It may be just as safe and effective to treat children with juvenile idiopathic arthritis, or JIA, using oral methotrexate as it is to give them injectable methotrexate, according to a retrospective analysis of a Germany database. But the authors of the study caution that a randomized, clinical trial is needed to compare these two routes of administration before either one can be established as superior. The study was recently published online in Arthritis Care & Research.

Methotrexate is a cornerstone of treatment for JIA, a term used to describe several different categories of arthritis in children less than the age of 16 years. “The question of how to start treatment with methotrexate in children with JIA – orally or via subcutaneous injections – is of great importance. There is no common consensus,” says lead author Ariane Klein, MD, Askelapios Klinik in Sankt Augustin, Germany.

The study notes that methotrexate injections tend to have better response rates than oral methotrexate in adults with rheumatoid arthritis, or RA. But the authors write that injections may be especially painful for pediatric patients. This can “pose a significant burden for the patients and their families, and result in more consultations with physicians and health professionals if parents feel unable to give the injections themselves,” says Dr. Klein.

In the United States, injectable methotrexate is often given to JIA patients at the start of treatment to achieve maximum effects, and once the disease is brought under control, the patient is switched to oral methotrexate, according to pediatric rheumatologist Carol Wallace, MD. Dr. Wallace is past chair of CARRA – the Childhood Arthritis and Rheumatology Research Alliance – professor and division chief of rheumatology at the University of Washington Seattle Children’s Hospital, and has authored several studies on methotrexate use in JIA.

The retrospective analysis was based on data from the German Methotrexate Registry, which was started in 2005. The study group included 411 children with JIA (average disease duration about one year) who were newly treated with either oral methotrexate (259 patients) or injectable methotrexate (152 patients) for at least six months. The method of methotrexate delivery was not assigned randomly; it was chosen by each child’s doctor.