Introduction. Juvenile idiopathic arthritis (JIA) is one of the more common chronic diseases of childhood and a major cause of acquired disability. It is not a single disease, but rather a heterogeneous group of disorders of unknown cause. Oligoarticular JIA is a subtype of JIA and it is a distinctly pediatric disease, and accounts for most of all white children with chronic arthritis in North America and Europe. It is defined as an arthritis that affects four or fewer joint during the first 6 months of illness, but in most cases at the onset it affects a single articulation, particularly the knee. Intra-articular corticosteroid (IAC) injection is widely used in children with JIA to induce rapid relief of symptoms of active synovitis, particularly pain and functional impairment. This intervention could enable correction of joint contractures, prevention of leg-length discrepancy, regression of Baker’s cysts, and improvement of tenosynovitis. Nowadays, this kind of treatment is largely used in children with arthritis in a small number of large joint, but the role of IAC in the current disease management remains unclear and controversial. Numerous predictors of the effectiveness of IAC therapy have been reported, but these studies are difficult to compare due to the differences in the disease subtypes included, type and number of joints injected, definitions of improvement used, concomitant systemic therapy, time frame adopted to assess treatment response or failure and predictors investigated. The objective of this study is to investigate the efficacy and seek for outcome predictors of IAC injection as first therapy in children with knee monoarthritis as onset of JIA . Patients and methods. The clinical charts of all consecutive who met the International League of Associations for Rheumatology criteria for JIA and knee monoarthritis onset, had received their first IAC injection at study centre between January 2002 and December 2019 and had a minimum follow-up of 6 months after the IAC injection were reviewed retrospectively. In each patient, the follow-up period after the IAC injection was censored after 6 month, after 12 month and at the last follow-up visit. Follow-up was stopped at the time of a relapse in injected joint and/or another joint. Based on which joint was interested, patients were divided in four groups: i) flare of synovitis only in injected joint; ii) continued remission of synovitis in injected joint but recurrence of synovitis in uninjected joint; iii) flare of synovitis in injected and uninjected joint, and iv) complete remission in all joints. The following indipendent variables were recorded at the time of IAC injection: sex, age at disease onset, age at the first evaluation, age at IAC injection, ANA status, diagnosis of iridocyclitis, general anaesthesia, ESR (Westengren method), CRP (immunoturbidimetric assay), ongoing therapy, newly started therapy. Results. 248 children knee monoarthritis undergoing IAC were examined. 83% of patients were ANA positive and 14% had iridocyclitis at the onset. Of all patients undergoing IAC, 29% did not relapse and 20% were still in remission more than 1 year after the first infiltration. Of the patients who relapsed, 32% had relapse of arthritis in the same joint undergoing IAC, 35% had arthritis only in other joints while 33% had both recurrence in the joint undergoing IAC and in other joints. In case of relapse, the time between IAC and relapse ranged from a minimum of about 1 month to 12 years, but the median was 0.6 years. Regarding possible predictors, patients who relapsed showed significantly higher ESR levels at the time of IAC than patients in persistent remission after at least 1 year after IAC. Conclusion. IAC is confirmed as a good first therapeutic approach in case of monoarticular onset of JIA. Although further studies are needed to confirm this finding, ESR levels at disease onset could be useful predictors of IAC outcome.
Predizione dell’outcome dell’iniezione intra-articolare di corticosteroidi nei bambini con artrite idiopatica giovanile (AIG) e monoartrite di ginocchio. Introduzione. L'artrite idiopatica giovanile (AIG) è una delle più frequenti malattie croniche del bambino ed è una causa importante di disabilità. Non si tratta di una singola malattia quanto piuttosto di un gruppo eterogeneo di malattie articolari ad eziologia sconosciuta. L'AIG oligoarticolare è uno specifico sottotipo di AIG, definita come un’artrite che colpisce quattro o meno articolazioni nel corso dei primi sei mesi di malattia; nella maggior parte dei casi viene interessata solo un'articolazione, in particolare il ginocchio. L'infiltrazione intra-articolare di corticosteroide (IAC) è una metodica terapeutica largamente utilizzata nei pazienti con artrite idiopatica giovanile, ed è in grado di indurre rapida remissione della sintomatologia. Per questo motivo è spesso utilizzato come primo approccio terapeutico nei pazienti con AIG ad esordio monoarticolare di ginocchio, nonostante non vi siano evidenze assolute a riguardo. Successivamente ad una IAC, in alcuni casi si assiste comunque alla recidiva di artrite a livello della stessa articolazione infiltrata e/o in altre articolazioni. Alcuni studi hanno preso in considerazione numerosi possibili predittori di efficacia della IAC, ma questi studi sono di difficile interpretazione in quanto comprendono numerosi sottotipi di AIG, diverse metodiche di infiltrazione ed eventuali terapie sistemiche concomitanti. L'obiettivo di questo studio e valutare l'efficacia della IAC come primo approccio terapeutico nell’AIG ad esordio monoarticolare di ginocchio e di individuare eventuali fattori predittivi l'outcome di questi pazienti. Materiali e metodi. Sono state valutate retrospettivamente le cartelle cliniche di tutti i pazienti affetti da AIG ad esordio monoarticolare di ginocchio che avevano ricevuto una IAC come primo approccio terapeutico presso il nostro Centro tra il gennaio 2002 e il dicembre 2019, con un follow up minimo successivo di sei mesi. Per ogni paziente è stato valutato il follow up a 6 mesi e a 12 mesi dalla infiltrazione e all'ultima visita di controllo. Il follow up è stato interrotto in caso di recidiva di artrite nell'articolazione interessata o in qualunque altra articolazione. Sulla base della articolazione interessata dalla recidiva i pazienti sono stati suddivisi in quattro gruppi: recidiva di sinovite nella sola articolazione sottoposta ad infiltrazione; remissione di sinovite nell'articolazione sottoposta ad infiltrazione ma comparsa di sinovite in un'articolazione differente; recidiva di sinovite sia nell'articolazione già sottoposta ad infiltrazione che in altre articolazioni ed infine completa remissione in tutte le articolazioni. Le seguenti variabili sono state valutate al momento della IAC: sesso, età all’esordio della malattia, età alla prima valutazione specialistica, età alla IAC, ANA, presenza di iridociclite, eventuale IAC in anestesia generale, VES, PCR, terapie già in corso, eventuali nuove terapie. I dati sono stati raccolti in tabelle demografiche e sono stati ricercati eventuali fattori predittivi di recidiva. Risultati. Sono stati presi in esame 248 bambini affetti da artrite mono-articolare di ginocchio sottoposti a IAC, nell’83% dei casi i pazienti presentavano ANA positivi e nel 14 dei casi presentavano iridociclite all’esordio. Di tutti i pazienti sottoposti ad IAC il 29% non ha presentato recidive ed il 20% era ancora in remissione dopo oltre 1 anno dalla prima infiltrazione. Dei pazienti che hanno presentato recidiva, il 32% ha presentato recidiva di artrite nella stessa articolazione sottoposta ad IAC, il 35% ha presentato artrite solo in altre articolazioni mentre il 33% ha presentato sia recidiva nella articolazione sottoposta ad IAC che in altre articolazioni. In caso di recidiva, il tempo trascorso tra la IAC e la recidiva variava da un minimo di circa 1 mese a 12 anni, ma la mediana si attestava a 0.6 anni. Per quanto concerne i possibili predittori, i pazienti che hanno presentato recidiva hanno mostrato livelli di VES al momento della IAC significativamente più elevati rispetto ai pazienti in persistente remissione dopo almeno 1 anno dalla IAC. Conclusioni. La IAC si conferma un buon primo approccio terapeutico in caso di esordio monoarticolare di AIG. Anche se ulteriori studi sono necessari per confermare questo dato, i livelli di VES all’esordio di malattia potrebbero essere utili predittori di outcome di IAC.
Predizione dell’outcome dell’iniezione intra-articolare di corticosteroidi nei bambini con artrite idiopatica giovanile e monoartrite di ginocchio
LEONI, MASSIMILIANO
2022-05-13
Abstract
Introduction. Juvenile idiopathic arthritis (JIA) is one of the more common chronic diseases of childhood and a major cause of acquired disability. It is not a single disease, but rather a heterogeneous group of disorders of unknown cause. Oligoarticular JIA is a subtype of JIA and it is a distinctly pediatric disease, and accounts for most of all white children with chronic arthritis in North America and Europe. It is defined as an arthritis that affects four or fewer joint during the first 6 months of illness, but in most cases at the onset it affects a single articulation, particularly the knee. Intra-articular corticosteroid (IAC) injection is widely used in children with JIA to induce rapid relief of symptoms of active synovitis, particularly pain and functional impairment. This intervention could enable correction of joint contractures, prevention of leg-length discrepancy, regression of Baker’s cysts, and improvement of tenosynovitis. Nowadays, this kind of treatment is largely used in children with arthritis in a small number of large joint, but the role of IAC in the current disease management remains unclear and controversial. Numerous predictors of the effectiveness of IAC therapy have been reported, but these studies are difficult to compare due to the differences in the disease subtypes included, type and number of joints injected, definitions of improvement used, concomitant systemic therapy, time frame adopted to assess treatment response or failure and predictors investigated. The objective of this study is to investigate the efficacy and seek for outcome predictors of IAC injection as first therapy in children with knee monoarthritis as onset of JIA . Patients and methods. The clinical charts of all consecutive who met the International League of Associations for Rheumatology criteria for JIA and knee monoarthritis onset, had received their first IAC injection at study centre between January 2002 and December 2019 and had a minimum follow-up of 6 months after the IAC injection were reviewed retrospectively. In each patient, the follow-up period after the IAC injection was censored after 6 month, after 12 month and at the last follow-up visit. Follow-up was stopped at the time of a relapse in injected joint and/or another joint. Based on which joint was interested, patients were divided in four groups: i) flare of synovitis only in injected joint; ii) continued remission of synovitis in injected joint but recurrence of synovitis in uninjected joint; iii) flare of synovitis in injected and uninjected joint, and iv) complete remission in all joints. The following indipendent variables were recorded at the time of IAC injection: sex, age at disease onset, age at the first evaluation, age at IAC injection, ANA status, diagnosis of iridocyclitis, general anaesthesia, ESR (Westengren method), CRP (immunoturbidimetric assay), ongoing therapy, newly started therapy. Results. 248 children knee monoarthritis undergoing IAC were examined. 83% of patients were ANA positive and 14% had iridocyclitis at the onset. Of all patients undergoing IAC, 29% did not relapse and 20% were still in remission more than 1 year after the first infiltration. Of the patients who relapsed, 32% had relapse of arthritis in the same joint undergoing IAC, 35% had arthritis only in other joints while 33% had both recurrence in the joint undergoing IAC and in other joints. In case of relapse, the time between IAC and relapse ranged from a minimum of about 1 month to 12 years, but the median was 0.6 years. Regarding possible predictors, patients who relapsed showed significantly higher ESR levels at the time of IAC than patients in persistent remission after at least 1 year after IAC. Conclusion. IAC is confirmed as a good first therapeutic approach in case of monoarticular onset of JIA. Although further studies are needed to confirm this finding, ESR levels at disease onset could be useful predictors of IAC outcome.File | Dimensione | Formato | |
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