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Intra-articular steroids can control JIA

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Corticosteroid (CS) injection into affected joints is a safe and effective treatment for juvenile idiopathic arthritis (JIA), according to one review. Much of the supporting evidence comes from uncontrolled studies, but its sheer volume attests to the treatment’s effectiveness.

The method is used most for oligoarticular and polyarticular JIA, with early injection in the oligoarticular form—without awaiting the outcome of NSAIDs treatment—to gain control and hasten return to normal activity. This avoids joint contractures and unequal leg lengths developing while also avoiding use of systemic CSs.

RCTs and clinical evidence have shown that triamcinolone hexacetonide is the best to use, so its present unavailability is regrettable. UK practice is to inject 1 mg/kg into large joints, 0.5 mg/kg into small joints, and 0.6–2 mg/joint into the hands and feet.

One RCT in children has suggested 246/300 triamcinolone hexacetonide injections produced complete resolution in a cohort including all JIA subtypes. In another study of nearly 1500 injections in almost 200 children median length of improvement with triamcinolone hexacetonide was 74 weeks. Best results occurred after the first injection.

The real value of the treatment is obscured in most published studies, because of confusion about JIA subtypes and differing definitions of improvement and length of follow up, not to mention a non-uniform approach to how the injection is given, the precise method, and the recovery schedule. Subcutaneous atrophy is the most well known side effect according to clinical experience. However, true assessment of outcome, CS joint versus systemic injection, or whether treatment modifies JIA await future RCTs.

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