LAUSR

Dear Editor, We read with great interest the paper by Naveen et al. entitled: “Hip involvement in children with enthesitis-related arthritis (ERA) is associated with poor outcomes in adulthood.” We congratulate the authors on their valuable work highlighting the outcomes of patients suffering from ERA [1]. In accordance with previous data, ERA is the most severe JIA subtype with a higher disability. Nearly 90% of ERA patients had an active disease in adulthood. HLA B27, hip involvement, and axial involvement were reported as predictors of poor outcomes. We are prompted to rise in debate on that point. The authors insist on the gravity of hip joint involvement in the prognostic of ERA. As many clinicians, considering the significant functional impact and the high risk of disability caused by hip involvement, we feel the urgent need to an intensive therapeutic strategy, especially in the growing skeleton. According to the ACR guidelines, the glucocorticoids (GCs) injections are considered the first-line therapy for peripheral disease affecting fewer than five joints [2]. Local treatment is recommended in persistent swollen joints or as a “bridge therapy” in patients awaiting the delayed effect of systemic drugs. In addition to pain relief, the GC injections promptly resolve the synovitis and improve the range of motion [3]. However, it is worth noting that the effect of GC injections in the hip in juvenile arthritis or juvenile spondylarthritis is little studied. In the second point, and as recommended by the ACR, the hip joint is considered as a high-risk site requiring the use of second-line therapy that includes TNF blockers and conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). The promoting result of TNF blockers in adult spondylarthritis with hip involvement emphasizes their use in young patients [4]. The TNF blockers efficacity in the hip in juvenile arthritis has been proved in only one study, showing the joint space improvement in patients treated with etanercept [5]. Nevertheless, as in our country, the financial constraints represent the main barrier to access to biologics [6]. Furthermore, we argue that there are some approaches to overcome regarding the hip radiological progression assessment in this study. Specific tools and scoring systems focusing on destruction radiographic variables in children with hip JIA are available [7]. We invite the authors to use The Childhood Arthritis Radiographic Score of the Hip (CRASH) and the new radiographic. These reliable scores are based on the joint evaluation of the space narrowing, erosions, growth abnormalities, subchondral cysts, malalignment, acetabulum sclerosis, and avascular necrosis of the femoral head [8, 9]. Lastly, we believe that the treatment goal of ERA is to prevent joint destruction and to avoid structural damage. It, therefore, seems relevant that the monitoring of inflammatory lesions is advisable rather than that of structural lesions. Consequently, the ultrasound should be considered in peripheral arthritis monitoring, as well as the hip joint [10]. In closing, the most significant issue that we wanted to discuss was hip involvement. Options to improve the prognosis of ERA include early detection of hip involvement, This comment refers to the article available online at https:// doi. org/ 10. 1007/ s1006702105807-3.