Rheumatologists Recognize the Need to Create Pediatric Enthesitis Scoring Tool

A study discovered that, although only a few respondents use an established enthesitis scoring measure, most are interested in one being created for pediatric patients.

Children can have enthesitis-related arthritis (ERA) but also have enthesitis in other juvenile idiopathic arthritis subtypes. Enthesitis is more common in juvenile ERA than in adult-onset ankylosing spondylarthritis, and yet, enthesitis indices only exist for adults with spondylarthritis. Investigators aimed to determine the frequency and indications for evaluating enthesitis in clinical practice, along with the sites most assessed and the contributing factors to an enthesitis diagnosis.

“There are measures and standardized tools for assessing enthesitis in the adult population, but one has not yet been developed in the pediatric population,” investigator Erin Treemarcki, DO, from the University of Utah, told HCPLive at ACR Convergence 2024. “Part of our work was to determine if there was a clear need for that and a clear desire for that among our colleagues.”

Treemarcki recognized the difficulty of diagnosing enthesitis in a pediatric population since it may overlap with other conditions or trigger points such as in amplified pain syndromes or fibromyalgia.

The CARRA Juvenile Spondylarthritis (JSpA) Workgroup developed a survey that asked questions revolving around demographics, practice patterns for assessing enthesitis, and knowledge of enthesitis. The survey was distributed electronically to CARRA members.

A total of 139 people responded to the survey, making it a 40.5% response rate. Respondents were mostly pediatric rheumatologists (72.26%) at academic medical centers (91.1%) in the US (86%). Pediatric rheumatology fellows (16.55%), med-peds rheumatologists (4.32%), and med-peds rheumatology fellows (2.16%) also completed the survey. Other than the US, some respondents lived in Canada (10.37%), Israel (0.74%), and an unspecified country (2.96%).

Respondents included a mix of people who were new in their career and more experienced, with time in practice ranging from < 5 years (31.11%) to > 15 years (31.11%) (5 – 10 years: 23.70%; 11 – 15 years (14.07%). Additionally, respondents reported seeing JSpA patients annually for 0 visits (4.48%), 1 – 10 visits (43.28%), 11 – 30 visits (38.81%), and > 30 (13.43%).

Less than half (42.98%) of respondents said they assess for enthesitis at every visit regardless of symptoms of the JIA subtype. 52.07% reported they assess for enthesitis at every visit for certain JIA subtypes. 21.49% reported assessing enthesitis only at visits where patients report symptoms concerning for enthesitis.

When asked what would lead to a routine assessment of enthesitis, providers’ top responses were patients with ERA (92.6%), HLA B27 associated conditions such as uveitis, psoriasis, and inflammatory bowel disease (86.8%), JPsA (85.1%), new patients with concern for JIA (80.1%0, and undifferentiated JIA (75%).

The survey revealed 4% of respondents use an established enthesitis scoring measure. Despite this low percentage, 83.3% of respondents said they would be interested in the creation of a scoring tool for pediatric patients. Most respondents (75.86%) said the main reason they did not use an established measure was because they were not familiar with it, although nearly a quarter (24.14%) reported using an established measure was too time-consuming.

The most assessed sites were in the lower extremities with the Achilles tendon (100%). The survey also showed the most concerning features for enthesitis were tenderness (100%), swelling (81.7%), and pain with motion, heel walking, or squatting (73.9%). When evaluating enthesitis, most participants (93.04%) reported applying pressure with thumb until nail bed blanches, although 9.57% reported using a point-of-care ultrasound.

Overall, most providers were interested in a pediatric-specific enthesitis scoring system. Investigators said the next step is to develop a pediatric enthesitis scoring tool to standardize enthesitis evaluation.

“There are different adult tools or measures for assessing enthesitis and those tools look at different entheses and so we want to try to standardize which entheses are being assessed in the pediatric population,” Treemarcki said. “We know the CARRA registry tracks enthesitis, and we really have a numerator without a dominator. Our hope is that if we standardize which entheses are being assessed, if we standardize how many are being checked, we’d have a better understanding of how active the enthesitis component is.”

Relevant disclosure for Treemarcki includes SOBI, INC.

References

^{Treemarcki, E, Tse, S, Klein-Gitelman, et al. Assessment of Enthesitis by Pediatric Rheumatology Providers. Presented at ACR Convergence 2024 in Washington DC from November 14 – 19, 2024.}