Intra-Articular Corticosteroid and Hyaluronic Acid Injections in the Management of Osteoarthritis
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78 Review / Derleme Intra-Articular Corticosteroid and Hyaluronic Acid Injections in the Management of Osteoarthritis Osteoartrit Tedavisinde ‹ntraartiküler Kortikosteroid ve Hyaluronik Asit Enjeksiyonlar› G. Guy VANDERSTRAETEN, Martine De MUYNCK, Luc Vanden BOSCCHE, Tina DECORTE Ghent University Hospital, Department of Physical Medicine and Rehabilitation, Ghent, Belgium Summary Özet Intra-articular corticosteroid injections have long been used to treat oste- Eklem içi kortikosteroid enjeksiyonlar› osteoartrit tedavisinde uzun sü- oarthritis, whereas intra-articular hyaluronic acid injections for only a few reden beri kullan›lmaktad›r. Oysa eklem içi hyaluronik asit injeksiyonlar› years. In the literature, evidence-based reports on the efficacy of these sadece son y›llarda kullan›l›r hale gelmifltir. Literatürde bu ajanlar›n et- compounds are non-existent. In the presence of acute hydrops in an oste- kinli¤i aç›s›ndan kan›ta dayal› raporlar bulunmamaktad›r. Osteoartritli oarthritic knee an intra-articular corticosteroid injection following aspirati- bir dizde akut efüzyon varl›¤›nda eklemden aspirasyonu takiben eklem on of the joint can be considered. A maximum of 3 injections can be admi- içi kortikosteroid uygulamas› düflünülebilir. 8-10 günlük aralar ile en faz- nistered at intervals of 8 to 10 days, to be repeated every 6 months if ab- la 3 enjeksiyon uygulanabilir ve e¤er çok gerekli ise her 6 ayda bir tek- solutely necessary. A patient with a dry and painful osteoarthritic knee can rarlanabilir. Kuru ve a¤r›l› bir diz ise haftal›k aralar ile uygulanan eklem be a candidate for intra-articular hyaluronic acid injections at weekly inter- içi hyaluronik asit enjeksiyonu için aday olabilir. Gereksinime göre uygu- vals, every 6 months if need be. There is a need for a clear consensus abo- lamalar 6 ayda bir tekrarlan›r. Osteoartrite ba¤l› olarak geliflen monoart- ut the management of monoarthritis consequent upon osteoarthritis. In ritlerin tedavisinde aç›k bir konsensuse ihtiyaç vard›r. Bu yaz›da mevcut the present paper a practical approach is proposed, based on the availab- literatür ›fl›¤›nda pratik bir yaklafl›m önerisinde bulunulmaktad›r. Türk le literature. Turk J Phys Med Rehab 2005;51(3):79-82 Fiz T›p Rehab Derg 2005;51(3):79-82 Key Words: Intra-articular corticosteroids, intra-articular hyaluronic Anahtar Kelimeler: ‹ntraartiküler kortikosteroidler, intraartiküler acid, osteoarthritis hyaluronik asit, osteoartrit Introduction synovial membrane inflammation. In this way an attempt was made to alleviate the complaints and halt the progression of the Intra-articular (IA) corticosteroid injections have long been disease. IA corticosteroids were frequently administered for the used to treat osteoarthritis, whereas IA hyaluronic acid injecti- symptomatic treatment of peripheral joint osteoarthritis. Most ons for only a few years. Unfortunately, in the literature, eviden- of the studies deal with osteoarthritis of the knee. This also app- ce-based reports on the efficacy of these compounds are non- lies to the evidence-based literature. existent. There is a need for a clear consensus about the mana- Different forms of IA corticosteroids exist, based on the che- gement of monoarthritis consequent upon osteoarthritis. mical structure and solubility. Hydrocortisone is the most physi- In the present paper a practical approach is proposed, based ological of all available corticosteroids. Prednisolone is less solub- on the available literature. le. The addition of a methyl group to obtain methylprednisolone diminishes the solubility to some extent and may prolong the du- 1. Intra-Articular Corticosteroid Injections ration of effectiveness. The introduction of a fluoro atom incre- ases the pharmacological activity. It can be postulated that the Already in 1930 IA injections were used for the treatment of more complex the molecule, the less soluble and the longer it is osteoarthritis in order to directly address cartilage damage and retained in the joint. Fluoridated molecules have the strongest Yaz›flma Adresi: Dr. G. Guy Vanderstraeten-Ghent University Hospital Department of Physical Medicine and Rehabilitation, De Pintelaan 185/P5, B 9000, Ghent, Belgium Tel: 0032-9-2402234 Faks: 0032-9-2404975 e-posta: [email protected] Kabul Tarihi: Temmuz 2005 Türk Fiz T›p Rehab Derg 2005;51(3):79-82 Vanderstraeten et al. Turk J Phys Med Rehab 2005;51(3):79-82 Intra-Articular Corticosteroids and Hyaluronic Acid 79 action (1). Nevertheless, IA corticosteroids do not remain in place al, meticulous skin disinfection and judicious use. for a long time. A systemic effect is also present. The depression A variety of systemic effects can occur. In the musculoskele- of endogenous plasma cortisol after an IA corticosteroid injecti- tal system these include muscle weakness and atrophy, steroid on may last three to four weeks (2). The anti-inflammatory acti- myopathy, avascular necrosis, and osteoporosis. Gastrointestinal on of each product in relation to an equivalent dose must also be systemic effects are peptic ulcer, abdominal distension and taken into account. The anti-inflammatory effect of betamethaso- pancreatitis. Fluid and electrolyte disturbances have also been ne and dexamethasone is 20 to 25 times greater than that of described and are characterized by sodium retention, potassium hydrocortisone. The most commonly available 1 ml vials contain depletion, hypokalemic alkalosis and hypertension. Endocrinolo- an equivalent dose. The short-acting water-soluble forms are ra- gical systemic effects include irregular menses, Cushing syndro- pidly absorbed into the blood stream and consequently have mo- me, reactivation of latent diabetes, dysregulation of diabetes re systemic effects. The long-acting crystalline depot preparati- mellitus, and growth inhibition. Dermatologically, delayed wound ons slowly release the corticosteroid and have less systemic ef- healing, skin atrophy, petechiae and ecchymoses, striae, hirsu- fects. Mixed preparations also exist. The injected dose usually de- tism, hyperpigmentation and acne are observed. The ophtalmo- pends on the size of the joint. For the knee, ankle or shoulder jo- logical effects include glaucoma, exophtalmia and posterior sub- int 1 ml vial is sufficient, for a medium-size joint (wrist) half of a capsular cataract. Corticosteroids can also mask an infection or vial, and for smaller a quarter of a vial is adequate. activate a latent infection and diminish the resistance to myco- IA corticosteroids are administered to reduce local inflam- bacteria, Candida albicans, tuberculosis and viruses. mation. The principal effect of glucocorticoids is the increased Evaluation of the literature data production of certain proteins, mainly lipocortin. Its anti-inflam- Papers on the use of IA corticosteroids for osteoarthritis are matory action is based on the inhibition of phospholipase A2, mainly confined to the knee. Corticosteroid injections for rhe- which converts membrane phospholipids into arachidonic acid umatoid arthritis or juvenile rheumatoid arthritis, and facet joint with a subsequent intracellular production of prostaglandins, le- injections are beyond the scope of this review. ukotrienes and oxygen radicals (3). Stimulation of lipocortin pro- In a systematic review paper on IA corticosteroids for oste- duction inhibits the pro-inflammatory cytokine production, inc- oarthritis of the knee, a minor advantage and pain reduction las- luding interleukin-1, interleukin-2, interferon-α, tumor necrosis ting from one week to one month, were found compared to pla- factor, etc. (4). Glucocorticoids inhibit the synthesis of pro-inf- cebo (6). lammatory enzymes, like collagenase, elastase and plasminogen In a randomized clinical trial (7) 89 patients with osteoarth- activator (5). ritis of the knee underwent joint aspiration followed by a stero- Indications and contra-indications id injection, with a beneficial effect on pain and functional index IA corticosteroid injections are frequently used to treat a fla- in the short term (four weeks). re of osteoarthritis with hydrops, or posttraumatic synovitis. Ot- In a more recent meta-analysis (8) corticosteroids were fo- her indications include early retractile capsulitis of the shoulder, und to have a positive effect on the symptoms for two weeks. rheumatoid arthritis, and even crystal monosynovitis, although The dose was equivalent to 6.25 to 80 mg prednisolone. The ef- corticosteroids are definitely not the first choice for this last fect also remained positive in the long term. A significant condition. symptomatic improvement was obtained after 16 to 24 weeks General contra-indications for IA corticosteroids are local or ge- with a dose equivalent to 50 mg prednisolone. neralized infection, immune deficiency, coagulation disorders, The authors mentioned a possible positive effect of publica- prostheses and a pregnancy of less than 16 weeks. Relative contra- tion bias. indications are diabetes and a pregnancy of more than 16 weeks. In two systematic review papers (9,10) the use of IA corticos- Side effects teroid injections for shoulder pain was evaluated. Compared to IA corticosteroid injections may have a number of side ef- placebo, no advantage with respect to pain reduction and impro- fects, of which facial flushing is the most common (up to 40%). vement of the range of motion was found. In a randomized clini- It is benign, self-limiting, and disappears within 24 to 48 hours, cal trial Snels (11) et al. treated 37 patients with three IA triamci- but