06-The use of corticosteroids in juvenile idiopathic arthritis

77 Pages·2015·0.92 MB·English

by  Nadia Corp

Paed-006: The use of corticosteroids in juvenile idiopathic arthritis (JIA)

FEEDBACK FOLLOWING PRELIMINARY SEARCH
QUERY
 REF:
 Paed-­‐006

Received:
 1st
 December
 2014

Feedback
 to
 CSG:
 10th
 January
 2015
 (due),
 7th
 January
 2015
 (sent)

SEARCH METHODOLOGY
The
 content
 of
 this
 feedback
 report
 refers
 only
 to
 the
 most
 relevant
 material
 located
 under

each
 of
 the
 evidence
 headings
 and
 is
 drawn
 predominantly
 from
 author
 abstracts
 or

research
 recommendations
 within
 guidelines.
 The
 question
 is
 posed
 in
 the
 context
 of
 the
 use

corticosteroids
 for
 remission
 induction
 or
 treatment
 of
 children
 in
 juvenile
 idiopathic

arthritis
 (JIA).
 Further
 details
 of
 all
 the
 studies
 included
 in
 this
 report
 are
 shown
 in
 the

appendix,
 sorted
 by
 report
 section
 and
 author
 name.

Criteria used (PICO):
Who? (population)
Children
 with
 juvenile
 idiopathic
 arthritis

What? (intervention/exposure/measure)
Corticosteroids

Comparison
N/A

What is measured? What are the outcomes?
Remission,
 reduction
 in
 disease
 activity,
 JIA
 core
 outcomes,
 juvenile
 arthritis
 disease

activity
 score
 (JADAS)

Location and setting
Any

Exclusion Criteria
Non-­‐English
 language
 guidelines,
 recommendations,
 systematic
 reviews,
 overviews
 and

clinical
 opinions.
 However,
 non-­‐English
 language
 primary
 research
 articles
 with
 English

abstracts
 were
 included
 if
 relevant,
 see
 Section
 D:
 Primary
 Research.

Conference
 abstracts
 were
 only
 included
 in
 feedback,
 where
 no
 peer-­‐reviewed
 article
 was

available.

P age 1
Databases Searched
CINAHL;
 Cochrane
 Library;
 EMBASE;
 MEDLINE;
 ISRCTN
 Register;
 UK
 Clinical
 Research

Network
 Study
 Portfolio;
 NIH
 records
 on
 ClinicalTrials.gov;
 Nederlands
 Trial
 Register;

German
 Clinical
 Trials
 Register;
 Australian
 New
 Zealand
 Clinical
 Trials
 Registry;
 World
 Health

Organization
 (WHO):
 International
 Clinical
 Trials
 Registry.

Types of Study
Clinical
 trials;
 Observational
 studies

Keywords searched
Search
 protocols
 were
 designed
 around
 the
 following
 terms:
 juvenile
 (idiopathic)
 arthritis

AND
 steroids
 (e.g.
 see
 Appendix
 1
 for
 MEDLINE
 protocol)

Date limits
Last
 5
 years
 i.e.
 2009-­‐2014.

Summary of available evidence

EVIDENCE
 TYPE
  INCLUDED
 IN
 FEEDBACK

A
  Evidence
 Summaries
  10
 (11
 papers)

B
  Systematic
 Reviews
 &
 Meta-­‐analyses
  12

C
  Clinical
 Trial
 Registries
 (Current
 and
 Closed)
  0

D
  Primary
 Research
  85
 studies
 (91
 articles)

E
  Overviews
 and
 expert
 opinions
  n/a

F
  Intellectual
 Property
 Office
  n/a

Note:
 where
 abstracts
 refer
 to
 depomedrone
 and/or
 methyl
 prednisolone
 these
 drugs
 have

been
 highlighted
 using
 italics
 and
 bold
 fonts.

RESULTS
A: Good Quality Evidence Summaries (including guidelines)
See
 Appendix
 2,
 Section
 A
 for
 details
 of
 reviews
 included
 in
 this
 section.

Ten
 guidelines
 and/or
 consensus
 statements
 (11
 papers)
 were
 identified
 as
 pertinent
 to
 this

evidence
 review.

• Seven
 evidence
 summaries
 (8
 papers)
 addressed
 the
 general
 treatment
 of
 JIA

(Beukelman,
 et
 al.
 2011;
 DeWitt,
 et
 al.
 2012;
 Dueckers,
 et
 al.
 2012;
 Munro,
 et
 al.
 2014;

Ringold,
 et
 al.
 2014;
 The
 Royal
 Australian
 College
 of
 General
 Practitioners,
 2009),

Page 2
including
 tuberculosis
 screening
 for
 children
 with
 JIA
 on
 biologic
 medication
 (Ringold,
 et

al.
 2013a
 &
 b);

• One
 guideline
 specifically
 addressed
 uveitis
 associated
 with
 JIA
 (Heiligenhaus,
 et
 al.

2012);

• And
 another,
 the
 use
 of
 methyl-­‐prednisolone
 in
 paediatric
 rheumatology
 (BSPAR,
 2011).

In
 general
 these
 evidence
 summaries
 identify
 a
 paucity
 of
 evidence
 regarding
 the
 use
 of

systemic
 steroids
 e.g.
 Beukelman,
 et
 al.
 (2011)
 conclude
 there
 is
 a
 “near
 complete
 lack
 of

published
 evidence”
 (page
 14)
 for
 the
 use
 of
 systemic
 glucocorticoids,
 whilst
 Dueckers,
 et
 al.

(2012)
 state
 “There
 are
 no
 controlled
 trials
 and
 no
 standardized
 therapeutic
 regimes
 for
 the

use
 of
 systemic
 GC”
 (page
 180).
 In
 contrast,
 there
 appears
 to
 be
 reasoable
 quality
 studies
 to

support
 the
 use
 of
 intraarticular
 injections
 in
 JIA,
 leading
 to
 Grade
 A
 recommendations
 for

use.
 In
 the
 case
 of
 JIA-­‐associated
 uveitis
 other
 forms
 of
 steroids
 are
 also
 considered:

Heiligenhaus,
 et
 al.
 (2012)
 report
 there
 is
 high
 quality
 evidence
 for
 the
 use
 of
 topical

steroids,
 with
 low
 quality
 evidence
 for
 intravitreal
 injections.

B: Systematic Reviews and Meta-analyses
See
 Appendix
 2,
 Section
 B
 for
 details
 of
 reviews
 included
 in
 this
 section.

Twelve
 systematic
 reviews
 (SRs)
 were
 identified
 for
 this
 evidence
 review.

• Eight
 SRs
 addressed
 the
 use
 of
 intraarticular
 steroid
 injections:

o Four
 SRs
 in
 JIA
 (Bloom,
 Alario
 and
 Miller,
 2011;
 Gotte,
 2009)
 specifically
 affecting

the
 lower
 limb
 (Jennings,
 Hennessy
 and
 Hendry,
 2014)
 and
 temporomandibular

joint
 (Stoustrup,
 et
 al.
 2013);

o Four
 SRs
 across
 a
 broader
 range
 of
 conditions
 including
 OA,
 RA
 and
 JIA
 (Garg
 ad

Deodhar,
 2013
 [conference
 abstract];
 Habib
 2009;
 Habib,
 Saliba
 and
 Nashashibi,

2010;
 Scherer,
 Rainsford,
 Kean
 and
 Kean,
 2014);

• Two
 SRs
 (possibly
 related)
 examine
 the
 DMARDs,
 compared
 to
 conventional
 treatment

i.e.
 NSAIDs
 and/or
 intraarticular
 corticosteroids,
 in
 children
 with
 JIA
 (Kemper,
 et
 al.
 2011;

Kemper,
 van
 Mater,
 Coeytaux,
 Williams
 and
 Sanders,
 2012).

• Two
 SRs
 focus
 on
 uveitis,
 of
 which
 one
 includes
 (Pilly,
 Health,
 Tschuor,
 Lightman
 and

Gale,
 2013)
 and
 the
 other
 specifically
 addresses
 JIA-­‐associated
 uveitis
 (Heiligenhaus,

2014
 [conference
 abstract]);

In
 the
 case
 of
 intraarticular
 steroid
 injections,
 there
 appears
 to
 be
 reasonable
 evidence
 to

suggest
 it
 is
 a
 safe
 and
 effective
 treatment
 for
 JIA.
 There
 is
 also
 some
 indication
 that

triamcinolone
 hexacetonide
 may
 have
 greater
 efficacy
 and/or
 onset
 of
 action
 compared
 to

other
 corticosteroids.

C: Clinical Trial Registries
No
 clinical
 trials
 were
 identified
 for
 this
 report.

Page 3
D: Primary Research
See
 Appendix
 2,
 Section
 D
 for
 details
 of
 studies
 included
 in
 this
 section.

Ninety-­‐one
 primary
 research
 articles,
 reporting
 85
 studies
 were
 identified
 for
 this
 review,

including
 4
 intervention
 studies
 (5
 articles),
 12
 prospective
 observational
 studies
 (13

articles),
 4
 cross-­‐sectional
 observation
 studies
 (5
 articles),
 59
 retrospective
 observational

studies
 (61
 articles)
 and
 6
 unclear
 observational
 studies
 (7
 articles).

Intervention
 studies

See
 Appendix
 2,
 Section
 D.1
 for
 details
 of
 studies
 included
 in
 this
 section.

Four
 interventions
 studies,
 5
 publications,
 were
 identified
 for
 this
 evidence
 review;
 all

involved
 the
 use
 of
 intra-­‐articular
 steroid
 injections:

• RCT
 with
 active
 control

o with
 or
 without
 methotrexate
 in
 oligoarticular
 JIA
 (Bracciolini,
 et
 al.,
 2014)

[conference
 abstract]

o in
 the
 temporomandibular
 joint
 in
 children
 with
 JIA
 (Olsen-­‐Bergem
 and
 Bjornland,

2010;
 2014)

• Uncontrolled
 feasibility
 study

o Efficacy
 (Verma,
 Gupta,
 Lodha
 and
 Kabra,
 2009)
 and
 effect
 on
 isokinetic
 muscle

strength
 (McKay,
 Ostring,
 Broderick,
 Chaitow
 and
 Singh-­‐Grewal,
 2013)

Observational
 studies

See
 Appendix
 2,
 Section
 D.2
 for
 details
 of
 studies
 included
 in
 this
 section.

Eighty
 one
 observational
 studies,
 reported
 in
 86
 papers,
 were
 pertinent
 to
 this
 evidence

review.
 These
 have
 been
 subdivided
 according
 to
 whether
 the
 studies
 were
 prospective
 (12

studies),
 retrospective
 (59
 studies),
 cross-­‐sectional
 (4
 studies)
 or
 unclear
 (6
 studies).

Prospective

Twelve
 prospective
 observational
 studies,
 in
 13
 papers,
 were
 identified.

• Two
 studies
 examined
 the
 current
 management
 of
 JIA
 including
 use
 of
 oral
 steroids
 e.g.

low-­‐dose
 prednisolone
 (Oen,
 et
 al.
 2010;
 Shen,
 Yao,
 Yeh
 and
 Huang,
 2013);

• Ten
 studies,
 11
 articles,
 focused
 on
 intra-­‐articular
 injections:

o In
 children
 with
 JIA
 (Carrasco,
 et
 al.,
 2014
 [conference
 abstract];
 Mrazik
 and

Vargova,
 2013;
 Rintamaki,
 et
 al.,
 2011)
 including
 particularly
 oligoarticular
 JIA

(Barsalou,
 et
 al.,
 2011
 [conference
 abstract])

o Specifically
 of
 the
 ankle
 (Laurell,
 et
 al.,
 2011),
 wrist
 (Laurell,
 et
 al.,
 2012)
 and
 TMJ

(Martini,
 Fusetti,
 Vittadello,
 Buccella
 and
 Zulian,
 2011
 [conference
 abstract])
 in

JIA

o Use
 of
 ‘Doctors-­‐medical
 clowns’
 in
 nitrous
 oxide
 sedation
 for
 intra-­‐articular

injections
 in
 JIA
 (Uziel,
 et
 al.,
 2013;
 2014
 [conference
 abstract])

Page 4
o The
 effect
 of
 RANTES
 polymorphism
 on
 clinical
 response
 to
 intraarticular

triamcinolone
 injection
 in
 juvenile
 rheumatoid
 arthritis
 (Yao,
 Tsai
 and
 Huang,

2009);

o And
 responsiveness
 of
 the
 Juvenile
 Arthritis
 Foot
 disability
 Index
 (Esbjornsson,

Iversen,
 Brostrom,
 Hagelberg
 and
 Andre,
 2013
 [conference
 abstract]).

Retrospective

Fifty
 nine
 retrospective
 observational
 studies,
 across
 61
 papers,
 were
 identified.

• Thirty
 eight
 studies,
 in
 40
 articles,
 focused
 on
 intraarticular
 steroid
 injections,
 as
 follows:

o Role
 of
 IA
 injections
 in
 the
 management
 of
 JIA
 (Akikusa,
 Munro,
 Buckle
 and
 Allen,

2013;
 James,
 et
 al.,
 2014
 [conference
 abstract];
 Papadopoulou,
 et
 al.,
 2013),
 along

with
 tendon
 sheath
 injections
 (Messia,
 Marafon,
 De
 Benedetti
 and
 Magni-­‐Manzoni,

2014
 [conference
 abstract])

o Efficacy
 including
 probability
 of
 sustained
 remission
 following
 single
 and
 multiple

steroid
 joint
 injection
 in
 JIA
 (de
 Oliveria
 Sato,
 et
 al.,
 2014;
 Lanni,
 et
 al.
 2011;
 2013

[conference
 abstract];
 Leow,
 et
 al.,
 2014;
 Melo,
 Dias
 and
 Brito,
 2010
 [conference

abstract];
 Sato,
 Fernandes,
 Nascimento,
 Brito
 and
 Saad-­‐Magalhaes,
 2011
 [conference

abstract];
 Srinivasan,
 et
 al.,
 2011
 [conference
 abstract];
 Stefan,
 et
 al.,
 2011

[conference
 abstract];
 Trigilia,
 et
 al.,
 2011
 [conference
 abstract])

o Dosing
 schedule
 in
 juvenile
 arthritis
 (Eberhard,
 Ilowite
 and
 Sison,
 2012)

o Specifically
 for
 children
 with
 JIA
 with
 the
 following
 joints
 affected:

 Elbow
 (Marino,
 et
 al.,
 2012)

 Knee
 joint
 (Pastore,
 Crocco,
 Taddio
 and
 Lepore,
 2011)

 Ankle
 (Proulx-­‐Gauthier,
 LeBlanc
 and
 Chedeville,
 2014
 [conference
 abstract]),

aswell
 as
 the
 wrist
 (Jadhav
 and
 Kan,
 2014;
 Kan
 and
 Graham,
 2011)

 Temporomandibular
 joint
 (Davidson,
 Santere,
 Krisjane,
 Urtane
 and
 Stanevica,

2013;
 Groh
 and
 Tashima,
 2014
 [conference
 abstract];
 Habibi,
 Ellis,
 Strike
 and

Ramanan,
 2012;
 Lochbuhler,
 Sauernmann,
 Muller
 and
 Kellenberger,
 2013;

Sharpe,
 Good,
 Beukelman,
 Waite
 and
 Cron,
 2010
 [conference
 abstract];
 Smith

and
 Friswell,
 2011
 [conference
 abstract];
 Stoll,
 et
 al.,
 2012)

 Including
 use
 of
 early
 TMJ
 MRI
 and
 its
 effect
 on
 treatment
 including
 IA

injection
 (Hauser,
 et
 al.
 2014;
 Saurenmann,
 et
 al.,
 2011
 [conference

abstract])

 Specifically
 US
 guided
 IA
 injections
 (Parra,
 et
 al.,
 2010)

 Hip
 joint,
 using
 US
 guided
 injections
 (Agarwal,
 Kavirayani,
 Ramanan
 and
 Ellis,

2012
 [conference
 abstract])

 Sacroiliac
 joint
 for
 refractory
 enthesitis-­‐related
 arthritis
 in
 children
 (Fritz,
 et

al.
 2011)

o Use
 of
 ultrasound
 of
 knee
 and
 ankle
 in
 JIA
 including
 response
 to
 IA
 steroid
 injections

(Trinh,
 et
 al.,
 2010
 [conference
 abstract]).

Page 5
o Use
 of
 MRI
 prior
 to
 wrist
 injection
 in
 children
 with
 JIA
 (Davis,
 Kan
 and
 Brent
 Graham,

2011
 [conference
 abstract])

o Ultrasound
 guided
 percutaneous
 joint,
 tendon
 sheath
 (Young,
 et
 al.,
 2012)
 and
 bursal

corticosteroid
 injections
 in
 children
 with
 JIA
 (Shiels,
 et
 al.,
 2010
 [conference

abstract]).

o Use
 of
 dream-­‐doctors/medical
 clowns
 for
 children
 with
 JIA
 undergoing
 intra-­‐articular

injection
 procedures
 (Oren-­‐Ziv,
 Hanuka,
 Rotchild,
 Gluzman
 and
 Uziel,
 2012)

o Use
 of
 nitrous
 oxide
 analgesia
 for
 intraartricular
 steroid
 injections
 in
 children
 with
 JIA

(Chan,
 Wyllie
 and
 Foster,
 2012;
 2013
 [conference
 abstracts])

o Targeted
 corticosteroid
 injection
 into
 the
 deep
 infrapatellar
 bursa
 in
 children
 with

deep
 infrapatellar
 bursitis
 assocated
 with
 JIA
 (Alqanatish,
 et
 al.,
 2011)

o Arthroscopy
 of
 TMJ
 in
 children
 with
 JIA
 including
 steroid
 injection
 (Kinard,
 Bouloux,

Abramowicz
 and
 Prahalad,
 2014
 [conference
 abstract]).

• Eleven
 studies
 reported
 on
 other
 forms
 of
 steroid
 treatment
 for
 JIA
 and
 associated

conditions:

o General
 management
 of
 systemic
 onset
 JIA
 including
 oral
 glucocorticoids
 (Jariwala,

Agarwal,
 Kumar
 and
 Sawhney,
 2013)

o Oral
 corticoid
 treatment
 for
 systemic
 JIA
 or
 Still’s
 disease
 (Lord,
 Allaoua
 and
 Ratib,

2011)

o Management
 of
 a
 case
 of
 refractory
 systemic
 JIA
 including
 oral
 and
 intravenous

steroids
 (Mellos,
 et
 al.,
 2014
 [conference
 abstract])

o Dexamethasone
 iontophoresis
 for
 temporomandibular
 joint
 involvement
 in
 JIA

(Mina,
 et
 al.,
 2011)

o Management
 of
 JIA-­‐associated
 uveitis
 including
 use
 of
 topical
 medicaions
 and

systemic
 glucocorticoid
 therapy
 (Marvillet,
 et
 al.,
 2009;
 Nouar,
 Hoarau,
 Uettwiller

and
 Lez,
 2014)

o Case
 of
 cricoarytenoid
 arthritis
 –
 methylprednisolone
 followed
 by
 maintenance
 oral

steroids
 (Ladak,
 Abbas,
 Harrison,
 Davis
 and
 McDongah,
 2014
 [conference
 abstract])

o Intravitreal
 implant
 for

 JIA-­‐associated
 uveitis
 (Serafino,
 et
 al.,
 2014
 [conference
 abstract]);

 paediatric
 uveitis
 including
 uveitis
 associated
 with
 JIA
 (Bratton,
 He
 and

Weakley,
 2014;
 Cordero-­‐Coma,
 et
 al.,
 2013)

 cystoid
 macular
 oedema
 associated
 with
 JIA
 (Totan,
 et
 al.,
 2014)

• Ten
 retrospective
 observational
 studies,
 reporting
 cases
 of
 Macrophage
 activation

syndrome
 (MAS)
 in
 JIA:

o Steroids
 used
 in
 the
 treatment
 of
 MAS
 (Choudhary,
 Berwal,
 Khichar
 and
 Baid,
 2014;

Hollister,
 Umer
 ad
 Casillas,
 2012
 [conference
 abstract];
 Lazarevic
 and
 Vojinovic,
 2013

[conference
 abstract];
 Lin,
 et
 al.,
 2012;
 Minoia,
 et
 al.,
 2014;
 Reddy,
 Bhatia,
 Scott
 and

Page 6
Nagarajan,
 2013;
 Singh,
 et
 al.,
 2012;
 Vishwanath,
 Krishnamurthy,
 Karyampudi
 and

Dutta,
 2010)

o where
 management
 failed
 and
 resulted
 in
 death
 (Juneji,
 Jain
 and
 Mishra,
 2009)

o which
 occurred
 during
 treatment
 for
 systemic
 onset
 JIA
 (Kumar
 and
 Rajam,
 2011)

Cross-­‐sectional

Four
 cross-­‐sectional
 studies,
 in
 5
 articles,
 all
 reported
 on
 intraarticular
 injections:

• In
 the
 treatment
 of
 temporomandibular
 joint
 involvement
 in
 JIA
 (Foeldvari,
 Tzaribachev

and
 Cron,
 2014)

• The
 use
 of
 sedation
 (Casado,
 et
 al.,
 2013)
 and
 anaesthesia
 (Weiss,
 Uribe,
 Malleson
 and

Kimura,
 2010)
 in
 intraarticular
 injection
 or
 children
 with
 JIA

• Survey
 regarding
 nurses
 giving
 intraarticular
 steroid
 injections
 to
 children
 with
 JIA
 (Lee,

Hawley,
 Edgerton
 and
 Al-­‐Obaidi,
 2013;
 2014
 [conference
 abstracts])

Unclear

For
 six
 studies,
 in
 7
 papers,
 it
 was
 unclear
 whether
 the
 study
 had
 been
 carried
 out

prospectively
 or
 retrospectively.
 All
 six
 studies
 were
 conference
 abstracts
 and
 were

concerned
 with
 IA
 steroid
 injections,
 namely:

• Effect
 of
 IA
 triamcinolone
 hexacetonide
 in
 JIA
 (Miotto
 e
 Silva,
 et
 al.,
 2014)

• IA
 steroid
 injection
 into
 TMJ
 (Saurenmann,
 et
 al.,
 2009).

• US
 guided
 ankle
 injections,
 including
 triamcinolone
 and
 depomedrone
 (Savage,
 Pascoli,

McAllister
 and
 Rooney,
 2012
 [conference
 abstract];
 Savage,
 Pascoli
 and
 Rooney,
 2011)

• 3D/4D
 power
 Doppler
 sonography
 of
 knee
 joint
 in
 JIA
 to
 determine
 response
 to
 IA

steroid
 or
 infliximab
 injection
 (Harjacek,
 Lamot,
 Vidovic,
 Perica
 and
 Bukovac,
 2014)

• Analgesia
 for
 IA
 steroid
 injections
 in
 JIA
 in
 the
 form
 of
 nitrous
 oxide
 (Pastore,
 Moressa,

Gortani
 and
 Lepore,
 2013)
 and
 as
 a
 Fentanyl
 lollipop
 (Zareen,
 Finn
 and
 Killeen,
 2011)

E: Overviews and Expert Opinions
Not
 relevant
 to
 this
 report.

F: Intellectual Property Office
Not
 relevant
 to
 this
 report.

Additional articles of interest
Whilst
 not
 the
 main
 focus
 of
 this
 evidence
 review,
 a
 number
 of
 papers
 reported
 on
 side

effects,
 adverse
 effects
 and
 associations
 with
 steroid
 treat,
 others
 on
 remission
 and
 steroid

use
 in
 general:
 these
 have
 been
 listed
 in
 Appendix
 3.

Page 7
CONCLUSION
Primary
 research
 comprises
 the
 majority
 of
 evidence
 included
 in
 this
 report
 (85/107;
 79.4%)

with
 no
 clinical
 trials
 on-­‐going
 or
 recently
 completed
 and
 unpublished
 identified.

Observational
 studies
 represented
 95.3%
 (81/85)
 of
 the
 primary
 research,
 of
 which
 59

studies
 were
 retrospective.
 Only
 four
 intervention
 studies
 were
 found,
 all
 concerned

intraarticular
 steroid
 injections:
 two
 were
 RCTs
 with
 active
 controls
 and
 two
 uncontrolled

studies.
 Furthermore,
 10
 guidelines/consensus
 statements
 and
 12
 systematic
 reviews
 were

pertinent
 to
 this
 review.

Overall,
 this
 report
 identifies
 a
 large
 body
 of
 observational
 studies
 regarding
 the
 use
 of

intraarticular
 steroid
 injections
 in
 the
 treatment
 of
 paediatric
 JIA,
 in
 addition
 four

intervention
 studies
 were
 found:
 two
 controlled
 and
 two
 uncontrolled.
 In
 contrast
 no

intervention
 studies
 and
 only
 13
 observational
 studies
 were
 identified
 for
 other
 forms
 of

steroid
 treatment.
 These
 findings
 concur
 with
 those
 reported
 in
 the
 systematic
 reviews
 and

consensus
 statements
 included
 in
 this
 evidence
 review.
 In
 general,
 it
 appears
 that
 there
 is
 a

good
 body
 of
 reasonable
 quality
 evidence
 for
 the
 use
 of
 IA
 steroid
 injections
 in
 paediatric
 JIA

leading
 to
 Grade
 A
 recommendations
 for
 use,
 whilst
 in
 contrast
 there
 is
 a
 dearth
 of
 research

into
 the
 use
 of
 other
 forms
 of
 steroid
 treatment
 e.g.
 systemic
 and
 topical.
 Given
 the
 paucity

of
 well-­‐designed
 (randomized)
 controlled
 trials
 to
 substantiate
 the
 effectiveness
 of

corticosteroids
 in
 the
 treatment
 of
 JIA,
 future
 trials
 are
 warrented.

Abbreviations
GC

  Glucocorticoids

IA

  Intraarticular

JIA

  Juvenile
 idiopathic
 arthritis

MAS

  Macrophage
 activation
 syndrome

OA

  Osteoarthritis

RA

  Rheumatoid
 arthritis

SR

  Systematic
 review

TMJ

  Temporomandibular
 joint

US

  Ultrasound

Page 8
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