BNF for Children 2011-2012

BNFC 2011–2012 10.1.3 Drugs that suppress the rheumatic disease process 507Triamcinolone hexacetonideTriamcinolone hexacetonide (Non-proprietary) AInjection, various strengths available from ’specialorder’ manufacturers or specialist importing companies,see, p. 809Dose. By intra-articular injection(for details consult product literature)Child 1–18 years for larger joints 1 mg/kg (usual max.20 mg, but higher doses have been used); if appropriaterepeat treatment for relapseTriamcinolone acetonideAdcortyl c Intra-articular/Intradermal (Squibb) AInjection (aqueous suspension), triamcinoloneacetonide 10 mg/mL, net price 1-mL amp = 90p; 5-mL vial = £3.63Excipients include benzyl alcohol (avoid in neonates, see Excipients,p. 2)Dose. By intra-articular injection(for details consult product literature)Child 1–18 years for larger joints 2 mg/kg (max. 15 mg);for doses above 15 mg use Kenalog c Intra-articular/Intramuscular; if appropriate repeat treatment forrelapseKenalog c Intra-articular/Intramuscular (Squibb)AInjection (aqueous suspension), triamcinoloneacetonide 40 mg/mL, net price 1-mL vial = £1.49Dose. By intra-articular injection(for details consult product literature)Child 1–18 years for larger joints 2 mg/kg (usual max.40 mg, but higher doses have been used); if appropriaterepeat treatment for relapse10.1.3 Drugs that suppress therheumatic diseaseprocessCertain drugs, such as methotrexate, cytokine modulators,and sulfasalazine, are used to suppress the diseaseprocess in juvenile idiopathic arthritis (juvenile chronicarthritis); these drugs are known as disease-modifyingantirheumatic drugs (DMARDs). In children, diseasemodifyingantirheumatic drugs should be used underspecialist supervision.Some children with juvenile idiopathic arthritis do notrequire disease-modifying antirheumatic drugs. Methotrexateis effective in juvenile idiopathic arthritis; sulfasalazineis an alternative but should be avoided in systemic-onsetjuvenile idiopathic arthritis. Gold andpenicillamine are no longer used. For the role of cytokinemodulators in polyarticular juvenile idiopathicarthritis, see p. 509.Unlike NSAIDs, disease-modifying antirheumatic drugscan affect the progression of disease but they mayrequire 3–6 months of treatment for a full therapeuticresponse. Response to a disease-modifying antirheumaticdrug may allow the dose of the NSAID tobe reduced.Disease-modifying antirheumatic drugs can improvenot only the symptoms of inflammatory joint diseasebut also extra-articular manifestations such as vasculitis.They reduce the erythrocyte sedimentation rate and C-reactive protein.AntimalarialsThe antimalarial hydroxychloroquine is rarely used totreat juvenile idiopathic arthritis. Hydroxychloroquinecan also be useful for systemic or discoid lupus erythematosus,particularly involving the skin and joints, andin sarcoidosis.Retinopathy (see below) rarely occurs provided that therecommended doses are not exceeded.Mepacrine is used on rare occasions to treat discoidlupus erythematosus [unlicensed].Cautions Hydroxychloroquine should be used withcaution in neurological disorders (especially in thosewith a history of epilepsy), in severe gastro-intestinaldisorders, in G6PD deficiency (section 9.1.5), and inacute porphyria. Hydroxychloroquine may exacerbatepsoriasis and aggravate myasthenia gravis. Concurrentuse of hepatotoxic drugs should be avoided; otherinteractions: Appendix 1 (chloroquine and hydroxychloroquine).Pregnancy It is not necessary to withdraw an antimalarialdrug during pregnancy if the rheumatic diseaseis well controlled; however, the manufacturer ofhydroxychloroquine advises avoiding use.Breast-feeding Hydroxychloroquine is present inbreast milk leading to a risk of toxicity in infants—breast-feeding should be avoided when it is used totreat rheumatic disease.Screening for ocular toxicityHydroxychloroquine is rarely associated with oculartoxicity. The British Society for Paediatric and AdolescentRheumatology recommends that childrenshould have their vision tested before long-termtreatment with hydroxychloroquine and have anannual review of visual acuity. Children should bereferred to an ophthalmologist if there is visualimpairment, changes in visual acuity, or blurredvision. The Royal College of Ophthalmologists hasrecommended that a locally agreed protocolbetween the prescribing doctor and ophthalmologistbe established to monitor the vision of these children.ImportantTo avoid excessive dosage in obese children, thedose of hydroxychloroquine should be calculated onthe basis of ideal body-weight; ocular toxicity isunlikely with doses under 5–6.5 mg/kg or max.400 mg daily.Side-effects The side-effects of hydroxychloroquineinclude gastro-intestinal disturbances, headache, andskin reactions (rashes, pruritus); those occurring lessfrequently include ECG changes, convulsions, visualchanges, retinal damage (see above), keratopathy, oto-10 Musculoskeletal and joint diseases