it, and enthesitis-related arthritis in children over 12 years
who have had an inadequate response to conventional
therapy or cannot tolerate it. Infliximab has been used in
refractory polyarticular juvenile idiopathic arthritis
[unlicensed indication] when other treatments, such as
etanercept, have failed.
Abatacept p. 641 prevents the full activation of
T-lymphocytes; it can be used for the management of active
polyarticular juvenile idiopathic arthritis. Abatacept is not
recommended for use in combination with TNF inhibitors.
Canakinumab p. 526 inhibits the activity of interleukin- 1
beta (IL- 1 b) and is licensed for the treatment of active
systemic juvenile idiopathic arthritis in children over 2 years,
when there has been an inadequate response to NSAIDs and
systemic corticosteroids.
Tocilizumab p. 640 antagonises the actions of
interleukin- 6 ; it can be used for the management of active
systemic juvenile idiopathic arthritis when there has been an
inadequate response to NSAIDs and systemic corticosteroids
and polyarticular juvenile idiopathic arthritis when there has
been an inadequate response to methotrexate. Tocilizumab
can be used in combination with methotrexate, or as
monotherapy if methotrexate is not tolerated or is contra-
indicated. Tocilizumab is not recommended for use with
other cytokine modulators.
Sulfasalazine
Sulfasalazine has a beneficial effect in suppressing the
inflammatory activity associated with some forms of juvenile
idiopathic arthritis; it is generally not used in systemic-onset
disease.
Other drugs used for ArthritisDiclofenac potassium, p. 651
.Diclofenac sodium, p. 652 .Etoricoxib, p. 653 .Flurbiprofen,
p. 654 .Ibuprofen, p. 655 .Indometacin, p. 657 .Meloxicam,
p. 658 .Naproxen, p. 659 .Piroxicam, p. 660DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS
Hydroxychloroquine sulfate
lINDICATIONS AND DOSE
Active rheumatoid arthritis (including juvenile idiopathic
arthritis) (administered on expert advice)|Systemic and
discoid lupus erythematosus (administered on expert
advice)|Dermatological conditions caused or aggravated
by sunlight (administered on expert advice)
▶BY MOUTH
▶Child: 5 – 6. 5 mg/kg once daily (max. per dose 400 mg),
dose given based on ideal body-weightlUNLICENSED USEPlaquenil®not licensed for use in
children for dermatological conditions caused or
aggravated by sunlight.
lCAUTIONSAcute porphyrias p. 603 .diabetes (may lower
blood glucose).G6PD deficiency.may aggravate
myasthenia gravis.may exacerbate psoriasis.neurological
disorders (especially in those with a history of epilepsy).
severe gastro-intestinal disorders
CAUTIONS, FURTHER INFORMATION
▶Screening for ocular toxicityHydroxychloroquine is rarely
associated with ocular toxicity. The British Society for
Paediatric and Adolescent Rheumatology recommends
that children should have their vision tested before long-
term treatment with hydroxychloroquine and have an
annual review of visual acuity. Children should be referred
to an ophthalmologist if there is visual impairment,
changes in visual acuity, or blurred vision. The Royal
College of Ophthalmologists has recommended that a
locally agreed protocol between the prescribing doctor and
ophthalmologist be established to monitor the vision of
these children. A review group convened by the Royal
College of Ophthalmologists has updated guidelines for
screening to prevent ocular toxicity on long-term
treatment with hydroxychloroquine (Hydroxychloroquine
and Ocular Toxicity: Recommendations on Screening 2009 );
this includes the recommendation that a child treated for
juvenile idiopathic arthritis should receive slit-lamp
examination routinely to check for uveitis.
lINTERACTIONS→Appendix 1 : hydroxychloroquine
lSIDE-EFFECTS
▶Common or very commonAbdominal pain.appetite
decreased.diarrhoea.emotional lability.headache.
nausea.skin reactions.vision disorders.vomiting
▶UncommonAlopecia.corneal oedema.dizziness.eye
disorders.hair colour changes.hearing impairment.
nervousness.neuromuscular dysfunction.retinopathy.
seizure.vertigo
▶Frequency not knownAcute hepatic failure.
agranulocytosis.anaemia.angioedema.bone marrow
disorders.bronchospasm.cardiac conduction disorders.
cardiomyopathy.hypoglycaemia.leucopenia.movement
disorders.muscle weakness.myopathy.photosensitivity
reaction.psychosis.reflexes absent.severe cutaneous
adverse reactions (SCARs).thrombocytopenia.tremor.
ventricular hypertrophy
Overdose Hydroxychloroquine is very toxic in
overdosage; overdosage is extremely hazardous and
difficult to treat. Urgent advice from the National Poisons
Information Service is essential. Life-threatening features
include arrhythmias (which can have a very rapid onset)
and convulsions (which can be intractable).
lPREGNANCYIt is not necessary to withdraw an
antimalarial drug during pregnancy if the rheumatic
disease is well controlled; however, the manufacturer of
hydroxychloroquine advises avoiding use.
lBREAST FEEDINGAvoid—risk of toxicity in infant.
lHEPATIC IMPAIRMENTCaution in moderate to severe
hepatic impairment.
lRENAL IMPAIRMENTManufacturer advises caution.
MonitoringMonitor plasma-hydroxychloroquine
concentration in severe renal impairment.
lPRESCRIBING AND DISPENSING INFORMATIONTo avoid
excessive dosage in obese patients, the dose of
hydroxychloroquine should be calculated on the basis of
ideal body-weight.lMEDICINAL FORMS
There can be variation in the licensing of different medicines
containing the same drug. Forms available from special-order
manufacturers include: oral suspension, oral solution
Tablet
CAUTIONARY AND ADVISORY LABELS 21
▶Hydroxychloroquine sulfate (Non-proprietary)
Hydroxychloroquine sulfate 200 mgHydroxychloroquine 200 mg
tablets| 60 tabletP£ 32. 49 DT = £ 5. 83
▶Quinoric(Bristol Laboratories Ltd)
Hydroxychloroquine sulfate 200 mgQuinoric 200 mg tablets|
60 tabletP£ 4. 75 DT = £ 5. 83BNFC 2018 – 2019 Arthritis 639
Musculoskeletal system10