Question
My son is fourteen yeas old and has been complaining of back pain for the past four months. Vioxx 25ng QD and Pepcid 20mg QD is prescribed. He does not experiencing any joint pain other than his back which is mild somedays and others can get moderate to severe but does experiece pain on a daily basis. He has no difficulties with movement and feels better with excerise but complains of pain with standing. His HLA B27 is (+), sed and CBC and back x-ray are normal, but his liver enyzems are evelated. The CT showed mild subchondral sclerosis and 2mm erosion in the left ileum at the sacroiliac joint. The right sacroiliac is normal. His eyes tend to get red and irritated and did have burning with urination. These symptons occurred just prior to the back pain but did resolve on its own. Renal and bladder infection or disorders were ruled out and my son has never had any sexual relations. His Rheumatologist diagnosed him as havig AS. I and not aware of any of family history of AS or RA. The Rheumatologist wants to treat this “agressively” with Enbrel. What drug is the best for this situation, Methotrexate or Anbrel and the safest? What is the prognosis of AS? Do patients often go into remission for years? Is there better prognosis with a child developing AS than adult? My son had a growth spurt prior to this of one foot in a two years span, could that contribited to this?
Answer
You are asking a tough question. Both methotrexate and Enbrel are approved for juvenile rheumatoid arthritis (JRA) and both are effective. Some might classify your son’s disease as a spondylitis variant of JRA. There have been no studies with either of these 2 drugs on prevention of spinal fusion and deformity. He likely will note symptomatic improvement with either drug. This is similar to the dilemma we are facing in adult RA. Up till now, most of us have been using methotrexate before the TNF inhibitors such as Enbrel because there is more long term safety data with the older drug. However, if your son has elevated liver enzymes, then Enbrel might be favored. You should discuss this with your son’s rheumatolgist.
