Background/Purpose: Intra-articular corticosteroid injection (IACI) therapy in juvenile idiopathic arthritis (JIA) is generally considered for the treatment of children with arthritis in a small number of joints, particularly large joints. However, the current place of multiple IACIs in the management of JIA is still uncertain. The aim of this study was to investigate the efficacy and safety of multiple IACIs, and to seek for factors associated with sustained remission of synovitis in injected joints.

Methods: The clinical charts off all JIA patients who received an IACI in ≥ 3 joints and had a follow-up ≥ 6 months after the IACI were reviewed. The corticosteroid preparation used was triamcinolone hexacetonide for large joints and methylprednisolone acetate for small or difficult to access joints. In each patient, the follow-up period after the IACI was censored when one of the following two events occurred: 1) first visit with flare of synovitis in ≥ 1 injected joint; 2) last follow-up visit with sustained remission of synovitis in all injected joints. Flare of synovitis was defined as recurrence (or persistence) of joint inflammation in ≥ 1 joint that required a new IACI or the initiation or change of systemic therapy, and remission of synovitis as complete resolution of all signs and symptoms of joint inflammation.

Results: A total of 220 patients (79.5% females) who underwent an IACI in 1086 joints (median 4 joints per patient) were included. The median age at IACI was 3.7 years and the median disease duration was 0.6 years. The most common ILAR categories were RF-negative polyarthritis (37.1%) and extended oligoarthritis (34.1%). The most frequently injected joints were the knee (84.5% of patients), ankle (76.4%), subtalar (30.5%), elbow (29.1%), and proximal interphalangeal (PIP) (26.4%) joints. Concomitant therapy included methotrexate in 56.8% of patients and biologic medications in 9.5% of patients. Seventy (31.8%) of patients had sustained remission in all injected joints after a median follow-up of 1 year, whereas 150 patients (68.2%) experienced flare of synovitis after a median of 0.5 years. Univariate analyses showed that patients with sustained remission had more frequently a positive ANA status (p=0.04) and an oligoarticular disease course (p=0.004), and had received more frequently general anesthesia (p=0.03) and concomitant methotrexate therapy (0.003) than did patients who experienced flare of synovitis. Flare of synovitis was seen more frequently in the ankle (45.2%), wrist (40.2%), and subtalar (34.5%) joints, than in the knee (20.8%), metacarpophalangeal (26.2%), PIP (21.3%), and elbow (15.5%) joints. Side effects occurred in only 1% of joints and were represented by skin hypopigmentation or subcutaneous atrophy.

Conclusion: Around one third of the patients who received multiple IACIs experienced long-lasting remission of synovitis in all injected joints. General anesthesia and concomitant administration of methotrexate may increase the effectiveness of IACI procedures. The presence of ankle, subtalar and wrist joint involvement may constitute an indication to the simultaneous initiation of a more aggressive systemic therapy at the time of the injection.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/delineating-the-role-of-multiple-corticosteroid-joint-injections-in-the-management-of-juvenile-idiopathic-arthritis-in-the-biologic-era/