title: The role of synthetic drugs in the biologic era: therapeutic strategies for treating juvenile idiopathic arthritis.
abstract: BACKGROUND
  Juvenile idiopathic arthritis is the most frequent chronic rheumatic disease in childhood. Synthetic disease modifying drugs (DMARDs) have been used in its treatment since the 1980s and have led to substantial improvement of quality of life and disease outcome. Recent pharmacological research has focused on newer medications, especially biologic agents.
  
  
  METHODS
  Synthetic DMARDS, especially methotrexate, rightfully remain the first-line treatment of most categories of juvenile arthritis, as attested by several international guidelines. A substantial body of evidence supports these medications, and recent research tries to clarify their optimal use in the clinical setting, both as monotherapy and in combination with biologics. In addition, new forms of synthetic DMARDs are in the research pipeline, or are already used for rheumatoid arthritis.
  
  
  CONCLUSIONS
  Methotrexate remains the preferred first-line medication for polyarticular arthritis, with leflunomide as a viable alternative in case of intolerance or toxicity, despite lack of approval in Europe and the US. Sulfasalazine and hydroxychloroquine are used only rarely in clinical practice, considered in combination with methotrexate if biologics are not available. New synthetic DMARDS are in the research pipeline for JIA, in the form of small molecules.
authors.affiliation: a German Center for Pediatric Rheumatology , Garmisch-Partenkirchen , Germany.
authors.forename: Boris
authors.initials: B
authors.lastname: Hügle
authors.affiliation: b Department of Pediatrics , Asklepios Clinic Sankt Augustin , Sankt Augustin , Germany.
authors.forename: Gerd
authors.initials: G
authors.lastname: Horneff
mesh_terms: D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001171:Arthritis, Juvenile / Q000188:drug therapy*; D001688:Biological Products / Q000627:therapeutic use*; D004359:Drug Therapy, Combination; D006801:Humans; D006886:Hydroxychloroquine / Q000627:therapeutic use; D007555:Isoxazoles / Q000627:therapeutic use; D000077339:Leflunomide; D008727:Methotrexate / Q000627:therapeutic use; D011788:Quality of Life; D012460:Sulfasalazine / Q000627:therapeutic use
chemical_list: D018501:Antirheumatic Agents; D001688:Biological Products; D007555:Isoxazoles; D012460:Sulfasalazine; D006886:Hydroxychloroquine; D000077339:Leflunomide; D008727:Methotrexate
keywords: Hydroxychloroquine; juvenile idiopathic arthritis; leflunomide; methotrexate; non-steroidal anti-inflammatory drugs; sulfasalazine; synthetic DMARDS; tofacitinib