Rev. Bras. Reumatol. vol.56 número6

w w w . r e u m a t o l o g i a . c o m . b r

REVISTA BRASILEIRA DE

REUMATOLOGIA

Original article

Intra-articular injection in patients with juvenile

idiopathic arthritis: factors associated with a good

response

Ana Luiza Garcia Cunha

, Vanessa Bugni Miotto e Silva

, Fabiane Mitie Osaku

,

Luísa Brasil Niemxeski

_{, Rita Nely Vilar Furtado}

_{, Jamil Natour}

_,

Maria

Teresa

de

Sande

e

Lemos

Ramos

Ascensão

Terreri

a_{Universidade Federal de São Paulo (UNIFESP), Departamento de Pediatria, Disciplina de Alergia, Imunologia Clínica e Reumatologia,}

São Paulo, SP, Brazil

b_{Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil}

c_{Universidade Federal de São Paulo (UNIFESP), Departamento de Medicina, Disciplina de Reumatologia, São Paulo, SP, Brazil}

a r t i c l e

i n f o

Article history:

Received 24 September 2014 Accepted 30 August 2015 Available online 26 February 2016

Keywords:

Intra-articular injection Juvenile idiopathic arthritis Triamcinolone hexacetonide Treatment and uveitis

a b s t r a c t

Introduction:Intra-articular injection of corticosteroids (IIC) for treatment of patients with

juvenile idiopathic arthritis (JIA) is increasingly used in Pediatric Rheumatology.

Objectives:To describe the clinical course of patients undergoing IIC in our Pediatric

Rheuma-tology Unit.

Methods:Retrospective study of patients with JIA undergoing IIC from January 2008 to

December 2012, with a minimum follow-up of six months after the injection. Good response to IIC was set as the presence of inactivity on the infiltrated joint by at least six months.

Results:Eighty-eight patients underwent a total of 165 IICs. Of these, 75% were girls and

35.2% had persistent oligoarticular JIA. The mean age at diagnosis was 6.8 years, and when IIC was carried out, 12.2 years. Regarding patients, younger age at diagnosis (p= 0.037) and the occurrence of uveitis in the course of the disease (p= 0.015) were associated with good response to IIC. From 165 IICs, 63% had a good response and joints remained inactive for a median of 18.1 months. The type of joint injection (p= 0.001), lesser values stated in the overall visual analog scale by the physician (p= 0.015) and by parents/patient (p= 0.01) have been associated with a good response to IIC. Nine adverse events (5.4%) were observed.

Conclusion:In our study, more than half of the joints showed a good response to IIC. Younger

patients at diagnosis and uveitis during the course of the disease had good response to IIC. Knees, wrists and elbows were the joints that best responded to IIC. IIC proved to be a safe procedure.

© 2016 Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

∗ _{Corresponding author.}

E-mail:analuiza.cunha@gmail.com(A.L.G. Cunha). http://dx.doi.org/10.1016/j.rbre.2016.01.001

Infiltrac¸ão

intra-articular

em

pacientes

com

artrite

idiopática

juvenil:

fatores

associados

à

boa

resposta

Palavras-chave:

Infiltrac¸ãointra-articular Artriteidiopáticajuvenil Hexacetonidodetriancinolona Tratamentoeuveíte

r

e

s

u

m

o

Introduc¸ão:Ainfiltrac¸ãointra-articulardecorticosteroides(IIC)paratratamentodepacientes

comartriteidiopáticajuvenil(AIJ)écadavezmaisusadaemreumatologiapediátrica.

Objetivos: Descreveraevoluc¸ãoclínicadospacientessubmetidosàIICemnossosetorde

reumatologiapediátrica.

Métodos: EstudoretrospectivodepacientescomAIJsubmetidosà IICdejaneiro/2008a

dezembro/2012,comseguimentomínimodeseismesesapósainfiltrac¸ão.Boaresposta àIICfoidefinidacomoinatividadenaarticulac¸ãoinfiltradapor,nomínimo,seismeses.

Resultados: Foramsubmetidosa88pacientesa165IICs.Desses,75%erammeninase35,2%

apresentavamAIJoligoarticularpersistente.Amédiadeidadeaodiagnósticofoide6,8anos eàIICde12,2anos.Emrelac¸ãoaospacientes,amenoridadeaodiagnóstico(p=0,037)ea ocorrênciadeuveítenocursodadoenc¸a(p=0,015)foramassociadosàboarespostaàIIC. Das165IICs,63%apresentaramboarespostaeasarticulac¸õespermaneceraminativaspor umtempomédiode18,1meses.Otipodearticulac¸ãoinfiltrada(p=0,001),menoresvalores naescalavisualanalógicaglobaldomédico(p=0,015)edospais/paciente(p=0,01)foram associadosaumaboarespostaàIIC.Noveefeitosadversos(5,4%)foramobservados.

Conclusão: Emnossoestudo,maisdametadedasarticulac¸õesmostrouboarespostaàIIC.

Ospacientescommenoridadeaodiagnósticoeuveíteduranteocursodadoenc¸ativeram boarespostaàIIC.Osjoelhos,punhosecotovelosforamasarticulac¸õesquemaisbem responderamàIIC.AIICmostrouserumprocedimentoseguro.

©2016ElsevierEditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCC BY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Juvenileidiopathicarthritis(JIA)isachronicrheumatic dis-easemostcommoninchildhood,beingasignificantcauseof disabilityandreducedqualityoflife.1

The goal of JIA treatment is to control inflamma-tion and prevent a premature loss of cartilage and joint function. JIA can be treated with a combination of non-steroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), biologic drugs, systemiccorticosteroids,intra-articularinjectionsof cortico-steroids(IIC)andphysiotherapy.1–4

IICisoftenusedtotreatJIA.5,6 _{Currentlythisprocedure}

isinusenotonlyinpatientswiththeoligoarticularsubtype (i.e.thosewithapoorresponsetoNSAIDsandasafirst-line therapy),butalsointhosesufferingalengthyorcomplicated arthritis(accompaniedbyjointcontracturesandgrowth dis-orders),oreveninthosecaseswhereoneisawaitingbythe therapeuticeffectofDMARDs.2,7–10

Althoughthelong-termefficacyand thepotentialeffect onactivityandprogressionofJIAstillneedmorestudies,IIC canpromotesignificantpainrelief,functionaljoint improve-ment,andanincreasedlikelihoodofdeformitycorrectionand ofadaptationofbonegrowth.Inaddition,IICisconsidered asasafeandeffectivemethodtotreataffectedjoints.1,11–16

Furthermore, this procedure allows an early rehabilitation and a reduction – or even discontinuation – of systemic medications.16,17

Mostofourknowledgeonjointinjectioncomesfrom stud-iesinadults,withfewreportsinchildren.Thisstudydescribes

theclinicaloutcomeofpatientsundergoingIICinaPediatric RheumatologyUnitatUNIFESPoveraperiodoffiveyears,and alsoevaluatesfactorsassociatedwithagoodresponsetothis therapy.

Patients

and

methods

Thisisaretrospective studyofmedicalrecordsofpatients withJIA,who werefollowed atthe PediatricRheumatology unitofUNIFESPandsubmittedtoIICintheperiodfrom Jan-uary1,2008toDecember31,2012.Theirinclusioncriterion wasaminimum6-monthfollow-upafterthejointinjection. PatientswithIICsproceduresperformedinotherunitswere excluded.

Demographic and clinical data of each patient were assessed, and a preliminaryclassification and evolutionof JIAwascarriedoutaccordingtothecriteriaofthe Interna-tionalLeagueofAssociationsforRheumatology(ILAR)18_:the

presenceofuveitisinthecourseofdisease,thepresenceof autoantibodies(antinuclearantibody–ANA–consideredas positiveforchildrenwithtitles≥1:160,andrheumatoidfactor –RF)andofhumanleukocyteantigen(HLA)B27.

visualanalogscale(VAS,0–10)valueassignedbythephysician andbyparents/patient,C-reactiveprotein(CRP),and erythro-cytesedimentationrate(ESR)atthetimeofinjection.Adverse eventswererecordedaftereachinjection.

IICswereperformedbyasinglepediatricrheumatologist trainedaccordingtoprotocolsspecificforeachtypeofjoint.19

Injections were performed under localanesthesia with 2% lidocainewithoutvasoconstrictor.Theonlymedicationused was triamcinolone hexacetonide in doses of 1–2mg/kg for largejoints,0.5–1mg/kgformediumjoints,and4–10mgfor smalljoints,withamaximumdoseof100mg.Thepatients wereaskedtoresttheirjointaftertheprocedureforaperiod of48h.

Weconsideredajointasinactiveintheabsenceofarthritis checkedbyclinicalexaminationand/orUS.Thepatientwas consideredaswithagoodresponsetoIICwhenallinjected joints remained inactive forat leastsix months(complete response)orwhensomeofinjectedjointsremainedinactive foratleastsixmonths(partialresponse).Poorresponsewas definedaswhenallinfiltratedjointsremainedactiveor exhib-itedreactivationwithinaperiodundersixmonthsafterIIC. TheanswertoIICineachjointwasrankedas“goodresponse” (theinfiltratedjointremainedinactiveforatleastsixmonths) and“poorresponse”(theinfiltratedjointdidnotanswer,orits reactivationoccurredinlessthansixmonths).

Demographicand clinicalcharacteristics were described inabsoluteandrelativefrequencies,means±standard devi-ation,andminimumandmaximumvalues,accordingtothe natureofthevariables.Tocomparethedistributionsof con-tinuous variables between two groups, Student’s t test or Mann–Whitneytestwasused,takinginto accountthe data normality.Categoricalvariables betweengroups were com-paredusingtheChi-squaredtestorFisher’sexact test.The statisticalsignificancewassetat5%.

ThisstudywasapprovedbytheResearchEthicsCommittee oftheUniversidadeFederaldeSãoPaulo(OpinionNumber: 326891).

Results

FromJanuary2008toDecember2012,88patientswithJIAwere subjectedtoatotalof165IICs,withameanof1.87(range,1–6) injectionsperpatient.Themeanlengthoffollow-upwas7.1 (0.8–17.1)years.

Sixty-twopatients(70.4%)hadagoodresponsetoIIC,39 (44.3%)patientsachievedacompleteresponse,23(26.1%)were benefitedwithapartialresponsetoIIC,and26patients(29.5%) exhibitedapoorresponsetoallIICstowhichtheywere sub-jected.Forthesakeofourstatisticalanalysis,subtypesofJIA weregroupedaccordingtothecourseofthediseasein: oligoar-ticular–37.5%(persistentoligoarticularJIA,enthesitis-related arthritis[ERA],andpsoriaticJIA[patientswithamaximumof4 affectedjoints]),polyarticular–58%(polyarticularRF-positive JIA,polyarticularRF-negativeJIA,andextended oligoarticu-larJIA) and systemic – 4.5%.Regarding our evaluationper patient,agoodresponsetoIICwasassociatedwithyounger ageatdiagnosisofJIA(p=0.037)andalsoforthosepatients withuveitisoccurringatanytimeinthecourseofthedisease (p=0.015).Of21patientswithuveitis,13wereANApositive.

ElevenpatientswereinvestigatedforthepresenceofHLA-B27 andallofthemwerenegative.Table1listsdemographicand clinicaldataforthegroupofpatients.

Regardingthe165jointsinjected,104(63%)showedgood responsetoIIC,whichwasassociatedwithlowerVASvalues assigned bythephysician(p=0.015)andbyparents/patient (p=0.010).ThelowestvaluesofVASwereassociatedwitha better generalconditionofthe patientwithgood response toIIC,andwithlesspainandinflammatoryactivity. Further-more,thetypeofjointsubmittedtoinjection(p=0.001),also was associatedwith agood response toIIC; knees, wrists, andelbowswerethosejointsshowingbetterresponsetoIIC. Table2listsdatarelatingtointra-articularinjections.

Generally,US-guidedinjectionsinthissmallsampleof16 patientswithlongerdiseasedurationandpreviousinjections showedpoorresponsetoIICs(p=0.02);thisfactisassociated withhighervaluesofCHAQ(p=0.03),highernumberof injec-tionswithpoorresponse(p=0.01)andashortertimetorelapse (p=0.02)comparedtopatientssubmittedtoblindlyperformed procedures.DatarelatedtoUS-guidedinjectionsareshownin Table3.

ThejointsthatrespondedfavorablytoIICremained inac-tiveforameanof18.1±13.2months.Ontheotherhand,in thosejointswithpoorresponse,therewasrecurrenceaftera meanperiodof2.6±2.1months.

Ofthe165injectionscarriedout,43(26.1%)wereapplied in17patientswhosejointswereinfiltratedinmorethanone occasion(14knees,3ankles,and2hips),withameanof2.26 (range,2–3)IICsperjoint.Amongthesejoints,24(55.8%)hada goodresponsetoIIC,withameantimeof12.3monthsofjoint inactivityaftertheprocedure.

Takinginto accountthetotalnumberofIICsperformed, nine(5.4%)adverseeffectsoccurredinninepatients:fivecases ofperiarticularhypotrophyandfourcasesofhypochromiaat thesiteofinjection.

Discussion

Inthisstudy,weobservedagoodresponsetoIICinmorethan halfofpatients,especiallythoseyounger-agedatthe diagno-sisofJIA,andpatientspresentinguveitisduringthecourse ofthedisease.Additionally,thetypeofinjectedjoint(knees, wrists, andelbows) and lowvaluesofVASassigned bythe physicianandbytheparents/patientwereassociatedwitha goodresponsetoIIC.TheuseofUStoguidetheprocedures wasassociatedwithworseresponsestoIIC.

OfthetotalnumberofIICsperformedout,morethanhalf presentedinactivityofarthritisformorethan6months,with ameandurationofaboutoneandahalfyears.Theinactivity ratesaftertheinjectionvariesdependingonthestudy:around 56.1–82% aftersixmonths,42–80%after1year,and30–63% after2years.5,10,12–14,20–22_{Theliteraturerevealsawide}

varia-tionamongstudieswithrespecttomeanresponseduration timeinpatientswithJIA,rangingfrom6to23.5months.7,23–25

Among the potential factors associated with a good responsetoIICdescribedintheliterature,wefoundabsence ofANA,11,23_{presenceofHLA-B27,}23_{absenceofatrophyinthe}

localofinjection,23_{concomitantuseofMTX,}7,10,23

Table1–Demographicandclinicaldataofpatientswhounderwentjointinjections.

Variables Totalof

patients (n=88)

Good responseto

IIC(n=62)

Poorresponse toIIC(n=26)

p-Value

Demographicdata

Femalegender 66 48(72.7%) 18(27.3%) 0.42a

Timeelapsedbetweenthefirst symptomsanddiagnosis(months)

10.5(±16.5) 11.7(±18.9) 7.8(±7.8) 0.73b

AgeatdiagnosisofJIA(years) 6.8(±4.0) 6.2(±3.7) 8.3(±4.4) 0.037b

Meanfollow-uptothelastvisit(years) 7.1(±4.0) 7.5(±3.9) 6.1(4.1) 0.08b

ANA,positive 37 30(81%) 7(19%) 0.126a

RF,positive 9 8(88.9%) 1(11.1%) 0.271c

UveitisassociatedwithJIA 12 12(100%) 0 0.015c

JIAsubtype 0.076a

Systemic 4 1(25%) 3(75%)

Oligoarticular,persistent 31 22(70.9%) 9(29.1%)

Oligoarticular,extended 17 14(82.3%) 3(17.7%)

Polyarticular,RFpositive 9 8(88.9%) 1(11.1%)

Polyarticular,RFnegative 25 17(68%) 8(32%)

Psoriatic 1 0 1(100%)

ARE 1 0 1(100%)

ClusteredsubtypeofJIA 0.08a

Oligoarticular 33 22(66.7%) 11(33.3%)

Polyarticular 51 39(76.4%) 12(23.6%)

Systemic 4 1(25%) 3(75%)

IIC,intra-articularinjectionofcorticosteroids;ANA,antinuclearantibody;RF,rheumatoidfactor;JIA,juvenileidiopathicarthritis;ARE,arthritis relatedtoenthesitis.

a _{Chi-squaredtest.} b _{Mann–Whitneytest.} c _{Fisher’sexacttest.}

presenceofANA,useofDMARDs,andJIAsubtypewerenot associatedwithabetterorworseresponsetoIIC.Amongour patients,nonewasHLAB-27-positiveandinnoneofthemIIC wasperformedundersedation,whichpreventedthe assess-mentofthesefactors.

The literature also describes as indicators of worse response: absence of ANA (contrary to the studies cited above),7,10_{increasesinCRPandESR,}7,10,22_systemicand

pol-yarticularJIAsubtypes,7,10,20,25_{andelbowinfiltration.}10_Inour

studywefoundagoodresponsetoelbowinjection.Despitethe smallnumberofpatientswithsystemicJIAinthisstudy,and takingintoaccountthatnostatisticalsignificancewasfound, wealsonotedworseresponsestoIICinpatientswithsystemic JIA,showingthattheprocedureinthisdiseasesubtypeshould beevaluatedindividually.

No association was observed between the occurrence of uveitis and a better response to IIC in the study con-ducted by Marti et al.,23 _{contrary to our study, where the}

occurrenceofuveitiswasassociatedwithabetterresponse toIIC.

ComparedtoVASvaluesassignedbythephysicianandby parents/patient,theseparameterswerenotassociatedwith responsetoIICinthestudybyRavellietal.22 _Ontheother

hand,thestudybyMorettietal.26 _{showedthatalowerVAS}

value assigned by the physician was a good predictor of responsetoIICinpatientswiththeoligoarticularsubtype.In ourstudy,higherprocedurevaluesofVAS,bothassignedby thephysicianandthepatient,wereassociatedwithaworse responsetoIIC.

Studies suggestthatthebesttimeforthecompletionof anIICprocedureisasearlyaspossibleinthecourseofthe disease–andthisisafactorofgoodresponsetoIIC.11,16 _In

ourstudy,wefoundthatyounger-agedpatientsatdiagnosis showedagoodresponsetoIIC.Thismayberelatedtothemost commonsubtypeinthisagegroup,whichistheoligoarticular subtype;butalsodemonstratesthat,bybeingyounger,these patientscouldbeinanearlierstageofthedisease,whichisin linewithliteraturefindings.

One may obtain a long-lasting answer to IIC when using hexacetonide triamcinolone versus acetonide triamcinolone.5,21,23,27,28_{Thus,wechosetousehexacetonide}

triamcinoloneinallofourinjections.

ThereisevidenceinfavorofabetterresponsetoIICwhen theprocedureisguidedbyanimagingtechnology(ultrasound orMRI),especiallyinthewrist,ankleandhip.3,29,30_Contrary

tothis,wefoundapoorresponsetoUS-guidedIICinjection. Thisfindingmaybeduetothefactthat,inourstudy,guided injectionswereperformedonjointsthathadalreadyshowed apoorresponsetoblindly-conductedIIC,andislikelythatthis playedaroleinourresults.Prospectivestudiesinjointsnever subjectedtoinjectionshouldbeconducted,inordertobetter assesstheutilityofUStoguideIICinchildren.

Table2–Demographicandclinicaldatarelatedtojointssubjectedtoinjection.

Variables Totalofpatients

(n=165)

Goodresponseto IIC(n=104)

Poorresponseto IIC(n=61)

p-Value

Descriptor

TimefromdiagnosistoIIC(years) 5.3(±3.8) 5.6(±3.8) 4.9(±3.8) 0.25a

AgeatIIC(years) 12.2(±4.3) 12.1(±4.5) 12.5(±4.1) 0.53a

CHAQ(n=28),mean(range) 0.41(0–2.25) 0.30(0–2.25) 0.67(0–1.75) 0.53a

VASparents/patient(n=80),median(range) 0(0–9) 0(0–9) 3(0–8) 0.015a

VASphysician(n=60),median(range) 1(0–8) 0(0–7) 4(1–8) 0.010a

CRP(n=124)±SD 10.2(±18.5) 10.5(±21.6) 9.6(±11.9) 0.22a

ESR(n=129)±SD 25.8(±24.5) 27.2(±26.7) 23.2(±20.3) 0.41a

Activejoints±SD 3.1(±4.3) 2.6(±3.0) 4.1(±5.8) 0.09a

Restrictedjoints±SD 3.2(±6.1) 3.0(±5.6) 3.5(±6.9) 0.77a

Injectedjoint 0.001b

Knees 100 71(71%) 29(29%)

Ankles 30 11(36.7%) 19(63.3%)

Wrists 15 10(66.7%) 5(33.3%)

Elbows 9 9(100%) 0

Shoulders 3 1(33.3%) 2(66.7%)

Hips 6 2(33.3%) 4(66.7%)

Proximalinterphalangealjoints 2 0 2(100%)

Jointeffusiondegree(n=156) 0.49b

Mild 55 33(60%) 22(40%)

Moderate 84 56(66.7%) 28(33.3%)

Severe 17 9(52.9%) 8(47.1%)

Guidedbyultrasound 16 6(37.5%) 10(62.5%) 0.02b

DrugsinuseatthetimeofIIC 0.32b

NoneorNSAIDs 55 39(71%) 16(29%)

DMARDs 80 48(60%) 32(40%)

Biologicals 30 17(56.7%) 13(43.3%)

Useoforalcorticosteroids 21 12(57.1%) 9(42.9%) 0.55b

IIC,intra-articularinjectioncorticosteroids;SD,standarddeviation;CHAQ,ChildhoodHealthAssessmentQuestionnaire;VAS,visualanalog scale;CRP,C-reactiveprotein,ESR,erythrocytesedimentationrate;NSAIDs,nonsteroidalanti-inflammatorydrugs;DMARDs,disease-modifying antirheumaticdrugs.

a _{Mann–Whitneytest.} b _{Chi-squaredtest.}

Table3–Comparisonbetweeninjectionguidedversusnotguidedbyultrasound(US).

Variables US-guidedinfiltrations

(n=16)

InfiltrationsunguidedbyUS (n=149)

p-Value

Descriptor

TimefromdiagnosistoIIC(years) 5.9(±3.4) 5.2(±3.7) 0.63a

AgeatIIC(years) 12.1(±5.2) 12.2(±4.2) 0.94a

CHAQ(n=28),mean(range) 1.6(1–2.25) 0.3(0–1.75) 0.03a

VASparents/patient(n=80),median(range) 5(1–6) 0(0–9) 0.42a

VASphysician(n=60),median(range) 1(1–4) 3(0–8) 0.46a

CRP(n=124)±SD 11(±17.5) 10(±18.6) 0.89a

ESR(n=129)±SD 25.3(±18.4) 25.8(±25.2) 0.73a

Activejoints±SD 4.5(±6.7) 2.9(±3.9) 0.55a

Restrictedjoints±SD 6.7(±12.8) 2.8(±4.8) 0.30a

Numberofinjectionswithpoorresponse 1.4(±0.8) 0.8(±0.8) 0.01a

Relapsetime(months) 6.5(±7.2) 13(±13.2) 0.01a

Jointeffusiondegree(n=156) 0.29b

Mild 7 48

Moderate 8 76

Severe 0 17

IIC,intra-articularinjectionofcorticosteroids;SD,standarddeviation;CHAQ,ChildhoodHealthAssessmentQuestionnaire;VAS,visualanalog scale;CRP,C-reactiveprotein,ESR,erythrocytesedimentationrate.

The most common adverse events are: local subcuta-neoustissueatrophyattheIIC site,5,7,10,21–23,25,29 _localskin

hypopigmentation,25,29_{acuteonsetofpain(jointirritationby}

crystals ofthe drug),27 _{local calcification,}25 _{adverse effects}

relatedtogeneral/localanesthesia,23 _{and possiblesystemic}

effectsofcorticosteroids(facialflushing,increasedappetite, moodswings).23,25,29_{Post-injectioninfectionisarareeventin}

adults,27_{andtherearenopublishedreportsofpediatriccases.}

Inourstudy,weobservedalowrateofadverseevents,none ofwhichwascharacterizedasasevereevent.

Ourstudyshowed thatIIC isan effectiveandsustained therapeuticmodality;morethanhalfofourpatientspresented agoodresponsetotheprocedure.Furthermore,ICCisasafe methodwithalowrateofadverseevents.Tothebestofour knowledge,thisisthefirststudyinchildrenandadolescents withJIAinourpopulation,thatsoughttoassessthefactors associatedwithIICresponse.However,thisstudyhassome limitations,suchasitsretrospectivedesign,whichaffected datacollection.Andwealsodidnotincludedatafrom injec-tionsappliedtothesepatientsinotherunits,whichoccurred inafewcases.Moreprospectivestudiesareneededtobetter definetheprofileofpatientswithJIAwhomaybenefitfrom IICprocedures.

Ourstudyalsoshowedthatayoungerageatthediagnosis ofJIA,occurrenceofuveitisinthecourseofthedisease,aswell asknee,wristandelbowinjectionandlowerVASvaluesboth fromthephysicianandpatientwerefactorsassociatedwitha betterresponsetoIIC.IICisaneffectivetherapeuticmodality presentingasustainedresponse.Furthermore,itisalsoasafe procedurethatcancontributetoimprovingthequalityoflife ofpatientswithJIA.

Conflict

of

interests

Theauthorsdeclarenoconflictofinterests.

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