Do patients with juvenile idiopathic arthritis in remission exhibit active synovitis on joint ultrasound?

Silva, Vanessa Bugni Miotto e; Silva, Carolina de Freitas Tavares da; Mitraud, Sônia de Aguiar Vilela; Furtado, Rita Nely Vilar; Hilário, Maria Odete Esteves; Natour, Jamil; Terreri, Maria Teresa

doi:10.1007/s00296-013-2909-7

Cited by 30 publications

(18 citation statements)

References 28 publications

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“…(6, 8, 11) With regard to imaging, studies have shown that MRI and ultrasound can detect subclinical arthritis in children with JIA in clinical remission. (20–22) However, the clinical and prognostic significance of such findings remains unclear. (23, 24) Perhaps this uncertainty helps explain why more than half of respondents seldom or never use imaging to guide decisions on withdrawing therapy.…”

Section: Discussionmentioning

confidence: 99%

Attitudes and Approaches for Withdrawing Drugs for Children with Clinically Inactive Nonsystemic JIA: A Survey of the Childhood Arthritis and Rheumatology Research Alliance

et al. 2017

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Objective To assess the attitudes and strategies of pediatric rheumatology clinicians towards withdrawing medications for children with clinically inactive juvenile idiopathic arthritis (JIA). Methods Members of the Childhood Arthritis and Rheumatology Research Alliance (CARRA) completed an anonymous electronic survey on decision-making and approaches for withdrawing medications for inactive non-systemic JIA. Data were analyzed using descriptive statistics. Results Of 388 clinicians in CARRA, 124 completed surveys (32%), predominantly attending pediatric rheumatologists. The most highly ranked factors in decision-making for withdrawing medications were duration of clinical inactivity, drug toxicity, duration of prior activity, patient/family preferences, joint damage, and JIA category. Diagnoses of RF-positive polyarthritis and persistent oligoarthritis made respondents less likely and more likely, respectively, to withdraw JIA medications. Three-quarters of respondents waited for 6–12 months of inactive disease before stopping methotrexate or biologics, but preferences varied. There was also considerable variability in the strategies used to reduce, taper, or stop medications for clinically inactive JIA; most commonly, clinicians reported slow medication tapers lasting at least 2 months. For children on combination methotrexate-biologic therapy, 63% of respondents preferred stopping methotrexate first. Most clinicians reported using imaging only seldom or sometimes to guide decision-making, but most were also reluctant to withdraw medications in the presence of asymptomatic imaging abnormalities suggestive of subclinical inflammation. Conclusion Considerable variability exists among pediatric rheumatology clinicians regarding when and how to withdraw medications for children with clinically inactive JIA. More research is needed to identify the most effective approaches to withdraw medications and predictors of outcomes.

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Section: Discussionmentioning

confidence: 99%

Attitudes and Approaches for Withdrawing Drugs for Children with Clinically Inactive Nonsystemic JIA: A Survey of the Childhood Arthritis and Rheumatology Research Alliance

et al. 2017

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“…Erosions are less common in patients with JIA than in patients with rheumatoid arthritis (18). Erosions are commonly associated with more aggressive disease, a worse prognosis, positive rheumatoid factor test results, and polyarticular over oligoarticular subtypes (34,42). The location of JIA-induced erosions depends on the patient's age; older children (mean age, 14.4 years) tend to present with marginal erosions and younger children (mean age, 8.7 years) with epiphyseal erosions (16).…”

Section: Bone Changesmentioning

confidence: 99%

“…For example, up to 36% of healthy children have "abnormalities" in one joint, including joint effusion, synovial thickening, and tenosynovitis (46). Conversely, substantial numbers of JIA patients who fulfill the clinical criteria for remission present with asymptomatic joint effusion, synovial thickening, tenosynovitis, and/ or increased vascularity (23,42,(46)(47)(48), although only 29%-39% of them progress to active disease at 6-month to 2-year follow-up (22,25,46). Interestingly, the rate of synovial hyperplasia, joint effusion, and tenosynovitis is comparable between patients with continued remission and patients with synovitis flare, while the rate of positive power Doppler signal is greater in patients with continued remission (46).…”

Section: Enthesopathymentioning

confidence: 99%

US Evaluation of Juvenile Idiopathic Arthritis and Osteoarticular Infection

et al. 2017

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Juvenile idiopathic arthritis (JIA) and osteoarticular infection can cause nonspecific articular and periarticular complaints in children. Although contrast material-enhanced magnetic resonance imaging is the reference standard imaging modality, musculoskeletal ultrasonography (US) is emerging as an important adjunct imaging modality that can provide valuable information relatively quickly without use of radiation or the need for sedation. However, diagnostic accuracy requires a systemic approach, familiarity with various US techniques, and an understanding of maturation-related changes. Specifically, the use of dynamic, Doppler, and/or multifocal US assessments can help confirm sites of disease, monitor therapy response, and guide interventions. In patients with JIA, ongoing synovial inflammation can lead to articular and periarticular changes, including synovitis, tenosynovitis, cartilage damage, bone changes, and enthesopathy. Although these findings can manifest in adult patients with rheumatoid arthritis, important differences and pitfalls exist because of the unique changes associated with an immature and maturing skeleton. In patients who are clinically suspected of having osteoarticular infection, the inability of US to evaluate the bone marrow decreases its sensitivity. Therefore, the US findings should be interpreted with caution because juxtacortical inflammation is suggestive, but neither sensitive nor specific, for underlying osteomyelitis. Similarly, the absence of a joint effusion makes septic arthritis extremely unlikely but not impossible. US findings of JIA and osteoarticular infection often overlap. Although certain clinical scenarios, laboratory findings, and imaging appearances can favor one diagnosis over the other, fluid analysis may still be required for definitive diagnosis and optimal treatment. US is the preferred modality for fluid aspiration and administering intra-articular corticosteroid therapy. RSNA, 2017.

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“…It has been recently argued that remission of JIA defined on clinical grounds does not couple with remission defined with imaging [ 32 – 34 ]. However, the clinical significance and prognostic value of this finding is unclear, as the presence of MSUS abnormalities, including PD signal, in patients with clinically defined inactive disease did not predict subsequent synovitis flare [ 35 ].…”

Section: Introductionmentioning

confidence: 99%

Ultrasound in juvenile idiopathic arthritis

Magni‐Manzoni

2016

Pediatr Rheumatol

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BackgroundIn the recent years, musculoskeletal ultrasound (MSUS) has been regarded as especially promising in the assessment of juvenile idiopathic arthritis (JIA), as a reliable method to precisely document and monitor the synovial inflammation process.Main contentMSUS is particularly suited for examination of joints in children due to several advantages over other imaging modalities. Some challenges should be considered for correct interpretation of MSUS findings in children, due to the peculiar features of the growing skeleton. MSUS in JIA is considered particularly useful for its ability to detect subclinical synovitis, to improve the classification of patients in JIA subtypes, for the definition of remission, as guidance to intraarticular corticosteroid injections and for capturing early articular damage. Current evidence and applications of MSUS in JIA are documented by several authors. Recent advances and insights into further investigations on MSUS in healthy children and in JIA patients are presented and discussed in the present review.ConclusionsMSUS shows great promise in the assessment and management of children with JIA. Nonetheless, anatomical knowledge of sonographic changes over time, underlying immunopathophysiology, standardization and validation of MSUS in healthy children and in patients with JIA are still under investigation. Further research and educational efforts are required for expanding this imaging modality to more clinicians in their daily practice.

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Do patients with juvenile idiopathic arthritis in remission exhibit active synovitis on joint ultrasound?

Cited by 30 publications

References 28 publications

Attitudes and Approaches for Withdrawing Drugs for Children with Clinically Inactive Nonsystemic JIA: A Survey of the Childhood Arthritis and Rheumatology Research Alliance

Attitudes and Approaches for Withdrawing Drugs for Children with Clinically Inactive Nonsystemic JIA: A Survey of the Childhood Arthritis and Rheumatology Research Alliance

US Evaluation of Juvenile Idiopathic Arthritis and Osteoarticular Infection

Ultrasound in juvenile idiopathic arthritis

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