Thirteen children with juvenile idiopathic arthritis (JIA) were treated with intraarticular steroid injection of triamcilone acetonide as a day care procedure. More than half (53.4%) the children were free of pain, limp and NSAID’s use, with improvement in functional score at 12 weeks. No side effects were reported during the period of the study.

Key words: Intraarticular Steroids (IAS), Juvenile Idiopathic Arthritis (JIA), Pain, Functional score, Resource poor setting,

Children <6 years of age were given sedation with midazolam (0.1mg/kg/dose) and ketamine (1mg/kg/dose) prior to the procedure. Continuous pulse oximetry, heart rate, respiratory rate and non-invasive blood pressure monitoring was done during the procedure, and then every 15 minutes till the child was awake and fully conscious. Older children were given IAS under local anesthesia.

The joints were injected with triamcinolone acetonide (0.5-1mL, 20-40mg) using standard technique(3). The parent and child were instructed to keep the movement in the particular joint to the least possible for next 24 hours. Children enrolled in the study were evaluated for 6 outcome measures at 0, 6, and 12 weeks: pain scale (0-10)(4); functional score (0-3) questionnaire, with the score for the desired task given as follows: without any difficulty 0, with some difficulty 1, with much difficulty 2 and unable to do 3(5); limp; limb length, mid-thigh and mid-leg circumference (affected lower limbs) at baseline and repeated at 12 weeks, and NSAID use.

Thirteen children with JIA (12, oligoarticular and 1 polyarticular) were included. The mean age of the study population was 8±3.38 years (range 2-12 years). Boys (n=6, mean age 10.16±0.89 years) and girls (n=7, mean age 6.28±3.42 years) with the mean age of onset of JIA was 6.67±3.19 years (range 1-11 years) were enrolled. Eighteen joints were injected in these patients (13 knee, 3 ankle and 2 elbow joints). Two patients had uncontrolled arthritis and were termed failure of IAS trial at 6 week visit, and subsequently taken off the study. Four children were lost to follow-up at the end of 12 weeks study period.

All the patients who responded to treatment showed significant improvement in pain and functional scores (Table I). NSAID use at the initiation of the study was 100%(13), 20%(2) at 6 weeks and none of the patient reported NSAID drug use at 12 weeks, except the ones who failed IAS trial (n=2). None of the study patients had a post-injection flare for a period of 6 months. Our results are similar to that reported by Neidel, et al.(1).

TABLE I



Outcome Parameters on JIA Patients Given Intraarticular Steroids 

Our study demonstrated that it is feasible and safe to give intraarticular steroid injection in JIA patients of all age group by pediatrician using sedation with midazolam and ketamine without significant side effect. Small patient population and a short follow-up of 3 months were limitation of the study.

1. Neidel J, Boehnke M, Kuster RM. The efficacy and safety of intraarticular corticosteroid therapy for coxitis in juvenile reumatoid arthritis. Arthritis Rheum 2002; 46: 1620-1628.

2. Cleary AG, Murphy HD, Davidson JE. Intra-articular corticosteroid injections in juvenile idiopathic arthritis. Arch Dis Child 2003; 88: 192-196.

3. Wise C. Arthrocentesis and injection of joints and soft tissues. In Harris Jr. ED, Budd RC, Genovese MC, Firestein GS, Sergent JS, Sledge CB Eds. Kelly’s Textbook of Rheumatology, 7th Ed., Elseiver Saunders, Philadelphia, 2005. p. 692-709.

4. McCaffery M, Pasero C. Numeric Pain Scale Rating. In McCaffery M, Pasero C Eds. Pain: Clinical Manual. 2nd Ed. St. Louis: Mosby Inc., 1999; p 67.