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.

Pediatric Antibiotic-refractory Lyme Arthritis: A Multicenter Case-control Study

“…Notably, among children age ≥ 8 years, a similar percentage of cases (65%) and controls (64%) took doxycycline as a first-line antibiotic (p = 0.91). Over half of cases were prescribed > 10 weeks of antibiotics, while controls were prescribed antibiotics for a median of 30 days (IQR [28][29][30][31][32][33][34][35]. Cases were also more likely to receive IV antibiotics (57% vs 7%) and be prescribed NSAID at any point (80% vs Consistent with this higher treatment burden, reported adverse events during the antibiotic treatment period were more common among children with ARLA (37% vs 15%), including rash (18% vs 4%), headache (8% vs 1%), and hospitalization for adverse events [6% (3 cases) vs 1% (1 control)].…”

“…Our results support the notion that IV antibiotics may be required for adequate spirochetal killing in children who do not respond to oral antibiotics, even though IV antibiotic therapy does not prevent ARLA or the need for nonantibiotic treatment for all children. Given the lack of high-quality evidence about second-line treatment regimens, the risks of IV antibiotics, and the potential benefit of early IAGC injection for LA 30 , pediatricians should consider referring children to pediatric rheumatologists for LA that remains persistently active after 2 antibiotic courses.…”

Recent Progress in Lyme Disease and Remaining Challenges

“…Around 10% of LA patients experience persistent LA that does not resolve within a couple months after one or more rounds of antibiotic therapy (95)(96)(97). LA patients refractory to oral antibiotics are treated with intravenous ceftriaxone antibiotic therapy, with mixed results in adults (97,98) and children (99). Persistent LA despite aggressive treatment with antibiotics is referred to as antibiotic refractory LA (100), or if no evidence of ongoing infection, post-infectious LA (101).…”

Lyme-Arthritis

“…Auch bei Kindern mit ARLA konnte ein positives Ansprechen auf eine antiinflammatorische bzw. immunmodulierende Therapie beobachtet werden 24 , 48 , 49 . Somit lässt sich der Krankheitsverlauf der ARLA sowohl mit der Synovektomie als auch mit entzündungshemmenden medikamentösen Therapien verkürzen.…”

“…Eine intraartikuläre Injektion von Glukokortikoiden sollte jedoch nicht vor Abschluss der antibiotischen Therapie erfolgen. Möglicherweise könnte jedoch bei persistierender Arthritis eine intraartikuläre Injektion von Glukokortikoiden bereits nach Abschluss des 1. antibiotischen Behandlungszyklus den weiteren Erkrankungsverlauf positiv beeinflussen [48].…”