High-dose steroids increase bacterial infection in children with juvenile arthritis

Steroids increase risk of bacterial infection in kids with juvenile arthritis over methotrexate or TNF inhibitors.

Children with juvenile idiopathic arthritis have higher rates of bacterial infection requiring hospitalization, and use of high-dose steroids significantly increases that risk, according to research from the University of Alabama at Birmingham. In findings published in Arthritis & Rheumatism, the journal of the American College of Rheumatology, the researchers show that steroid use led to increased risk, while other commonly used medications — methotrexate and tumor necrosis factor inhibitors — did not increase infection risk in children with JIA.  


“Among children with JIA, questions have persisted about a possible increased risk of serious infections associated with the use of TNF inhibitors, one of the so-called biologics which have become increasingly popular as a treatment for JIA,” said Timothy Beukelman, M.D., MSCE, associate professor of pediatric rheumatology and scientist in the UAB Center for Clinical and Translational Science.  “But the relationship between JIA and serious bacterial infections has not been extensively studied and is not well understood.”

Beukelman’s team set out to answer several questions. They wanted to know the infection rates for children with JIA in general, along with the rates for children whose disease was managed by methotrexate, TNF inhibitors and steroids known as oral glucocorticoids, another commonly used treatment.

The researchers used Medicaid data to identify 8,479 JIA patients and compared them to 360,489 children diagnosed with attention-deficit hyperactivity disorder. They used pharmacy claims to determine medication use and identified infections through hospital discharge diagnoses. They found that children with JIA had an increased rate of infection, regardless of treatment strategy, when compared to children with ADHD.

“This finding suggests the inflammatory or autoimmune process itself may predispose children to infection regardless of therapy,” said Beukelman.

Beukelman’s group also found that the infection rate among JIA patients was not any higher in children treated with either methotrexate or TNF inhibitors, but that the rate was significantly higher in those children treated with high-dose glucocorticoids.

“The use of a high dose of glucocorticoid, more than 10 mg of prednisone daily, was consistently associated with a doubling of the infection rate,” Beukelman said. “This strongly indicates that a treatment strategy that limits steroid use may reduce the risk of serious infection in children with JIA.”

Arthritis is an inflammation of the joints that causes pain, swelling, stiffness and can lead to disability.  JIA is the most common type of childhood arthritis and may affect 300,000 children in the United States, according to the American College of Rheumatology. 

This research was supported by grants from the Agency for Healthcare Research and Quality, the Food and Drug Administration, U.S. Department of Health and Human Services and the National Institutes of Health.