Paeds · clinical-pharmacology-and-therapeutics
Immunosuppressive and biologic therapies
Also known as Methotrexate in juvenile idiopathic arthritis · TNF inhibitors in children · Biologic therapies in paediatrics · DMARDs in children · Pre-biologic screening in children
A fellowship approach to immunosuppressive and biologic therapies in children covering low-dose weekly methotrexate as the anchor disease-modifying antirheumatic drug in juvenile idiopathic arthritis, the tumour necrosis factor inhibitors etanercept, adalimumab and infliximab across rheumatology and inflammatory bowel disease, the interleukin-1, interleukin-6 and B-cell-depleting biologics, the pre-biologic screen for tuberculosis, hepatitis B and varicella with dual tuberculin and IGRA testing, folic acid supplementation and full-blood-count and liver-enzyme monitoring on methotrexate, and live-vaccine timing before immunosuppression begins.
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Target exams
Red flags
- A biologic or methotrexate started without documented latent tuberculosis, hepatitis B and varicella screening
- Methotrexate prescribed daily rather than once weekly — a cytotoxic overdose error
- A live vaccine (measles-mumps-rubella, varicella, rotavirus) given to a child already on biologic therapy
- Methotrexate continued with a rising alanine aminotransferase, falling neutrophil count, or new mouth ulceration without rechecking bloods
- An anti-TNF agent started in a child with untreated latent tuberculosis
- Folic acid omitted from a methotrexate prescription
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Allergy and Immunology
- Current 2026 PREP curriculum — Learning Objective: Safe prescribing and medication management in infants, children and young people
- Current 2026 PREP curriculum — Learning Objective 2.2.1: Recognise, prioritise and manage an acutely ill infant, child or young person
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Clinical management – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 9: Quality and safety, including medication safety
- Clinical Applications
- Medical Sciences
- Long Cases
- Short Cases
- 4. Professional skills and knowledge: Patient management
- 7. Patient safety, including safe prescribing
- 8. Quality improvement and patient safety
- General Paediatrics: Prescribes and monitors immunosuppressive and biologic medicines safely with appropriate pre-treatment screening
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- General Pediatrics Content Outline — Domain 10: Principles of Pharmacology and Medication Management
- General Pediatrics Content Outline — Universal Task 4: Management and Treatment
- General Pediatrics Content Outline — Universal Task 2: Health Maintenance
- Systems-Based Practice 2: Coordinated chronic disease care
- Patient Safety/Quality Improvement 1: Medication Safety
- Medical Knowledge 2: Diagnostic and Therapeutic Decision Making
- Medical Expert
- Collaborator
- Pediatrics: Core EPA #5 — Recommending and Initiating Pharmacologic Interventions
Overview & Definition
Picture a six-year-old with polyarticular juvenile idiopathic arthritis whose morning stiffness will not settle, a twelve-year-old with Crohn's disease who is losing weight despite steroids, and a child with frequent-relapse nephrotic syndrome who has become steroid-dependent. Each of them will meet an immunosuppressive or a biologic drug. Methotrexate comes first in the rheumatic diseases, and the tumour necrosis factor inhibitors follow or run alongside it. [1] [6]
Two ideas carry the whole topic. The first is the screen-treat-monitor sequence: every biologic and every conventional immunosuppressant is started only after latent tuberculosis, hepatitis B, hepatitis C, HIV and varicella have been excluded or treated, and then kept safe by structured blood-count and liver-enzyme monitoring. The second is the anchor-and-target principle: methotrexate is the anchor disease-modifying drug in juvenile idiopathic arthritis, and the biologics are precision tools that block a single named cytokine when the anchor alone is not enough. [5] [6]
From the first referral to a child safely on therapy
- 1
1 · Confirm the diagnosis
Establish the immune-mediated disease with the specialist team before starting any immunosuppressive or biologic agent.
- 2
2 · Complete the pre-start screen
Screen for latent tuberculosis (tuberculin skin test and interferon-gamma release assay), hepatitis B, hepatitis C, HIV, varicella, and baseline bloods.
- 3
3 · Give live vaccines first
Complete measles-mumps-rubella and varicella vaccination, then wait before starting the immunosuppressant.
- 4
4 · Start the anchor or the biologic
Begin methotrexate once weekly with folic acid, or the chosen biologic at a weight-based or surface-area dose, under specialist guidance.
- 5
5 · Monitor and review
Check the full blood count and liver enzymes on a structured schedule, watch for infection, review growth and adherence, and plan the duration with the team.
References11ShowHide
- [1]Giannini EH; Brewer EJ; Kuzmina N Methotrexate in resistant juvenile rheumatoid arthritis. Results of the U.S.A.-U.S.S.R. double-blind, placebo-controlled trial. The Pediatric Rheumatology Collaborative Study Group and The Cooperative Children's Study Group The New England journal of medicine, 1992.PMID 1549149
- [2]Lovell DJ; Giannini EH; Reiff A Etanercept in children with polyarticular juvenile rheumatoid arthritis. Pediatric Rheumatology Collaborative Study Group The New England journal of medicine, 2000.PMID 10717011
- [3]Lovell DJ; Ruperto N; Goodman S Adalimumab with or without methotrexate in juvenile rheumatoid arthritis The New England journal of medicine, 2008.PMID 18716298
- [4]Foell D; Wulffraat N; Wedderburn LR Methotrexate withdrawal at 6 vs 12 months in juvenile idiopathic arthritis in remission: a randomized clinical trial JAMA, 2010.PMID 20371785
- [5]Ferrara G; Mastrangelo G; Barone P Methotrexate in juvenile idiopathic arthritis: advice and recommendations from the MARAJIA expert consensus meeting Pediatric rheumatology online journal, 2018.PMID 29996864
- [6]Shenoi S; Horneff G; Aggarwal A Treatment of non-systemic juvenile idiopathic arthritis Nature reviews. Rheumatology, 2024.PMID 38321298
- [7]Hyams J; Crandall W; Kugathasan S Induction and maintenance infliximab therapy for the treatment of moderate-to-severe Crohn's disease in children Gastroenterology, 2007.PMID 17324398
- [8]Faubion WA; Dubinsky M; Ruemmele FM Long-term Efficacy and Safety of Adalimumab in Pediatric Patients with Crohn's Disease Inflammatory bowel diseases, 2017.PMID 28129288
- [9]Calzada-Hernández J; Anton J; Martín de Carpi J Dual latent tuberculosis screening with tuberculin skin tests and QuantiFERON-TB assays before TNF-α inhibitor initiation in children in Spain European journal of pediatrics, 2023.PMID 36335186
- [10]Parigi S; Licari A; Manti S Tuberculosis and TNF-α inhibitors in children: how to manage a fine balance Acta bio-medica : Atenei Parmensis, 2020.PMID 33004779
- [11]Jansen MHA; Rondaan C; Legger GE EULAR/PRES recommendations for vaccination of paediatric patients with autoimmune inflammatory rheumatic diseases: update 2021 Annals of the rheumatic diseases, 2023.PMID 35725297