Comparison of intra-articular triamcinolone hexacetonide and triamcinolone acetonide in oligoarticular juvenile idiopathic arthritis

OBJECTIVE: To compare the efficacy and safety of intra-articular triamcinolone hexacetonide (TH) and triamcinolone acetonide (TA) in children with oligoarticular juvenile idiopathic arthritis (JIA). METHODS: One hundred and thirty joints of 85 patients undergoing intra-articular injections were randomly treated with either TH or TA depending on the availability of the drug. The efficacy of both treatments was evaluated prospectively in a blinded fashion. A good response was defined as a decrease in the articular score of > or =60% from baseline. Clinical, laboratory and immunological variables were noted in order to examine possible factors, other than treatment, predictive of the result. RESULTS: Seventy injections were performed using TH and 60 with TA. The two groups were comparable for clinical, immunological and laboratory characteristics. The rate of response was significantly higher with TH than with TA: 81.4% vs 53.3% (P = 0.001) at 6 months, 67.1 vs 43.3% (P = 0.006) at 12 months, and 60 vs 33.3% (P = 0.002) at 24 months. CONCLUSION: At comparable doses TH appeared to be much more effective than TA for intra-articular use, in both short- and long-term follow-up. This result was not affected by disease duration or degree of local and systemic inflammation.     

A subgroup-specific evaluation of the efficacy of intraarticular triamcinolone hexacetonide in juvenile chronic arthritis

OBJECTIVE: To determine the subgroup-specific differences of intraarticular triamcinolone hexacetonide (TH) in the treatment of joint inflammation in patients with juvenile chronic arthritis (JCA). METHODS: A retrospective review of 194 children of all subgroups of JCA, treated by a single or repeated TH injection between 1989 to 1994. Efficacy and duration of benefit were evaluated after a mean duration of 3, 15, 30, and 64 weeks. RESULTS: In all, 1439 TH injections were given to 194 patients; 368 of these were reinjections. The median duration of improvement of all injections was 74 weeks. Responses were significantly different among subgroups (p = 0.0001): there were 121 weeks of efficacy in early-onset pauciarticular JCA type I (223 injections), 47 weeks in late-onset pauciarticular JCA type II (190 injections), 105 weeks in rheumatoid factor negative polyarticular JCA (445 injections), 63 weeks in rheumatoid factor positive polyarticular JCA (127 injections), and 36 weeks in systemic JCA (413 injections). Forty-one injections were done in other rheumatic diseases. In relation to this result there were also differences with regard to joint groups, antinuclear antibody (ANA) and HLA-B27 status, and sex. Side effects were rare: infections of skin or joints were not noted; skin and lipoatrophy were seen after 15 injections, necrosis of the hip in one case, luxation of 2 shoulders of one patient, and periarticular calcification in 3 patients. CONCLUSION: Intraarticular TH is an effective therapy for inflammatory joint disease in all subgroups of JCA. The risk of major complications is low. The median duration of improvement depends on the subgroup of the disease.     

Outcomes of intraarticular triamcinolone acetonide injection in children with non-systemic juvenile idiopathic arthritis

Clinical Rheumatology - The objectives were to explore the response to intraarticular triamcinolone acetonide (TA) injection in children with non-systemic juvenile idiopathic arthritis (JIA) and...     

Triamcinolone acetonide and hexacetonide intra-articular treatment of symmetrical joints in juvenile idiopathic arthritis: a double-blind trial

OBJECTIVE: Pharmacokinetic studies have shown that the biological effect of triamcinolone acetonide (TA) is equivalent to that of triamcinolone hexacetonide (TH), if used at double the dosage. In this study we compared the efficacy of intra-articular TA at a dose twice that of TH in symmetrically involved joints, in children with juvenile idiopathic arthritis (JIA). METHOD: Children with active arthritis and a similar degree of inflammation in two symmetrical joints were enrolled in the study. The symmetry was assessed by both clinical examination and synovial fluid analysis. The dose given was 1 mg/kg up to 40 mg of TH or 2.0 mg/kg up to 80 mg of TA. The identity of injected compound was blinded to the patient and to the physician. RESULTS: Thirty-seven patients, 30 female, seven male, with JIA, entered the study. A total of 86 joints were injected. Twenty-one (53.8%) of the joints injected with TA relapsed first compared with only six (15.4%) of the joints injected with TH. In three (7.7%) relapse occurred simultaneously. Nine (23%) were still in remission after 24-month follow-up. The percentage of joints with lasting remission was higher with TH than with TA (80 vs 47.5% after 12 months and 63.6 vs 32.4% after 24 months, respectively; log rank test P = 0.003). CONCLUSION: Even when TA is given at higher doses, TH is more effective and should be considered the drug of choice for intra-articular treatment of JIA.     

A double-blind randomized comparative study of triamcinolone hexacetonide and dexamethasone intra-articular injection for the treatment of knee joint arthritis in rheumatoid arthritis

Intra-articular glucocorticoid (GC) injection has been used for more than half a century in the treatment of refractory synovitis in patients with rheumatoid arthritis (RA). There are limited data about the efficacy of intra-articular injection of various preparations of GCs on inflamed joint. The aim of this study was to compare the efficacy and side effects of intra-articular injection of dexamethasone (DEX) and triamcinolone hexacetonide (TH) in the treatment of knee joint arthritis in RA. In a double-blind randomized clinical trial, 70 patients with RA and knee joint arthritis were recruited to the study. Swelled knee joints were injected with 40 mg TH or 8 mg DEX randomly. The primary outcome measures were reduction of knee joint swelling and pain 1 and 3 weeks after joint injection. The secondary outcome measures were relapse of knee arthritis at 2, 4, and 6 months after injection and side effects of intra-articular injection. Difference in the knee circumferences between DEX and TH groups at weeks 1 and 3 was not significant. The average times of pain reduction after injection were 3.4 ± 2.3 and 2.3 ± 1.8 days in TH and DEX, respectively. There were no differences of knee pain between the two groups. Relapse of knee arthritis was occurred in two (6.7 %) and three (9.4 %) patients in the DEX and TH groups, respectively. Intra-articular injection of DEX like TH causes rapid and long-term reduction of knee pain and swelling in patients with RA and is safe.     

Erbium--169 versus triamcinolone hexacetonide in the treatment of rheumatoid finger joints.

Erbium--169 was compared with triamcinolone hexacetonide in the topical treatment of 32 patients suffering from rheumatoid arthritis. Erbium--169 was injected into 83 and triamcinolone hexacetonide into 54 proximal interphalangeal or metacarpophalangeal joints. Both treatments produced alleviation of joint pain and swelling and improvement of grip strength. At every check-up (1--18 months) the percentage of remissions was higher after triamcinolone hexacetonide injection than after erbium--169. The difference was significant at 1, 3, and 6 months.     

Treatment of rheumatoid joint inflammation with triamcinolone hexacetonide

Prolonged (more than 1 year) reversal of inflammation, as judged by decreased swelling, tenderness and synovial thickening, occurred in 12 patients in whom the joints of one hand and the wrist were treated locally with triamcinolone hexacetonide. Better preservation of grip strength, structural joint integrity and range of motion on the treated side were evidence of a beneficial effect on function. Fewer new lesions developed on the treated side as observed radiographically over the period of follow-up, which averaged 21 months. Recurrence and progression of arthritis, both clinical and radiologic, definitely occurred in some injected joints. Unwanted effects such as soft tissue atrophy and periarticular calcification were common; their true incidence and the significance of the latter remain to be determined. The doses used here are regarded as experimental and, while promising, warrant further study before adoption as a possible method of “medical synovectomy”.     

Intraarticular triamcinolone hexacetonide in the management of chronic arthritis in children

The use of intraarticular triamcinolone hexacetonide in the management of persistent arthritis of the knee joint that is unresponsive to nonsteroidal anti-inflammatory drugs was prospectively evaluated in 40 children with chronic arthritis. Of 49 knees that were injected, 63.3% maintained complete resolution of effusion and other signs of inflammation at the 6-month followup. This favorable outcome correlated with a young age, a short disease duration, and a higher dose of triamcinolone hexacetonide. At the 12-month followup, 45% of the injected knees remained in remission.     

Secondary Cushing's syndrome in children with juvenile idiopathic arthritis following intra-articular triamcinolone acetonide administration

SIR, Intra-articular corticosteroid injection is a widely usedtreatment in the management of juvenile idiopathic arthritis(JIA) that generally induces rapid resolution of synovitis [1].Triamcinolone hexacetonide (TH) is the preferred drug, withsustained symptom relief over longer periods than triamcinoloneacetonide (TA) [2–4]. However,     

Flurbiprofen in the treatment of juvenile rheumatoid arthritis

Thirty-four patients with juvenile rheumatoid arthritis, who were treated with flurbiprofen at a maximum dose of 4 mg/kg/day, had statistically significant decreases from baseline in 6 arthritis indices after 12 weeks of treatment. Improvements were seen in the number of tender joints, the severity of swelling and tenderness, the time of walk 50 feet, the duration of morning stiffness and the circumference of the left knee. The most frequently observed side effect was fecal occult blood (25% of patients); however, there was no other evidence of gastrointestinal (GI) bleeding in these patients. One patient was prematurely discontinued from the study for severe headache and abdominal pain. Most side effects were mild and related to the GI tract.     

Auranofin in the treatment of juvenile rheumatoid arthritis

A 6-month double-blind, parallel, randomized, placebo-controlled multicenter trial of auranofin (0.15–0.20 mg/kg/day) was conducted in 231 children with juvenile rheumatoid arthritis (JRA) in the United States and in the Union of Soviet Socialist Republics. Approximately 80% of the children had polyarticular disease. The auranofin-treated patients showed greater mean decreases from baseline in 11 of the 12 articular disease indices measured than did the placebo-treated subjects after 3 months of therapy, and in 9 of the 12 indices after 6 months. However, the actual intergroup mean differences were relatively small and were not statistically significant. According to the physician's global assessment, 69% of the auranofin-treated patients and 61% of the placebo-treated patients demonstrated clinically significant improvement from baseline after 6 months (P = 0.24). Children whose disease onset occurred less than 2 years prior to entry improved more than did those who had arthritis for a longer period. In addition, those with polyarticular involvement at baseline improved more than did patients with mild disease. However, these relationships were observed in both the auranofin- and placebo-treated groups, and again, there were no significant intergroup differences. Diarrhea was the most common adverse effect of auranofin. We conclude that the clinical efficacy of auranofin is modestly higher than that of placebo in the treatment of JRA, as evidenced by the consistent trends observed in the data. However, the magnitude of the individual intergroup differences is not statistically significant. Auranofin appears to be very safe in children with JRA.     

The efficacy and safety of intraarticular corticosteroid therapy for coxitis in juvenile rheumatoid arthritis

OBJECTIVE: To study the efficacy and safety of intraarticular triamcinolone hexacetonide (IATH) for the treatment of coxitis in patients with juvenile rheumatoid arthritis (JRA). METHODS: Fifty consecutive patients with JRA and coxitis were studied prospectively. Forty-eight children received IATH in 67 arthritic hips. The remaining 2 children exhibited 3 cases of femoral head necrosis (FHN) at the initial assessment and were only followed up; both were receiving long-term systemic steroids. After a minimum of 2 years, the study was concluded with a final evaluation that included magnetic resonance imaging. RESULTS: In 39 of 67 hip joints (58%), remission of the coxitis for a period of 2 years was obtained through a single administration of IATH, while another 12 hip joints showed remission of coxitis after repeated TH injections (total remission rate 76%). We observed 2 patients with FHN following IATH. Both of these children were receiving long-term systemic steroids. During the period between onset of JRA and screening assessment for this study, the children exhibited 2.4 cases of FHN per 100 patient-years, while 1.5 cases of FHN per 100 patient-years were observed between IATH treatment and final followup. All 5 observed cases of FHN occurred among the 20 children who received long-term systemic steroids, while no necrosis occurred in the 30 children who did not receive systemic corticosteroids (P = 0.009 by Fisher's exact test). CONCLUSION: IATH for juvenile rheumatoid coxitis was an effective treatment that did not increase the rate of FHN. Systemic steroids, however (or their covariable, severity of JRA), may increase the risk of FHN in JRA.     

Complications of intra-articular injections of triamcinolone hexacetonide in chronic arthritis in children

Intra-articular injections of triamcinolone hexacetonide (THA) are a useful therapy in JRA and HLA B 27 related arthritis (B 27 RA). Published data have indicated good results and few side effects. We evaluate here the frequency of occurrence of local side effects in 35 children with JRA (115 joints treated) and 13 children with B 27 RA (29 joints treated). With a mean follow up of 25 months in JRA and 18 months in B 27 RA, we observed 12 cases (8.3%) of subcutaneous tissue atrophy with local depigmentation (knees 5 cases, wrists 2 cases, ankles 3 cases, metatarsophalangeal joints 2 cases) and 7 cases (4.9%) of intra-articular calcifications all in the JRA group (wrists 3 cases, knees 2 cases, ankles 2 cases). Youth and joint size are possible predisposing factors for subcutaneous tissue atrophy and intra-articular calcification. Spontaneous improvement previously reported for these local side effects was not observed in our study. These results underline the necessity of discussing on a case by case basis whether intra-articular, non long-acting corticosteroid or THA are indicated. THA must be injected with a rigorous technique and with a dosage adapted to the articular volume.     

Immediate "steroid flare" from intraarticular triamcinolone hexacetonide injection: case report and review of the literature

We describe a patient who had an immediate, intense, localized synovitis due to intraarticular triamcinolone hexacetonide injection. The reaction was secondary to rapid intracellular ingestion of the steroid microcrystals as demonstrated by compensated polarized microscopy. We report the unique nature of this patient's response, and we review previous literature regarding "steroid flare" after intraarticular injection.     

Radiographic followup of joints injected with triamcinolone hexacetonide for the management of childhood arthritis

Evidence of deleterious effects following intraarticular injection of triamcinolone hexacetonide was sought through a review of radiographs of 145 joints of 55 children with chronic arthritis. Possible deleterious effects were noted in 16 joints of 11 patients. These effects included: small patella (2 joints), patellar osteochondritis dissecans (1 joint), periarticular calcification (9 joints), intraarticular tibial bony spur (1 joint), avascular necrosis of the distal radial epiphysis (2 joints), and avascular necrosis of the proximal femoral epiphysis (1 joint). Only the latter possible complication was symptomatic. Serial radiographs of 76 joints of 30 children showed mild progressive changes compatible with the underlying disease, except in the hip joint, where changes were more severe. The intraarticular injection of triamcinolone hexacetonide is a procedure that appears to be associated with an acceptably low frequency of radiologic abnormalities for many joints in children with chronic arthritis, but its effects on the hip joint remain uncertain.     

Comparison of intravitreal injection of bevacizumab and triamcinolone acetonide in the treatment of uveitic macular edema

Background: Cystoid Macular Edema (CME) is one of the most common and sight threatening complications of uveitis. Intravitreal injection of corticosteroids and Anti-VEGF are two routine options for treatment. Objective: To compare the effects of intravitreal injections of Bevacizumab and Triamcinolone Acetonide for the treatment of persistent macular edema in non-infectious uveitis. Methods: In a randomized clinical trial, sixty eyes of 55 patients were enrolled in the study. Patients were divided into two groups with randomized digits table. 29 eyes received 4 mg of intravitreal triamcinolone acetonide, and 31 eyes received 1.25 mg of intravitreal bevacizumab. Two main outcome measures were changes in visual acuity, measured with logarithm of minimal angle of resolution, and central macular thickness, measured with optical coherence tomography. Results: The mean follow-up was 25.3 weeks. The best visual acuities were achieved 6 months after injection in both groups. Improvement in visual acuity at 6 months was achieved in 28/29 (96%) of eyes in Triamcinolone group and in 26/31 (83%) eyes in Bevacizumab group (p=0.196). None of the eyes showed worsening of visual acuity after 6 months. Mean of central macular thickness in the pre-injection time for intravitreal triamcinolone acetonide (IVTA) group was 295.62 μ, and 309.87 μ in intravitreal bevacizumab (IVB) group, which were decreased after six months to 199.27 μ and 221.06 μ, respectively (p<0.001). Conclusion: This study shows that IVT and IVB are both effective in improving vision in uveitic CME. Although effects of triamcinolone on Central Macular Thickness (CMT) are more apparent, this superiority is not seen on Best Corrected Visual Acuity (BCVA).