Session Information
Date: Sunday, November 13, 2016
Title: Pediatric Rheumatology – Clinical and Therapeutic Aspects I: Juvenile Arthritis
Session Type: ACR Concurrent Abstract Session
Session Time: 2:30PM-4:00PM
Background/Purpose: First-line treatment for Lyme arthritis is fairly standardized, but second-line strategies are more variable. We compared the effectiveness of oral antibiotics, intra-articular glucocorticoid injections (IAGC), and intravenous (IV) antibiotics in second-line regimens for pediatric Lyme arthritis.
Methods: We performed a retrospective cohort study of children age ≤18 seen in 3 pediatric rheumatology clinics for Western blot-confirmed Lyme arthritis. We limited the cohort to children who began second-line therapy ≤4 months after starting antibiotics, a timeline consistent with usual practice at these sites. Second-line strategies were: 1) a second course of oral antibiotics alone, 2) IAGC with or without oral antibiotics, or 3) a course of IV antibiotics. The primary outcome was development of antibiotic-refractory Lyme arthritis (ARLA), defined as persistent arthritis ≥2 months after completing ≥56 days of oral antibiotics or ≥14 days of IV antibiotics, per IDSA/Red Book guidelines. The secondary outcome was rate of clinical resolution of arthritis. We compared second-line treatment strategies using logistic regression for ARLA and Cox regression for rate of resolution, adjusted for confounders.
Results: There were 129 children with second-line treatment for Lyme arthritis, of whom 42 (33%) developed ARLA: 29/83 (35%) on oral antibiotics alone; 3/18 (17%) with IAGC ± oral antibiotics; and 10/28 (36%) after IV antibiotics. Children who received second-line IAGC or IV antibiotics were more likely female (Table 1). Children whose arthritis markedly worsened after antibiotic initiation were more likely to receive second-line IV antibiotics (P<0.01). After adjusting for sex and worsening arthritis, children who received IAGC ± oral antibiotics appeared to have a decreased risk of developing ARLA compared with children receiving second-line oral antibiotics alone, but this did not meet traditional levels of significance (aOR 0.4, 95% CI 0.1, 1.4, P = 0.14) (Table 2). Similarly, second-line IAGC was associated with non-significantly increased rates of resolution of arthritis (aHR 1.6, 95% CI 0.9, 2.9, P = 0.11). There was no significant difference in the risk of developing ARLA (P=0.55) or rate of resolution (P=0.46) between groups receiving second-line IV or oral antibiotics (Table 2). Results were similar after excluding children whose disease worsened after antibiotic initiation.
Conclusion: Use of second-line intra-articular glucocorticoid injection may hasten the resolution of Lyme arthritis and prevent chronic Lyme arthritis in children. Further study of this strategy in larger cohorts is warranted.
| Table 1. Clinical and treatment characteristics of children who received second-line treatment for Lyme arthritis | |||||
| Characteristic |
(1) Oral antibiotics alone (N=83) |
(2) IAGC ± oral antibiotics (N=18) |
P-value (2) vs. (1) |
(3) IV antibiotics (N=28) |
P-value (3) vs. (1) |
| Age in years, median (IQR) |
12.1 (9.4, 14.5) |
11.2 (8.3, 13.7) |
0.38 |
12.2 (10.2, 14.2) |
0.77 |
| Male sex, N (%) |
64 (77) |
10 (56) |
0.06 |
15 (54) |
0.02 |
| Duration of initial joint symptoms in days, median (IQR) |
7 (4, 28) |
3 (3, 21) |
0.26 |
14 (7, 28) |
0.36 |
| More than 1 joint involved,1 N (%) |
12 (14) |
3 (17) |
0.81 |
5 (18) |
0.67 |
| Non-knee joint involved, N (%) |
11 (13) |
2 (11) |
0.81 |
2 (7) |
0.39 |
| Marked clinical worsening ≤6 weeks after antibiotic initiation,2 N (%) |
10 (12) |
0 |
0.12 |
10 (36) |
<0.01 |
| First antibiotic course ≥28 days in duration, N (%) |
55 (66) |
11 (61) |
0.68 |
19 (68) |
0.88 |
| First antibiotic course dose correct per guidelines, N (%) |
58 (70) |
12 (67) |
0.79 |
22 (79) |
0.38 |
| Second-line antibiotics, N (%) |
|
|
<0.01 |
|
<0.01 |
| Doxycycline |
61 (73) |
10 (56) |
|
0 |
|
| Amoxicillin |
17 (20) |
3 (17) |
|
0 |
|
| Cefuroxime |
4 (5) |
1 (6) |
|
0 |
|
| Other oral antibiotic |
1 (1) |
0 |
|
0 |
|
| Ceftriaxone |
0 |
0 |
|
28 (100) |
|
| None |
0 |
4 (22) |
|
0 |
|
| IAGC, intra-articular glucocorticoid injection; IQR, interquartile range; IV, intravenous. 1 Two knees would count as two joints 2 New massive effusion, joint capsule rupture, or joint recruitment | |||||
|
Table 2. Multivariable analysis comparing second-line regimens for pediatric Lyme arthritis |
||||
|
Risk of developing antibiotic-refractory Lyme arthritis |
Rate of clinical resolution of arthritis1 |
|||
| Treatment strategy |
aOR2 (95% CI) |
P-value |
aHR2 (95% CI) |
P-value |
| Oral antibiotics alone (reference) |
1.0 |
– |
1.0 |
– |
| IAGC ± oral antibiotics |
0.4 (0.1, 1.4) |
0.14 |
1.6 (0.9, 2.9) |
0.11 |
| IV antibiotics |
0.7 (0.3, 2.0) |
0.55 |
1.2 (0.7, 2.1) |
0.46 |
| aHR, adjusted hazard ratio; aOR, adjusted odds ratio; CI, confidence interval; IAGC, intra-articular glucocorticoid injection; IV, intravenous. 1Presence of mild, asymptomatic joint swelling was considered compatible with clinical resolution if there was no subsequent worsening or recurrence of symptomatic arthritis 2 Multivariable models also adjusted for male sex and marked worsening on antibiotics, defined as a new massive effusion, joint capsule rupture, or joint recruitment within 6 weeks of antibiotic initiation | ||||
To cite this abstract in AMA style:
Horton DB, Taxter AJ, Groh B, Sherry DD, Rosé CD. Comparative Effectiveness of Second-Line Treatment Strategies for Lyme Arthritis in Children [abstract]. Arthritis Rheumatol. 2016; 68 (suppl 10). https://acrabstracts.org/abstract/comparative-effectiveness-of-second-line-treatment-strategies-for-lyme-arthritis-in-children/. Accessed .« Back to 2016 ACR/ARHP Annual Meeting
ACR Meeting Abstracts - https://acrabstracts.org/abstract/comparative-effectiveness-of-second-line-treatment-strategies-for-lyme-arthritis-in-children/