Welcome to Juvenile Rheumatoid Arthritis or JRA, by Connie Martin, MS, RDN; Claire Stephens, MS, RDN; and Lolita McLean, MPH, RDN...

Transcription

1 Welcome to Juvenile Rheumatoid Arthritis or JRA, by Connie Martin, MS, RDN; Claire Stephens, MS, RDN; and Lolita McLean, MPH, RDN...all of Alabama s Children s Rehabilitation Service, part of the Alabama Department of Rehabilitation Services. Special thanks for Lauren Williams, a senior student in Food and Nutrition at the University of Alabama, for help in putting together this PowerPoint presentation. 1

2 At the conclusion of this presentation, participants will be able to: define juvenile rheumatoid arthritis (JRA); describe different types of medical treatment; explain the nutritional concerns of JRA; and discuss the implications of JRA for exercise 2

3 To begin with, let s talk about what JRA, or Juvenile Rheumatoid Arthritis, is. It is inflammation of the joints, an autoimmune disease; it causes pain, stiffness & swelling. There are approximately 294,000 children under the age of 18 that are affected. There are 3 types of JRA. Polyarticular JRA affects about 30% of children with JRA, and it typically affects 5 or more joints. They are usually the small joints of the body, mainly in the hands and feet. Pauciarticular JRA typically affects 4 or fewer joints and they are usually the larger joints, such as the knees. Systemic JRA typically has signs of joint swelling, like a pink rash and fever on the body. It also can affect internal organs such as the liver, heart, spleen, and lymph nodes. Systemic JRA affects about 20% of all children with JRA, and a small percentage of these children develop arthritis in many joints. They can have severe arthritis that continues into adulthood. 3

4 Treatments for JRA include nonsteroidal anti-inflammatory drugs (or NSAIDs ), Methotrexate, Etanercept injections, Infliximab injections, and Celebrex. 4

5 Nonsteroidal anti-inflammatory drugs, or NSAIDs, help to reduce inflammation. They can be used fairly safely but can be rough on the gastrointestinal system. They are typically used as the first line of defense, and their most common side effects are upset stomach & nausea. Naproxen and Ibuprofen are examples of commonly used NSAIDs. 5

6 Methotrexate began as a medication used in cancer treatment. When used in JRA, it takes about 8 to 12 weeks to fully see positive results. Methotrexate can be taken either in tablet or injection form once a week. Some of the side effects are damage to the lining of the stomach, mouth, and intestines. It does decrease the immune system and, if taken with NSAIDs, which is common, the number and likelihood of side effects may be increased. Methotrexate can be used to treat Crohn s Disease, as well as JRA. 6

7 Etanercept, or Enbrel, injections suppress the immune system, so there is decreased ability to fight bacteria, fungi, and viruses. These injections also slow healing. Some common side effects of Etanercept include headaches, a rash at the injection site, and/or upper respiratory infection. 7

8 With Infliximab, or Remicade, injections, children are more prone to develop lymphoma. For some patients, relief of JRA symptoms is seen in as little as 2 weeks. Infliximab can be used to treat Crohn s Disease, as well as JRA. 8

9 Celebrex is given by weight to children 2 years of age and older. It helps to reduce symptoms for 24 hours. The most common side effects are diarrhea, vomiting, upper respiratory infection, abdominal pain, headache, fever, and nausea. It was approved by the FDA in Although available now, it was taken off the market in the past, so it is not as commonly prescribed as before. 9

10 When performing a nutrition assessment on a child with JRA, your data collection should include an assessment of weight and height measurements, a dietary recall, bowel patterns, appetite, and drug-nutrient interactions and complications. Always plot measurements on growth charts. Some of these kids do not feel well & are not eating well, so you will see some weight loss. A 24-hour dietary recall focused on food groups will help in assessing whether they are eating healthy, balanced meals. They may not tell you that their stomachs are bothering them because of the medicine they are on but, when you start asking about bowel movements (how often, what they look like, etc.), they will give you the details. Make sure that you always have a drug nutrient interaction book readily available. Routinely re-measure! Though the years, if children with JRA are feeling bad or experiencing a JRA flare-up, you will likely see some height discrepancies. Good days, where they re feeling better, may show growth that isn t true growth. You also want to look closely at discrepancies in linear growth because some children with JRA taking corticosteroid treatments may be experiencing compression fractures, if they are not taking calcium supplements. Several years ago, a clinic dietitian measured a 12 year old child and requested my assistance in re-measuring. We re-measured multiple times but kept finding that the child had lost one-half to three-quarters of an inch. The dietitian consulted the child s doctor who confirmed that a bone scan, ordered due to complaints of pain, had revealed a compression fracture. The child had been on corticosteroids for a long time and had not been taking calcium supplements, as ordered. I cannot re-emphasize enough how important it is to make sure that 10

11 measurements are taken and re-taken! Of course, the higher the child s weight, the higher the stress on the child s joints, and increased stress on joints causes increased pain. 10

12 With prolonged use of steroids, always look at calcium supplementation. I have listed here the Daily Reference Intakes for calcium for children and for males and females. Calcium supplementation is not recommended for children who have JRA but are NOT on corticosteroid treatments. If they ARE on corticosteroid treatments, then calcium IS recommended. Make sure these children get a calcium supplement with vitamin D. Talk to them and educate them about how calcium carbonate is typically best absorbed with meals and how calcium citrate can be taken between or with meals but is actually absorbed better between meals. Calcium is better absorbed in amounts of around 500 milligrams or less per dose. If they are eating calcium-rich foods (broccoli; almonds; and dairy products such as cheese, yogurt, milk and soy milk), they are going to need milligrams of calcium, which will be best divided into a morning and evening dose. If they are taking a multivitamin, tell them not to take their calcium supplement with their multivitamin. Also, encourage them to take their calcium supplement during their waking hours instead of at night time. When you take a calcium supplement and are up and moving around, bone mineralization is enhanced. Also, be aware that calcium supplementation may cause constipation. 11

13 Studies have found that folic acid reduces the incidence of liver function test abnormalities and the gastrointestinal intolerance often associated with Methotrexate use. Folic acid may also offset the elevation in plasma homocysteine associated with the use of Methotrexate. Elevated homocysteine levels have been associated with cardiovascular disease risk. Some researchers have suggested that folic acid may reduce the effectiveness of Methotrexate. In determining whether or not to use folic acid with a child, or how to administer folic acid, check with the child s Rheumatologist, as there are several approaches to folic acid supplementation. As examples of the variety of approaches you are likely to see, some Rheumatologists use no folic acid supplementation unless the child develops side effects such as oral ulcers, some skip the child s routine folic acid supplementation on the day before and/or the day following methotrexate administration, some provide 2.5 to 5.0 milligrams of folic acid once per week beginning 2 days after methotrexate administration, and some provide 1 milligram of folic acid daily for all children begun on oral or subcutaneous methotrexate.

14 When it comes to nutrition in JRA, what is typically encouraged is a diet high in Omega-3 fatty acids, to reduce inflammation, and low in or devoid of red meat. Red meat contains an amino acid that can contribute to inflammation. Through the years, I have had some parents tell me that red meat does not bother their children & others tell me that their children do not eat red meat because it causes flare-ups and pain. Encourage children with JRA to take a multivitamin and eat a lot of fruits & vegetables that contain antioxidants. A vegetarian diet may be beneficial for some. Avoid food allergens, which will contribute to the inflammatory process. Make sure that their diets are adequate when it comes to the intake of calcium; folic acid; magnesium; zinc; selenium; and vitamins E, D, C & B. 13

15 Some encourage the Mediterranean diet for children with JRA, as it is high in monounsaturated fats, fish, poultry, fruits and vegetables. 14

16 Exercise is important for kids with JRA, as are Physical & Occupational Therapy evaluations. Strengthening and stretching exercises can help with joint problems. Also, exercise helps to reduce pain and stiffness, increase range of motion, and improve muscle endurance and strength. The typical exercises recommended include swimming, walking, bike riding, and other low impact sports. Exercise should be done at times when the child feels better & rest should be emphasized at times when the child is not feeling well. 15

17 Many struggle with getting into a downward spiral, emotionally and socially. Be aware of this and be careful about the questions you ask. Assess their pain levels and limitations. Other things that can help with JRA include massage, hot and cold treatment, splints, ultrasound, electrical stimulation, relaxation, and Tai Chi. 16

18 JRA can be accompanied by Crohn s Disease, Ulcerative Colitis, Lupus, and Sjogren's Syndrome. 17

19 This slide contains some useful JRA references. 18

20 Thank you for your attention! 19