Application of Intra-articular Corticosteroid Injection in Juvenile Idiopathic Arthritis

Efficacy and safety of ibuprofen and naproxen in the treatment of oligoarticular juvenile idiopathic arthritis: bi-national cohort study

OBJECTIVES

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children. Nonsteroidal anti-inflammatory drugs (NSAIDs) and intra-articular corticosteroid injections are first-line therapy for oligoarticular JIA. NSAIDs Adverse events (AEs) include gastrointestinal ulcers/bleeding and impaired renal function. The most prescribed NSAIDs for oligoarticular JIA are ibuprofen and naproxen. However, direct comparison between these drugs is lacking. We aimed to compare the efficacy and safety of ibuprofen versus naproxen for oligoarticular JIA.

METHODS

This is a bi-national retrospective study of oligoarticular JIA patients treated with either ibuprofen or naproxen as first-line therapy. Efficacy was defined as patients that achieved complete response (no evidence for arthritis). Safety was assessed by the occurrence of adverse events during follow-up.

RESULTS

Of 164 patients, 103 were treated in the Israeli group and 61 in the US group. The study population had a mean age of 4.49 ± 3.55 years, with F:M ratio of ∼2.5:1. No significant difference was found in drug efficacy [Complete response was observed in 15% of the ibuprofen group vs. 17.3% in naproxen group (p = 0.7)]. Treatment duration > 28 days was associated with significantly higher odds for complete response (p = 0.021). For safety, 12 AEs were associated with naproxen, whereas no AEs were associated with ibuprofen (p = 0.004). Treatment was discontinued in all AEs cases.

CONCLUSIONS

Ibuprofen and naproxen showed similar albeit low efficacy which emphasizes their role as bridging therapy until IACI is achieved. However, ibuprofen showed better safety profile naproxen and therefore should be considered as first-line therapy.

A bilayer scaffold of collagen and nanohydroxyapatite promotes osteochondral defect in rabbit knee joints

Aims

A large number of surgical operations are available to treat osteochondral defects of the knee. However, the knee joint arthroplasty materials cannot completely mimic the articular cartilage and subchondral bone, which may bring some obvious side effects. Thus, this study proposed a biocompatible osteochondral repair material prepared from a double-layer scaffold of collagen and nanohydroxyapatite (CHA), consisting of collagen hydrogel as the upper layer of the scaffold, and the composite of CHA as the lower layer of the scaffold.

Methods

The CHA scaffold was prepared, and properties including morphology, internal structure, and mechanical strength of the CHA scaffold were measured by scanning electron microscopy (SEM) and a MTS electronic universal testing machine. Then, biocompatibility and repair capability of the CHA scaffold were further evaluated using a rabbit knee cartilage defect model.

Results

The CHA scaffold was well suited for the repair of articular cartilage and subchondral bone; the in vitro results showed that the CHA scaffold had good cytocompatibility. In vivo experiments demonstrated that the material had high biocompatibility and effectively induced cartilage and subchondral bone regeneration.

Conclusion

The CHA scaffold has a high potential for commercialization and could be used as an effective knee repair material in clinical applications.

Intraarticular corticosteroid injections in pediatric rheumatology: insights from specialists

Juvenile idiopathic arthritis (JIA) refers to various types of arthritis appearing before age 16, categorized into seven subtypes by ILAR. Treatments target disease control, growth support, and quality of life, utilizing NSAIDs, DMARDs, and intraarticular corticosteroid injections (IACIs). Despite IACIs' efficacy for oligoarticular JIA, their usage and techniques vary due to anecdotal evidence. This study compares IACI strategies among pediatric rheumatologists in Turkey and India as part of a PReS Sister Center activity. A cross-sectional survey via Google Forms gathered IACI practice data from pediatric rheumatologists in Turkey and India. The 33-item questionnaire covered demographics, JIA subtypes treated with IACIs, preferred agents/dosages, injection sites, follow-up, complications, anesthesia, and post-IACI treatments. Seventy clinicians' responses were analyzed, with ethical approval from Gazi University's Ethics Committee. Seventy participants, with a mean age of 39.75 (±8.80) years responded, mostly clinical fellows (38.6%) at university hospitals (58.6%). All utilized IACIs, primarily for oligoarticular JIA (100%), with 20% exclusively using them for this subtype. Triamcinolone hexacetonide (TH) was preferred (74.3%), mainly targeting knee joints (15.7%). Initial side effect follow-up was 1-2 weeks post-IACI (65.7%), with ultrasound guidance used by 17.1%. Common complications included cutaneous hypopigmentation (38.6%) and subcutaneous atrophy (38.6%). Ketamine was the favored anesthesia (44.2%). Post-IACI, 21.4% did not add treatment for new-onset oligoarticular JIA, while NSAIDs and methotrexate were common for polyarticular JIA (51.4%).

CONCLUSION

IACIs are widely utilized in pediatric rheumatology for oligoarticular JIA, yet practice variability exists. Standardized protocols through randomized studies can enhance IACI efficacy and patient outcomes.

WHAT IS KNOWN

• Intraarticular corticosteroid injections (IACIs) are a widely utilized and effective treatment modality in managing oligoarticular and polyarticular juvenile idiopathic arthritis (JIA), offering rapid symptom relief and the potential to prevent long-term joint deformities. • Despite their widespread use, there is significant variability in the indications, techniques, and anesthetic methods employed for IACI administration among pediatric rheumatologists, and much of the supporting evidence remains anecdotal.

WHAT IS NEW

• This study highlights the diverse clinical practices and preferences regarding IACI use in pediatric rheumatology across two different countries, revealing considerable variations in the use of ultrasound guidance, anesthetic approaches, and corticosteroid formulations. • The findings underscore the need for standardized treatment protocols and further research to optimize IACI procedures, aiming to reduce variability and improve outcomes in the management of JIA.

Juvenile idiopathic arthritis management: insights into the utilization of intra-articular corticosteroid injections

BACKGROUND

Juvenile idiopathic arthritis (JIA) is a common chronic rheumatic disease in children, requiring careful management to reduce both short- and long-term morbidity. In this study, our objective was to assess the clinical features of patients diagnosed with JIA who received intra-articular corticosteroid injections (IACI).

METHODS

In this retrospective study, we evaluated the clinical and laboratory characteristics of 225 JIA patients monitored from January 2012 to October 2023 at a tertiary care center. We focused on patients who underwent intra-articular corticosteroid injections (IACI) as part of their treatment. Triamcinolone hexacetonide (TH) was used due to its demonstrated safety and efficacy.

RESULTS

Our analysis revealed that IACI, particularly utilizing TH, was a widely employed and effective adjunct therapy, contributing to rapid symptom relief and local disease control. Patients receiving IACI exhibited earlier symptom onset, younger age at diagnosis, longer follow-up durations, and higher cumulative treatment burden (p < 0.001, p < 0.001, p < 0.01, p < 0.001 respectively). Despite inconclusive acute-phase reactants, a higher frequency of ANA positivity and elevated initial lymphocyte counts were associated with increased IACI use (p < 0.001, p < 0.001 respectively). Importantly, on a joint basis, a high percentage of arthritis remission following IACI underscores its efficacy and favorable safety profile.

CONCLUSIONS

Notably, the high percentage of arthritis remission achieved with intra-articular corticosteroid injections (IACI) on a joint-specific basis highlights its efficacy and favorable safety profile. A lymphocyte count exceeding 5000/mm3 at the time of diagnosis may serve as an early indicator for considering intra-articular steroid administration. These findings emphasize the need for nuanced and individualized treatment strategies in JIA management to optimize outcomes for affected children.

Interventional Radiology for Rheumatic Diseases

Imaging plays a key role in the management of rheumatological pathologies, also as guidance for diagnostic and therapeutic interventional procedures, as it can provide better accuracy and safety compared to palpation-guided interventions. Inflammatory and degenerative conditions nonresponsive to systemic treatment may benefit from intra-articular and periarticular administration of drugs, with therapeutic and symptomatic actions or providing a bridge for surgery. Desired effects include reduction of inflammation and pain and improvement of physical function of patients. Training and knowledge of indications, appropriate procedures, contraindications, and side effects are necessary to obtain maximum accuracy and safety in performing interventional procedures.

Bone health and physical activity in adolescents with juvenile idiopathic arthritis: a cross-sectional case-control study

BACKGROUND

Adolescents with juvenile idiopathic arthritis (JIA) tend to engage in less physical activity than their typically developing peers. Physical activity is essential for bone development and reduced physical activity may detrimentally effect bone health. Thus, we examined differences in total body bone mineral content (BMC) and areal bone mineral density (aBMD) between adolescents with JIA and adolescent controls without JIA. We also examined associations between moderate-to-vigorous physical activity (MVPA), lean mass, and bone outcomes.

METHODS

Participants included 21 adolescents with JIA (14 females, 7 males) and 21 sex- and age-matched controls aged 10-20 years. Assessments included: height; weight; triple-single-leg-hop distance (TSLH); MVPA by accelerometry; and total body BMC, aBMD, and lean mass measured using dual X-ray absorptiometry. Height-adjusted z-scores were calculated for BMC and aBMD and used for all analyses. Multiple linear mixed effects models examined group differences in BMC and aBMD, adjusting for sex, maturity, MVPA, TSLH, and lean mass. Participants clusters, based on sex and age (within 18 months), were considered random effects.

RESULTS

Adolescents with JIA had lower total body aBMD z-scores [β (95% CI); -0.58 (-1.10 to -0.07), p = 0.03] and BMC z-scores [-0.47 (-0.91 to -0.03), p = 0.04] compared with controls. Mean daily MVPA was 22.0 min/day lower in adolescents with JIA than controls; however, MVPA was not associated with aBMD [-0.01 (-0.01 to 0.01), p = 0.32] or BMC [0.00 (-0.01 to 0.00), p = 0.39]. Lean mass was positively associated with aBMD [0.05 (0.01 to 0.09) g/cm2, p = 0.03] and BMC [0.06 (0.03 to 0.10) g, p < 0.001].

CONCLUSION

Adolescents with JIA had lower total body aBMD and BMC compared with sex- and age-matched controls without JIA. Group differences in bone outcomes were not associated with the lower MVPA participation of adolescents with JIA. Despite this, physical activity should still be encouraged as it promotes physical well-being.

Management of temporomandibular joint arthritis in children and adolescents: An introduction for orthodontists

Juvenile idiopathic arthritis (JIA) is the most common inflammatory rheumatic disease of childhood. JIA can affect any joint and the temporomandibular joint (TMJ) is one of the joints most frequently involved. TMJ arthritis impacts mandibular growth and development and can result in skeletal deformity (convex profile and facial asymmetry), and malocclusion. Furthermore, when TMJs are affected, patients may present with pain at joint and masticatory muscles and dysfunction with crepitus and limited jaw movement. This review aims to describe the role of orthodontists in the management of patients with JIA and TMJ involvement. This article is an overview of evidence for the diagnosis and treatment of patients with JIA and TMJ involvement. Screening for the orofacial manifestation of JIA is important for orthodontists to identify TMJ involvement and related dentofacial deformity. The treatment protocol of JIA with TMJ involvement requires an interdisciplinary collaboration including orthopaedic/orthodontic treatment and surgical interventions for the management of growth disturbances. Orthodontists are also involved in the management of orofacial signs and symptoms; behavioural therapy, physiotherapy and occlusal splints are the suggested treatments. Patients with TMJ arthritis require specific expertise from an interdisciplinary team with members knowledgeable in JIA care. Since disorders of mandibular growth often appear during childhood, the orthodontist could be the first clinician to see the patient and can play a crucial role in the diagnosis and management of JIA patients with TMJ involvement.

Outcomes of intraarticular triamcinolone acetonide injection in children with non-systemic juvenile idiopathic arthritis

OBJECTIVES

The objectives were to explore the response to intraarticular triamcinolone acetonide (TA) injection in children with non-systemic juvenile idiopathic arthritis (JIA) and factors associated with time to arthritis flare.

METHODS

This was a retrospective cohort study of children with non-systemic JIA who received intraarticular TA injections at a tertiary care hospital in Bangkok, Thailand. Response to intraarticular TA injection was defined as absence of arthritis at 6 months after procedure. Time from joint injection to arthritis flare was recorded. Kaplan-Meier survival analysis with logarithmic rank test and multivariable Cox proportional hazards regression analysis were used for outcome analyses.

RESULTS

Intraarticular TA injection was performed in 177 joints among 45 children with non-systemic JIA, most common in the knees (57 joints, 32.2%). Response to intraarticular TA injection at 6 months was observed in 118 joints (66.7%). Ninety-seven joints (54.8%) had arthritis flare following injection. The median time to arthritis flare was 12.65 months (95%CI 8.20-17.10 months). The significant risk factor associated with arthritis flare was the JIA subtypes other than persistent oligoarthritis (HR 2.62, 95%CI 1.085-6.325, p = 0.032); the significant protective factor was concomitant sulfasalazine use (HR 0.326, 95%CI 0.109-0.971, p = 0.044). Adverse effects included pigmentary changes (3, 1.7%) and skin atrophy (2, 1.1%).

CONCLUSION

Intraarticular TA injection in children with non-systemic JIA had favorable response in two thirds of injected joints at 6 months. The JIA subtypes other than persistent oligoarthritis was a predictor of arthritis flare following intraarticular TA injection. Key Points • Intraarticular TA injection in children with non-systemic JIA had a favorable response in two-thirds of injected joints at 6 months. • The median time from intraarticular TA injection to arthritis flare was 12.65 months. • The risk factor predicting arthritis flare was the JIA subtypes other than persistent oligoarthritis (extended oligoarthritis, polyarthritis, ERA, and undifferentiated JIA), while the concomitant use of sulfasalazine was a protective factor. • Local adverse reactions from intraarticular TA injection were less than 2% of injected joints.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.