dr shridhar jia children and young people with arthritis
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Children with Arthritis (JIA)Children with Arthritis (JIA)
Dr A Sridhar, Consultant Dr A Sridhar, Consultant Paediatrician, UHL NHS Trust, Paediatrician, UHL NHS Trust,
Leicester Leicester
Juvenile Idiopathic Arthritis (JIA)Juvenile Idiopathic Arthritis (JIA)
Most common connective tissue disease in childhoodMost common connective tissue disease in childhoodThe The DOH Musculo-skeletal frameworkDOH Musculo-skeletal framework states that states that musculo-skeletal conditions are the musculo-skeletal conditions are the biggest cause of biggest cause of disability in childrendisability in children. . In recent years, the management of children with In recent years, the management of children with Arthritis has changed significantly. Arthritis has changed significantly. The availability of the new drugs (DMARDS, Biologicals) The availability of the new drugs (DMARDS, Biologicals) has lead to a marked improvement in disease outcomeshas lead to a marked improvement in disease outcomesThe emphasis is on early diagnosis and tight disease The emphasis is on early diagnosis and tight disease controlcontrol
J.I.A.J.I.A. R.A. R.A.a disease affecting a a disease affecting a growing developing growing developing skeleton.skeleton.
a disease affecting a a disease affecting a
developed skeletondeveloped skeleton..
In children there is the capacity for regeneration, re-modelling and repairIn children there is the capacity for regeneration, re-modelling and repair
This needs to be used to a maximumThis needs to be used to a maximum
The treatment needs to be different
JIA- DefinitionJIA- Definition
Is a group of conditions Is a group of conditions
in which there is chronic arthritis in which there is chronic arthritis
lasting lasting more than 6 weeksmore than 6 weeks, ,
presenting presenting
before 16 years of agebefore 16 years of age
JIA- Criteria for DiagnosisJIA- Criteria for DiagnosisAmerican College of Rheumatology Revised American College of Rheumatology Revised
CriteriaCriteria
Age of onset < 16 yearsAge of onset < 16 years
Arthritis of one or more jointsArthritis of one or more joints
Duration of disease Duration of disease >> 6 weeks 6 weeks
Other conditions which present with Other conditions which present with arthritis in childhood must be excludedarthritis in childhood must be excluded
AetiologyAetiology
Autoimmune disease in which the cause of arthritis is Autoimmune disease in which the cause of arthritis is largely unknownlargely unknown
combination of factorscombination of factors– Environment (infection, trauma, stress)Environment (infection, trauma, stress)– Immuno-geneticImmuno-genetic
JIAJIAEpidemiologyEpidemiology
Described in all races and geographic areasDescribed in all races and geographic areasThe UK prevalence is estimated at 1:1000 under The UK prevalence is estimated at 1:1000 under 16 years with an incidence of approximately 16 years with an incidence of approximately 1:10000 1:10000 Females predominate 2:1Females predominate 2:1Leicestershire has a population of approximately Leicestershire has a population of approximately 117,600 children (Mid-2006 population 117,600 children (Mid-2006 population estimates) estimates)
JIA- JIA- Onset TypesOnset Types
Pauciarticular (Pauciarticular (<< 4 joints) 4 joints)
Polyarticular (Polyarticular (>> 5 joints) 5 joints)
Systemic (arthritis with fever and rash)Systemic (arthritis with fever and rash)
ILAR Proposed Classification CriteriaILAR Proposed Classification Criteria
Juvenile Idiopathic Arthritis (JIA)Juvenile Idiopathic Arthritis (JIA)SystemicSystemicPolyarticular: RF+ and RF-Polyarticular: RF+ and RF-Oligoarticular: persistent and extendedOligoarticular: persistent and extendedPsoriatic arthritisPsoriatic arthritisEnthesitis-related arthritisEnthesitis-related arthritis
Presenting features of Arthritis Presenting features of Arthritis
Joint PainJoint Pain
Joint StiffnessJoint Stiffness
Joint swellingJoint swelling
LimpLimp
Restriction of movementRestriction of movement
Eye symptoms Eye symptoms
Systemic symptoms Systemic symptoms
Common Differential DiagnosisCommon Differential Diagnosis
Irritable hip- Transient SynovitisIrritable hip- Transient Synovitis
Septic Arthritis, OsteomyelitisSeptic Arthritis, Osteomyelitis
Infection – Viral, Bacterial, Lyme diseaseInfection – Viral, Bacterial, Lyme disease
Malignancy – leukaemia, NeuroblastomaMalignancy – leukaemia, Neuroblastoma
Perthe’s Disease Perthe’s Disease
Slipped Capital Femoral Epiphysis (SCFE)Slipped Capital Femoral Epiphysis (SCFE)
Generalised Joint and Bone painsGeneralised Joint and Bone pains
Non-specific but clinically well, No joint Non-specific but clinically well, No joint SwellingSwelling
Hyper-mobility of Joints- either Syndromic Hyper-mobility of Joints- either Syndromic or Benign Hypermobilty syndromesor Benign Hypermobilty syndromes
Vitamin D deficiencyVitamin D deficiency
JIAJIAManagementManagement
No cure but treatable No cure but treatable
Remissions and Relapses Remissions and Relapses
Involves multidisciplinary team (MDT) Involves multidisciplinary team (MDT) approachapproach
Relieve pain, reduce inflammation, Relieve pain, reduce inflammation, preserve joint function, maintain normal preserve joint function, maintain normal growth and developmentgrowth and development
Screen for Uveitis Screen for Uveitis
Medical ManagementMedical Management
NSAIDS – Ibuprofen, Naproxen, Piroxicam NSAIDS – Ibuprofen, Naproxen, Piroxicam DMARDS (Disease modifying anti rheumatic drugs)DMARDS (Disease modifying anti rheumatic drugs)
- under Rheumatologist’s supervision- under Rheumatologist’s supervision
- Methotrexate: Orally or subcutaneously: Weekly- Methotrexate: Orally or subcutaneously: Weekly
Joint steroid injectionsJoint steroid injectionsCorticosteroids : Oral or IV Methyprednisolone Corticosteroids : Oral or IV Methyprednisolone Anti- TNF agents Anti- TNF agents
– – block the immune protein TNF : Infliximab, Etarncept, block the immune protein TNF : Infliximab, Etarncept, Adalimumab Adalimumab
Physiotherapist & Occupational Physiotherapist & Occupational TherapistsTherapists
Develop exercise programsDevelop exercise programs
Strengthen muscles & keep joints flexibleStrengthen muscles & keep joints flexible
Encourage normal limb developmentEncourage normal limb development
Maintain function and prevent deformitiesMaintain function and prevent deformities
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JIAJIAPrognosisPrognosis
Chronic disease which is treatable but cannot be Chronic disease which is treatable but cannot be curedcured
Characterized by remissions and Relapses Characterized by remissions and Relapses
Overall the prognosis is much better in JIA Overall the prognosis is much better in JIA compared to RAcompared to RA
JUVENILE RHEUMATOID ARTHRITISJUVENILE RHEUMATOID ARTHRITISPoor Prognostic SignsPoor Prognostic Signs
PauciarticularPauciarticular– Long duration of active diseaseLong duration of active disease– Conversion to polyarticular disease Conversion to polyarticular disease – Chronic uveitisChronic uveitis
PolyarticularPolyarticular– Long duration of active diseaseLong duration of active disease– Articular erosionsArticular erosions– RF positivityRF positivity
SystemicSystemic– Conversion to polyarticular disease Conversion to polyarticular disease
Paediatric Rheumatology Service Paediatric Rheumatology Service Aims of the Service Aims of the Service
To provide a high quality care for children To provide a high quality care for children and young people with Rheumatological and young people with Rheumatological problems locally problems locally
To provide or enable them to receive the To provide or enable them to receive the care at home care at home
Paediatric Rheumatology Service Paediatric Rheumatology Service
Running the service:15 yrs Running the service:15 yrs
All children < 16 yrs ageAll children < 16 yrs age
Children between 16-18 yrs( full time Children between 16-18 yrs( full time education) or with other chronic medical education) or with other chronic medical conditions conditions
Significant number of children with JIA on Significant number of children with JIA on Methotrexate therapy Methotrexate therapy
Clinical team Clinical team
Consultant Paediatricians with specialist Consultant Paediatricians with specialist interest in Paediatric Rheumatology interest in Paediatric Rheumatology
Adult Rheumatologist Adult Rheumatologist
Specialist RegistrarSpecialist Registrar
Clinical Nurse Specialist (CNS)Clinical Nurse Specialist (CNS)
Conditions seen Conditions seen
JIA and other Inflammatory Arthropathies JIA and other Inflammatory Arthropathies
Non-inflammatory Musculo-skeletal pain Non-inflammatory Musculo-skeletal pain syndromessyndromes
Childhood Vasculitis Childhood Vasculitis
Hyper-mobility syndromes Hyper-mobility syndromes
OPD clinicsOPD clinics
OPD Clinics; New and follow up OPD Clinics; New and follow up
Consultant/Registrar ledConsultant/Registrar led
Weekly clinics Weekly clinics
Rapid access clinics Rapid access clinics
Annual ReviewsAnnual Reviews
Children’s Day Care Unit Children’s Day Care Unit
Mon-Fri, 0800- 1800 hrs Mon-Fri, 0800- 1800 hrs Methotrexate info, counselling , injections, Methotrexate info, counselling , injections, training to parents training to parents Bloods sampling Bloods sampling Joint steroid injections Joint steroid injections Specialist Nurse support- Close liaison with Specialist Nurse support- Close liaison with Diana team in the community Diana team in the community Methotrexate MDT meetings: Methotrexate MDT meetings:
( 2 meetings/month): Specialist nurse, ( 2 meetings/month): Specialist nurse, Pharmacist and Consultant Pharmacist and Consultant
Inpatient ServicesInpatient Services
Dedicated support by on-call teamDedicated support by on-call team
Open access to Children’s assessment Open access to Children’s assessment unit- 24x 7unit- 24x 7
Multi-disciplinary team: Physiotherapy, Multi-disciplinary team: Physiotherapy, OT, other speciality input OT, other speciality input
Support ServicesSupport Services
Paediatric Physiotherapist Paediatric Physiotherapist
Occupational Therapist (O.T)Occupational Therapist (O.T)
Podiatrist/OrthotistPodiatrist/Orthotist
Paediatric PharmacistPaediatric Pharmacist
Paediatric Dietician Paediatric Dietician
Play therapist Play therapist
Dedicated secretarial support Dedicated secretarial support
Specialist ServicesSpecialist Services
Paediatric Ophthalmologist Paediatric Ophthalmologist
Paediatric Dermatologist Paediatric Dermatologist
Paediatric Orthopaedic SurgeonPaediatric Orthopaedic Surgeon
Paediatric Radiologist: X-rays, U/S, MRI Paediatric Radiologist: X-rays, U/S, MRI ScansScans
Musculo-Skeletal Radiologist; Monthly Musculo-Skeletal Radiologist; Monthly meetingsmeetings
Transition Transition
Transitional Services Transitional Services