For children with extended oligoarticular or polyarticular subtypes, weekly administration of methotrexate now stands as the first-line drug of choice. Methotrexate, an antimetabolite, may be administered via the oral or parenteral route with no significant difference in efficacy. Daily leflunomide has been shown to be as effective as methotrexate in controlling JIA symptoms but is associated with increased frequency of gastrointestinal side effects. For patients who fail traditional disease-modifying agents, the development of the biologic response modifiers has represented an important advance in therapy. These agents are a class of medication that selectively inhibits specific proinflammatory cytokines or pathways critical to perpetuating arthritis. Anti–TNF-α agents such as etanercept and adalimumab have been shown to significantly increase the number of children achieving clinical remission with treatment beyond the rates observed with methotrexate. Abatacept, an inhibitor of T-cell co-stimulation, has also been proved to be significantly more effective than methotrexate in controlling JIA symptoms and increasing the likelihood of remission.

Treatment strategies for children with enthesitis-related arthritis are similar to those with polyarticular JIA. However, these children may also respond favorably to sulfasalazine, which is metabolized to the anti-inflammatory 5-aminosalicylic acid. Methotrexate, as well as etanercept, has been successfully used to treat children with juvenile psoriatic arthritis.

The therapeutic approach to children with systemic-onset disease is markedly different than that for other subtypes of JIA. Systemic corticosteroids are used frequently to treat the constitutional symptoms. For those patients who require ongoing systemic corticosteroids to control their disease, the interleukin-1 (IL-1) inhibitors such as anakinra, have been demonstrated to dramatically improve the constitutional symptoms. Methotrexate is often required for patients with polyarticular arthritis. Systemic-onset patients with signs of macrophage activation syndrome respond well to high doses of corticosteroids and anakinra, with the possible addition of cyclosporine.

Children with uveitis related to their JIA also pose unique therapeutic challenges. Frequently, ocular inflammation occurs when joint disease is quiescent. However, given the threat of permanent vision impairment, these children are aggressively treated with topical prednisolone, methotrexate, and biologic response modifiers such as adalimumab and infliximab.

In addition to pharmacologic treatment, children with JIA will often require care from physical and occupational therapists. These specialists play a critical role in improving the function of those children with functional impairments such as limb-length discrepancy or muscle atrophy. Nutritionists may be required for those patients on systemic therapy with corticosteroids to design dietary strategies to minimize weight gain. Psychologists may be needed to help patients and families develop strategies to deal with the stress inherent to a chronic illness. JIA patients may require modifications to school activities and schedules requiring a strong advocate, such as a guidance counselor, within their educational system. With the care of a multidisciplinary team and the advances in drug therapy, children with JIA should expect to lead normal and productive lives.