Crohn's Disease Forum » Parents of Kids with IBD » Question about arthritis and Crohn's


 
05-08-2019, 03:03 PM   #1
Pilgrim
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Question about arthritis and Crohn's

H has had chronic swelling in her ankle, mostly left but sometimes she complains about the right one also. For years it was just pain but in the past few months there is fluid.
So she has xray next week and then GP will send info to GI.
Meanwhile GI called to set up a conference on Friday. Her labs are showing flags now, anemia related, and that tends to be her sign of Crohn's activity.
Presumably, he will want to adress it. If he wants steroids should I decline in order to get the possible arthritis diagnosed? Or is it better to just let the meds do their thing so she is better faster?
I will ask him this too, depending on what her options are. Just looking for experience related advice as ever.
05-08-2019, 03:34 PM   #2
my little penguin
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X-ray will only show damage (after years I think ?)
Arthritis needs to be observed by a pediatric Rheumo
And mri /ultrasound of the joint
Plus they need to examine the joint (all of her joints )
If she has had joint pain for years why didnít the Gi refer her to a rheumatologist at the beginning ?
Completely confused on why the gp didnít refer either
Since crohns and arthritis go hand in hand
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05-08-2019, 04:42 PM   #3
Pilgrim
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X-ray will only show damage (after years I think ?)
Arthritis needs to be observed by a pediatric Rheumo
And mri /ultrasound of the joint
Plus they need to examine the joint (all of her joints )
If she has had joint pain for years why didnít the Gi refer her to a rheumatologist at the beginning ?
Completely confused on why the gp didnít refer either
Since crohns and arthritis go hand in hand
The GP referred for an xray because he had to confirm no injury to the joint before assuming arthritis.
So...GI will get the info and refer to Rheumatologist- being able to get her in more quickly I think.
Anyway, assuming arthritis, what do you think about the med question?
05-08-2019, 05:11 PM   #4
crohnsinct
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Not well versed on the arthritic front (although T had painful joints with no swelling for years) but wanted to say that joint issues are also an EIM of Crohn's and if her Crohn's is not well controlled then joints can flare as well. It seems like this poor kid has never really hit a good solid remission.

I will let MLP and Maya142 handle the arthritis questions.
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Crohns & Remicade induced Psoriasis
Remicade
Vit d 2000IU
Multi vitamin plus iron
Calcium

Previously used - Prednisone, Prevacid, Enteral Nutrition, Methotrexate oral and injections, Folic Acid, Probiotics, Cortofoam

Daughter T dx 1/2/15 at age 11
Vitaligo, Precoscious puberty & Crohn's
Remicade
Vit D 2000IU

Previously used, Exclusive Enteral Nutrition, Methotrexate (injections and oral), Folic Acid, Entocort,IBD-AID Diet
05-08-2019, 06:16 PM   #5
Maya142
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H has had chronic swelling in her ankle, mostly left but sometimes she complains about the right one also. For years it was just pain but in the past few months there is fluid.
So she has xray next week and then GP will send info to GI.
Meanwhile GI called to set up a conference on Friday. Her labs are showing flags now, anemia related, and that tends to be her sign of Crohn's activity.
Presumably, he will want to address it. If he wants steroids should I decline in order to get the possible arthritis diagnosed? Or is it better to just let the meds do their thing so she is better faster?
I will ask him this too, depending on what her options are. Just looking for experience related advice as ever.
Yes, an MRI or ultrasound is much more accurate. I would honestly want her seen by a rheumatologist before putting her on steroids. It will be hard for the rheumatologist to assess her if she's on steroids. I do know it takes quite a while to get into pediatric rheumatology (there are only about 300 pediatric rheumatologists in all of the US!) though.

The x-ray will likely not show arthritis damage yet. Damage can develop fast in kids with aggressive arthritis, but most often it is slow. So what a rheumatologist would do is examine each joint (even ones that don't hurt, because just like with IBD, you can have inflammation without pain or with young kiddos, they are so used to pain that they don't complain) and look for signs of inflammation - swelling, fluid, redness, warmth etc.

An ultrasound will show active inflammation. So will an MRI. An MRI is more accurate and will also show early stage damage that doesn't show up on x-rays yet (such as small erosions).

Arthritis with IBD can flare when the IBD flares or it can flare independently. Typically, if peripheral joints are involved (peripheral means joints other than the spine, which are called axial joints), particularly large joints like knees, then treating the Crohn's may get rid of the arthritis.

If the arthritis is the type that flares independently, then you could treat the Crohn's with Humira and she still may have arthritis. At that point you consider adding something like MTX or upping the dose of Humira.

Axial arthritis (involving the spine or sacroiliac joints) almost always flares independently of the Crohn's.

With peripheral arthritis - it could go either way. It's possible that if you get her Crohn's into remission the arthritis will go away. But it's also possible that a child may have Crohn's that is in remission (like my daughter) and yet still have very active arthritis (in my daughter's case, both axial and peripheral).

There are certainly cases of peripheral arthritis which flares independently of the Crohn's.

Given H's case, it sounds to me like her Crohn's isn't well controlled. Is that right? I do remember that she had a low Fecal Cal a little while ago. So you may need to change meds - typically Remicade would be the next option.

There are only so many drugs that treat both inflammatory arthritis and IBD - Humira, Remicade, Cimzia, Simponi. Anti-TNFs treat both axial and peripheral arthritis.

The other option is Stelara. That works well for peripheral arthritis, but NOT for axial arthritis.

I am surprised that H hasn't been referred to rheumatology if she has been complaining of pain for years. Arthritis, just like IBD, can cause significant damage. My 22 year old will be having joint replacements this summer.

Just like with IBD, you want to treat it aggressively, and get it under control and ideally, in remission. That lowers her chances of permanent damage. Permanent damage = permanent pain, so you definitely want to avoid that.

I would push to have her seen by rheumatology as fast as possible.

Also want to add - anemia can be caused by both Crohn's and juvenile arthritis. If she has Crohn's symptoms right now, then it's probably that. But if her Crohn's has been quiet and well-controlled, it is possible that the arthritis (if she has it) is causing anemia.
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diagnosed with Crohn's Disease at 16
Juvenile Idiopathic Arthritis at 12
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Mom of S (23)
dx with JIA at 14
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05-08-2019, 06:18 PM   #6
Maya142
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Also wanted to add - if her GI wants her on steroids, then something like Entocort or Uceris would not affect the arthritis too much. But if you were to put her on 40 mg of Prednisone and then see a rheumatologist, it is very possible her joints will look normal.

Additionally, it is possible to have joint pain without inflammation caused by Crohn's - that's called arthralgia. It's painful, but unlike arthritis, it won't cause permanent damage since there's no inflammation.

But if you're seeing swelling then that does sound like inflammation .
05-08-2019, 08:45 PM   #7
Pilgrim
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Her fcal in early April was 75! It was the first she has been under 200. Her appetite has been good,she is growing. The main Crohn's symptom we've seen is that creeping fatigue and brain fog, worse from month to month and correlating with bloodwork. We had a week of diarrhea a month ago but it disappeared completely.

I didn't realize that anemia could happen due to arthritis.

I will bring her fcal result (I don't run them through GI) to round out the picture.

I will push for an investigation through rheumatologist.

She is taking 40mg Humira weekly plus 10mg methotrexate weekly.
05-08-2019, 08:54 PM   #8
Pilgrim
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And yes, the swelling is the new part. She described it feeling like there was a rubber band around her ankle after walking. Then we took a closer look and the fluid was there behind her left ankle bone.

I watched it first for a month. Swelling is minimal in the morning and increases with use. It is different from the descriptions of arthritic swelling that I have read where a person would wake up stiff.
05-08-2019, 10:53 PM   #9
Maya142
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Yes, it can most definitely cause anemia. There are many names for this type of arthritis - technically, it's a type of spondyloarthritis. It can be peripheral or axial or both (if both the spine AND peripheral joints are involved, it is still considered axial for treatment purposes).

Peripheral SpA can be treated with MTX. Axial SpA requires a biologic or an NSAID (contraindicated for many patients with IBD). My daughter's axial SpA is MUCH, MUCH worse than her Crohn's, so she is allowed to be on an NSAID. Typically, they try one that is relatively easy on the gut - usually Mobic or Celebrex.

You may also hear this type of arthritis called enteropathic arthritis or IBD-related arthritis. In kids specifically, it is also called enthesitis related arthritis which is the newer name juvenile spondyloarthritis.

My point is that it's all the same condition, which overlaps with Crohn's. So don't get too worried if they call it enteropathic or IBD related - those are all just different names for the same disease.

Here is some info: https://www.aboutkidshealth.ca/Artic...nguage=English

So if her Fecal calprotectin is 75 and that's the lowest it's been, then it's very possible that it is arthritis that flares independently of the Crohn's.

Sometimes if it's just one or two joints involved, they will do steroid injections directly into the joint. That gives the child almost immediate relief. Little kids are usually sedated for joint injections.

But as you know, steroids can be harmful. They can lower bone density and they don't like injecting joints too often. So it's usually done to get the arthritis under control quickly, while you're waiting for a medication to work.

Given that H is on 40 mg of Humira weekly, I'm not sure what they will do if they do find active inflammation in her ankles. We actually did up Humira to every 6 days for a while.

You could certainly up her MTX and that might be enough.

In terms of swelling, you are right that there is definitely more stiffness in the morning. That gets better as the day goes on. Does H limp or walk funny (my daughter says "like the tin-man from the Wizard of Oz)??

But in terms of swelling, it varies. I know that my daughter's ankles are the same way - the least swelling in the morning. Not sure why.

I do know that typically while in arthritis the stiffness and pain is high in the morning and at night, in enthesitis, the opposite is true. Pain and swelling actually get worse through the day because you use your tendons and ligaments a LOT during the day (enthesitis is inflammation where tendons and ligaments insert into the bone).

So for my daughter's ankles, we can actually see her achilles tendon become puffier and puffier as the day goes on.

In terms of the swelling being new, it's possible there was some degree of inflammation and swelling was much less obvious then. H could have had pain from that and as the inflammation got worse, swelling became more evident.

That would be my best guess though - as an arthritis mom and not a doc .
05-08-2019, 10:58 PM   #10
Maya142
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Oh wanted to add - based on your description it could be a tendon and not the joint. Tendons are trickier than joints in some ways - hard to treat. Typically biologics work best for enthesitis. There are some tendons that can be injected with steroids if necessary. But with others, the risk of rupture is too high (like the achilles tendon).

Does she play any sports? Anything that could have caused an injury? I know it's a long shot, but I hate for H to have to deal with something else besides the Crohn's, especially since her Crohn's is severe. And sometimes, arthritis can be a beast .
05-09-2019, 06:33 AM   #11
Pilgrim
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Oh wanted to add - based on your description it could be a tendon and not the joint. Tendons are trickier than joints in some ways - hard to treat. Typically biologics work best for enthesitis. There are some tendons that can be injected with steroids if necessary. But with others, the risk of rupture is too high (like the achilles tendon).

Does she play any sports? Anything that could have caused an injury? I know it's a long shot, but I hate for H to have to deal with something else besides the Crohn's, especially since her Crohn's is severe. And sometimes, arthritis can be a beast .
H has never been an athlete. She has always avoided strenuous activity, sometimes very cleverly. She has been known to make up games where she calls the shots...and the others do the running.
But there is always the possibility of injury, so we are investigating that first.
I do like to walk with her. But even the 10 minute walk to and from school is not always easy between her ankle and anemia.
Thank you so much Maya142 for the details in your posts. I laugh when you say "just a mom"!
05-09-2019, 11:26 AM   #12
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H has never been an athlete. She has always avoided strenuous activity, sometimes very cleverly. She has been known to make up games where she calls the shots...and the others do the running.
Very smart kiddo . Made me laugh out loud!!

My younger daughter always played on the left side as a soccer player. Even though she is right-handed. Everyone always marveled at her ability to play well with both feet but it was because she had arthritis in her knee. But she started playing on the left at age 7 and wasn't diagnosed till 12.

That's when we realized WHY she always wanted to be on the left - we had no idea that there had been pain and stiffness all along, probably because M was so young and so used to pain.
05-09-2019, 11:53 AM   #13
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My son wasn't into sports as a teen and didn't like gym and I think it was because he had limitations way before we ever knew about them. He told me years later, that his friends said he "ran funny". Eventually his walk was affected.

I like to correct May142 on "just a mom" - I would say "just a supermom".
05-09-2019, 04:31 PM   #14
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Unfortunately, that is one of the things I see a LOT of JIA Facebook groups - parents saying that their child always "runs funny" or "walks funny" but being brushed off by their pediatrician when they mention their concerns.

It's not uncommon at all for parents to say that their kids had been complaining for years before diagnosis. JIA is tricky to diagnose and this particular subtype that is associated with IBD (juvenile spondyloarthritis/enthesitis related arthritis) is one of the rarer JIA subtypes and so it is even harder to diagnose kids with JSpA because they often don't present with dramatic swelling that you seen in other subtypes.

I like to correct May142 on "just a mom" - I would say "just a supermom".
That is kind of you but honestly, we have made 8 bad decisions for every good one. But that's parenting I suppose .

My goal is to prevent children from having to go through what my daughter has been through - 8 biologics, 6 immunosuppressants, 8 surgeries (counting the 2 replacements this summer) and of course, completely debilitating pain.
05-11-2019, 07:13 AM   #15
Pilgrim
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Our consult was interesting. He will refer to Rheumatologist but is wondering why low hemoglobin but also low crp. Crp was .8
So, yes we need to address the ankle but Crp should be elevated.
He ordered extra labs including ferritin, B12, zinc and so on. I didn't see the lab sheet.
Also booking mre to see if anything is active.
He said next med step is 80mg Humira weekly. 😦
Poor H. She is so tough, never cries, but yesterday was too much. Sobbing during her labs, sobbing at the thought of going to school. She just...cracked.
Broke my heart.
The upside is, it really doesn't look like active disease at this point. But what?
05-11-2019, 08:51 AM   #16
my little penguin
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Arthritis
Crp can be normal and still have inflammation
Ds was on 80 mg weekly of humira (1 shot every 5 days)
Sorry she had a rough day
Sometimes itís just tough
Hope Rheumo can help
05-11-2019, 12:14 PM   #17
Maya142
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No, very common for kids with this type of arthritis to have negative bloodwork. My younger daughter, who has severe AS, had perfectly normal blood work when diagnosed (except anemia and a positive HLA B27+ - that's a genetic test). But ESR and CRP were fine.

Now that has changed - she has had a high CRP for 3 years (goes to 0 on steroids though, so we know it's inflammatory). But now her AS is much worse.

But her older sister, who also has AS, has normal ESR/CRP, even when she has very obvious swelling in joints.

In AS - so the adult form of the disease - 40% of patients have NORMAL inflammatory markers. I suspect those numbers are much higher in the kiddie form of AS - enthesitis related arthritis/juvenile spondyloarthritis, based on talking to JIA Moms.

A GI may not know this though. A rheumatologist, particularly a pediatric rheumatologist would.

We did Humira every 6 days, but not more often than that - though my girls were on Humira quite a few years ago (3-5 years or so). But I have heard of 80 mg weekly being given now.

All kiddos have rough days. But sometimes they need some extra support. Both her GI or her rheumatologist can probably refer you to a psychologist who helps kids with chronic illnesses to learn how to cope.

Poor kiddo. Ice cream or chocolate or a little reward for being brave helps too .
05-11-2019, 12:41 PM   #18
Pilgrim
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Thank you Maya142 . I am very grateful that you share your knowledge.

So, GI is working to get that referral to peds rheumatologist for her. The specialists at our children's hospital work closely together so hopefully it won't take too long.

The stories about your daughters give me the confidence to push for help for H.

I think the GI is ruling out any GI causes in the meanwhile.

We don't have citrate free Humira yet. I asked him to try to help H be the first one in Canada. Especially if the dose changes!
05-11-2019, 04:45 PM   #19
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I was actually thinking about that. I hear really great things about citrate free Humira - stories about kids who would hide in a closet to get out of taking the shot, who would kick and scream and cry and have to be held down, and now their parents say that the citrate free Humira has been a miracle.

I wish it was available in Canada. I'm not sure why it isn't, if it is in Europe (and has been for several years there) and now in the US.

But before we had citrate free Humira, I know that adding Lidocaine helped. We never tried it but I know my little penguin did that for her son, and I believe it helped him a lot.

My younger daughter takes a biologic that was approved in the last few years for psoriasis and psoriatic arthritis. It contains citrate/citric acid. She says it burns a LOT - just like Humira did, and while she loves that it helps her, she says she still dreads it. And she's 22... It breaks my heart to think of a 6 year old having to deal with that .
05-11-2019, 05:03 PM   #20
Pilgrim
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H is already 8...time flies! But she has been taking Humira injections since age 4. She has been weekly for awhile but even so it is always on her mind.
She has a whole inner dialogue she goes through while we prepare the shot to make herself go through with it. She told me out loud once.
It is dreadful!
05-11-2019, 06:41 PM   #21
Maya142
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Oh my! How is she 8 already?! She was just 4!

She has been weekly for awhile but even so it is always on her mind.
Poor kiddo. I don't get why they are even still making biologics with citrate if it is known to cause so much burning.

The one thing that helped my older daughter when she first started Humira was learning that if she tensed up it would hurt more. Her rheumatologist told her that and had her practice tensing up the muscle in her leg and then relaxing it. Both my girls still use that trick - first they make it tense up, then relax it as much as possible.
05-11-2019, 07:16 PM   #22
pdx
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So so sorry about all of this, Pilgrim. I don't have experience with the arthritis side, but I'm glad that your GI ordered an MRE to check on Crohn's activity. My daughter has had low CRP and ESR during several Crohn's flares, so it's good to check on that side of things too. Hugs to you and her.
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Daughter E (16) dx with Crohn's 12/18/14 at age 12

Current treatment:

Remicade started 12/24/14 (9 mg/kg every 6 weeks)
Methotrexate restarted 12/2/16 (15 mg weekly)
vitamin D, folic acid, multivitamin, Prozac

Past Treatment
90% EN via NG tube 2/9/15 - 4/2/15
50% EN via NG tube 4/3/15 - 4/18/15
Supplemental EN via NG tube 5/7/15-6/19/15
Budesonide 3/3/15-6/30/15, 3/24/18-5/18/18
Methotrexate 3/13/15 - 5/14/16 (15 mg weekly)
Clobetasol for Remicade-induced psoriasis
05-11-2019, 08:35 PM   #23
Pilgrim
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Thanks pdx. It could be the Crohn's but labs good, and zero GI symptoms (fatigue aside). She's growing well, thankfully! I will be surprised if MRI shows anything.

Maya142 we will try the tensioning and see if it helps! That's a new Humira tip!
05-11-2019, 09:45 PM   #24
Maya142
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Don't get too excited - unfortunately, it helps only a little, not a lot.

Honestly, I never really mentioned it because I never considered it much of a tip . This is just me grasping at straws because I hate the idea of giving an 8 yo two burning injections a week.

Have you ever asked about Lidocaine? I know that there was a ped. rheumatology group that actually studied the addition of Lidocaine to Humira and found it did not alter efficacy and helped with pain. If you show that to your GI, maybe he'll consider it.
05-11-2019, 10:49 PM   #25
my little penguin
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Background/Purpose: Up to 37% of patients prescribed adalimumab (AD) report significant injection-site pain (Registered Prescribing Information, 2016). For AD to be a stable pre-filled product, the pH is 5.2, which contributes to injection-site discomfort. Injection site pain is a major factor in patient willingness to initiate/continue AD. Literature reports less injection-site pain with older age, smaller volume, and use of autoinjectors. In 2008, we also reported that addition of lidocaine (LID) decreased discomfort by 80% and improved acceptance of AD. Incompatibility is not reported between AD and LID. AD and LID were combined at room temperature; no precipitation occurred. In our practice, when initiating AD, patients are offered the option of adding 0.2 ml of LID to AD.

To better understand the impact of LID added to AD, we evaluated two groups of JIA patients: those who used AD with LID, compared to those who did not. Our aim was to understand characteristics of the groups and to identify patients who might benefit by adding LID. We also sought to assess differences in disease control and adverse events that might occur when adding LID

Methods: Chart review of AD-treated JIA patients was performed. Age when instituting AD, sex, diagnoses, ESR, joint counts, and adverse events were reviewed. Results were compared between LID users (LID+) and non-users (LID-). Chi Square, T-Test and Z-score statistics assessed differences between groups.

Results: 98 JIA patients treated with AD from 2008 to May 2017 were included; 71 patients added LID, whereas 27 did not. JIA subtypes were: 28 ERA, 17 poly, 26 oligo, 23 psoriatic, 1 undifferentiated, 3 systemic; uveitis was present in 19 patients. No differences in LID use by diagnosis were found. Fewer males than females added LID (56% versus 78%)( p = 0.036). Mean age when AD was instituted and duration of use was similar: 12.2 years of age in LID+ group and 12.7 years in LID- group; AD taken for 16.2 mos Ī14.2 in the LID- group and taken for 20.9 Ī 20.6 mos in the LID+ group (both age and duration NS). JIA patients ≤ 10 yo did not add LID more often than those ≥ 11 yo. Further analysis by age showed that 91% of early adolescents aged 10-14 years added LID, compared to 59% children aged 1-9 years and 50% teens ≥15 years (p=0.002). In the LID+ group, joint counts and ESR improved significantly after taking AD (p =0.002 and p< 0.00001, respectively), but no improvement was seen in either metric in the LID- group. 11% of the total population reported mild adverse events. One patient in LID- group discontinued AD due to injection site pain.

Conclusion: In our cohort, adding LID to AD was preferred more by female and early adolescent patients. Adding LID produced no increased adverse events and did not impede response to AD, as shown by improved joint count/ESR in the LID+ group after starting AD. Interestingly, the LID- group demonstrated no such improvement. This may reflect non-adherence to AD in the latter group possibly due to painful injections and will need further study. Our previous work showed AD plus LID produced less injection-site pain; hence patients continued this treatment. We conclude that it is safe to add LID to AD and certain JIA patients prefer this addition, possibly with improved adherence and better disease control.

Disclosure: B. Ostrov, None; B. Groh, None; L. V. Scalzi, None; C. A. Bingham, None; N. Gaffney, None; M. Buckley, None; L. Robbins, None; R. Ayala, None.
From


To cite this abstract in AMA style:

Ostrov B, Groh B, Scalzi LV, Bingham CA, Gaffney N, Buckley M, Robbins L, Ayala R. Adalimumab Therapy in Juvenile Idiopathic Arthritis: Addition of Lidocaine for Prevention of Injection Site Pain or Not? That Is the Question. a Comparison Study [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10). https://acrabstracts.org/abstract/ad...parison-study/. Accessed May 11, 2019.

05-11-2019, 10:52 PM   #26
my little penguin
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We added lidocaine for years to humira
Doc prescribed lidocaine vial and syringe
Then we just pulled the stopper out of the back of the humira
And added the 0.2 ml of lidocaine to the humira
Replaced the stopper (using good practices not to let the stopper touch anything
Or let the lidocaine syringe needle touch anything )

Helped Ds a lot
05-12-2019, 03:54 PM   #27
Maya142
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For AD to be a stable pre-filled product, the pH is 5.2, which contributes to injection-site discomfort. Injection site pain is a major factor in patient willingness to initiate/continue AD. Literature reports less injection-site pain with older age, smaller volume, and use of autoinjectors.
Interesting - I generally hear on here that syringes are less painful. My older daughter switched from the auto-injector to the syringe and thought it was MUCH less painful.

In contrast, my younger daughter prefers auto-injectors because she says that while the poke is more painful (since you can't control the speed of the injection), but the injection is over much faster and she thinks using the syringe prolongs burning.
05-17-2019, 10:16 AM   #28
Pilgrim
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I looked into lidocaine in the beginning but the doctor I talked to thought the extra prep to use it just prolonged anxiety.
If they doubled her dose to 80mg weekly, I will push to try it, at least. Doesn't really sound like a huge hassle to use it.

Good news for us. We see Peds Rheumatologist in two weeks!
05-17-2019, 01:33 PM   #29
my little penguin
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Glad your getting in quickly
Thatís great news

No extra prep while the kiddo is there
I just put the two together
And then called Ds in for the shot
So no time difference as far as he was concerned.
But big pain difference
Hugs
05-17-2019, 04:11 PM   #30
Maya142
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So glad you'll be seeing the rheumatologist soon!! That's great!

In terms of Lidocaine, I wonder if they are thinking about topical Lidocaine. That does increase anxiety for some kids (generally little kids) because it (usually in the form of EMLA cream) has to stay on 30 minutes before the shot. And in that time, some kids get very worked up over the anticipation of the shot. Some even vomit because they get so nervous.

But injectable Lidocaine is different - like MLP said, I'd prep it in a different room and then get H to come in only when you're ready with everything. Distract her with whatever works - blowing bubbles, very sweet or sour candy, playing a video game, watching a favorite show - whatever takes her mind off the shot. I've heard of parents saving a special video game for shot night - the kiddo only gets to play during the shot and right after the shot as a reward.

In terms of seeing the ped. rheumatologist, try to log her pain levels, stiffness complaints (especially in the morning or sitting for a prolonged period of time), whether she limps, whether she gets a fever or rash. Take her in clothes that will let the doc examine her easily -- shorts or leggings or a dress. They will likely check all her joints for warmth, swelling, range of motion etc. Wearing skinny jeans/jeggings doesn't help . I know H is only six, but my girls always grumbled when they made them take their jeans off for a gown , so figured I'd warn you!

Rheumatologist appts. can take a long time, so take something for her to play with.
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Crohn's Disease Forum » Parents of Kids with IBD » Question about arthritis and Crohn's
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