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Zulian F, Pierobon B, Zannin ME, Politi C, Vittadello F, Meneghel A, Tirelli F, Martini G. Monoarticular juvenile idiopathic arthritis as a distinct clinical entity A proof-of-concept study. Pediatr Rheumatol Online J 2023; 21:81. [PMID: 37563674 PMCID: PMC10416450 DOI: 10.1186/s12969-023-00869-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/25/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Currently, monoarticular Juvenile Idiopathic Arthritis (monoJIA) is included in the ILAR classification as oligoarticular subtype although various aspects, from clinical practice, suggest it as a separate entity. OBJECTIVES To describe the clinical characteristics of persistent monoJIA. METHODS Patients with oligoJIA and with at least two years follow-up entered the study. Those with monoarticular onset and persistent monoarticular course were compared with those with oligoJIA. Variables considered were: sex, age at onset, presence of benign joint hypermobility (BJH), ANA, uveitis, therapy and outcome. Patients who had not undergone clinical follow-up for more than 12 months were contacted by structured telephone interview. RESULTS Of 347 patients with oligoJIA, 196 with monoarticular onset entered the study and 118 (60.2%), identified as persistent monoJIA, were compared with 229 oligoJIA. The mean follow-up was 11.4 years. The switch from monoarticular onset to oligoarticular course of 78 patients (38.8%) occurred by the first three years from onset. In comparison with oligoJIA, the most significant features of monoJIA were later age at onset (6.1 vs. 4.7 years), lower female prevalence (70.3 vs. 83.4%), higher frequency of BJH (61.9 vs. 46.3%), lower frequency of uveitis (14.4 vs. 34.1%) and ANA+ (68.6 vs. 89.5%) and better long-term outcome. CONCLUSIONS MonoJIA, defined as persistent arthritis of unknown origin of a single joint for at least three years, seems to be a separate clinical entity from oligoJIA. This evidence may be taken into consideration for its possible inclusion into the new classification criteria for JIA and open new therapeutic perspectives.
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Affiliation(s)
- Francesco Zulian
- Department of Woman and Child Health, University of Padova, Via Giustiniani 3, Padova, 35128, Italy.
| | - Beatrice Pierobon
- Department of Woman and Child Health, University of Padova, Via Giustiniani 3, Padova, 35128, Italy
| | - Maria Elisabetta Zannin
- Department of Woman and Child Health, University of Padova, Via Giustiniani 3, Padova, 35128, Italy
| | - Caterina Politi
- Legal Medicine, Caterina Politi, University of Padova, Padua, MD, Italy
| | | | - Alessandra Meneghel
- Department of Woman and Child Health, University of Padova, Via Giustiniani 3, Padova, 35128, Italy
| | - Francesca Tirelli
- Department of Woman and Child Health, University of Padova, Via Giustiniani 3, Padova, 35128, Italy
| | - Giorgia Martini
- Department of Woman and Child Health, University of Padova, Via Giustiniani 3, Padova, 35128, Italy
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Benvenuto S, Barbi E, Boaretto S, Landolfo M, Rispoli F, Cozzi G, Carbone M. Study Confirms Safety and Effectiveness of Intra-Articular Glucocorticoids for Painful Hip Dislocation in Children and Young Adults with Neurologic Impairment. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1353. [PMID: 37628352 PMCID: PMC10453576 DOI: 10.3390/children10081353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Hip dislocation is a common source of pain in children with neurologic impairment. When medical interventions fail, orthopedic surgery does not guarantee a definitive result as the displacement may continue postoperatively and a second operation is often required. METHODS Retrospective analysis of data regarding the safety and effectiveness of an intra-articular corticosteroid injection (IACI) in 11 patients, aged 15 ± 5 years old, collected through a telephonic questionnaire administered to parents. RESULTS 21 IACIs were performed, a mean number of 1.9 ± 1.5 times for each patient, at a mean age (of the first IACI) of 13.5 ± 5 years. According to the parents, the IACI significantly lowered the number of participants experiencing pain (82% reduction) and using analgesics (60% reduction). There was also a significant improvement in the children's hip mobility (63% reduction in patients experiencing stiffness), decubitus (90% reduction in obligated positioning), behavior (80% reduction in lamenting or crying patients), sleep quality (87.5% reduction in patients awakening every night), and caregivers' quality of life (91% reduction in worried parents). The mean reported duration of the IACIs' benefit was 5.4 ± 2.4 months (range 1-9), with a positive correlation with the number of IACIs (r = 0.48; p-value = 0.04) and a negative correlation with the age at the first injection (r = -0.71; p-value = 0.02). The only reported adverse event was mild local swelling in one child. CONCLUSIONS the IACI could represent a safe and effective intervention for painful hip dislocation, both before and after surgery, with a long-lasting benefit which seems to increase as multiple IACIs are performed.
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Affiliation(s)
- Simone Benvenuto
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Egidio Barbi
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, 34127 Trieste, Italy
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Silvia Boaretto
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Matteo Landolfo
- Medical Clinic, Cattinara Hospital, Azienda Sanitaria Universitaria Giuliano Isontina, 34149 Trieste, Italy
| | - Francesco Rispoli
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Giorgio Cozzi
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Marco Carbone
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, 34137 Trieste, Italy
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Maleki A, Patel PD, Foster CS. Juvenile idiopathic arthritis and its associated uveitis. Expert Rev Clin Immunol 2023; 19:1157-1169. [PMID: 37401872 DOI: 10.1080/1744666x.2023.2231154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 06/26/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION Juvenile idiopathic arthritis is the most common chronic rheumatologic disease in children. Uveitis is the most common extra-articular manifestation of JIA, and it can be a sight-threatening condition. AREAS COVERED In this review article, we discussed epidemiology, risk factors, clinical presentation, supportive laboratory tests, treatment options, and complications of Juvenile idiopathic arthritis and Juvenile idiopathic arthritis associated uveitis. We covered conventional immunomodulatory therapy and biologic response modifiers agents for different types of Juvenile idiopathic arthritis and their associated uveitis. Finally, we discussed the course of disease, functional outcome, and the quality of life of Juvenile idiopathic arthritis and Juvenile idiopathic arthritis-associated uveitis. EXPERT OPINION Although clinical outcomes of Juvenile idiopathic arthritis and its associated uveitis have been improved over the past three decades by biologic response modifier agents, a significant proportion of patients require active treatment into adult life therefore screening and monitoring of these patients is required during the patient's entire life. The limited number of food and drug administration approved biologic response modifier agents for the treatment of Juvenile idiopathic arthritis associated uveitis justify more randomized clinical trials with new medications in this field.
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Affiliation(s)
- Arash Maleki
- Department of Ophthalmology, University of Florida, Gainesville, FL, USA
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA
- The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - Priya D Patel
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA
- The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - C Steven Foster
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA
- The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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Sukharomana M, Charuvanij S. Outcomes of intraarticular triamcinolone acetonide injection in children with non-systemic juvenile idiopathic arthritis. Clin Rheumatol 2023; 42:1665-1674. [PMID: 36892711 DOI: 10.1007/s10067-023-06569-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/02/2023] [Accepted: 02/28/2023] [Indexed: 03/10/2023]
Abstract
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.
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Affiliation(s)
- Maynart Sukharomana
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Sirirat Charuvanij
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.
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Khawaja K, Kalas R, Almasri N. Subtype frequency, demographic features, treatment and outcome of Juvenile Arthritis in one Centre in Abu Dhabi in the United Arab Emirates. Pediatr Rheumatol Online J 2023; 21:14. [PMID: 36750870 PMCID: PMC9903437 DOI: 10.1186/s12969-023-00796-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 01/22/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Juvenile Idiopathic Arthritis is a chronic inflammatory disease that affects 1 in 1000 children worldwide. Our population in the United Arab Emirates is diverse. The objective of this study is to describe the subtype frequency, demographic features and treatments received and outcome of our patients. METHODS Patients with the diagnosis of Juvenile Arthritis identified through the hospital electronic medical records system (EMR), which was implemented for all medical documentation in January 2011. All patients included are patients who presented to our center for treatment and follow up from 2011 to end of 2021. Retrospective case notes review of patients electronic medical records with the diagnosis of JIA was performed. RESULTS One hundred thirty-eight patients in total. Oligoarticular subtype was the most represented with 75 patients (55%) followed by Rheumatoid factor negative polyarticular JIA with 32 patients (23%) then Enthesitis related arthritis (ERA) with 10 patients (7%) then psoriatic (6%) then systemic JIA (5%). Undifferentiated subtype of 2%. The most diagnostic delay is in enthesitis related arthritis subtype with a mean of 11.4 months (6-25) followed by undifferentiated JIA with a mean of 7.5 months (4-8.5). 131 (96%) out of 138 received steroid treatment. Only 6 patients did not receive steroids. Out of 138 patients, 101 (73%) were on synthetic disease modifying medication methotrexate. Sixty-eight patients out of the total 138 required biologic treatment (49%). In total 93 patients achieved clinical remission (67%). In remission on treatment 78 patients which is (56%) of the total number of patients with follow up ranging from 1 to 5 years and 84% of patients in remission. In remission off treatment 15 patients (11% of all patients and 16% of patients in remission). CONCLUSION The most common subtype in our cohort of patients is oligoarticular JIA. Longest delay is for ERA subtype. All our patients with oligoarticular JIA received Intra articular steroid injection as first line treatment. 49% of our patients received biologic treatment similar to rate in Northern Europe. Our remission rate is 67% with 11% of patients are in remission off treatment. Access to care remains a priority to treat patients effectively.
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Affiliation(s)
- K. Khawaja
- Paediatric Rheumatology, Pediatrics, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - R. Kalas
- Division of Internal Medicine, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - N. Almasri
- Division of Pediatrics, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
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Hahn T, Daymont C, Beukelman T, Groh B, Hays K, Bingham CA, Scalzi L, Abel N, Abulaban K, Adams A, Adams M, Agbayani R, Aiello J, Akoghlanian S, Alejandro C, Allenspach E, Alperin R, Alpizar M, Amarilyo G, Ambler W, Anderson E, Ardoin S, Armendariz S, Baker E, Balboni I, Balevic S, Ballenger L, Ballinger S, Balmuri N, Barbar-Smiley F, Barillas-Arias L, Basiaga M, Baszis K, Becker M, Bell-Brunson H, Beltz E, Benham H, Benseler S, Bernal W, Beukelman T, Bigley T, Binstadt B, Black C, Blakley M, Bohnsack J, Boland J, Boneparth A, Bowman S, Bracaglia C, Brooks E, Brothers M, Brown A, Brunner H, Buckley M, Buckley M, Bukulmez H, Bullock D, Cameron B, Canna S, Cannon L, Carper P, Cartwright V, Cassidy E, Cerracchio L, Chalom E, Chang J, Chang-Hoftman A, Chauhan V, Chira P, Chinn T, Chundru K, Clairman H, Co D, Confair A, Conlon H, Connor R, Cooper A, Cooper J, Cooper S, Correll C, Corvalan R, Costanzo D, Cron R, Curiel-Duran L, Curington T, Curry M, Dalrymple A, Davis A, Davis C, Davis C, Davis T, De Benedetti F, De Ranieri D, Dean J, Dedeoglu F, DeGuzman M, Delnay N, Dempsey V, DeSantis E, Dickson T, Dingle J, Donaldson B, Dorsey E, Dover S, Dowling J, Drew J, Driest K, Du Q, Duarte K, Durkee D, Duverger E, Dvergsten J, Eberhard A, Eckert M, Ede K, Edelheit B, Edens C, Edens C, Edgerly Y, Elder M, Ervin B, Fadrhonc S, Failing C, Fair D, Falcon M, Favier L, Federici S, Feldman B, Fennell J, Ferguson I, Ferguson P, Ferreira B, Ferrucho R, Fields K, Finkel T, Fitzgerald M, Fleming C, Flynn O, Fogel L, Fox E, Fox M, Franco L, Freeman M, Fritz K, Froese S, Fuhlbrigge R, Fuller J, George N, Gerhold K, Gerstbacher D, Gilbert M, Gillispie-Taylor M, Giverc E, Godiwala C, Goh I, Goheer H, Goldsmith D, Gotschlich E, Gotte A, Gottlieb B, Gracia C, Graham T, Grevich S, Griffin T, Griswold J, Grom A, Guevara M, Guittar P, Guzman M, Hager M, Hahn T, Halyabar O, Hammelev E, Hance M, Hanson A, Harel L, Haro S, Harris J, Harry O, Hartigan E, Hausmann J, Hay A, Hayward K, Heiart J, Hekl K, Henderson L, Henrickson M, Hersh A, Hickey K, Hill P, Hillyer S, Hiraki L, Hiskey M, Hobday P, Hoffart C, Holland M, Hollander M, Hong S, Horwitz M, Hsu J, Huber A, Huggins J, Hui-Yuen J, Hung C, Huntington J, Huttenlocher A, Ibarra M, Imundo L, Inman C, Insalaco A, Jackson A, Jackson S, James K, Janow G, Jaquith J, Jared S, Johnson N, Jones J, Jones J, Jones J, Jones K, Jones S, Joshi S, Jung L, Justice C, Justiniano A, Karan N, Kaufman K, Kemp A, Kessler E, Khalsa U, Kienzle B, Kim S, Kimura Y, Kingsbury D, Kitcharoensakkul M, Klausmeier T, Klein K, Klein-Gitelman M, Kompelien B, Kosikowski A, Kovalick L, Kracker J, Kramer S, Kremer C, Lai J, Lam J, Lang B, Lapidus S, Lapin B, Lasky A, Latham D, Lawson E, Laxer R, Lee P, Lee P, Lee T, Lentini L, Lerman M, Levy D, Li S, Lieberman S, Lim L, Lin C, Ling N, Lingis M, Lo M, Lovell D, Lowman D, Luca N, Lvovich S, Madison C, Madison J, Manzoni SM, Malla B, Maller J, Malloy M, Mannion M, Manos C, Marques L, Martyniuk A, Mason T, Mathus S, McAllister L, McCarthy K, McConnell K, McCormick E, McCurdy D, Stokes PMC, McGuire S, McHale I, McMonagle A, McMullen-Jackson C, Meidan E, Mellins E, Mendoza E, Mercado R, Merritt A, Michalowski L, Miettunen P, Miller M, Milojevic D, Mirizio E, Misajon E, Mitchell M, Modica R, Mohan S, Moore K, Moorthy L, Morgan S, Dewitt EM, Moss C, Moussa T, Mruk V, Murphy A, Muscal E, Nadler R, Nahal B, Nanda K, Nasah N, Nassi L, Nativ S, Natter M, Neely J, Nelson B, Newhall L, Ng L, Nicholas J, Nicolai R, Nigrovic P, Nocton J, Nolan B, Oberle E, Obispo B, O’Brien B, O’Brien T, Okeke O, Oliver M, Olson J, O’Neil K, Onel K, Orandi A, Orlando M, Osei-Onomah S, Oz R, Pagano E, Paller A, Pan N, Panupattanapong S, Pardeo M, Paredes J, Parsons A, Patel J, Pentakota K, Pepmueller P, Pfeiffer T, Phillippi K, Marafon DP, Phillippi K, Ponder L, Pooni R, Prahalad S, Pratt S, Protopapas S, Puplava B, Quach J, Quinlan-Waters M, Rabinovich C, Radhakrishna S, Rafko J, Raisian J, Rakestraw A, Ramirez C, Ramsay E, Ramsey S, Randell R, Reed A, Reed A, Reed A, Reid H, Remmel K, Repp A, Reyes A, Richmond A, Riebschleger M, Ringold S, Riordan M, Riskalla M, Ritter M, Rivas-Chacon R, Robinson A, Rodela E, Rodriquez M, Rojas K, Ronis T, Rosenkranz M, Rosolowski B, Rothermel H, Rothman D, Roth-Wojcicki E, Rouster-Stevens K, Rubinstein T, Ruth N, Saad N, Sabbagh S, Sacco E, Sadun R, Sandborg C, Sanni A, Santiago L, Sarkissian A, Savani S, Scalzi L, Schanberg L, Scharnhorst S, Schikler K, Schlefman A, Schmeling H, Schmidt K, Schmitt E, Schneider R, Schollaert-Fitch K, Schulert G, Seay T, Seper C, Shalen J, Sheets R, Shelly A, Shenoi S, Shergill K, Shirley J, Shishov M, Shivers C, Silverman E, Singer N, Sivaraman V, Sletten J, Smith A, Smith C, Smith J, Smith J, Smitherman E, Soep J, Son M, Spence S, Spiegel L, Spitznagle J, Sran R, Srinivasalu H, Stapp H, Steigerwald K, Rakovchik YS, Stern S, Stevens A, Stevens B, Stevenson R, Stewart K, Stingl C, Stokes J, Stoll M, Stringer E, Sule S, Sumner J, Sundel R, Sutter M, Syed R, Syverson G, Szymanski A, Taber S, Tal R, Tambralli A, Taneja A, Tanner T, Tapani S, Tarshish G, Tarvin S, Tate L, Taxter A, Taylor J, Terry M, Tesher M, Thatayatikom A, Thomas B, Tiffany K, Ting T, Tipp A, Toib D, Torok K, Toruner C, Tory H, Toth M, Tse S, Tubwell V, Twilt M, Uriguen S, Valcarcel T, Van Mater H, Vannoy L, Varghese C, Vasquez N, Vazzana K, Vehe R, Veiga K, Velez J, Verbsky J, Vilar G, Volpe N, von Scheven E, Vora S, Wagner J, Wagner-Weiner L, Wahezi D, Waite H, Walker J, Walters H, Muskardin TW, Waqar L, Waterfield M, Watson M, Watts A, Weiser P, Weiss J, Weiss P, Wershba E, White A, Williams C, Wise A, Woo J, Woolnough L, Wright T, Wu E, Yalcindag A, Yee M, Yen E, Yeung R, Yomogida K, Yu Q, Zapata R, Zartoshti A, Zeft A, Zeft R, Zhang Y, Zhao Y, Zhu A, Zic C. Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry. Pediatr Rheumatol Online J 2022; 20:107. [PMID: 36434731 PMCID: PMC9701017 DOI: 10.1186/s12969-022-00770-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 11/08/2022] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Timothy Hahn
- Department of Pediatrics, Penn State Children's Hospital, 500 University Dr, Hershey, 90 Hope Drive, P.O. Box 855, Hershey, PA, 17033-0855, USA.
| | - Carrie Daymont
- grid.240473.60000 0004 0543 9901Department of Pediatrics, Penn State Children’s Hospital, 500 University Dr, Hershey, 90 Hope Drive, P.O. Box 855, Hershey, PA 17033-0855 USA
| | - Timothy Beukelman
- grid.265892.20000000106344187Department of Pediatrics, University of Alabama at Birmingham, CPPN G10, 1600 7th Ave South, Birmingham, AL 35233 USA
| | - Brandt Groh
- grid.240473.60000 0004 0543 9901Department of Pediatrics, Penn State Children’s Hospital, 500 University Dr, Hershey, 90 Hope Drive, P.O. Box 855, Hershey, PA 17033-0855 USA
| | | | - Catherine April Bingham
- grid.240473.60000 0004 0543 9901Department of Pediatrics, Penn State Children’s Hospital, 500 University Dr, Hershey, 90 Hope Drive, P.O. Box 855, Hershey, PA 17033-0855 USA
| | - Lisabeth Scalzi
- grid.240473.60000 0004 0543 9901Department of Pediatrics, Penn State Children’s Hospital, 500 University Dr, Hershey, 90 Hope Drive, P.O. Box 855, Hershey, PA 17033-0855 USA
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Oommen PT, Strauss T, Baltruschat K, Foeldvari I, Deuter C, Ganser G, Haas JP, Hinze C, Holzinger D, Hospach A, Huppertz HI, Illhardt A, Jung M, Kallinich T, Klein A, Minden K, Mönkemöller K, Mrusek S, Neudorf U, Dückers G, Niehues T, Schneider M, Schoof P, Thon A, Wachowsky M, Wagner N, Bloedt S, Hofer M, Tenbrock K, Schuetz C. Update of evidence- and consensus-based guidelines for the treatment of juvenile idiopathic arthritis (JIA) by the German Society of Pediatric and Juvenile Rheumatic Diseases (GKJR): New perspectives on interdisciplinary care. Clin Immunol 2022; 245:109143. [DOI: 10.1016/j.clim.2022.109143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 11/15/2022]
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Onel KB, Horton DB, Lovell DJ, Shenoi S, Cuello CA, Angeles-Han ST, Becker ML, Cron RQ, Feldman BM, Ferguson PJ, Gewanter H, Guzman J, Kimura Y, Lee T, Murphy K, Nigrovic PA, Ombrello MJ, Rabinovich CE, Tesher M, Twilt M, Klein-Gitelman M, Barbar-Smiley F, Cooper AM, Edelheit B, Gillispie-Taylor M, Hays K, Mannion ML, Peterson R, Flanagan E, Saad N, Sullivan N, Szymanski AM, Trachtman R, Turgunbaev M, Veiga K, Turner AS, Reston JT. 2021 American College of Rheumatology Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Oligoarthritis, Temporomandibular Joint Arthritis, and Systemic Juvenile Idiopathic Arthritis. Arthritis Care Res (Hoboken) 2022; 74:521-537. [PMID: 35233986 PMCID: PMC10124899 DOI: 10.1002/acr.24853] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/29/2021] [Accepted: 11/23/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To provide updated guidelines for pharmacologic management of juvenile idiopathic arthritis (JIA), focusing on treatment of oligoarthritis, temporomandibular joint (TMJ) arthritis, and systemic JIA with and without macrophage activation syndrome. Recommendations regarding tapering and discontinuing treatment in inactive systemic JIA are also provided. METHODS We developed clinically relevant Patient/Population, Intervention, Comparison, and Outcomes questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation approach was used to rate the quality of evidence (high, moderate, low, or very low). A Voting Panel including clinicians and patients/caregivers achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS Similar to those published in 2019, these JIA recommendations are based on clinical phenotypes of JIA, rather than a specific classification schema. This guideline provides recommendations for initial and subsequent treatment of JIA with oligoarthritis, TMJ arthritis, and systemic JIA as well as for tapering and discontinuing treatment in subjects with inactive systemic JIA. Other aspects of disease management, including factors that influence treatment choice and medication tapering, are discussed. Evidence for all recommendations was graded as low or very low in quality. For that reason, more than half of the recommendations are conditional. CONCLUSION This clinical practice guideline complements the 2019 American College of Rheumatology JIA and uveitis guidelines, which addressed polyarthritis, sacroiliitis, enthesitis, and uveitis. It serves as a tool to support clinicians, patients, and caregivers in decision-making. The recommendations take into consideration the severity of both articular and nonarticular manifestations as well as patient quality of life. Although evidence is generally low quality and many recommendations are conditional, the inclusion of caregivers and patients in the decision-making process strengthens the relevance and applicability of the guideline. It is important to remember that these are recommendations. Clinical decisions, as always, should be made by the treating clinician and patient/caregiver.
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Affiliation(s)
- Karen B Onel
- Hospital for Special Surgery, New York, New York
| | - Daniel B Horton
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Daniel J Lovell
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Susan Shenoi
- Seattle Children's Hospital and Research Center and University of Washington, Seattle
| | | | - Sheila T Angeles-Han
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | | | | | | | | | - Harry Gewanter
- Children's Hospital of Richmond at VCU, Richmond, Virginia
| | - Jaime Guzman
- BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Yukiko Kimura
- Hackensack Meridian School of Medicine, Hackensack, New Jersey
| | | | | | - Peter A Nigrovic
- Boston Children's Hospital and Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | | | - Marinka Twilt
- University of Calgary and Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Marisa Klein-Gitelman
- Ann & Robert Lurie Children's Hospital of Chicago and Northwestern University, Chicago, Illinois
| | | | | | | | | | - Kimberly Hays
- Penn State Health Children's Hospital, Hershey, Pennsylvania
| | | | | | | | | | | | | | | | | | - Keila Veiga
- Maria Fareri Children's Hospital, Valhalla, New York
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
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Chun A, Muhammad LN, De Ranieri D. Comparison of efficacy between triamcinolone acetonide and triamcinolone hexacetonide for intraarticular therapy in juvenile idiopathic arthritis: a retrospective analysis. BMC Rheumatol 2022; 6:18. [PMID: 35354497 PMCID: PMC8969272 DOI: 10.1186/s41927-022-00249-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/24/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
There are many FDA-approved corticosteroid preparations available for intra-articular injection, however triamcinolone hexacetonide is not one of them. It was the intraarticular drug of choice among pediatric rheumatologists up until approximately a decade ago, when production of this medication ceased. It can be obtained in the United States and Canada via importation from Europe, but it is not FDA-approved at this time. We wish to compare the duration of remission of intraarticular triamcinolone hexacetonide (TH) with that of triamcinolone acetonide (TA) in children with juvenile idiopathic arthritis (JIA) and demonstrate its safety in this population.
Methods
This retrospective chart review included 39 patients with JIA who received intraarticular corticosteroid injections (IACIs) from September 2018 to September 2019. These patients were reviewed and their life-time injections with either TH (41 joints) or TA (124 joints) was noted through May 30, 2021. Patients with concomitant systemic therapy initiation were excluded. The primary outcome was time to relapse. Relapse was defined by the presence of arthritis on physical examination by an attending rheumatologist. Kaplan–Meier curves and a log-rank test were constructed to compare the probability of time to relapse between IACI injections. Additionally, mixed effects cox regression models were constructed to account for multiple injections per participant.
Results
Kaplan–Meier estimator of median relapse time in months was higher for TH. Based on the log-rank test, TA joints had a higher probability of experiencing a relapse during the study time (p value < 0.001). The hazard of time to relapse was reduced when comparing TH to TA in both unadjusted and adjusted mixed effects cox regression models [unadjusted hazard ratio (95% confidence interval): 0.184 (0.089, 0.381); adjusted hazard ratio (95% confidence interval): 0.189 (0.092, 0.386)].
Conclusions
TH has longer duration of action than TA and is associated with less systemic side effects. It should be considered the drug of choice for intraarticular corticosteroid injections in children with JIA.
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Onel KB, Horton DB, Lovell DJ, Shenoi S, Cuello CA, Angeles-Han ST, Becker ML, Cron RQ, Feldman BM, Ferguson PJ, Gewanter H, Guzman J, Kimura Y, Lee T, Murphy K, Nigrovic PA, Ombrello MJ, Rabinovich CE, Tesher M, Twilt M, Klein-Gitelman M, Barbar-Smiley F, Cooper AM, Edelheit B, Gillispie-Taylor M, Hays K, Mannion ML, Peterson R, Flanagan E, Saad N, Sullivan N, Szymanski AM, Trachtman R, Turgunbaev M, Veiga K, Turner AS, Reston JT. 2021 American College of Rheumatology Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Oligoarthritis, Temporomandibular Joint Arthritis, and Systemic Juvenile Idiopathic Arthritis. Arthritis Rheumatol 2022; 74:553-569. [PMID: 35233993 PMCID: PMC10161784 DOI: 10.1002/art.42037] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/29/2021] [Accepted: 11/23/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To provide updated guidelines for pharmacologic management of juvenile idiopathic arthritis (JIA), focusing on treatment of oligoarthritis, temporomandibular joint (TMJ) arthritis, and systemic JIA with and without macrophage activation syndrome. Recommendations regarding tapering and discontinuing treatment in inactive systemic JIA are also provided. METHODS We developed clinically relevant Patient/Population, Intervention, Comparison, and Outcomes questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation approach was used to rate the quality of evidence (high, moderate, low, or very low). A Voting Panel including clinicians and patients/caregivers achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS Similar to those published in 2019, these JIA recommendations are based on clinical phenotypes of JIA, rather than a specific classification schema. This guideline provides recommendations for initial and subsequent treatment of JIA with oligoarthritis, TMJ arthritis, and systemic JIA as well as for tapering and discontinuing treatment in subjects with inactive systemic JIA. Other aspects of disease management, including factors that influence treatment choice and medication tapering, are discussed. Evidence for all recommendations was graded as low or very low in quality. For that reason, more than half of the recommendations are conditional. CONCLUSION This clinical practice guideline complements the 2019 American College of Rheumatology JIA and uveitis guidelines, which addressed polyarthritis, sacroiliitis, enthesitis, and uveitis. It serves as a tool to support clinicians, patients, and caregivers in decision-making. The recommendations take into consideration the severity of both articular and nonarticular manifestations as well as patient quality of life. Although evidence is generally low quality and many recommendations are conditional, the inclusion of caregivers and patients in the decision-making process strengthens the relevance and applicability of the guideline. It is important to remember that these are recommendations. Clinical decisions, as always, should be made by the treating clinician and patient/caregiver.
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Affiliation(s)
- Karen B Onel
- Hospital for Special Surgery, New York, New York
| | - Daniel B Horton
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Daniel J Lovell
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Susan Shenoi
- Seattle Children's Hospital and Research Center and University of Washington, Seattle
| | | | - Sheila T Angeles-Han
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | | | | | | | | | - Harry Gewanter
- Children's Hospital of Richmond at VCU, Richmond, Virginia
| | - Jaime Guzman
- BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Yukiko Kimura
- Hackensack Meridian School of Medicine, Hackensack, New Jersey
| | | | | | - Peter A Nigrovic
- Boston Children's Hospital and Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | | | - Marinka Twilt
- University of Calgary and Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Marisa Klein-Gitelman
- Ann & Robert Lurie Children's Hospital of Chicago and Northwestern University, Chicago, Illinois
| | | | | | | | | | - Kimberly Hays
- Penn State Health Children's Hospital, Hershey, Pennsylvania
| | | | | | | | | | | | | | | | | | - Keila Veiga
- Maria Fareri Children's Hospital, Valhalla, New York
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
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Rubin S, Ohana O, Goldberg O, Peled O, Gendler Y, Habot-Wilner Z, Levinsky Y, Tal R, Harel L, Amarilyo G. The efficacy and safety of intra-articular injection of triamcinolone acetonide versus triamcinolone hexacetonide for treatment of juvenile idiopathic arthritis. Pediatr Rheumatol Online J 2022; 20:5. [PMID: 35093116 PMCID: PMC8801083 DOI: 10.1186/s12969-022-00666-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 01/16/2022] [Indexed: 03/05/2023] Open
Abstract
OBJECTIVES Juvenile idiopathic arthritis (JIA) is the most common childhood rheumatic disease. Intra-articular corticosteroids joint injection (IAJI), with triamcinolone hexacetonide (TH) or triamcinolone acetonide (TA), is an effective additional treatment for oligo and polyarticular JIA. Previous studies have shown the benefits of TH over TA; however, TA is still used in many pediatric rheumatology centers. Our unit has experience with both regimens, and therefore we aimed to compare the efficacy and safety of TA versus TH for JIA patients. METHODS Chart review of JIA patients who were randomly (based on drug availability) treated with TA or TH IAJI during 2010-2019. Primary outcomes for efficacy were defined as full recovery from arthritis one month after IAJI and a relapse rate of arthritis 3 months after IAJI. Primary outcome for safety was defined as the occurrence of adverse events (AEs) during the follow up period after IAJI. RESULTS Overall, 292 joints of 102 JIA patients were treated (138 TA/154 TH joints). Complete recovery after one month was documented in 107 (69.6%) of TA treated joints and 96 (69.5%) of TH treated joints (P = 0.232). However, rate of relapse after 3 months was significantly higher for TA treated joints (27 (20.1%) vs. 13 (8.8%), respectively, P < 0.01). No AEs were documented except minor scars at four joint injection sites. CONCLUSION The recovery from arthritis was similar (~ 70%) with both regimens, however relapse rate was more than double in TA as compared to TH injected joints. These findings are important due to a contemporary shortage of TH in the US market.
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Affiliation(s)
- Shiri Rubin
- Pediatric Hematology Oncology Division, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Ohana
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatrics C, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Ori Goldberg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Pulmonary Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Orit Peled
- Department of Pharmacy, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Yulia Gendler
- The Department of Nursing, Ariel University, Ariel, Israel
| | - Zohar Habot-Wilner
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yoel Levinsky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatrics B, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Rotem Tal
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Liora Harel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Gil Amarilyo
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.
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Abstract
Juvenile idiopathic arthritis (JIA) is an umbrella term for arthritis of unknown origin, lasting for >6 weeks with onset before 16 years of age. JIA is the most common chronic inflammatory rheumatic condition of childhood. According to the International League Against Rheumatism (ILAR) classification, seven mutually exclusive categories of JIA exist based on disease manifestations during the first 6 months of disease. Although the ILAR classification has been useful to foster research, it has been criticized mainly as it does not distinguish those forms of chronic arthritis observed in adults and in children from those that may be unique to childhood. Hence, efforts to provide a new evidence-based classification are ongoing. Similar to arthritis observed in adults, pathogenesis involves autoimmune and autoinflammatory mechanisms. The field has witnessed a remarkable improvement in therapeutic possibilities of JIA owing to the availability of new potent drugs and the possibility to perform controlled trials with support from legislative interventions and large networks availability. The goal of drug therapy in JIA is to rapidly reduce disease activity to inactive disease or clinical remission, minimize drug side effects and achieve a quality of life comparable to that of healthy peers. As JIA can influence all aspects of a child's and their family's life, researchers increasingly recognize improvement of health-related quality of life as a key treatment goal.
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Li S, Zhang W, Lin Y. Application of Intra-articular Corticosteroid Injection in Juvenile Idiopathic Arthritis. Front Pediatr 2022; 10:822009. [PMID: 35425732 PMCID: PMC9002113 DOI: 10.3389/fped.2022.822009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/11/2022] [Indexed: 11/29/2022] Open
Abstract
Juvenile idiopathic arthritis (JIA) is one of the common rheumatic diseases in pediatrics. Persistent synovitis and joint pain cause reduced range of motion, deformity and gait interruption, which are important reasons for children's disability and a decline in their quality of life. Rheumatology experts have explored good treatment strategies, among which intra-articular corticosteroid injections (IACIs) targeting joints can greatly reduce these systemic adverse reactions while still obtaining local anti-inflammatory effects. Local inhibition of synovitis by the use of steroid hormones in a joint cavity can avoid or reduce adverse reactions of systemic therapy, prevent or treat leg length variance and joint contracture, solve Baker's cyst, improve tenosynovitis, promote physical therapy and rehabilitation, make gait change smoothly, relieve pain, and restore joint function. Given the importance of IACIs in treating JIA, this paper reviewed the case selection, drug injection, dose selection, current anesthesia and injection techniques, the efficacy, recurrence, and influencing factors of IACIs, the management of physiotherapy intervention post-injection, the application of ultrasound guidance and the safety and complications of IACIs in children with JIA. This study aims to guide the use of IACIs for the best approach throughout the review.
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Affiliation(s)
- Sha Li
- Department of Rheumatology, The Affiliated Women's and Children's Hospital, School of Medicine UESTC, Chengdu Women and Children's Central Hospital, Chengdu, China
| | - Wei Zhang
- Department of Rheumatology, The Affiliated Women's and Children's Hospital, School of Medicine UESTC, Chengdu Women and Children's Central Hospital, Chengdu, China
| | - Yan Lin
- Department of Outpatient, The Affiliated Women's and Children's Hospital, School of Medicine UESTC, Chengdu Women and Children's Central Hospital, Chengdu, China
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Cosickic A, Alić A, Suljendic S, Selimovic A, Skokic M, Delibegovic D, Delibegovic M. INTRAARTICULAR STEROIDS IN TREATMENT OF JUVENILE IDIOPATHIC ARTHRITIS: A SINGLE CENTER EXPERIENCE. SANAMED 2021. [DOI: 10.24125/sanamed.v16i1.487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Goh TS, Ahn TY, Kim K, Shin WC, Moon NH, Woo SH. Outcome of triamcinolone acetonide injection for lateral malleolar bursitis. J Orthop Surg (Hong Kong) 2021; 28:2309499020952893. [PMID: 32873149 DOI: 10.1177/2309499020952893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE This study aimed to evaluate the feasibility and effect of triamcinolone acetonide (TA) injection for lateral malleolar (LM) bursitis. METHODS We retrospectively reviewed data of 49 consecutive patients (49 ankles) who received TA injection between March 2016 and March 2019. All cases received 1 ml (40 mg) of TA injection after aspiration of fluid in the LM bursal sac. Subsequently, the ankle was compressed with an elastic cohesive bandage for 2 weeks. Treatment responses were assessed according to the degree of fluctuation, shrinkage of the bursal sac, and soft tissue swelling. We used the Medical Outcomes Study Short Form Health Survey (SF-36) and complications at 2 and 4 weeks and at 3 and 6 months after TA injection. RESULTS Forty-four patients (89.8%) experienced complete resolution, four (8.2%) had partial resolution, and one (2.0%) had no resolution after the first or second TA injection. The physical component scores of SF-36 improved from 72.8 ± 6.0 to 82.3 ± 6.5 at the last follow-up (p < 0.001). Associated complications included skin atrophy in three patients (6.1%) and transient hyperglycemia in four (8.2%). CONCLUSION TA injection is an effective and safe procedure for LM bursitis. It should be considered as a primary treatment method.
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Affiliation(s)
- Tae Sik Goh
- Department of Orthopedic Surgery and Biomedical Research Institute, 220312Pusan National University Hospital, Seo-gu, Busan, Republic of Korea
| | - Tae Young Ahn
- Department of Orthopedic Surgery and Biomedical Research Institute, 220312Pusan National University Hospital, Seo-gu, Busan, Republic of Korea
| | - Kyeongbaek Kim
- Department of Orthopedic Surgery, 194197Pusan National University Yangsan Hospital, Mulgeum-eup, Yangsan, Republic of Korea
| | - Won Chul Shin
- Department of Orthopedic Surgery, 194197Pusan National University Yangsan Hospital, Mulgeum-eup, Yangsan, Republic of Korea
| | - Nam Hoon Moon
- Department of Orthopedic Surgery and Biomedical Research Institute, 220312Pusan National University Hospital, Seo-gu, Busan, Republic of Korea
| | - Seung Hun Woo
- Department of Orthopedic Surgery, 194197Pusan National University Yangsan Hospital, Mulgeum-eup, Yangsan, Republic of Korea
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Harhay R, Jeelani W, Agbor BTA, Hennon T, Wrotniak BH, Abdul-Aziz R. Response to treatment with intra-articular triamcinolone hexacetonide and triamcinolone acetonide in oligo articular juvenile idiopathic arthritis. Pediatr Rheumatol Online J 2021; 19:36. [PMID: 33743721 PMCID: PMC7981872 DOI: 10.1186/s12969-021-00520-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 03/04/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Oligo-articular juvenile idiopathic arthritis (Oligo JIA) is the most common subtype of juvenile idiopathic arthritis. Intra-articular corticosteroid (IAC) injection is a mainstay treatment of oligo JIA providing pain relief, improving mobility and preventing further joint destruction in the majority of patients. In 2015, production of triamcinolone hexacetonide (TH) an intra-articular corticosteroid was discontinued in the United States leading to use of triamcinolone acetonide (TA) as an alternative. In this study, we compared response to treatment in children with oligo JIA who underwent therapy with intra-articular TA and TH injection. METHODS Our study is a retrospective chart review of children with oligo JIA who were treated with IAC injections with TH between January 2012 and June 2015 and TA between J uly 2015 and December 2018. The two groups were followed at John R. Oishei Children's Hospital of Buffalo and were evaluated for response to treatment, side effects and predictors of response including duration of disease before treatment, erythrocyte sedimentation rate (ESR), and c-reactive protein (CRP). Response to treatment was defined as at least 6 months follow up without evidence of active arthritis in injected joints. Patients were considered to be non-responders if they continued to show active arthritis during their first follow up after joint injection. The primary objective was to evaluate whether there was a significant difference in rate of response between TH and TA. RESULTS Forty-nine patients, 38 female and 11 male with oligo JIA were included in the study. The average age was 6.7 years. A total of 111 joints were injected includin g 78 knees, 13 ankles, 9 wrists, 4 hips, 4 elbows, 2 TMJ and one subtalar joint. In the TA group, 49% (29/59) did not show response to injection compared to 27% (14/52) in the TH group. After 6 months, response rates were better for individuals injected with TH compared to TA (73% vs. 51%). In general, response to intra-articular TH was superior to TA with P = .016 using chi-square test of independence. This difference in outcome was not influenced by other variables such as duration of illness before treatment (P value 0.784) or elevated ESR and CRP. No difference in side effects between the two groups were noted. CONCLUSION Our results in conjunction with prior published data suggests that TH intra-articular joint injection in oligo JIA is superior to TA, although future controlled trials are necessary for confirmation. An effective, long lasting treatment can have a great impact on the outcome of these children.
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Affiliation(s)
- Rana Harhay
- Department of Pediatrics, University at Buffalo, Oishei Children's Hospital, Buffalo, NY, USA.
| | - Wajiha Jeelani
- grid.273335.30000 0004 1936 9887Department of Pediatric Rheumatology, University at Buffalo, Oishei Children’s Hospital, Buffalo, NY USA
| | - Barbine Tchamba Agbor Agbor
- grid.273335.30000 0004 1936 9887Department of Microbiology and Immunology, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY USA
| | - Teresa Hennon
- grid.273335.30000 0004 1936 9887Department of Pediatric Rheumatology, University at Buffalo, Oishei Children’s Hospital, Buffalo, NY USA
| | - Brian H. Wrotniak
- grid.273335.30000 0004 1936 9887Department of Pediatrics, University at Buffalo, Oishei Children’s Hospital, Buffalo, NY USA
| | - Rabheh Abdul-Aziz
- grid.273335.30000 0004 1936 9887Department of Pediatric Rheumatology, University at Buffalo, Oishei Children’s Hospital, Buffalo, NY USA
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Dhanrajani A, Khubchandani RP. Joint injection practice variations in pediatric rheumatology - a global survey and call for action. Pediatr Rheumatol Online J 2020; 18:81. [PMID: 33069262 PMCID: PMC7568404 DOI: 10.1186/s12969-020-00475-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 10/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intraarticular injections (IAI) were first reported in adult rheumatology in the 1950s and subsequently gained acceptance as a safe and efficacious treatment in Juvenile idiopathic arthritis (JIA). IAIs are now widely performed and recommended as the initial or only treatment of oligoarticular JIA and ancillary treatment of actively inflamed joints in other varieties of JIA. However, the performance of the procedure is currently not guided by standardized recommendations, and several practice variations are observed. METHODS This worldwide survey of pediatric rheumatologists (with 48.5% response from Pediatric Rheumatology International Trials Organization [PRINTO and Pediatric Rheumatology Collaborative Study Group [PRCSG] members) captures the differences in pre-procedural, procedural and post-procedural protocols and practices observed across the globe and asks the necessity of developing consensus in this area of Pediatric Rheumatology. RESULTS This worldwide survey of Pediatric Rheumatologists had a response rate of just under 50% and the views of about 42% who routinely performed the procedure. It captured the differences in IAI protocols and practices observed across the globe. Significant variations in practice were noted in use of Local anesthesia, choice, and dose of therapeutic agent for the intraarticular injection and use of ultrasound to guide injections. While some practice variations may be explained by institutional protocols in different parts of the world, the clinical implications of these are largely unknown and beg the need for further studies. CONCLUSIONS Given these practice variations, the authors recommend further studies to explore the cost and clinical implications and subsequently work towards developing consensus plans to ensure uniformity in this widely used procedure in Pediatric Rheumatology.
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Affiliation(s)
- Anita Dhanrajani
- Hospital for Sick Children, 8253, Burton Wing, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - Raju P. Khubchandani
- Pediatric Rheumatology, SRCC Children’s Hospital, 1-1A, Keshavrao Khadye Marg, Haji Ali, Haji Ali Government Colony, Mahalakshmi, Mumbai, Maharashtra 400034 India
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18
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Saougou IG, Markatseli TE, Voulgari PV, Drosos AA. Current Therapeutic Options for the Treatment of Juvenile Idiopathic Arthritis. Curr Rheumatol Rev 2020; 17:41-57. [PMID: 32942977 DOI: 10.2174/1573403x16999200917151805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 12/15/2022]
Abstract
Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disease and an exclusion diagnosis that includes all forms of arthritis that persists for more than 6 weeks under the age of 16. Although there is not yet a cure for JIA, and recent advances in the therapeutic field have created a more hopeful present and future for the patients. In the past, therapies for JIA have depended on non-steroidal medication, conventional synthetic disease-modifying antirheumatic drugs and corticosteroids. However, over the last decades, the advent of biologic therapies in JIA contributed to the preservation of functional activity, control of pain, avoidance of joint damage, and extra-articular manifestations. Furthermore, over the last years, international institutions, such as the American College of Rheumatology, have released recommendations and guidelines for rheumatologists for optimal JIA management. All the above have revolutionized the treatment of JIA with promising outcomes. To this end, the relevant literature is reviewed and discussed appropriately.
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Affiliation(s)
- Ioanna G Saougou
- Department of Internal Medicine, Rheumatology Clinic, Medical School, University of Ioannina, Ioannina, Greece
| | - Theodora E Markatseli
- Department of Internal Medicine, Rheumatology Clinic, Medical School, University of Ioannina, Ioannina, Greece
| | - Paraskevi V Voulgari
- Department of Internal Medicine, Rheumatology Clinic, Medical School, University of Ioannina, Ioannina, Greece
| | - Alexandros A Drosos
- Department of Internal Medicine, Rheumatology Clinic, Medical School, University of Ioannina, Ioannina, Greece
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19
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Jones AP, Clayton D, Nkhoma G, Sherratt FC, Peak M, Stones SR, Roper L, Young B, McErlane F, Moitt T, Ramanan AV, Foster HE, Williamson PR, Deepak S, Beresford MW, Baildam EM. Different corticosteroid induction regimens in children and young people with juvenile idiopathic arthritis: the SIRJIA mixed-methods feasibility study. Health Technol Assess 2020; 24:1-152. [PMID: 32758350 PMCID: PMC7443738 DOI: 10.3310/hta24360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In the UK, juvenile idiopathic arthritis is the most common inflammatory disorder in childhood, affecting 10 : 100,000 children and young people aged < 16 years each year, with a population prevalence of around 1 : 1000. Corticosteroids are commonly used to treat juvenile idiopathic arthritis; however, there is currently a lack of consensus as to which corticosteroid induction regimen should be used with various disease subtypes and severities of juvenile idiopathic arthritis. OBJECTIVE The main study objective was to determine the feasibility of conducting a randomised controlled trial to compare the different corticosteroid induction regimens in children and young people with juvenile idiopathic arthritis. DESIGN This was a mixed-methods study. Work packages included a literature review; qualitative interviews with children and young people with juvenile idiopathic arthritis and their families; a questionnaire survey and screening log to establish current UK practice; a consensus meeting with health-care professionals, children and young people with juvenile idiopathic arthritis, and their families to establish the primary outcome; a feasibility study to pilot data capture and to collect data for future sample size calculations; and a final consensus meeting to establish the final protocol. SETTING The setting was rheumatology clinics across the UK. PARTICIPANTS Children, young people and their families who attended clinics and health-care professionals took part in this mixed-methods study. INTERVENTIONS This study observed methods of prescribing corticosteroids across the UK. MAIN OUTCOME MEASURES The main study outcomes were the acceptability of a future trial for children, young people, their families and health-care professionals, and the feasibility of delivering such a trial. RESULTS Qualitative interviews identified differences in the views of children, young people and their families on a randomised controlled trial and potential barriers to recruitment. A total of 297 participants were screened from 13 centres in just less than 6 months. In practice, all routes of corticosteroid administration were used, and in all subtypes of juvenile idiopathic arthritis. Intra-articular corticosteroid injection was the most common treatment. The questionnaire surveys showed the varying clinical practice across the UK, but established intra-articular corticosteroids as the treatment control for a future trial. The primary outcome of choice for children, young people, their families and health-care professionals was the Juvenile Arthritis Disease Activity Score, 71-joint count. However, results from the feasibility study showed that, owing to missing blood test data, the clinical Juvenile Arthritis Disease Activity Score should be used. The Juvenile Arthritis Disease Activity Score, 71-joint count, and the clinical Juvenile Arthritis Disease Activity Score are composite disease activity scoring systems for juvenile arthritis. Two final trial protocols were established for a future randomised controlled trial. LIMITATIONS Fewer clinics were included in this feasibility study than originally planned, limiting the ability to draw strong conclusions about these units to take part in future research. CONCLUSIONS A definitive randomised controlled trial is likely to be feasible based on the findings from this study; however, important recommendations should be taken into account when planning such a trial. FUTURE WORK This mixed-methods study has laid down the foundations to develop the evidence base in this area and conducting a randomised control trial to compare different corticosteroid induction regimens in children and young people with juvenile idiopathic arthritis is likely to be feasible. STUDY REGISTRATION Current Controlled Trials ISRCTN16649996. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 36. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ashley P Jones
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
| | - Dannii Clayton
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
| | - Gloria Nkhoma
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
| | | | - Matthew Peak
- Alder Hey Children's NHS Foundation Trust, a member of the Liverpool Health Partners, Liverpool, UK
| | | | - Louise Roper
- School of Psychology, University of Liverpool, Liverpool, UK
| | - Bridget Young
- School of Psychology, University of Liverpool, Liverpool, UK
| | - Flora McErlane
- Paediatric Rheumatology, Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - Tracy Moitt
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
| | - Athimalaipet V Ramanan
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Helen E Foster
- Paediatric Rheumatology, Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - Paula R Williamson
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
| | - Samundeeswari Deepak
- Paediatric Rheumatology, Nottingham Children's Hospital, Queen's Medical Centre, Nottingham, UK
| | - Michael W Beresford
- Faculty of Health and Life Science, University of Liverpool and Alder Hey Children's NHS Foundation Trust, members of Liverpool Health Partners, Liverpool, UK
| | - Eileen M Baildam
- Alder Hey Children's NHS Foundation Trust, a member of the Liverpool Health Partners, Liverpool, UK
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20
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Chamlati R, Connolly B, Laxer R, Stimec J, Panwar J, Tse S, Muthusami P, Amaral J, Temple M, Parra DA. Image guided sacroiliac joint corticosteroid injections in children: an 18-year single-center retrospective study. Pediatr Rheumatol Online J 2020; 18:52. [PMID: 32552835 PMCID: PMC7301971 DOI: 10.1186/s12969-020-00435-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 05/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sacroiliitis is commonly seen in enthesitis-related arthritis (ERA), a subtype of juvenile idiopathic arthritis (JIA). Sacroiliitis is characterized by the inflammation of the sacroiliac (SI) joints (+/- adjacent tissues). The treatment options include systemic therapy with or without corticosteroid SI joint injections. Image guided SI joint injections are frequently requested in pediatric patients with sacroiliitis. The purpose of this study was to evaluate the feasibility and efficacy of SI joint injections in children with sacroiliitis. METHODS A retrospective study of patients referred to Interventional Radiology (IR) for SI joint corticosteroid injections (2000-2018). Clinical information was collected from Electronic Patient Charts and procedural details from PACS. Efficacy was determined clinically, by MRI, or both when available. RESULTS 50 patients (13.8 years; M:F = 35:15) underwent image-guided SI joint corticosteroid injections. Most common indications were JIA (84%) and inflammatory bowel disease (14%). 80% had bilateral injections. 80% were performed under general anesthesia and 20% under sedation. The corticosteroid of choice was triamcinolone hexacetonide in 98% of patients. Needle guidance and confirmation was performed using CT and fluoroscopy (54%), Cone Beam CT (CBCT, 46%), with initial ultrasound assistance in 34%. All procedures were technically successful without any complications. 32/50 patients had long-term follow-up (2 years); 21/32 (66%) had clinical improvement within 3-months. Of 15 patients who had both pre- and post-procedure MRIs, 93% showed short-term improvement. At 2 years, 6% of patients were in remission, 44% continued the same treatment and 47% escalated treatment. CONCLUSION Image-guided SI joint injections are safe and technically feasible in children. Imaging modalities for guidance have evolved, with CBCT being the current first choice. Most patients showed short-term clinical and imaging improvement, requiring long-term maintenance or escalation of medical treatment.
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Affiliation(s)
- Racha Chamlati
- grid.17063.330000 0001 2157 2938Division of Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
| | - Bairbre Connolly
- grid.17063.330000 0001 2157 2938Division of Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
| | - Ronald Laxer
- grid.17063.330000 0001 2157 2938Division of Rheumatology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Jennifer Stimec
- grid.17063.330000 0001 2157 2938Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Jyoti Panwar
- grid.17063.330000 0001 2157 2938Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Shirley Tse
- grid.17063.330000 0001 2157 2938Division of Rheumatology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Prakash Muthusami
- grid.17063.330000 0001 2157 2938Division of Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
| | - Joao Amaral
- grid.17063.330000 0001 2157 2938Division of Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
| | - Michael Temple
- grid.17063.330000 0001 2157 2938Division of Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
| | - Dimitri A. Parra
- grid.17063.330000 0001 2157 2938Division of Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
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21
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Time Effect of Intra-articular Injection With Triamcinolone Hexacetonide and Its Correlations: A Case-Control Prospective 12-Month Study. Am J Phys Med Rehabil 2020; 98:872-878. [PMID: 31584880 DOI: 10.1097/phm.0000000000001217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study was to assess the time effect of intra-articular injection with triamcinolone hexacetonide in rheumatic patients. DESIGN A prospective case-control study with patients submitted to one intra-articular injection with triamcinolone hexacetonide. Patients were followed monthly (12 mos) for pain and swelling. RESULTS Two hundred sixty-two joints were assessed in 158 patients with mean ± SD age of 60 ± 13.7 yrs. Remission was observed at 3, 6, and 12 mos in 142 (54.19%), 111 (42.36%), and 105 (40.07%) joints, respectively. The mean ± SD time effect were 8 ± 4.0 mos; 8.4 ± 3.9 for rheumatoid arthritis patients and 6.9 ± 4.0 for osteoarthritis patients (P = 0.012) and 10.4 ± 2.7 mos for small, 7.7 ± 4.1 for medium, and 6.8 ± 4.0 for large joints. The joints were divided into two groups: long-term group (time effect of intra-articular injection longer than 6 mos) and short-term group. The following are the variables associated (P < 0.05) with long-term group: rheumatoid arthritis, small and medium-sized joints, female sex, lower pain and swelling visual analog scale scores, and use of leflunomide. The following are the variables associated with short-term group: receiving only one intra-articular injection, hypertension, diabetes mellitus, and biological therapy. CONCLUSIONS The mean ± SD time effect of intra-articular injection with triamcinolone hexacetonide was 8.0 ± 4.0 mos. The associated predictors were rheumatoid arthritis, small and medium joints, lower pain/swelling visual analog scale scores, and use of leflunomide.
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22
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Flanagan ER, Benham H, Figueroa J, Diaz J, Tress J, Sherry DD. Retrospective review of immobilization vs. immediate resumption of activity in patients with Oligoarticular juvenile idiopathic arthritis following knee injections. Pediatr Rheumatol Online J 2019; 17:42. [PMID: 31299977 PMCID: PMC6626321 DOI: 10.1186/s12969-019-0339-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 06/12/2019] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Intraarticular corticosteroid injection (IACI) is one of the most common treatments in oligoarticular Juvenile Idiopathic Arthritis (JIA). Activity recommendations following injection vary, as there are no published studies on splinting JIA patients post-IACI (splinting is a form of rest). Texas Scottish Rite Hospital for Children (TSRH) splints patients post-IACI for 24 h while The Children's Hospital of Philadelphia (CHOP) does not. The aim of this study was to compare the number of cases of recurrent arthritis following IACI between these two post-injection practices. METHODS Data were retrospectively collected at CHOP and TSRH. Patients diagnosed with oligoarticular JIA according to International League of Associations for Rheumatology (ILAR) criteria (2nd revision, 2001) between 2008 and 2010 were included. Bivariate analysis (Wilcoxon rank-sum tests, chi-squared tests) was run to assess differences in outcomes by site. Inverse probability of treatment weighted Cox regression was employed to adjust for site differences. RESULTS The population at TSRH was younger than at CHOP (p < 0.05) and had more whites (p = 0.03). Disease duration was significantly longer at TSRH than at CHOP (0.40 vs. 0.74 years, p = 0.014). More children were on biologics at the time of injection at CHOP (p < 0.05). The baseline physician global (p < 0.001) was higher at CHOP, as was the joint disease severity (p < 0.001). CHOP had fewer reoccurrences of knee arthritis compared to TSRH: 26% vs 38% (p = 0.14). CONCLUSIONS The baseline populations were different in that the TSRH group had more whites and Hispanics, were younger and, perhaps, had less severe disease than CHOP. Patients treated with post-injection splinting had a trend toward more arthritis reoccurrence (38% vs. 26%, p = 0.14). Splinting is not clearly beneficial post-injection. TRIAL REGISTRATION This is an observational study, so it is not applicable.
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Affiliation(s)
| | | | - Janet Figueroa
- Children’s Healthcare of Atlanta/Emory University, Atlanta, GA USA
| | - Janille Diaz
- Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Jenna Tress
- Children’s Hospital of Philadelphia, Philadelphia, PA USA
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Ringold S, Angeles-Han ST, Beukelman T, Lovell D, Cuello CA, Becker ML, Colbert RA, Feldman BM, Ferguson PJ, Gewanter H, Guzman J, Horonjeff J, Nigrovic PA, Ombrello MJ, Passo MH, Stoll ML, Rabinovich CE, Schneider R, Halyabar O, Hays K, Shah AA, Sullivan N, Szymanski AM, Turgunbaev M, Turner A, Reston J. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Non-Systemic Polyarthritis, Sacroiliitis, and Enthesitis. Arthritis Rheumatol 2019; 71:846-863. [PMID: 31021537 DOI: 10.1002/art.40884] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 02/27/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To develop treatment recommendations for children with juvenile idiopathic arthritis manifesting as non-systemic polyarthritis, sacroiliitis, or enthesitis. METHODS The Patient/Population, Intervention, Comparison, and Outcomes (PICO) questions were developed and refined by members of the guideline development teams. A systematic review was conducted to compile evidence for the benefits and harms associated with treatments for these conditions. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of evidence. A group consensus process was conducted among the Voting Panel to generate the final recommendations and grade their strength. A Parent and Patient Panel used a similar consensus approach to provide patient/caregiver preferences for key questions. RESULTS Thirty-nine recommendations were developed (8 strong and 31 conditional). The quality of supporting evidence was very low or low for 90% of the recommendations. Recommendations are provided for the use of nonsteroidal antiinflammatory drugs, disease-modifying antirheumatic drugs, biologics, and intraarticular and oral glucocorticoids. Recommendations for the use of physical and occupational therapy are also provided. Specific recommendations for polyarthritis address general medication use, initial and subsequent treatment, and adjunctive therapies. Good disease control, with therapeutic escalation to achieve low disease activity, was recommended. The sacroiliitis and enthesitis recommendations primarily address initial therapy and adjunctive therapies. CONCLUSION This guideline provides direction for clinicians, caregivers, and patients making treatment decisions. Clinicians, caregivers, and patients should use a shared decision-making process that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.
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Affiliation(s)
| | - Sheila T Angeles-Han
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Daniel Lovell
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | | | | | - Brian M Feldman
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | | | - Harry Gewanter
- Children's Hospital of Richmond, Virginia Commonwealth University, Richmond
| | - Jaime Guzman
- BC Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Peter A Nigrovic
- Brigham & Women's Hospital and Boston Children's Hospital, Boston, Massachusetts
| | | | | | | | | | - Rayfel Schneider
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
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24
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Ringold S, Angeles-Han ST, Beukelman T, Lovell D, Cuello CA, Becker ML, Colbert RA, Feldman BM, Ferguson PJ, Gewanter H, Guzman J, Horonjeff J, Nigrovic PA, Ombrello MJ, Passo MH, Stoll ML, Rabinovich CE, Schneider R, Halyabar O, Hays K, Shah AA, Sullivan N, Szymanski AM, Turgunbaev M, Turner A, Reston J. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Non-Systemic Polyarthritis, Sacroiliitis, and Enthesitis. Arthritis Care Res (Hoboken) 2019; 71:717-734. [PMID: 31021516 DOI: 10.1002/acr.23870] [Citation(s) in RCA: 162] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 02/27/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To develop treatment recommendations for children with juvenile idiopathic arthritis manifesting as non-systemic polyarthritis, sacroiliitis, or enthesitis. METHODS The Patient/Population, Intervention, Comparison, and Outcomes (PICO) questions were developed and refined by members of the guideline development teams. A systematic review was conducted to compile evidence for the benefits and harms associated with treatments for these conditions. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of evidence. A group consensus process was conducted among the Voting Panel to generate the final recommendations and grade their strength. A Parent and Patient Panel used a similar consensus approach to provide patient/caregiver preferences for key questions. RESULTS Thirty-nine recommendations were developed (8 strong and 31 conditional). The quality of supporting evidence was very low or low for 90% of the recommendations. Recommendations are provided for the use of nonsteroidal antiinflammatory drugs, disease-modifying antirheumatic drugs, biologics, and intraarticular and oral glucocorticoids. Recommendations for the use of physical and occupational therapy are also provided. Specific recommendations for polyarthritis address general medication use, initial and subsequent treatment, and adjunctive therapies. Good disease control, with therapeutic escalation to achieve low disease activity, was recommended. The sacroiliitis and enthesitis recommendations primarily address initial therapy and adjunctive therapies. CONCLUSION This guideline provides direction for clinicians, caregivers, and patients making treatment decisions. Clinicians, caregivers, and patients should use a shared decision-making process that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.
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Affiliation(s)
| | - Sheila T Angeles-Han
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Daniel Lovell
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | | | | | - Brian M Feldman
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | | | - Harry Gewanter
- Children's Hospital of Richmond, Virginia Commonwealth University, Richmond
| | - Jaime Guzman
- BC Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Peter A Nigrovic
- Brigham & Women's Hospital and Boston Children's Hospital, Boston, Massachusetts
| | | | | | | | | | - Rayfel Schneider
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
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Nieto-González JC, Monteagudo I. Estado actual del tratamiento con infiltraciones intraarticulares en la artritis idiopática juvenil. ACTA ACUST UNITED AC 2019; 15:69-72. [DOI: 10.1016/j.reuma.2018.07.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 07/16/2018] [Accepted: 07/19/2018] [Indexed: 11/27/2022]
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Sun W, Ho S, Fang XR, O’Shea T, Liu H. Simultaneous determination of triamcinolone hexacetonide and triamcinolone acetonide in rabbit plasma using a highly sensitive and selective UPLC–MS/MS method. J Pharm Biomed Anal 2018; 153:267-273. [DOI: 10.1016/j.jpba.2018.02.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 02/19/2018] [Accepted: 02/22/2018] [Indexed: 10/18/2022]
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Current and future perspectives in the management of juvenile idiopathic arthritis. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:360-370. [PMID: 30169269 DOI: 10.1016/s2352-4642(18)30034-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 11/22/2017] [Accepted: 11/24/2017] [Indexed: 12/11/2022]
Abstract
The treatment of juvenile idiopathic arthritis has improved tremendously in the past 20 years as a result of appropriate legislative initiatives, large international collaborative networks, and the availability of new potent medications. Despite these considerable advances, a sizable proportion of patients are still resistant to treatment. Further improvement will stem from a better definition of the disease entities under the broad term juvenile idiopathic arthritis (which includes all forms of arthritis with disease onset before the age of 16 years); the discovery of laboratory and imaging biomarkers that could help the tuning of therapy; smoother implementation of clinical trials; more standardised links between academia, regulatory authorities, and patient organisations for the planning of future trials; and the availability of new drugs that selectively target molecules or pathways involved in inflammation.
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Nguyen JC, Lee KS, Thapa MM, Rosas HG. US Evaluation of Juvenile Idiopathic Arthritis and Osteoarticular Infection. Radiographics 2017; 37:1181-1201. [PMID: 28696851 DOI: 10.1148/rg.2017160137] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Juvenile idiopathic arthritis (JIA) and osteoarticular infection can cause nonspecific articular and periarticular complaints in children. Although contrast material-enhanced magnetic resonance imaging is the reference standard imaging modality, musculoskeletal ultrasonography (US) is emerging as an important adjunct imaging modality that can provide valuable information relatively quickly without use of radiation or the need for sedation. However, diagnostic accuracy requires a systemic approach, familiarity with various US techniques, and an understanding of maturation-related changes. Specifically, the use of dynamic, Doppler, and/or multifocal US assessments can help confirm sites of disease, monitor therapy response, and guide interventions. In patients with JIA, ongoing synovial inflammation can lead to articular and periarticular changes, including synovitis, tenosynovitis, cartilage damage, bone changes, and enthesopathy. Although these findings can manifest in adult patients with rheumatoid arthritis, important differences and pitfalls exist because of the unique changes associated with an immature and maturing skeleton. In patients who are clinically suspected of having osteoarticular infection, the inability of US to evaluate the bone marrow decreases its sensitivity. Therefore, the US findings should be interpreted with caution because juxtacortical inflammation is suggestive, but neither sensitive nor specific, for underlying osteomyelitis. Similarly, the absence of a joint effusion makes septic arthritis extremely unlikely but not impossible. US findings of JIA and osteoarticular infection often overlap. Although certain clinical scenarios, laboratory findings, and imaging appearances can favor one diagnosis over the other, fluid analysis may still be required for definitive diagnosis and optimal treatment. US is the preferred modality for fluid aspiration and administering intra-articular corticosteroid therapy. © RSNA, 2017.
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Affiliation(s)
- Jie C Nguyen
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, Madison, Wis (J.C.N., K.S.L., H.G.R.); and the Department of Radiology, Seattle Children's Hospital, Seattle, Wash (M.M.T.)
| | - Kenneth S Lee
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, Madison, Wis (J.C.N., K.S.L., H.G.R.); and the Department of Radiology, Seattle Children's Hospital, Seattle, Wash (M.M.T.)
| | - Mahesh M Thapa
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, Madison, Wis (J.C.N., K.S.L., H.G.R.); and the Department of Radiology, Seattle Children's Hospital, Seattle, Wash (M.M.T.)
| | - Humberto G Rosas
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, Madison, Wis (J.C.N., K.S.L., H.G.R.); and the Department of Radiology, Seattle Children's Hospital, Seattle, Wash (M.M.T.)
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Wulffraat N. The value of old drugs for juvenile idiopathic arthritis. Lancet 2017; 389:883-884. [PMID: 28162780 DOI: 10.1016/s0140-6736(17)30180-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 11/07/2016] [Indexed: 01/07/2023]
Affiliation(s)
- Nico Wulffraat
- Department of Paediatric Rheumatology, University Medical Center Utrecht, Utrecht 3508AB, Netherlands.
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Injeção intra‐articular de hexacetonido de triancinolona em pacientes com artrite reumatoide: avaliação prospectiva da goniometria e parâmetros de inflamação articular. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2016.06.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Kumar A, Dhir V, Sharma S, Sharma A, Singh S. Efficacy of Methylprednisolone Acetate Versus Triamcinolone Acetonide Intra-articular Knee Injection in Patients With Chronic Inflammatory Arthritis: A 24-Week Randomized Controlled Trial. Clin Ther 2017; 39:150-158. [PMID: 28012569 DOI: 10.1016/j.clinthera.2016.11.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 11/22/2016] [Accepted: 11/24/2016] [Indexed: 11/16/2022]
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Cunha ALG, Miotto E Silva VB, Osaku FM, Niemxeski LB, Furtado RNV, Natour J, Sande MTD, Terreri LRA. Intra-articular injection in patients with juvenile idiopathic arthritis: factors associated with a good response. REVISTA BRASILEIRA DE REUMATOLOGIA 2016; 56:490-496. [PMID: 27914595 DOI: 10.1016/j.rbre.2016.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 08/30/2015] [Indexed: 10/22/2022] Open
Abstract
INTRODUCTION Intra-articular injection of corticosteroids (IIC) for treatment of patients with juvenile idiopathic arthritis (JIA) is increasingly used in Pediatric Rheumatology. OBJECTIVES To describe the clinical course of patients undergoing IIC in our Pediatric Rheumatology Unit. METHODS Retrospective study of patients with JIA undergoing IIC from January 2008 to December 2012, with a minimum follow-up of six months after the injection. Good response to IIC was set as the presence of inactivity on the infiltrated joint by at least six months. RESULTS Eighty-eight patients underwent a total of 165 IICs. Of these, 75% were girls and 35.2% had persistent oligoarticular JIA. The mean age at diagnosis was 6.8 years, and when IIC was carried out, 12.2 years. Regarding patients, younger age at diagnosis (p=0.037) and the occurrence of uveitis in the course of the disease (p=0.015) were associated with good response to IIC. From 165 IICs, 63% had a good response and joints remained inactive for a median of 18.1 months. The type of joint injection (p=0.001), lesser values stated in the overall visual analog scale by the physician (p=0.015) and by parents/patient (p=0.01) have been associated with a good response to IIC. Nine adverse events (5.4%) were observed. CONCLUSION In our study, more than half of the joints showed a good response to IIC. Younger patients at diagnosis and uveitis during the course of the disease had good response to IIC. Knees, wrists and elbows were the joints that best responded to IIC. IIC proved to be a safe procedure.
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Affiliation(s)
- Ana Luiza Garcia Cunha
- Universidade Federal de São Paulo (UNIFESP), Departamento de Pediatria, Disciplina de Alergia, Imunologia Clínica e Reumatologia, São Paulo, SP, Brazil.
| | - Vanessa Bugni Miotto E Silva
- Universidade Federal de São Paulo (UNIFESP), Departamento de Pediatria, Disciplina de Alergia, Imunologia Clínica e Reumatologia, São Paulo, SP, Brazil; Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Fabiane Mitie Osaku
- Universidade Federal de São Paulo (UNIFESP), Departamento de Pediatria, Disciplina de Alergia, Imunologia Clínica e Reumatologia, São Paulo, SP, Brazil
| | | | - Rita Nely Vilar Furtado
- Universidade Federal de São Paulo (UNIFESP), Departamento de Medicina, Disciplina de Reumatologia, São Paulo, SP, Brazil
| | - Jamil Natour
- Universidade Federal de São Paulo (UNIFESP), Departamento de Medicina, Disciplina de Reumatologia, São Paulo, SP, Brazil
| | - Maria Teresa de Sande
- Universidade Federal de São Paulo (UNIFESP), Departamento de Pediatria, Disciplina de Alergia, Imunologia Clínica e Reumatologia, São Paulo, SP, Brazil; Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Lemos Ramos Ascensão Terreri
- Universidade Federal de São Paulo (UNIFESP), Departamento de Pediatria, Disciplina de Alergia, Imunologia Clínica e Reumatologia, São Paulo, SP, Brazil; Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
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Furtado RNV, Machado FS, Luz KRD, Santos MFD, Konai MS, Lopes RV, Natour J. Intra-articular injection with triamcinolone hexacetonide in patients with rheumatoid arthritis: prospective assessment of goniometry and joint inflammation parameters. REVISTA BRASILEIRA DE REUMATOLOGIA 2016; 57:115-121. [PMID: 28343615 DOI: 10.1016/j.rbre.2016.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 06/01/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To evaluate local joint variables after intra-articular injection with triamcinolone hexacetonide in rheumatoid arthritis patients. METHODS We blindly and prospectively (baseline, 1, 4, 12 and 24 weeks) evaluated metacarpophalangeal, wrist, elbow, shoulder, knee and ankle joints after triamcinolone hexacetonide intra-articular injection by the following outcome measures: visual analogue scale 0-10cm (VAS) for rest pain (VASR); VAS for movement pain (VASM); VAS for joint swelling (VASSw); flexion (FlexG) and extension (ExtG). RESULTS 289 patients (635 joints) were studied. VASSw (p<0.001) and VASR (0.001<p<0.016) improved from T0 to T4, T12 and T24 for all joints. VASM improved from T0 to T4 (p<0.021) for all joints; T0 to T12 (p<0.023) for MCF and knee; T0 to T24 (p<0.019) only for MCF and knee. FlexG improved from T0 to T4 (p<0.001) for all joints; T0 to T12 (p<0.001) and T0 to T24 (p<0.02) only for MCF and knee. ExtG improved from T0 to T4 (p<0.001) for all joints except for elbow; T0 to T12 (p=0.003) for wrist, metacarpophalangeal and knee; and T0 to T24 (p=0.014) for MCF and knee. CONCLUSION VASSw responded better at short and medium term after IAI with triamcinolone hexacetonide in our sample of RA patients.
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Affiliation(s)
| | - Flávia Soares Machado
- Universidade Federal de São Paulo, Disciplina de Reumatologia, São Paulo, SP, Brazil
| | | | | | - Monique Sayuri Konai
- Universidade Federal de São Paulo, Disciplina de Reumatologia, São Paulo, SP, Brazil
| | - Roberta Vilela Lopes
- Universidade Federal de São Paulo, Disciplina de Reumatologia, São Paulo, SP, Brazil
| | - Jamil Natour
- Universidade Federal de São Paulo, Disciplina de Reumatologia, São Paulo, SP, Brazil
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Abramowicz S, Kim S, Prahalad S, Chouinard AF, Kaban LB. Juvenile arthritis: current concepts in terminology, etiopathogenesis, diagnosis, and management. Int J Oral Maxillofac Surg 2016; 45:801-12. [PMID: 27160609 DOI: 10.1016/j.ijom.2016.03.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 03/22/2016] [Indexed: 10/21/2022]
Abstract
The latest change in terminology from juvenile rheumatoid arthritis (JRA) to juvenile idiopathic arthritis (JIA), established by the International League of Associations for Rheumatology (ILAR), has resulted in some confusion for OMFS and other treating clinicians. JIA comprises a group of systemic inflammatory diseases that result in the destruction of hard and soft tissues in a single or multiple joints. In a significant number of patients, one or both temporomandibular joints (TMJ) are also involved. TMJ disease may be accompanied by pain, swelling, and limitation of motion, as well as mandibular retrognathism, open bite, and asymmetry. The purpose of this article is to provide a review, for the oral and maxillofacial surgeon, of the terminology, etiopathogenesis, diagnosis, and management of children with JIA.
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Affiliation(s)
- S Abramowicz
- Department of Surgery, Division of Oral and Maxillofacial Surgery, Emory University School of Medicine, Section of Dentistry/Oral and Maxillofacial Surgery, Children's Healthcare of Atlanta, Atlanta, GA, USA.
| | - S Kim
- Harvard Medical School, Rheumatology Program, Boston Children's Hospital, Boston, MA, USA
| | - S Prahalad
- Departments of Pediatrics and Human Genetics, Emory University School of Medicine, and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - A F Chouinard
- Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Harvard School of Dental Medicine, Boston, MA, USA
| | - L B Kaban
- Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Harvard School of Dental Medicine, Boston, MA, USA
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35
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Cunha ALG, Miotto E Silva VB, Osaku FM, Niemxeski LB, Furtado RNV, Natour J, Terreri MTDSELRA. Intra-articular injection in patients with juvenile idiopathic arthritis: factors associated with a good response. REVISTA BRASILEIRA DE REUMATOLOGIA 2016; 56:S0482-5004(15)00166-7. [PMID: 26970894 DOI: 10.1016/j.rbr.2015.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 08/06/2015] [Accepted: 08/30/2015] [Indexed: 10/22/2022] Open
Abstract
INTRODUCTION Intra-articular injection of corticosteroids (IIC) for treatment of patients with juvenile idiopathic arthritis (JIA) is increasingly used in Pediatric Rheumatology. OBJECTIVES To describe the clinical course of patients undergoing IIC in our Pediatric Rheumatology Unit. METHODS Retrospective study of patients with JIA undergoing IIC from January 2008 to December 2012, with a minimum follow-up of six months after the injection. Good response to IIC was set as the presence of inactivity on the infiltrated joint by at least six months. RESULTS Eighty-eight patients underwent a total of 165 IICs. Of these, 75% were girls and 35.2% had persistent oligoarticular JIA. The mean age at diagnosis was 6.8 years, and when IIC was carried out, 12.2 years. Regarding patients, younger age at diagnosis (p=0.037) and the occurrence of uveitis in the course of the disease (p=0.015) were associated with good response to IIC. From 165 IICs, 63% had a good response and joints remained inactive for a median of 18.1 months. The type of joint injection (p=0.001), lesser values stated in the overall visual analogue scale by the physician (p=0.015) and by parents/patient (p=0.01) have been associated with a good response to IIC. Nine adverse events (5.4%) were observed. CONCLUSION In our study, more than half of the joints showed a good response to IIC. Younger patients at diagnosis and uveitis during the course of the disease had good response to IIC. Knees, wrists and elbows were the joints that best responded to IIC. IIC proved to be a safe procedure.
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Affiliation(s)
- Ana Luiza Garcia Cunha
- Setor de Reumatologia Pediátrica, Disciplina de Alergia, Imunologia Clínica e Reumatologia, Departamento de Pediatria, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil.
| | - Vanessa Bugni Miotto E Silva
- Setor de Reumatologia Pediátrica, Disciplina de Alergia, Imunologia Clínica e Reumatologia, Departamento de Pediatria, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil; Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
| | - Fabiane Mitie Osaku
- Setor de Reumatologia Pediátrica, Disciplina de Alergia, Imunologia Clínica e Reumatologia, Departamento de Pediatria, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
| | | | - Rita Nely Vilar Furtado
- Disciplina de Reumatologia, Departamento de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
| | - Jamil Natour
- Disciplina de Reumatologia, Departamento de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
| | - Maria Teresa de Sande E Lemos Ramos Ascensão Terreri
- Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil; Disciplina de Alergia, Imunologia Clínica e Reumatologia, Departamento de Pediatria, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
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Carrasco R. Juvenile Idiopathic Arthritis Overview and Involvement of the Temporomandibular Joint. Oral Maxillofac Surg Clin North Am 2015; 27:1-10. [DOI: 10.1016/j.coms.2014.09.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Coulson EJ, Hanson HJM, Foster HE. What does an adult rheumatologist need to know about juvenile idiopathic arthritis? Rheumatology (Oxford) 2014; 53:2155-66. [PMID: 24987157 DOI: 10.1093/rheumatology/keu257] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
JIA is the most common chronic inflammatory arthritis in children and young people and an estimated one-third of individuals will have persistent active disease into adulthood. There are a number of key differences in the clinical manifestations, assessment and management of JIA compared with adult-onset arthritis. Transition and transfer to adult services present significant challenges for many patients, their families and health care professionals. We describe key clinical issues relevant to adult rheumatology health care teams responsible for ongoing care of these young people.
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Affiliation(s)
- Elizabeth J Coulson
- Rheumatology Department, Freeman Hospital, Newcastle Hospitals NHS Foundation Trust and Musculoskeletal Research Group, Institute for Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Helen J M Hanson
- Rheumatology Department, Freeman Hospital, Newcastle Hospitals NHS Foundation Trust and Musculoskeletal Research Group, Institute for Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Helen E Foster
- Rheumatology Department, Freeman Hospital, Newcastle Hospitals NHS Foundation Trust and Musculoskeletal Research Group, Institute for Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK. Rheumatology Department, Freeman Hospital, Newcastle Hospitals NHS Foundation Trust and Musculoskeletal Research Group, Institute for Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.
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Jennings H, Hennessy K, Hendry GJ. The clinical effectiveness of intra-articular corticosteroids for arthritis of the lower limb in juvenile idiopathic arthritis: a systematic review. Pediatr Rheumatol Online J 2014; 12:23. [PMID: 24959104 PMCID: PMC4066295 DOI: 10.1186/1546-0096-12-23] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 06/01/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Juvenile Idiopathic Arthritis (JIA) commonly affects joints of the lower limb including the knee, ankle, subtalar and other foot joints. Intra-articular corticosteroid injections (IACIs) are considered to be effective for short-term relief of synovitis, however, there appears to be a significant lack of published evidence from comparative effectiveness studies. The aim of this study was to identify and critically appraise the evidence for the efficacy of lower limb IACIs in children/adolescents with JIA. METHODS Studies were identified in databases Medline, Embase, CINAHL, AMED, PEDro, the Cochrane Library and TRIP, with no date restrictions. The primary search terms 'juvenile idiopathic arthritis', 'lower limb', 'knee'; 'ankle', 'foot' and 'intra-articular steroid injections' and related synonyms were used to develop a comprehensive pragmatic literature search strategy. Included studies were quantitative longitudinal design such as randomised controlled trials, pseudo-randomised and non-randomised experimental studies, cohort studies, and case-control studies. All outcomes measures were subject to analysis. Quality assessment was conducted using the Cochrane Collaboration criteria with additional criteria for sample population representativeness, quality of statistical analysis and compliant intervention use and presence of co-interventions. Qualitative data synthesis was conducted for the outcome domains. Meta-analyses were not possible as multiple randomised controlled trials for outcome measures were not available. Levels of evidence were assigned to each outcome measure. RESULTS The inclusion criteria were met by twenty-one studies. One study had high quality for internal validity and nine studies had high quality for external validity. No studies had high quality for both internal and external validity. Four outcome domains were identified. There was weak evidence for IACIs decreasing clinical signs and symptoms in the lower leg, improving joint range of motion, decreasing leg length discrepancy, and for imaging techniques detecting the effects of IACIs. CONCLUSIONS There is some weak evidence for the efficacy of IACIs improving certain outcome measures. However, there is also some inconclusive evidence due to a lack of quality studies. More high quality evidence is necessary to definitely determine the efficacy of IACIs for JIA in the lower leg.
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Affiliation(s)
- Heidi Jennings
- School of Science & Health, University of Western Sydney, Penrith, NSW, Australia
| | - Kym Hennessy
- School of Science & Health, University of Western Sydney, Penrith, NSW, Australia
| | - Gordon J Hendry
- School of Science & Health, University of Western Sydney, Penrith, NSW, Australia
- Institute for Applied Health Research/School of Health and Life Sciences, Glasgow Caledonian University, Glasgow G4 0BA, UK
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Scherer J, Rainsford KD, Kean CA, Kean WF. Pharmacology of intra-articular triamcinolone. Inflammopharmacology 2014; 22:201-17. [DOI: 10.1007/s10787-014-0205-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 04/15/2014] [Indexed: 12/16/2022]
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40
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Garg N, Perry L, Deodhar A. Intra-articular and soft tissue injections, a systematic review of relative efficacy of various corticosteroids. Clin Rheumatol 2014; 33:1695-706. [DOI: 10.1007/s10067-014-2572-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 03/02/2014] [Indexed: 11/28/2022]
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Abstract
Diarthrodial joints are well suited to intra-articular injection, and the local delivery of therapeutics in this fashion brings several potential advantages to the treatment of a wide range of arthropathies. Possible benefits over systemic delivery include increased bioavailability, reduced systemic exposure, fewer adverse events, and lower total drug costs. Nevertheless, intra-articular therapy is challenging because of the rapid egress of injected materials from the joint space; this elimination is true of both small molecules, which exit via synovial capillaries, and of macromolecules, which are cleared by the lymphatic system. In general, soluble materials have an intra-articular dwell time measured only in hours. Corticosteroids and hyaluronate preparations constitute the mainstay of FDA-approved intra-articular therapeutics. Recombinant proteins, autologous blood products and analgesics have also found clinical use via intra-articular delivery. Several alternative approaches, such as local delivery of cell and gene therapy, as well as the use of microparticles, liposomes, and modified drugs, are in various stages of preclinical development.
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Affiliation(s)
- Christopher H Evans
- Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, RN-115, Boston, MA 02215, USA
| | - Virginia B Kraus
- Duke University Medical Center, Department of Medicine, Box 3416, Durham, NC 27710, USA
| | - Lori A Setton
- Department of Biomedical Engineering, Duke University, Room 136 Hudson Hall, Box 90281, Durham, NC 27708, USA
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Furtado RNV, Pereira DF, Luz KRD, Santos MFD, Konai MS, Mitraud SDAV, Rosenfeld A, Fernandes ADRC, Natour J. Efetividade da infiltração intra-articular guiada por imagem: comparação entre fluoroscopia e ultrassom. REVISTA BRASILEIRA DE REUMATOLOGIA 2013; 53:476-82. [DOI: 10.1016/j.rbr.2013.07.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 07/14/2013] [Indexed: 10/25/2022] Open
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Goldzweig O, Carrasco R, Hashkes PJ. Systemic adverse events following intraarticular corticosteroid injections for the treatment of juvenile idiopathic arthritis: two patients with dermatologic adverse events and review of the literature. Semin Arthritis Rheum 2013; 43:71-6. [PMID: 23332901 DOI: 10.1016/j.semarthrit.2012.12.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 12/09/2012] [Accepted: 12/10/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Intraarticular corticosteroid injections are an important part of the treatment for juvenile idiopathic arthritis due to the ability to achieve high concentration of the medication in the affected joint, while minimizing potential systemic adverse effects. There may be some systemic absorption of corticosteroids resulting in systemic adverse events. Our aim was to demonstrate the potential of adverse events due to the systemic absorption of intraarticular corticosteroids through presentation of 2 case reports, a review of our practices and a systematic review of the literature. METHODS We reviewed the intraarticular injections performed at our 3 centers in 2010 and 2011 for the prevalence of systemic adverse events. We searched PubMed for articles in English on systemic adverse effects of intraarticular corticosteroid injection in children, using numerous keywords, as well as review articles and textbooks on juvenile rheumatoid/idiopathic arthritis up to and including December 2011. RESULTS We report the development of severe acneiform rashes in 2 adolescents with juvenile idiopathic arthritis following bilateral knee intraarticular injections of triamcinolone hexacetonide. The prevalence of systemic adverse events at our centers was in 4/179 (2.2%) injections, the 2 cases reported above, 1 case of insomnia in a 2-year-old child and 1 case of cushingoid features following injection of 21 joints. While in the literature there are some reports of general "Cushing-like" appearances, there are only very few reports of specific skin and other organ/system adverse effects resulting from systemic corticosteroid absorption. CONCLUSION It is important to recognize the potential of rare adverse events that are attributable to the systemic absorption of intraarticular corticosteroids in children.
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Affiliation(s)
- Ofra Goldzweig
- Pediatric Rheumatology, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
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Chan AY, Milojevic D. Treatment of juvenile idiopathic arthritis. Pediatr Ann 2012; 41. [PMID: 23814934 DOI: 10.3928/00904481-20121022-12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Alice Y Chan
- Pediatric Rheumatology, University of California San Francisco, 533 Parnassus Avenue, Box 0107, San Francisco, CA 94113, USA
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Hendry GJ, Gardner-Medwin J, Steultjens MPM, Woodburn J, Sturrock RD, Turner DD. Frequent discordance between clinical and musculoskeletal ultrasound examinations of foot disease in juvenile idiopathic arthritis. Arthritis Care Res (Hoboken) 2012; 64:441-7. [DOI: 10.1002/acr.20655] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Dueckers G, Guellac N, Arbogast M, Dannecker G, Foeldvari I, Frosch M, Ganser G, Heiligenhaus A, Horneff G, Illhardt A, Kopp I, Krauspe R, Markus B, Michels H, Schneider M, Singendonk W, Sitter H, Spamer M, Wagner N, Niehues T. Evidence and consensus based GKJR guidelines for the treatment of juvenile idiopathic arthritis. Clin Immunol 2012; 142:176-93. [DOI: 10.1016/j.clim.2011.10.003] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 10/14/2011] [Accepted: 10/19/2011] [Indexed: 11/28/2022]
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EBERHARD BANNE, ILOWITE NORMANT, SISON CRISTINA. A Dose Schedule for Intraarticular Steroids in Juvenile Arthritis: Table 1. J Rheumatol 2011; 39:374-6. [DOI: 10.3899/jrheum.110125] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.To determine whether the intraarticular (IA) dose of triamcinolone hexacetonide (TH) or triamcinolone acetonide (TA) influences time to relapse among patients with juvenile idiopathic arthritis (JIA).Methods.The primary endpoint variable was the time to relapse of arthritis in the affected joint after an intraarticular (IA) injection. A relapse was defined as the reoccurrence of active arthritis in the injected joint. Analysis was carried out including only the first IA joint injection for each patient. Further analysis was conducted including the first knee injection alone. A separate analysis within the IA corticosteroid groups was performed using the Spearman rank coefficient, to determine if dose of IA steroid affected time to relapse.Results.Records from 186 patients with JIA (145 females, 41 males) injected with either TH or TA were collected from January 1995 through December 2003. All subjects were followed for a minimum of 15 months from the time of IA injection. Of the 794 joint injections, 422 (53.1%) were injected with TH and 372 (46.9%) with TA. There were 111 first joint injections (all joints) with TH and 70 with TA. There were 89 first joint injections (knee only) with TH and 56 with TA. TH proved more effective than TA with respect to the time to relapse for first injection into all joints (10.47 ± 0.42 mo vs 8.66 ± 0.59 mo; p < 0.001), and for first injections into knee only (11.04 ± 0.44 vs 8.99 ± 0.65 mo; p < 0.001). IA doses ranged from 0.4 to 4 mg/kg (mean 1.56 ± 0.76) for TH and from 0.5 to 8 mg/kg (mean 2.54 ± 1.74) for TA. There was no correlation between time to relapse and dose of either TH and TA (r = 0.1, p > 0.5). There was no correlation between time to relapse and sex, duration of illness, age of patient, concurrent medications, or subtype of JIA.Conclusion.In a larger dataset (794 injections) we have confirmed our previous findings (227 injections) that TH is a more effective IA corticosteroid than TA. In this much larger data analysis, dose of IA corticosteroid in the range we studied did not significantly influence the duration of response.
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Beresford MW. Juvenile idiopathic arthritis: new insights into classification, measures of outcome, and pharmacotherapy. Paediatr Drugs 2011; 13:161-73. [PMID: 21500870 DOI: 10.2165/11588140-000000000-00000] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Significant advances have taken place in recent years in our understanding of the aetiopathogenesis, management, and clinical outcome of juvenile idiopathic arthritis (JIA). Fundamental to this advancement has been international collaborative efforts of the clinical scientific community and all those involved in the multidisciplinary care of children and young people with JIA. A key factor has been facing the challenge of developing a robust classification system for JIA, a clinically very heterogeneous group of conditions. JIA illustrates the necessity of disease classification to enable scientific progress but also the iterative and evolving process this entails. What is emerging is the imperative to improve our understanding of the biologic and genetic basis of JIA to underpin classification systems. Growing emphasis is centered on improved holistic care and outcome of children and young people with JIA. The expectation of patients, their families, and clinicians is the goal of inactive disease, remission off treatment, and the health and psychosocial well-being of young people emerging into adulthood. Validated tools that reflect these challenges are being developed, including those measuring disease improvement, flare, remission and minimal disease activity, health-related quality of life, and composite scores of activity and damage. Clinical research networks have driven success in developing an evidence-base for the treatment of JIA. Randomized comparative trials have demonstrated the benefit of early use of intra-articular corticosteroid injections, and the importance of methotrexate as the first-line, disease-modifying antirheumatic drug in JIA. The introduction of biologic therapies has opened a major new epoch in the medical management of JIA, with recent trials published on etanercept, infliximab, adalimumab, abatacept, tocilizumab, and anakinra. This review focuses on recent advances in JIA, especially developments in its classification, validation of appropriate measures of holistic outcome, and the specific contribution of established and newer pharmacologic agents available for treating children and young people.
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Affiliation(s)
- Michael W Beresford
- Department of Women's and Children's Health, Institute of Translational Medicine (Child Health), University of Liverpool, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
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Rintamäki H, Tamm K, Vaarala O, Sidoroff M, Honkanen V, Raivio T, Jänne OA, Kolho KL. Intra-articular corticoid injection induces circulating glucocorticoid bioactivity and systemic immune activation in juvenile idiopathic arthritis. Scand J Rheumatol 2011; 40:347-53. [DOI: 10.3109/03009742.2011.560893] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Beukelman T, Patkar NM, Saag KG, Tolleson-Rinehart S, Cron RQ, DeWitt EM, Ilowite NT, Kimura Y, Laxer RM, Lovell DJ, Martini A, Rabinovich CE, Ruperto N. 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: initiation and safety monitoring of therapeutic agents for the treatment of arthritis and systemic features. Arthritis Care Res (Hoboken) 2011; 63:465-82. [PMID: 21452260 PMCID: PMC3222233 DOI: 10.1002/acr.20460] [Citation(s) in RCA: 525] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are intended to provide guidance for particular patterns of practice and not to dictate the care of a particular patient. The ACR considers adherence to these guidelines and recommendations to be voluntary, with the ultimate determination regarding their application to be made by the physician in light of each patient’s individual circumstances. Guidelines and recommendations are intended to promote beneficial or desirable outcomes but cannot guarantee any specific outcome. Guidelines and recommendations developed or endorsed by the ACR are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice.
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Affiliation(s)
- Timothy Beukelman
- University of Alabama at Birmingham, Birmingham, AL 35233-1711, USA.
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