Steroid injection advanced osteoarthritis

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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For osteoarthritis (OA) , multiple treatment modalities have been used to effect relief. Mild OA will respond to relatively mild theraqpies. More severe OA will require more aggressive therapies.

Patients with severe OA often are treated with intraarticular joint injections of steroid. The theory is that local inflammation will be suppressed and pain will be relieved. For the most part, this is true. However, if the OA is very advanced, the benefit of steroid injection will be short-lived.

Steroid injections should not be given more frequently than three times a year per joint.

Guidelines for the treatment of knee osteoarthritis were outlined by a task force for the European League Against Rheumatism (EULAR) Standing Committee for Clinical Trials. The task force recommended intra-articular steroid injection for acute exacerbation of knee pain. This task force performed an evidence-based review and concluded at least 1 randomized control trial recommended intra-articular steroid for patients with osteoarthritis. It was noted that intra-articular steroid injections were effective for only short-term pain relief and that there are no predictors of success of treatment, such as the presence or absence of such factors as joint effusion, degree of radiologic change, age, or obesity.

The American College of Rheumatology Subcommittee on Osteoarthritis Guidelines developed both nonpharmacological and pharmacological recommendations for the treatment of osteoarthritis of the knee. These recommendations include: use of intra-articular steroid injection for patients with acute exacerbations who had evidence for joint inflammation, and joint aspiration accompanying the intra-articular injection for "short-term relief."

Another paper presented at the American College of Rheumatology meeting in 2002 outlines another use for steroid injection. Abstract 1826 Intra-articular Corticosteroid Injection of the Carpometacarpal Joint of the Thumb in Osteoarthritis
GK Meenagh, J Patton, C Kynes, GD Wright
Osteoarthritis has a predilection for several different joints in the appendicular skeleton, including the hip, knee, distal and proximal interphalangeal joints, and the 1st carpometacarpal joint of the thumb. The thumb CMC joint, however, has been the subject of relatively little study compared to the other joint groups, in terms of efficacy of current therapeutic strategies. Nevertheless, osteoarthritic changes at the base of the thumb do result in substantial morbidity and impairment in activities of daily living.

In order to rigorously evaluate the therapeutic benefit associated with steroid injection to this joint site, Meenagh et al performed a prospective randomized double-blind controlled trial. Patients were randomized to receive either intra-articular injection of triamcinolone or sterile water by a second blinded investigator.

At baseline each subject had a full clinical assessment by a blinded investigator. This included analgesic intake in the last week for thumb base pain, physician global assessment (PGA), patient global assessments (PtGA), and patient visual analogue pain score (VAS). The injection procedure was carried out under radiological guidance to ensure accuracy. The thumb was immobilized in a thumb spica splint in both groups for a period of 48 hours. Clinical assessments were repeated at 4 weeks, 3 months and 6 months following injection.

Results: Twenty patients were randomized to each arm of the trial. At baseline, clinical assessments and osteoarthritic changes visualized radiographically were similar in the two groups. During follow-up, the steroid arm of the trial showed no significant difference in PtGA, VAS and analgesic intake between baseline and 24 weeks. Similar results were found in the placebo group. In contrast, physician global assessment in the steroid group did show significant improvement compared to the placebo group. It appears that this trial revealed no appreciable benefit in the eyes of the patient participants, both in terms of pain and global assessment. In contrast, the doctors involved in the trial did perceive benefit associated with steroid injection.

Editorial Comments: The results of this trial point in opposite directions depending upon one’s status as participating patient or treating physician. Whereas there was no apparent benefit by patients from steroid injection of the CMC joint of the thumb, there was significant improvement in physician global assessment with steroid injection.

It is notable that the patient population in this trial did have moderately severe radiographic change at baseline and this may have exerted influence over the response to steroid injection. It is possible that those patients with mild or moderate osteoarthritic changes at the 1st CMC joint would stand to reap greater benefit from steroid injection, in contrast to the patients with more advanced radiographic changes seen in this study

For some patients, injections with viscosupplements (lubricants) might be more effective.

In recent years, the use of platelet-rich plasma (PRP) in OA has found advocates. Regenerative medicine techniques incorporating mesenchymal stem cells and growth factors do help regenerate cartilage.

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