Additional medications in a step-wise fashion make up the rest of the pyramid, as the disease persists longer and longer. Whether the development of biologic agents such as tumor necrosis factor receptor fusion protein usher in a new era of management of JRA and the impact of long-term outcome remains to be seen.
More therapeutic options are now available, including cytoxan and biologic agents.
In a study by Harel et al, serial radiographs were used to evaluate the response to methotrexate in 23 patients with JRA who had bilateral wrist involvement. The six non-responders had progressive loss of cartilage. Thus, it remains to be seen if the use of methotrexate earlier in the course of JRA favorably alters the long-term outcome. Also, there is not enough information regarding the role that physical and occupational therapies play in the long-term outcome. The children and adolescents who suffer from chronic arthritis in the present era receive more aggressive medication management.