Intra-articular injection in patients with juvenile idiopathic arthritis: factors associated with a good response

Cunha, Ana Luiza Garcia; Silva, Vanessa Bugni Miotto e; Osaku, Fabiane Mitie; Niemxeski, Luísa Brasil; Furtado, Rita Nely Vilar; Natour, Jamil; Terreri, Maria Teresa de Sande e Lemos Ramos Ascensão

doi:10.1016/j.rbre.2016.01.001

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Revista Brasileira de Reumatologia

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Original articles • Rev. Bras. Reumatol. 56 (6) • Nov-Dec 2016 • https://doi.org/10.1016/j.rbre.2016.01.001 copy

Intra-articular injection in patients with juvenile idiopathic arthritis: factors associated with a good response

Authorship SCIMAGO INSTITUTIONS RANKINGS

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.

Keywords:
Intra-articular injection; Juvenile idiopathic arthritis; Triamcinolone hexacetonide; Treatment and uveitis

Variables	Total of patients (n = 88)	Good response to IIC (n = 62)	Poor response to IIC (n = 26)	p-Value
Demographic data
Female gender	66	48 (72.7%)	18 (27.3%)	0.42^a a Chi-squared test.
Time elapsed between the first symptoms and diagnosis (months)	10.5 (±16.5)	11.7 (±18.9)	7.8 (±7.8)	0.73^b b Mann–Whitney test.
Age at diagnosis of JIA (years)	6.8 (±4.0)	6.2 (±3.7)	8.3 (±4.4)	0.037^b b Mann–Whitney test.
Mean follow-up to the last visit (years)	7.1 (±4.0)	7.5 (±3.9)	6.1 (4.1)	0.08^b b Mann–Whitney test.
ANA, positive	37	30 (81%)	7 (19%)	0.126^a a Chi-squared test.
RF, positive	9	8 (88.9%)	1 (11.1%)	0.271^c c Fisher's exact test.
Uveitis associated with JIA	12	12 (100%)	0	0.015^c c Fisher's exact test.

JIA subtype				0.076^a a Chi-squared test.
Systemic	4	1 (25%)	3 (75%)
Oligoarticular, persistent	31	22 (70.9%)	9 (29.1%)
Oligoarticular, extended	17	14 (82.3%)	3 (17.7%)
Polyarticular, RF positive	9	8 (88.9%)	1 (11.1%)
Polyarticular, RF negative	25	17 (68%)	8 (32%)
Psoriatic	1	0	1 (100%)
ARE	1	0	1 (100%)

Clustered subtype of JIA				0.08^a a Chi-squared test.
Oligoarticular	33	22 (66.7%)	11 (33.3%)
Polyarticular	51	39 (76.4%)	12 (23.6%)
Systemic	4	1 (25%)	3 (75%)

Variables	Total of patients (n = 165)	Good response to IIC (n = 104)	Poor response to IIC (n = 61)	p-Value
Descriptor
Time from diagnosis to IIC (years)	5.3 (±3.8)	5.6 (±3.8)	4.9 (±3.8)	0.25^a a Mann–Whitney test.
Age at IIC (years)	12.2 (±4.3)	12.1 (±4.5)	12.5 (±4.1)	0.53^a a Mann–Whitney test.
CHAQ (n = 28), mean (range)	0.41 (0–2.25)	0.30 (0–2.25)	0. 67 (0–1.75)	0.53^a a Mann–Whitney test.
VAS parents/patient (n = 80), median (range)	0 (0–9)	0 (0–9)	3 (0–8)	0.015^a a Mann–Whitney test.
VAS physician (n = 60), median (range)	1 (0–8)	0 (0–7)	4 (1–8)	0.010^a a Mann–Whitney test.
CRP (n = 124) ± SD	10.2 (±18.5)	10.5 (±21.6)	9.6 (±11.9)	0.22^a a Mann–Whitney test.
ESR (n = 129) ± SD	25.8 (±24.5)	27.2 (±26.7)	23.2 (±20.3)	0.41^a a Mann–Whitney test.
Active joints ± SD	3.1 (±4.3)	2.6 (±3.0)	4.1 (±5.8)	0.09^a a Mann–Whitney test.
Restricted joints ± SD	3.2 (±6.1)	3.0 (±5.6)	3.5 (±6.9)	0.77^a a Mann–Whitney test.

Injected joint				0.001^b b Chi-squared test.
Knees	100	71 (71%)	29 (29%)
Ankles	30	11 (36.7%)	19 (63.3%)
Wrists	15	10 (66.7%)	5 (33.3%)
Elbows	9	9 (100%)	0
Shoulders	3	1 (33.3%)	2 (66.7%)
Hips	6	2 (33.3%)	4 (66.7%)
Proximal interphalangeal joints	2	0	2 (100%)

Joint effusion degree (n = 156)				0.49^b b Chi-squared test.
Mild	55	33 (60%)	22 (40%)
Moderate	84	56 (66.7%)	28 (33.3%)
Severe	17	9 (52.9%)	8 (47.1%)
Guided by ultrasound	16	6 (37.5%)	10 (62.5%)	0.02^b b Chi-squared test.

Drugs in use at the time of IIC				0.32^b b Chi-squared test.
None or NSAIDs	55	39 (71%)	16 (29%)
DMARDs	80	48 (60%)	32 (40%)
Biologicals	30	17 (56.7%)	13 (43.3%)
Use of oral corticosteroids	21	12 (57.1%)	9 (42.9%)	0.55^b b Chi-squared test.

Variables	US-guided infiltrations (n = 16)	Infiltrations unguided by US (n = 149)	p-Value
Descriptor
Time from diagnosis to IIC (years)	5.9 (±3.4)	5.2 (±3.7)	0.63^a a Mann–Whitney test.
Age at IIC (years)	12.1 (±5.2)	12.2 (±4.2)	0.94^a a Mann–Whitney test.
CHAQ (n = 28), mean (range)	1.6 (1–2.25)	0.3 (0–1.75)	0.03^a a Mann–Whitney test.
VAS parents/patient (n = 80), median (range)	5 (1–6)	0 (0–9)	0.42^a a Mann–Whitney test.
VAS physician (n = 60), median (range)	1 (1–4)	3 (0–8)	0.46^a a Mann–Whitney test.
CRP (n = 124) ± SD	11 (±17.5)	10 (±18.6)	0.89^a a Mann–Whitney test.
ESR (n = 129) ± SD	25.3 (±18.4)	25.8 (±25.2)	0.73^a a Mann–Whitney test.
Active joints ± SD	4.5 (±6.7)	2.9 (±3.9)	0.55^a a Mann–Whitney test.
Restricted joints ± SD	6.7 (±12.8)	2.8 (±4.8)	0.30^a a Mann–Whitney test.
Number of injections with poor response	1.4 (±0.8)	0.8 (±0.8)	0.01^a a Mann–Whitney test.
Relapse time (months)	6.5 (±7.2)	13 (±13.2)	0.01^a a Mann–Whitney test.

Joint effusion degree (n = 156)			0.29^b b Chi-squared test.
Mild	7	48
Moderate	8	76
Severe	0	17

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[1] *Corresponding author. E-mail: analuiza.cunha@gmail.com (A.L.G. Cunha).