Pediatric Drugs

, Volume 8, Issue 6, pp 347–356 | Cite as

Recommendations for the Use of Methotrexate in Juvenile Idiopathic Arthritis

Therapy In Practice


Juvenile idiopathic arthritis (JIA) is one of the most common rheumatic diseases in childhood. In a significant number of JIA cases the disease is resistant to therapy with NSAIDs, intra-articular corticosteroid injections, and physiotherapy, and methotrexate is used as a second-line agent. The efficacy of methotrexate therapy in children with JIA has been demonstrated in prospective controlled trials and this agent appears to have slightly superior efficacy compared with leflunomide. Data from randomized studies indicate a starting dose of 10–15 mg/m2/week orally. The dose of parenteral methotrexate can be increased to 15–20 mg/m2/week. Combination therapy with methotrexate and an NSAID is recommended. However, there are still no data on when to initiate methotrexate in JIA and how long children should be treated.

The most common adverse effects are aversion to the drug and nausea. In the case of minor adverse effects the use of folic acid at a dosage of 1 mg/day is feasible. In JIA, daily folate supplementation has only been studied in one small heterogeneous cohort with a very short observation period and, at present, a general recommendation on daily folate supplementation cannot be made.

In summary, methotrexate is seen by many pediatric rheumatologists as the first-choice, second-line drug; there is good evidence of its efficacy in JIA. However, in light of the recent introduction of biologic agents, the place of methotrexate in the treatment of JIA may have to be redefined in the coming years.



We dedicate this work to Professor Dr Ulrich Göbel and thank him for his continuous support of our Pediatric Immunology and Rheumatology Division. We thank P. Knops for assistance in the preparation of this manuscript.

No sources of funding were used to assist in the preparation of this review. The authors have no conflicts of interest that are directly relevant to the content of this review.


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Authors and Affiliations

  1. 1.Department of Pediatric Oncology, Hematology and Immunology, Pediatric Immunology and Rheumatology, Centre for Child HealthHeinrich-Heine-UniversityDüsseldorfGermany

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