Background/Purpose:

Intra-articular corticosteroid injection (IACI) is routinely used in juvenile idiopathic arthritis (JIA) with oligoarticular disease and as adjunct therapy for other types of JIA. Adrenal gland suppression following IACI with Triamcinolone Acetonide (TA) has been scantly reported, but its incidence and risk factors are unknown. We studied 23 JIA patients following ultrasound guided IACI with TA to determine the incidence of adrenal gland suppression and risk factors for its development.

Methods:

This was a case-control study of patients who satisfied ILAR classification criteria for JIA, received ultrasound-guided IACI with TA between 01/2017-04/2018, had 8AM serum cortisol levels measured 2 weeks after joint injection and had not received systemic steroid therapy for over 3 months. Case subjects were those who developed adrenal gland suppression as defined by 8AM serum cortisol level of <7 micrograms/dL. Control subjects were those who received IACI but did not develop adrenal suppression. Repeat 8AM serum cortisol levels were measured 6 weeks post-IACI in case subjects who had documented adrenal suppression initially. Incidence and risk factors including total dose of TA per body weight, age, number of injected joints and types of JIA were analyzed.

Results:

Twenty-three patients, ages 2 to 21 years (mean 11.3 ± 1.09 years), with diagnoses of oligoarticular (9), polyarticular (8), psoriatic (4), and enthesitis-related JIA (2) receiving 0.43-6.8 mg/kg TA were studied. Incidence of adrenal suppression after receiving IACI was 43.5% (10/23); 5 with polyarticular JIA, 4 with oligoarticular JIA, and 1 with enthesitis-related arthritis. Total numbers of injected joints with adrenal suppression were 5 in 3 patients, 4 in 1 patients, 2 in 4 patients and 1 in 2 patients. The means of TA dose and age of patients with and without adrenal suppression were 2.986 mg/kg, 95% CI (2.116, 3.856), 8.9 years, 95% CI (5.1, 12.8) and 2.045 mg/kg, 95%CI (1.119, 2.972), 13.2 years, 95%CI (10.8, 15.7) respectively. Only significant risk factor for adrenal suppression was age ≤8 years (odd ratio 8.2, p = 0.03), but not TA dose, number of injected joints or types of JIA. Of the 10 patients who developed adrenal gland suppression, only one experienced symptomatic adrenal suppression. All patients with adrenal gland suppression at 2 weeks post-injection had normal 8AM serum cortisol levels by 6 weeks post-injection.

Conclusion:

Adrenal gland suppression may be seen in JIA patients 2 weeks post IACI. Children ≤8 years are at most risk. The suppression is transient and spontaneously recovers by 6 weeks post-IACI. Unexplained symptoms after IACI may be a manifestation of adrenal insufficiency. Further study of risk factors for adrenal gland suppression following IACI in JIA is warranted.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/incidence-of-and-risk-factors-for-adrenal-suppression-following-ultrasound-guided-intra-articular-corticosteroid-injection-with-triamcinolone-acetonide-in-juvenile-idiopathic-arthritis/