Intra-Articular Glucocorticoid Injection Safe for Pediatric Lyme Arthritis

Second-line intra-articular glucocorticoid injection appears to be an effective and safe second-line strategy for persistent Lyme arthritis in children.

Second-line intra-articular glucocorticoid (IAGC) injection may be a safe and effective means of managing Lyme arthritis in children, according to a study published in The Journal of Rheumatology. The treatment has demonstrated efficacy in quickly resolving clinical symptoms and reducing the burden of further treatment.

This observational study included 112 children whose Lyme arthritis persisted following first-line treatment with antibiotics; 18 were treated with second-line IAGCs and 94 received a second course of antibiotics without IAGCs. Of the 18 children treated with IAGCs, 72% (n=13) received concomitant oral antibiotics. Children were treated in 3 pediatric rheumatology facilities, each of which utilized a different clinical approach to second-line Lyme arthritis treatment.

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Logistic regression was used to examine the primary outcome (the relationship between IAGC treatment and risk of developing antibiotic-refractory Lyme arthritis [ARLA]), whereas Cox proportional hazards regression was used to evaluate the time to resolution.

Children treated with IAGCs alone showed lower rates of ARLA (17%) vs those treated with antibiotics alone (44%; odds ratio, 0.3; 95% CI, 0.1-0.95; P =.04). Additionally, the IAGC group had shorter time to clinical resolution (median time, 43 [IQR, 35 to 80] days) than the non-IAGC group (149 [IQR, 65 to 285] days), yielding a hazard ratio of 2.2 (95% CI, 1.2-3.9; P =.01) for time-to-event analysis.

Treatment-related adverse events occurred similarly among children in both cohorts, and those on IAGCs and concomitant antibiotics had outcomes similar to those without concomitant antibiotics.

However, children treated with intravenous antibiotics had a higher rate of adverse events than those treated with oral antibiotics (P =.03).

The effects of intravenous antibiotics were modified by age, with children younger than 10 years old at higher risk for ARLA (83%); they also had symptoms that were slower to resolve (median 315 [IQR, 148 to 525] days) vs those aged 10 years and above (28% developed ARLA; median days to resolution, 63 [IQR, 48 to 114]). P values for treatment/age were .05 for ARLA development risk and .003 for resolution time.

Limitations to this study include a lack of generalizability to adults, a small sample of children treated with the intervention, and an observational study design and consequential lack of data on long-term outcomes.

The study researchers concluded that “[second]-line IAGC injection appears to be an effective and safe second-line strategy for persistent Lyme arthritis in children, associated with rapid resolution of symptoms and reduced need for further treatment. Questions remain regarding the role of concomitant antibiotic therapy and the generalizability of these findings, particularly in adult populations. Further research is needed to confirm the effectiveness and safety of this therapeutic approach.”

Disclosure: Carlos D. Rose, MD, has received grant funding from GSK.


Horton DB, Taxter AJ, Davidow AL, Groh B, Sherry DD, Rose CD. Intra-articular glucocorticoid injection as second-line treatment for Lyme arthritis in children [published online March 1, 2019]. J Rheumatol. doi:10.3899/jrheum.180829