Intra-articular glucocorticoid injection as second-line treatment for Lyme arthritis in children

Objective To determine whether second-line intra-articular 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 three pediatric rheumatology centers with distinct clinical approaches to second-line treatment of Lyme arthritis. We primarily compared children receiving second-line IAGCs 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 IAGCs (13 with concomitant oral antibiotics). Compared to children receiving second-line oral antibiotics alone, children treated with IAGCs had similar baseline characteristics but lower rates of ARLA (17% vs. 44%, odds ratio 0.3 [95% CI 0.1, 0.95], P = 0.04) and faster rates of clinical resolution (hazard ratio 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 IAGCs, outcomes appeared similar irrespective of use of concomitant antibiotics. Outcomes were also similar between IV and oral antibiotictreated 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.