Joint corticosteroid injection for knee osteoarthritis
J Am Osteopath Assoc. When choosing the optimal drug or drug combination for IA injection, the experience of each doctor, and individual factors e. To determine the benefits and harms of intra-articular corticosteroids compared with sham or no intervention in people with knee osteoarthritis in terms of pain, physical function, quality of life, and safety.
Acknowledgements The authors contributed equally to this work This review was not supported by grants The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the review The authors hereby certify that all work contained in this review is the original work of Tommaso Iannitti, Daniele Lodi, and Beniamino Palmieri All the data from other articles, including tables and figures, have been referenced The authors claim full responsibility for the contents of the article. When the joint loses cartilage, the body responds by growing bone abnormally, which can result in the bone becoming misshapen and the joint painful and unstable. Data collection and analysis: We combined trials using an inverse-variance random-effects meta-analysis. Current as of August 21, The injections are given into the anterior part of the subacromial bursa, while the intra-articular local anesthetic injections are used as a diagnostic test for impingement. Corticosteroid injections for osteoarthritis of the knee:
The duration of effect in this preparation is only 5 weeks. The commonly recommended entry in the diary is pain vs. A majority of professionals in the field of pain management support the use of intra-articular steroid injections for the treatment of pain that arises due to osteoarthritis of the hip. However, another section of experts indicate that the use of intra-articular steroid injections for the hip may accelerate arthritis progression or may even increase infections after subsequent total hip arthoplasty.
Intra-articular Steroid Injections for the Hip Introduction Intra-articular steroid injections are a prescribed line of treatment for relief from joint-pain. Research Findings Research indicates that the intra-articular steroid injections delivered for relief from the pain related to hip osteoarthritis can produce highly effective results as compared to the standard form of treatment. Hip Osteoarthritis Intra-articular steroid injections are extensively used for treating the pain associated with hip osteoarthritis.
Steroid injections are often successfully used along with: Physical therapy Weight reduction programmes NSAIDs Topical and opioid analgesics Education The intra-articular steroid injections are an effective remedy for decreasing pain and swelling quickly. Types and Forms There are various types of preparation of steroids that have a different duration of effect and action. Selection of preparation to be used for the injection is done, after careful consideration of the extent of the problem and patient history.
This is to confirm whether the pain is relieved by the injection. Once done, an iodinated contrast is injected to observe immediate distribution of the steroid and local anaesthetic and confirm which joints are being treated. In addition, it has been pointed out that HA may relieve pain and improve function in patients with hip OA Moderate improvements in pain and function were reported for 3—6 months after HA injection, with no serious adverse events observed.
The efficacy and safety of IA corticosteroids in the treatment of knee OA was evaluated by Bellamy et al. Comparing corticosteroids with HA products, no statistically significant differences were detected at 1—4 weeks post-injection, according to the Cochrane systematic review.
WOMAC osteoarthritis index, Lequesne Index, pain, range of motion flexion , and number of responders In one study,[ 83 ] there was also a between-group difference in the range of motion flexion at 14 and 26 weeks that was in favor of HA, but no differences in efficacy were detected at 45—52 weeks In general, HA products and IA corticosteroids had a similar onset of effect, but HA products had a more durable response.
In the Cochrane systematic review,[ 82 ] comparisons between various IA corticosteroids showed that triamcinolone hexacetonide was superior to betamethasone with regard to the number of patients reporting pain reduction up to 4 weeks post-injection Comparisons between IA corticosteroid and joint lavage showed no differences in any of the efficacy or safety outcome measures.
In another systematic literature review conducted in , the efficacy including duration of action of IA corticosteroid injections in reducing pain caused by knee OA was assessed This review analyzed data from six trials reported in five articles that compared IA corticosteroids with placebo, and four articles that compared different IA corticosteroids The review observed that IA corticosteroids were associated with reductions in knee pain that lasted for at least 1 week It concluded that IA corticosteroids can only be considered as a short-term treatment for a chronic problem Two of four trials showed triamcinolone to be more effective in pain reduction than the other corticosteroids assessed.
The development of techniques that cause multipotent adult mesenchymal stem cells MSCs to differentiate into cells of the chondrogenic lineage have led to new insights in the attempt to restore the damaged cartilage in OA patients It has been proposed that MSCs may be used as progenitor cells to engineer cartilage implants that can be used to repair chondral and osteochondral lesions, and as trophic producers of bioactive factors to initiate endogenous regenerative activities in the OA joint.
Anakinra, a recombinant IL-1 receptor antagonist, at a dose of 50 or mg was well tolerated as a single IA injection in a multicenter, double-blind, placebo-controlled study involving patients with OA of the knee However, over a week follow-up period, the drug was not associated with improvements in OA symptoms compared with placebo.
In a phase II, randomized, partially-blind clinical trial, patients aged 50—75 years with primary knee OA were randomized to one of the following five IA therapies: The best treatment for OA is not yet clear, and an early diagnosis still plays a key role in the management of this condition Current OARSI Osteoarthritis Research Society International recommendations for the optimal management of patients with hip or knee OA were summarized by Zhang et al.
The recommendations are as follows: In the past, OA was not considered an inflammatory disorder, but nowadays it is associated with several inflammatory mediators Finding a way to modulate these inflammatory mediators could lead to new insights into the treatment of this pathologic condition see figure s1 in the Supplemental Digital Content. Although some active compounds are rapidly cleared from the OA joint, meaning that multiple injections are required with the subsequent potential for an increased incidence of adverse effects e.
Because IA injection is an invasive procedure, it has the disadvantage of being painful and putting the patient at risk of infection. When choosing the optimal drug or drug combination for IA injection, the experience of each doctor, and individual factors e.
Among various treatment choices oral, parenteral, or IA drugs , viscosupplementation with hyaluronans seems to be a promising option for the treatment of OA sections 2. HA plus corticosteroid therapy should form part of the short-term treatment plan for OA in order to take control of the acute inflammatory process as soon as possible Fixing a bandage to the joint and rest should complete the procedure In the follow-up, and depending on results from the SF examination and the local and general symptoms, the doctor should select the best procedure to repair or regenerate the synovial membrane and cartilage, preventing or delaying further relapse episodes At this time, HA alone or in combination with other compounds containing methotrexate, biphosphonates, somatostatin, NSAID, or biotechnologic products, should be selected, with administration frequency and dosages being determined according to the physiopathology of the disease and instrumental imaging of the process at follow-up.
In summary, IA HA has numerous restorative effects in patients with acute or chronic joint disease In our opinion, to achieve the most effective outcome, an individually tailored approach should be taken for each case For this reason, further investigation into different HA formulations including crosslinked and non-crosslinked formulations , and their synchronous or metachronous association with other compounds, is of importance. The authors contributed equally to this work This review was not supported by grants The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the review The authors hereby certify that all work contained in this review is the original work of Tommaso Iannitti, Daniele Lodi, and Beniamino Palmieri All the data from other articles, including tables and figures, have been referenced The authors claim full responsibility for the contents of the article.
National Center for Biotechnology Information , U. Journal List Drugs R D v. Published online Nov This article has been cited by other articles in PMC. Abstract Osteoarthritis OA , also called degenerative joint disease, is the most frequently occurring chronic musculoskeletal disease, particularly affecting the aging population.
Introduction The principal forms of chronic arthritis can be grouped as follows: Risk factors involved in the osteoarthritic process. Discussion The best treatment for OA is not yet clear, and an early diagnosis still plays a key role in the management of this condition Current OARSI Osteoarthritis Research Society International recommendations for the optimal management of patients with hip or knee OA were summarized by Zhang et al.
Acknowledgements The authors contributed equally to this work This review was not supported by grants The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the review The authors hereby certify that all work contained in this review is the original work of Tommaso Iannitti, Daniele Lodi, and Beniamino Palmieri All the data from other articles, including tables and figures, have been referenced The authors claim full responsibility for the contents of the article.
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This result is statistically significant. We found no results for pain 16 weeks after injection. A funnel plot of the six studies suggested that there was an absence of small studies with small effects fig 5. The smallest study had 12 patients and the largest Improvements at weeks after high dose steroid injection in knee for two high quality studies. A similar result was found for improvement up to two weeks for the high dose studies.
The effect at 16 to 24 weeks for these studies was the same as the two high quality studies. It was not possible to make a definitive analysis of the clinical conditions of the knee. The patients seemed to have mainly mild to moderate osteoarthritis. The dose equivalent to prednisone varied from 6. Intra-articular injections of corticosteroid improve symptoms of osteoarthritis of the knee. Effects were beneficial up to two weeks and at 16 to 24 weeks.
This is the first meta-analysis on this topic and the first review to show benefits of such injections in improvement of symptoms, which may extend beyond 16 weeks. We also report clinically significant numbers needed to treat, ranging between 1. The one study that investigated potential loss of joint space found no difference between corticosteroid and placebo up to two years.
Responses to intra-articular corticosteroids injections vary between the clinical experience of rheumatologists, where some patients have a significant and sustained response, to the short term benefit shown by randomised controlled trials.
One limitation of our review is possible publication bias, in that by missing unpublished trials or those that showed negative effects we may have overestimated the benefits of corticosteroid injections. We believe, however, that our comprehensive, systematic search strategy enabled us to identify most research in this discipline. Another limitation of our study was the small size of the included studies.
Unlike other reviews we report improvement in symptoms, as we believe this is a more important patient oriented outcome than increases in range of movement or pain reduction. The dose of corticosteroid required to improve symptoms is not clear from our review. The equivalent dose of prednisone varied from 6. Only one study used 40 mg triamcinolone, and this found a benefit at 24 months for night pain and stiffness on one scale but not on another.
The three studies that reported improvement at 16 weeks used different cortisones. The two studies using high doses showed a statistically significant difference suggesting that higher dose steroids may give a longer benefit. One study found that predicting benefit was not possible. Another explanation is that the presence of knee effusion is correlated with the presence of synovitis and that intra-articular steroids my be effective against the inflammation.
Evidence supports short term up to two weeks improvement of symptoms from intra-articular corticosteroid injection for osteoarthritis of the knee, and the only methodologically-sound studies addressing longer term response weeks also show significant improvement.
Doses of 50 mg equivalent of prednisone may be needed to obtain benefits at 16 to 24 weeks. Corticosteroid injection in addition to lavage needs further investigation. Currently no evidence supports the promotion of disease progression by steroid injections. Repeat injections seem to be safe over two years but needs confirmation from other studies. Intra-articular corticosteroids provide short term two weeks relief of symptoms of osteoarthritis of theknee.
Intra-articular corticosteroids are probably effectivein improving symptoms of osteoarthritis of the knee for16 to 24 weeks. Higher doses of cortisone equivalent to 50 mg prednisone may be more effective than lower doses, especially after16 or more weeks. Contributors BA and FG-S were involved in extracting the data, appraising the article, and writing the paper.
BA did the mathematical pooling; he will act as guarantor for the paper. The guarantor accepts full responsibility for the conduct of the study, had access to the data, and controlled the decision to publish.
Bruce Arroll , associate professor b.
Iamges: intra-articular steroid injection for osteoarthritis
Pure high molecular weight hyaluronan was first developed by Balazs[ 71 ] in the s It was known as non-inflammatory fraction sodium hyaluronan NIF-NaHA and was marketed for use in ocular surgery Hyaluronan was injected into the joints of racehorses for traumatic OA with effective results,[ 72 ] leading to the first use of viscosupplementation for human knee OA in the early s.
Only one study investigated potential loss of joint space and found no difference between corticosteroid and placebo up to two years. The duration of effect in this preparation is only 5 weeks. Authors of included studies were contacted for details of any further work.
Int J Exp Pathol. Intra-articular corticosteroids provide short term two weeks intra-articular steroid injection for osteoarthritis of symptoms of osteoarthritis of theknee. The potential role of vascular endothelial growth factor vegf in cartilage: The use of viscosupplementation, i. We found no evidence of an effect of corticosteroids on quality ibjection life compared to control SMD
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