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Content Update

March 25, 2022

Tofacitinib for Active Polyarticular Juvenile Idiopathic Arthritis: In September 2020, the U.S. Food and Drug Administration (FDA) approved tofacitinib (Xeljanz) to treat patients ages 2 and older for active polyarticular juvenile idiopathic arthritis (JIA), which is the first and only drug of its class for treatment. Tofacitinib is a disease modifying antirheumatic, Janus kinase (JAK) inhibitor that limits the intracellular enzymes involved in stimulating hematopoiesis and immune cell function. A randomized, withdrawal, double-blind, placebo-controlled study of patients between the ages of 2 and 18 with polyarticular JIA demonstrated that tofacitinib effectively decreased flare rates at week 44.



Upon completion of the chapter, the reader will be able to:

  1. Identify risk factors for developing adult rheumatoid arthritis (RA) or juvenile idiopathic arthritis (JIA).

  2. Describe the pathophysiology of RA, with emphasis on the specific immunologic components.

  3. Discuss the comorbidities associated with RA.

  4. Recognize the typical clinical presentation of RA or JIA.

  5. Create treatment goals for a patient with RA or JIA.

  6. Compare the available pharmacotherapeutic options, selecting the most appropriate regimen for a given patient.

  7. Propose a patient education plan that includes nonpharmacologic and pharmacologic treatment measures.

  8. Formulate a monitoring plan to evaluate the safety and efficacy of a therapeutic regimen designed for an individual patient with RA or JIA.


Rheumatoid arthritis (RA) is a complex systemic inflammatory condition manifesting initially as symmetric swollen and tender joints of the hands and/or feet. Some patients may experience low disease activity, whereas others may present with high disease activity and/or extraarticular manifestations. The systemic inflammation of RA leads to joint destruction, disability, and premature death. Juvenile idiopathic arthritis (JIA) is the most common form of arthritis in children.


RA has a prevalence of 0.5% to 1%.1,2 RA arises from an immunologic reaction, perhaps in response to a genetic or infectious antigen. Risk factors associated with the development of RA include the following:

  • Female gender (3:1 females to males)

  • Increasing age (peak onset 35–50 years of age)

  • Current tobacco smoking. Tobacco users are more likely to have increased disease activity. This risk is reduced when a patient has remained tobacco-free for at least 10 years.

  • Family history of RA. Genetic studies demonstrate a strong correlation between RA and the presence of major histocompatibility complex class II human leukocyte antigens (HLA), specifically HLA-DRB1 haplotypes.2 HLA is a molecule associated with the presentation of antigens to T lymphocytes.

  • Silica dust inhalation. Occupational exposure to silica is associated with an increased risk of developing RA.2

  • Emerging evidence suggests that stress may influence RA onset and disease activity. It appears that individual major stressful life events may increase risk of RA. Additionally, chronic ...

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