Special Article
Intra-articular Joint Injections in Juvenile Idiopathic Arthritis: State of the ArtEstado actual del tratamiento con infiltraciones intraarticulares en la artritis idiopática juvenil

https://doi.org/10.1016/j.reumae.2018.07.003Get rights and content

Abstract

Objective

Intra-articular corticosteroid injections (IACI) are a fundamental part in the treatment of juvenile idiopathic arthritis. The current situation of IACI is reviewed in a population of children.

Methods

We conducted a narrative review of the literature related to IACI in children, with respect to the injection technique, use of local and general anaesthesia, ultrasound guidance of the procedure, indications, special joints and type of optimal corticosteroid.

Results

IACI are indicated in any subcategory of juvenile idiopathic arthritis, especially in oligoarticular juvenile idiopathic arthritis. The use of local anaesthetic is highly recommended, and in patients younger than 6 years or requiring multiple joint injections, conscious sedation can also be an option. Ultrasound guidance of injections is recommended in expert hands, but not in a generalised way. Triamcinolone hexacetonide is the corticosteroid of choice in large joints, whereas a more soluble corticosteroid is a better alternative in small or superficial joints (betamethasone or methylprednisolone) to avoid subcutaneous atrophy or hypopigmentation, the most frequent adverse effect of IACI.

Conclusions

IACI are performed heterogeneously and scientific evidence is limited in many cases.

Resumen

Objetivo

Las infiltraciones intraarticulares con corticoides (IAC) son parte fundamental en el tratamiento de la artritis idiopática juvenil. Se realiza una revisión sobre la situación actual de las IAC en población infantil.

Métodos

Revisión narrativa de la literatura de las IAC en población infantil, relacionada con la técnica de infiltración, el uso de anestesia local y general, la guía ecográfica, las indicaciones, las articulaciones especiales y el tipo de corticoide.

Resultados

Las IAC están indicadas en cualquier subcategoría de artritis idiopática juvenil y especialmente en la forma oligoarticular. El uso de anestésico local es recomendable, y en pacientes menores de 6 años o que requieran infiltración múltiple, también la sedación consciente. La infiltración guiada por ecografía es recomendable en manos expertas, pero no de forma generalizada. El hexacetónido de triamcinolona es el corticoide de elección en articulaciones grandes, mientras corticoides más solubles (betametasona o metilprednisolona) serían la alternativa ideal en articulaciones pequeñas o superficiales para evitar la atrofia subcutánea o la hipopigmentación, los efectos adversos más frecuentes.

Conclusiones

Las IAC se realizan de forma heterogénea y la evidencia científica es limitada.

Introduction

Juvenile idiopathic arthritis (JIA) encompasses all arthritis of unknown origin in individuals under the age of 16 years old which lasts for longer than 6 weeks.1 In all of the sub-categories of JIA local treatment with the intra-articular infiltration of corticoids (IAC) is a part of normal therapeutic management.2 Oligoarticular JIA is the type that affects 4 or fewer joints during the first 6 months of evolution of the disease, and it may sometimes be treated exclusively with IAC.2 Although IAC is performed very frequently in the treatment of JIA, opinions vary widely regarding the use of general or local anaesthetics, the infiltration technique, ultrasound guiding of the procedure or the corticoid that should be used.3, 4 The differing ages of the patients and the different locations mean that it would be complicated to standardise the IAC procedure in children. This narrative review of the literature summarises the different aspects of IAC procedures in the treatment of JIA.

Section snippets

Infiltration Technique

Although the infiltration technique has not been completely established, it is governed by the same recommendations that apply in adults, and these are summarised in Table 1. The literature contains a great many single-centre studies which describe their experience in performing IAC,5, 6, 7, 8, 9 although there are no guides or recommendations about how to do so. IAC is a situation in which children feel stress and nervousness, so that it is positive to create a relaxed atmosphere before

Anaesthesia

It is recommendable to use a local anaesthetic in all IAC11 procedures, with lidocaine that is either in an ointment (Emla®) or subcutaneous, chlorethyl in a spray or iontophoresis with lidocaine, depending on what is available. There is more evidence for the use of local anaesthetics or conscious sedation than is the case for other aspects of IAC.11, 12, 13, 14, 15, 16 Uziel et al. compared the efficacy of a previous application of Emla® in reducing the pain reported by children with JIA

Ultrasound Scan Guidance

Ultrasound scan is an ideal imaging technique for evaluating the paediatric population, and it makes it possible to guide the needle during IAC.7, 8, 9 Ultrasound scan guidance in IAC has been proven to be more precise and effective in adults.17 However, in the paediatric population there is no enough scientific evidence to recommend the use of ultrasound scan guidance in all IAC procedures.7, 8, 9, 18, 19, 20, 21, 22 There are many description of its use in different hospitals, but they do not

Indications

All patients with JIA are treatable using IAC or peritendinous AC as a single or complementary procedure.2 The oligo-articular form may enter remission after one or several infiltrations. A recent systematic review found that IAC have a beneficial effect.20

The use of systemic treatment with methotrexate in oligo-articular JIA is controversial, and it is not commenced in a routine way, especially in patients with monoarthritis.23 Recently the open, longitudinal and multicentre study by Ravelli

Infiltration of Multiple Joints

Although there is no limit to the number of joints that may require infiltration, a systemic effect is inevitable when many joints are infiltrated.10 The efficacy of multiple infiltrations (3 or more joints per procedure) has been evaluated in descriptive single-centre studies.26, 27 In 2013, Papadopoulou et al. published a retrospective observational study in which joint remission following multiple IAC was observed in one third of the patients included, with an average follow-up of 11 months,

Temporomandibular Joints

TMJ are often affected by JIA and they must be examined in all patients, regardless of subcategory. IAC of the TMJ is a relative frequent procedure that improve pain and mouth opening.19, 28, 29, 30 The improvement is greater in those patients with a shorter time of evolution of their arthritis.29 In patients with morphological alterations and a longer time of evolution, hardly any functional improvement occurs and pain relief is temporary.30 The most common adverse effect of IAC in this

Type of Corticoid

The type of corticoid to be administered depends on the size of the joint: Table 2 shows the recommended dose and corticoid for each joint. It is here that the scientific evidence is the most solid, and where recommendations are the most widely accepted. IAC has longer-lasting efficacy when triamcinolone hexacetonide is used rather than more soluble corticoids such as betametasone.31 The former also undergoes less systemic diffusion and it causes less alteration of cortisol and glucose levels.32

Conclusions

IAC are very common procedures in the treatment of JIA, especially in the oligo-articular subcategory, together with systemic treatment or alone. It is highly recommendable to use local anaesthesia before or during the procedure, and to evaluate using conscious sedation in specific situations. Although ultrasound guidance is not recommended as a routine, it may be useful in expert hands to prevent complications in the procedure. In general, large joints benefit more from the administration of

Conflict of Interests

The authors have no conflict of interests to declare.

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  • Cited by (0)

    Please cite this article as: Nieto-González JC, Monteagudo I. Estado actual del tratamiento con infiltraciones intraarticulares en la artritis idiopática juvenil. Reumatol Clin. 2019;15:69–72.

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