Intraarticular Glucocorticoid Injection as Second-line Treatment for Lyme Arthritis in Children

Abstract

Objective: To determine whether second-line intraarticular glucocorticoid (IAGC) injection improves outcomes in children with persistently active Lyme arthritis after initial antibiotics.

Methods: We conducted an observational comparative effectiveness study through chart review within 3 pediatric rheumatology centers with distinct clinical approaches to second-line treatment of Lyme arthritis. We primarily compared children receiving second-line IAGC to children receiving a second course of antibiotics alone. We evaluated the risk of developing antibiotic-refractory Lyme arthritis (ARLA) using logistic regression and the time to clinical resolution of Lyme arthritis using Cox regression.

Results: Of 112 children with persistently active Lyme arthritis after first-line antibiotics, 18 children received second-line IAGC (13 with concomitant oral antibiotics). Compared to children receiving second-line oral antibiotics alone, children treated with IAGC had similar baseline characteristics but lower rates of ARLA (17% vs 44%; OR 0.3, 95% CI 0.1-0.95; p = 0.04) and faster rates of clinical resolution (HR 2.2, 95% CI 1.2-3.9; p = 0.01). Children in IAGC and oral antibiotic cohorts did not differ in treatment-associated adverse events. Among children receiving second-line IAGC, outcomes appeared similar irrespective of use of concomitant antibiotics. Outcomes were also similar between intravenous (IV) and oral antibiotic-treated cohorts, but older children seemed to respond more favorably to IV therapy. IV antibiotics were also associated with higher rates of toxicity.

Conclusion: IAGC injection appears to be an effective and safe second-line strategy for persistent Lyme arthritis in children, associated with rapid clinical resolution and reduced need for additional treatment.

Keywords: COMPARATIVE EFFECTIVENESS RESEARCH; EPIDEMIOLOGIC STUDIES; GLUCOCORTICOIDS; LYME ARTHRITIS; PEDIATRICS.

Figure 1.

Subject selection diagram Of 383 children with documented Lyme arthritis, 112 met inclusion criteria by beginning second-line treatment for persistent arthritis within 120 days after starting first-line antibiotics, of whom 18 individuals (16%) received second-line intra-articular glucocorticoid (IAGC) injection.

Figure 2.

Kaplan-Meier cumulative incidence curves of resolution of Lyme arthritis after initiating first-line antibiotics C-GC, intra-articular glucocorticoid cohort; C-IV, intravenous antibiotics cohort; C-PO, oral antibiotics cohort Cumulative incidence plots showing resolution of Lyme arthritis over the first 2 years of follow-up by cohort: C-PO (black, long dash line), C-GC (dark grey, solid line), or C-IV (light grey, short dash line). Log-rank tests are shown comparing either C-GC or C-IV antibiotics to C-PO.

Figure 3.

Timeline of outcomes among study subjects. C-GC, intra-articular glucocorticoid cohort; C-IV, intravenous antibiotics cohort; C-PO, oral antibiotics cohort. Box plots showing, by treatment cohort, the timing from second-line treatment to the resolution of arthritis or the last visit (for those lost to follow-up). Boxes indicate the median (central bar), 25th, and 75th percentiles of values, with adjacent values shown with whiskers and outliers shown as circles.