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Variation in the Initial Treatment of Knee Monoarthritis in Juvenile Idiopathic Arthritis: A Survey of Pediatric Rheumatologists in the United States and Canada TIMOTHY BEUKELMAN, JAMES P. GUEVARA, DANIEL A. ALBERT, DAVID D. SHERRY, and JON M. BURNHAM
ABSTRACT. Methods. We mailed a 32-item questionnaire to pediatric rheumatologists in the United States and Canada (n = 201). This questionnaire contained clinical vignettes describing recent-onset chronic monoarthritis of the knee and assessed physicians' treatment preferences, perceptions of the effectiveness and disadvantages of nonsteroidal antiinflammatory drugs (NSAID) and intraarticular corticosteroid injections (IACI), proficiency with IACI, and demographic and office characteristics. Results. One hundred twenty-nine (64%) questionnaires were completed and returned. Eighty-three percent of respondents were board certified pediatric rheumatologists. Respondents' treatment strategies for uncomplicated knee monoarthritis were broadly categorized: initial IACI at presentation (27%), initial NSAID with contingent IACI (63%), and initial NSAID with contingent methotrexate or sulfasalazine (without IACI) (10%). Significant independent predictors for initial IACI were believing that IACI is more effective than NSAID, having performed > 10 IACI in a single patient at one time, and initiating methotrexate via the subcutaneous route for OJIA. Predictors for not recommending initial or contingent IACI were believing that the infection risk of IACI is significant and lacking comfort with performing IACI. Conclusion. There is considerable variation in pediatric rheumatologists' initial treatment strategies for knee monoarthritis in OJIA. This variation is primarily associated with perceptions of medication effectiveness and proficiency with IACI. Further studies are warranted to clarify the optimal treatment of OJIA. (J Rheumatol 2007;34:1918-24) Key Indexing Terms:
JUVENILE IDIOPATHIC ARTHRITIS
From the Department of Pediatrics, Division of Rheumatology and Division of General Pediatrics, The Children's Hospital of Philadelphia, and the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA. T. Beukelman was supported by gifts from Amgen, Berlex, Merck, Novartis, Pfizer, and Wyeth to the pharmacoepidemiology training program of the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine. J.M. Burnham was supported by NIH grant 1K23RR021969-02. The small financial reimbursement to subjects was paid for by an unrestricted educational gift from Pfizer. T. Beukelman, MD, Fellow Physician, Department of Pediatrics, Division of Rheumatology, The Children's Hospital of Philadelphia and The Center for Clinical Epidemiology and Biostatistics, The University of Pennsylvania School of Medicine; J.P. Guevara, MD, MPH, Assistant Professor of Pediatrics, Department of Pediatrics, Division of General Pediatrics, The Children's Hospital of Philadelphia and The Center for Clinical Epidemiology and Biostatistics, The University of Pennsylvania School of Medicine; D.A. Albert, MD, Professor of Medicine and Pediatrics, Chief, Division of Rheumatology, Department of Medicine, Dartmouth-Hitchcock Medical Center, Dartmouth Medical School, Lebanon, New Hampshire; D.D. Sherry, MD, Professor of Pediatrics; J.M. Burnham, MD, MSCE, Assistant Professor of Pediatrics, Department of Pediatrics, Division of Rheumatology, The Children's Hospital of Philadelphia and The Center for Clinical Epidemiology and Biostatistics, The University of Pennsylvania School of Medicine. Address reprint requests to Dr. J.M. Burnham, The Children's Hospital of Philadelphia, 3535 Market Street, Room 1579, Philadelphia, PA 19104, USA. E-mail: burnhams@email.chop.edu Accepted for publication May 16, 2007. |
