Pharmacological therapy for initial symptoms of enthesitis-related arthritis
The approach to managing enthesitis-related arthritis, and the role of the drugs used for initial symptom management in it, is described in Management for enthesitis-related arthritis.
Nonsteroidal anti-inflammatory drugs (NSAIDs) may improve symptoms of peripheral arthritis and enthesitis. All of the NSAIDs listed below are considered to equally effective and drug choice should be based on patient factors (eg comorbidities). In children, it is important to consider additional factors that may influence compliance and tolerability (eg formulation, ability to dose around school schedule, age of patient). For pain and stiffness in enthesitis-related arthritis, give:
1celecoxib 2 to 4 mg/kg (for overweight children, use ideal body weight) up to 100 mg orally, twice daily until symptoms subside1 celecoxib celecoxib celecoxib
OR
1diclofenac 1 to 1.5 mg/kg (for overweight children, use ideal body weight) up to 75 mg orally, twice daily until symptoms subside1 diclofenac diclofenac diclofenac
OR
1ibuprofen immediate-release 5 to 10 mg/kg (for overweight children, use ideal body weight) up to 400 mg orally, 8-hourly until symptoms subside2 ibuprofen ibuprofen ibuprofen
OR
1indometacin 0.5 to 1 mg/kg (for overweight children, use ideal body weight) up to 50 mg orally, 2 to 3 times daily until symptoms subside1 indometacin indometacin indometacin
OR
1meloxicam 0.125 mg/kg (for overweight children, use ideal body weight) up to 15 mg orally, daily until symptoms subside1 meloxicam meloxicam meloxicam
OR
1naproxen immediate-release 5 to 7.5 mg/kg (for overweight children, use ideal body weight) up to 500 mg orally, twice daily until symptoms subside3 naproxen naproxen naproxen
OR
1naproxen modified-release (child 50 kg or heavier) 750 to 1000 mg orally, daily until symptoms subside naproxen naproxen naproxen
OR
1piroxicam 0.2 to 0.4 mg/kg (for overweight children, use ideal body weight) up to 20 mg orally, daily until symptoms subside4. piroxicam piroxicam piroxicam
Intra-articular corticosteroids are used by specialists for enthesitis-related peripheral arthritis if a small number of accessible joints are involved. Triamcinolone hexacetonide5 is most effective and can induce remission in injected joints for 12 months or longer—refer to local protocols for dosing advice.
Intra-articular corticosteroids are best given by someone with experience administering joint injections in children and adolescents. To improve tolerability of the procedure, procedural sedation and analgesia (eg midazolam, nitrous oxide) is usually used, although some teenagers will not require it. General anaesthesia may be needed for very young children (eg younger than 2 years) or if the child is distressed or having multiple joints injected. For further advice on procedural sedation and analgesia for painful procedures, including regimens used by suitably trained and credentialed practitioners, see Procedural sedation and Analgesia.