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Leow OM, Lim LK, Ooi PL, Shek LP, Ang EY, Son MB
Correspondence: Dr Mary Beth Son, marybethson@gmail.com
ABSTRACT
INTRODUCTION This study aimed to evaluate the efficacy and safety of intra-articular glucocorticoid (IAG) injections in our institution in children with juvenile idiopathic arthritis (JIA).
METHODS This is a retrospective assessment of IAG injections performed by the Department of Paediatrics, National University Hospital, Singapore, from October 2009 to October 2011. A total of 26 procedures were evaluated for efficacy, considering parameters such as clinical response, changes in systemic medication, length of time between repeat injections, safety, consent-taking, pre- and post-procedural advice, compliance with aseptic technique, and post-procedural complications.
RESULTS A total of 26 IAG injections of triamcinolone hexacetonide were administered over 17 occasions (i.e. patient encounters) to ten patients with JIA during the study period. After the injections, clinical scoring by a paediatric rheumatologist showed overall improvement by an average of 2.62 points out of 15. Besides six patient encounters that had an increase in systemic medication on the day of the injection, five required an increase within six months post injection, two required no adjustments, and one resulted in a decrease in medications. In all, 21 injections did not require subsequent injections. The mean interval between repeat injections was 7.8 months. Cutaneous side effects were noted in three anatomically difficult joints. Medical documentation with regard to patient progress was found to be lacking.
CONCLUSION As per the recommendations of the American College of Rheumatology, we safely used IAG injections as the first-line therapy in our group of patients with oligoarticular JIA, and/or as an adjunct to systemic therapy in our patients with JIA.
Keywords: complications, efficacy, intra-articular injections, juvenile idiopathic arthritis, safety
Singapore Med J 2014; 55(5): 248-252; http://dx.doi.org/10.11622/smedj.2014066
REFERENCES
| 1. Wu EY, Van Mater HA, Rabinovich CE. Juvenile Idiopathic Arthritis. In: Kliegman RM, Stanton BF, St. Geme III JW et al, eds. Nelson Textbook of Pediatrics, 19th ed. Philadelphia: Saunders, 2011: 829-39. http://dx.doi.org/10.1016/B978-1-4377-0755-7.00149-4 | ||||
| 2. Petty RE, Southwood TR, Baum J, et al. Revision of the proposed classification criteria for juvenile idiopathic arthritis. J Rheumatol 1998; 25:1991-4. PMid:9779856 | ||||
| 3. See Y, Koh ET, Boey ML. One hundred and seventy cases of childhood-onset rheumatological disease in Singapore. Ann Acad Med Singapore 1998; 27:496-502. PMid:9791653 | ||||
| 4. Arkachaisri T. Pediatric rheumatology in Southeast Asia: insights from the Singapore experience. Curr Rheumatol Rep 2011; 13:117-22. http://dx.doi.org/10.1007/s11926-010-0159-1 | ||||
| 5. Beukelman T, Patkar NM, Saag KG, et al. American College of Rheumatology 2011 Recommendations for the Treatment of Juvenile Idiopathic Arthritis. Initiation and Safety Monitoring of Therapeutic Agents for the Treatment of Arthritis and Systemic Features. Clinician's guide. | ||||
| 6. See Y. Intra-synovial corticosteroid injections in juvenile chronic arthritis--a review. Ann Acad Med Singapore 1998; 27:105-11. PMid:9588284 | ||||
| 7. Sherry DD, Stein LD, Reed AM, Schanberg LE, Kredich DW. Prevention of leg length discrepancy in young children with pauciarticular juvenile rheumatoid arthritis by treatment with intraarticular steroids. Arthritis Rheum 1999; 42:2330-4. http://dx.doi.org/10.1002/1529-0131(199911)42:11<2330::AID-ANR11>3.0.CO;2-B | ||||
| 8. Lepore L, Del Santo M, Malorgio C, et al. Treatment of juvenile idiopathic arthritis with intra-articular triamcinolone hexacetonide: evaluation of clinical effectiveness correlated with circulating ANA and T gamma/delta+ and B CD5+ lymphocyte populations of synovial fluid. Clin Exp Rheumatol 2002; 20:719-22. PMid:12412208 | ||||
| 9. Huppertz HI, Tschammler A, Horwitz AE, Schwab KO. Intraarticular corticosteroids for chronic arthritis in children: efficacy and effects on cartilage and growth. J Pediatr 1995; 127:317-21. http://dx.doi.org/10.1016/S0022-3476(95)70320-9 | ||||
| 10. Honkanen VE, Rautonen JK, Pelkonen PM. Intra-articular glucocorticoids in early juvenile chronic arthritis. Acta Paediatr 1993; 82:1072-4. http://dx.doi.org/10.1111/j.1651-2227.1993.tb12815.x | ||||
| 11. Zulian F, Martini G, Gobber D, et al. Triamcinolone acetonide and hexacetonide intra-articular treatment of symmetrical joints in juvenile idiopathic arthritis: a double-blind trial. Rheumatology (Oxford) 2004; 43:1288-91. http://dx.doi.org/10.1093/rheumatology/keh313 | ||||
| 12. Charalambous CP, Tryfonidis M, Sadiq S, Hirst P, Paul A. Septic arthritis following intra-articular steroid injection of the knee--a survey of current practice regarding antiseptic technique used during intra-articular steroid injection of the knee. Clin Rheumatol 2003; 22:386-90. http://dx.doi.org/10.1007/s10067-003-0757-7 | ||||
| 13. Chakravarty K, Pharoah PD, Scott DG. A randomized controlled study of post-injection rest following intra-articular steroid therapy for knee synovitis. Br J Rheumatol 1994; 33:464-8. http://dx.doi.org/10.1093/rheumatology/33.5.464 | ||||
| 14. Weitoft T, Rönnblom L. Randomised controlled study of postinjection immobilisation after intra-articular glucocorticoid treatment for wrist synovitis. Ann Rheum Dis 2003; 62:1013-5. http://dx.doi.org/10.1136/ard.62.10.1013 | ||||
| 15. Weitoft T, Forsberg C. Importance of immobilization after intraarticular glucocorticoid treatment for elbow synovitis: a randomized controlled study. Arthritis Care Res (Hoboken) 2010; 62:735-7. http://dx.doi.org/10.1002/acr.20039 | ||||
| 16. Dernis E, Ruyssen-Witrand A, Mouterde G, et al. Use of glucocorticoids in rheumatoid arthritis - pratical modalities of glucocorticoid therapy: recommendations for clinical practice based on data from the literature and expert opinion. Joint Bone Spine 2010; 77:451-7. http://dx.doi.org/10.1016/j.jbspin.2009.12.010 | ||||
| 17. Habib GS, Saliba W, Nashashibi M. Local effects of intra-articular corticosteroids. Clin Rheumatol 2010; 29:347-56. http://dx.doi.org/10.1007/s10067-009-1357-y | ||||
| 18. Lanni S, Bertamino M, Consolaro A, et al. Outcome and predicting factors of single and multiple intra-articular corticosteroid injections in children with juvenile idiopathic arthritis. Rheumatology (Oxford) 2011; 50:1627-34. http://dx.doi.org/10.1093/rheumatology/ker165 | ||||
| 19. Job-Deslandre C, Menkes CJ. Complications of intra-articular injections of triamcinolone hexacetonide in chronic arthritis in children. Clin Exp Rheumatol 1990; 8:413-6. PMid:2397629 | ||||
| 20. Hunter JA, Blyth TH. A risk-benefit assessment of intra-articular corticosteroids in rheumatic disorders. Drug Saf 1999; 21:353-65. http://dx.doi.org/10.2165/00002018-199921050-00002 | ||||
| 21. Pal B, Morris J. Perceived risks of joint infection following intra-articular corticosteroid injections: a survey of rheumatologists. Clin Rheumatol 1999; 18:264-5. http://dx.doi.org/10.1007/s100670050098 | ||||
| 22. Geirsson AJ, Statkevicius S, Víkingsson A. Septic arthritis in Iceland 1990-2002: increasing incidence due to iatrogenic infections. Ann Rheum Dis 2008; 67:638-43. http://dx.doi.org/10.1136/ard.2007.077131 | ||||
| 23. Breit W, Frosch M, Meyer U, Heinecke A, Ganser G. A subgroup-specific evaluation of the efficacy of intraarticular triamcinolone hexacetonide in juvenile chronic arthritis. J Rheumatol 2000; 27:2696-702. PMid:11093456 | ||||
| 24. Neidel J, Boehnke M, Küster RM. The efficacy and safety of intraarticular corticosteroid therapy for coxitis in juvenile rheumatoid arthritis. Arthritis Rheum 2002; 46:1620-8. http://dx.doi.org/10.1002/art.10313 | ||||
| 25. Beukelman T, Patkar NM, Saag KG, et al. 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. http://dx.doi.org/10.1002/acr.20460 | ||||
| 26. Hetland ML, Østergaard M, Ejbjerg B, et al. Short- and long-term efficacy of intra-articular injections with betamethasone as part of a treat-to-target strategy in early rheumatoid arthritis: impact of joint area,repeated injections, MRI findings, anti-CCP, IgM-RF and CRP. Ann Rheum Dis 2012; 71:851-6. http://dx.doi.org/10.1136/annrheumdis-2011-200632 | ||||
| 27. Cahill AM, Cho SS, Baskin KM, et al. Benefit of fluoroscopically guided intraarticular, long-acting corticosteroid injection for subtalar arthritis in juvenile idiopathic arthritis. Pediatr Radiol 2007; 37:544-8. http://dx.doi.org/10.1007/s00247-007-0457-6 | ||||
| 28. Laurell L, Court-Payen M, Nielsen S, Zak M, Fasth A. Ultrasonography and color Doppler in juvenile idiopathic arthritis: diagnosis and follow-up of ultrasound-guided steroid injection in the wrist region. A descriptive interventional study. Pediatr Rheumatol Online J 2012; 10:11. http://dx.doi.org/10.1186/1546-0096-10-11 | ||||