A common injection for treating arthritis could escalate the onset of the disease rather than prevent it, according to recent studies, which showed that compared with patients who received an injection of hyaluronic acid or no treatment at all, patients receiving corticosteroids shots had significantly more knee osteoarthritis progression.
In one study, hyaluronic injections showed a decreased progression of knee arthritis, specifically in bone marrow lesions, and the second study found that patients who received corticosteroid jabs had significantly more medial joint space narrowing.
Both studies were presented this week at the annual meeting of the Radiological Society of North America, reports Fox News.
Knee osteoarthritis is a chronic, degenerative and progressive condition with an estimated incidence of 800 000 patients each year. More than 10% of patients with knee osteoarthritis seek non-invasive treatment for pain relief through corticosteroid or hyaluronic acid injections.
Researchers in both studies chose cohorts from the Osteoarthritis Initiative, a multicentre, longitudinal, observational study of nearly 5 000 participants with knee osteoarthritis currently in its 14th year of follow-up.
In the first study, researchers at the University of California-San Francisco included 210 osteoarthritis Initiative participants, 70 of whom received intra-articular injections, and a control group of 140 who did not receive injections during a two-year period. Of the 70 patients who received injections, 44 were injected with corticosteroids, and 26 were injected with hyaluronic acid. The treatment and control groups were matched by age, sex, body mass index, pain and physical activity scores, and severity of disease.
MRI was performed on all patients at the time of the injection and two years before and after. The MRI scans were assessed using whole-organ magnetic resonance imaging score (WORMS), a grading system for knee osteoarthritis that focuses on the meniscus, bone marrow lesions, cartilage, joint effusion and ligaments.
The researchers identified osteoarthritis progression by comparing the imaging scores from the initial scans and two-year follow-up scans.
“This is the first direct comparison of corticosteroid and hyaluronic acid injections using the semi-quantitative, whole organ assessment of the knee with MRI,” said Dr Upasana Upadhyay Bharadwaj, a research fellow in the Department of Radiology at UCSF.
Statistical analysis showed that corticosteroid knee injections were significantly associated with the overall progression of osteoarthritis in the knee, specifically in the lateral meniscus, lateral cartilage and medial cartilage.
Hyaluronic acid knee injections were not significantly associated with the progression of osteoarthritis in the knee. Compared to the control group, the group who received hyaluronic injections showed a decreased progression of osteoarthritis, specifically in bone marrow lesions.
“While both corticosteroid and hyaluronic acid injections are reported to help with symptomatic pain relief for knee osteoarthritis, our results conclusively show that corticosteroids are associated with significant progression of knee osteoarthritis up to two years’ post-injection and must be administered with caution,” Bharadwaj said.
“Hyaluronic acid, on the other hand, may slow down progression of knee osteoarthritis and alleviate long term effects while offering symptomatic relief.”
In the second study, researchers at the Chicago Medical School of Rosalind Franklin University of Medicine and Science conducted a case-control study comparing the radiographic progression of osteoarthritis in patients who received injections of corticosteroids and hyaluronic acid.
“While these injections provide some patients with short-term pain relief, the effects of the injections on the progression of the disease are unknown,” said researcher and medical student Azad Darbandi.
Darbandi’s team selected a cohort of 150 patients with similar baseline characteristics from the Osteoarthritis Initiative database, including 50 patients who received corticosteroid injections, 50 who received hyaluronic acid injections, and 50 who were not injected over a 36-month time period. The groups were matched by sex, body mass index and X-ray findings.
Patients underwent X-ray imaging of the knee at baseline and two years later. The researchers analysed the X-ray imaging, including joint space narrowing, formation of bone spurs, and bone thickening around the knee cartilage.
Compared to patients who received an injection of hyaluronic acid or no treatment at all, patients injected with corticosteroids had significantly more osteoarthritis progression, including medial joint space narrowing, a hallmark of the disease.
“Even though imaging findings for all patients were similar at baseline, the imaging hallmarks of osteoarthritis were worse two years later in patients who received corticosteroid injections compared to patients who received hyaluronic acid injections or no treatment at all,” Darbandi said. “The results suggest that hyaluronic acid injections should be further explored for the management of knee osteoarthritis symptoms, and that steroid injections should be used with more caution.”
“Knowing the long-term effects of these injections will help osteoarthritis patients and clinicians make more informed decisions for managing the disease and the pain it causes,” Bharadwaj said.
Study 1 details
Medial Joint Space Narrowing and Kellgren-Lawrence Progression following Intraarticular Corticosteroid Injections compared to Hyaluronic Acid Injections and Nontreated Patients
Presented on 29 November at Radiological Society of North America Annual Meeting
Purpose
Osteoarthritis (OA) is a common degenerative disorder with an increasing global prevalence and economic burden, accounting for 4.3% of all hospitalisation costs in the US. Radiographic progression of knee OA has been shown to correlate with poor clinical outcomes. Currently, corticosteroid (CS) injections and hyaluronic acid (HA) injections are given for symptomatic treatment of osteoarthritis. However, the long-term effect of intra-articular joint injections on OA progression is heavily debated. To better understand the possible effect, we conducted a case-control study comparing the radiographic progression of OA in CS, HA, and control patients by using the data from the OA Initiative.
Methods and materials
A total of 7 314 knees were identified based on the presence of imaging at baseline and 48-months. After exclusion criteria, 210 knees were identified that received CS injections, 59 HA injections, and 6 827 control. 50 patients per group were matched for various confounding factors including age, sex, BMI, comorbidities, surgery, and semi-quantitative imaging outcomes at baseline. ANCOVA testing was done using 48-month semi-quantitative imaging outcomes as dependent variables and confounding variables as covariates. Imaging outcomes included joint space narrowing, Kellgren Lawrence (KL) grade, osteophyte formation in tibia/femur medial/lateral compartment, and sclerosis in tibia/femur medial/lateral compartment.
Results
At 48-months, average KL grade in the CS group was 2.79±.832, HA 2.11±1.35, and control 2.37±1.202 (p
Clinical relevance/applications
Corticosteroid injections increase the radiographic progression of osteoarthritis when compared to hyaluronic acid injections and non-treated patients, suggesting caution in the use for clinical management.
Study 2 details
Impact of Intra-Articular Knee Injections on the Progression of Knee Osteoarthritis: Data From the Osteoarthritis Initiative (OAI) Cohort
Presented on 29 November at Radiological Society of North America Annual Meeting
Purpose
To evaluate the association between the type of intra-articular knee injection (corticosteroid, hyaluronic acid) and progression of knee osteoarthritis (OA) compared to controls, assessed semi-quantitatively using whole-organ magnetic resonance imaging scores (WORMS) over two years.
Methods and materials
Participants (n=60: 36 female, age 62.2 [45.0, 79.0] years, BMI 28.3 [18.9, 38.3] kg/m2) from the Osteoarthritis Initiative (OAI) cohort who received a single injection of corticosteroid (n=8), hyaluronic acid (n=12), and controls (n=40) propensity-score matched on age, sex, BMI, KellgrenLawrence (KL) grade, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Physical Activity Scale for the Elderly (PASE) were selected at the timepoint when the injection was administered. 3T MRIs obtained at baseline, two years prior, and two years after the injection were semi-quantitatively graded using WORMS for the meniscus, bone marrow lesions, cartilage, joint effusion, and ligaments. Progression of OA was quantified using the difference in WORMS between baseline and two-year follow-up. Linear regression models, adjusted for age, sex, BMI, KL grade, WOMAC, PASE, were used to identify association between the type of injection (corticosteroid vs controls, hyaluronic acid vs controls) and progression of WORMS. A p-value < 0.05 was considered statistically significant. Results Significant association was found between corticosteroid injection and post-injection progression of WORMS over two years for the knee overall (p=0.03), lateral meniscus (p=0.02), lateral cartilage (p=0.03), and medial cartilage (p=0.002). No significant association (p > 0.05) was found between hyaluronic acid injection and post-injection progression of WORMS over two years. No significant association was found between either injection type and progression of pain over two years quantified by WOMAC (p > 0.05). No significant difference (p > 0.05) was found in progression of WORMS over the two years prior to injection for corticosteroid and hyaluronic acid injections.
Conclusions
Corticosteroid knee injections were significantly associated with the progression of knee OA assessed semi-quantitatively using WORMS as an outcome. Hyaluronic acid knee injections, however, did not show a significant association with the progression of knee OA.
Clinical relevance/applications
While both corticosteroid and hyaluronic acid injections are said to help with symptomatic pain relief in knee OA, in this study, hyaluronic acid injections did not show any progression of knee OA up to 2 years’ post-injection while progression was demonstrated with corticosteroid injections.
Study presentations at Radiological Society of North America (Open access)
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