treatment is started early, the response is good and it can prevent major complications such as joint destruction and functional disability.”

Dr Jose says that another issue is that JIA can be tricky to diagnose. “Diagnosis of juvenile idiopathic arthritis can be difficult because joint pain can be caused by many different types of problems. No single test can confirm a diagnosis, but tests can help rule out some other conditions that produce similar signs and symptoms.”

He refers to different measurements that can be taken from blood tests, such as the erythrocyte sedimentation rate (ESR), which can be indicative of inflammation. The blood can also be tested for antibodies such as cyclic citrullinated peptide (CCP) and the rheumatoid factor.

Treatment

“For some JIA patients, symptoms can be controlled by taking normal anti-inflammatory tablets to reduce the inflammation. Other patients need to take stronger medication which modulate the immune system. For flare-ups management, doctors may also use cortisone, also called corticosteroids or steroids,” says Dr Jose.

“Corticosteroids such as prednisone may be used to control symptoms until another medication takes effect. They are also used to treat inflammation when it is not in the joints, such as inflammation of the sac around the heart (pericarditis).”

He says that nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen sodium, can be prescribed to reduce pain and swelling.

If NSAIDs fail to relieve the symptoms of pain or swelling or the patient is at a high risk of future complications, Dr Jose says that disease-modifying antirheumatic drugs (DMARD) can be prescribed.

“These type of medicines can modulate the immune system to control the disease progression. The most commonly used DMARD for children is methotrexate.” When only a few joints are involved, a steroid can be injected into the joint before any additional medications are given.

Dr Jose also refers to new classes of drugs called biologic agents. “Also known as biologic response modifiers, this newer class of drugs includes tumor necrosis factor (TNF) blockers, such as etanercept and adalimumab. These medications can help reduce systemic inflammation and prevent joint damage.” Physiotherapy and support splints are also used when necessary.

Complications

“JIA is associated with multiple deformities in more than half of patients,” says Dr Jose. “Among these deformities, hand and wrist are the commonest involved joints followed by knee joints. These deformities are statistically significantly associated with polyarthritis, seropositivity, and late presentation of patients to tertiary care.

While early diagnosis is vital, JIA can also disrupt a child’s growth and bone development and some medications, such as corticosteroids, can also inhibit growth. Yet, Dr Gorva says that the emotional impact of the condition should also be considered.

“Apart from functional disabilities like joint contracture and stiffness the child can have emotional, psychological and social problems. Therefore a multi team approach would mitigate these problems and most of the children with JIA lead an active life and do things as their peers do,” he says.