Viscosupplement for knee arthritis
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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Viscosupplements are lubricants used to treat ostweoarthritis. Hyalgan was one of the first available injectable hyaluronon supplements.
Hyaluronon is a polysaccharide composed of glucuronic acid and N-acetylglucosamine. It is produced by chondrocytes and synovial cells. It acts as a lubricant as well as shock absorber in the joint. Since it is poorly absorbed orally, it has been used as an intra articular preparation. The use of intrarticular hyaluronon has been called “viscosupplementation” because it has been felt that these preparations restore normal viscoelastic properties to synovial fluid that has been changed due to pathologic changes from osteoarthritis.
Other proposed mechanisms of action include: suppression of matrix metalloproteinases, removal of oxygen free radicals, anti-inflammatory effect, and possibly, disease-modifying benefits.
While the use of intraarticular hyaluronon was approved by the FDA for use in human beings in 1997, it has been used to treat arthritis in horses for at least 25 years.
Hyalgan (sodium hyaluronate) is a low molecular weight hyaluronic acid replacement therapy. Among other viscosupplements are Synvisc, Supartz, and Orthovisc. These latter drugs all have higher molecular weights than Hyalgan. All of these viscosupplements are purified preparations of hyaluronon extracted from rooster combs… with the exception of Synvisc. Synvisc is chemically cross-linked with formaldehyde and vinylsulfone. In addition, Euflexxa, another viscosupplement, is bioengineered from bacterial cells.
We have used both Hyalgan as well as Supartz for approximately 25 years.
We have employed viscosupplements primarily for osteoarthritis of the knee but have used it in other joints as well including the shoulder, the fingers, and the base of the thumb. It has also been used for osteoarthritis of the hip. Imaging techniques such as ultrasound and fluoroscopy are mandatory in order to ensure proper placement of the viscosupplement within the synovial cavity.
Viscosupplements in our practice are generally used after a patient has failed at least one glucocorticoid injection.
Hyalgan and Supartz are administered as intra articular injections one week apart for a total of five weeks. Some practitioners give only three but in our experience five injections have better efficacy. Hyalgan and Supartz are approved for five injections, Synvisc for three, and Orthovisc for three. A new Synvisc preparation is now approved for a single injection.
Patients can undergo retreatment as frequently as every 6 months. Generally, if a patient has failed a course of viscosupplementation, they will not respond to another course.
Viscosupplements are generally safe. There is the advantage that viscosupplements are a local therapy- they do not have systemic effects. This is the advantage they may have over NSAIDS.
Viscosupplements are not inexpensive; however, most insurance plans will cover the use of these preparations.
In addition to cost, a few other drawbacks should be mentioned. Synvisc has been associated with “pseudoseptic” reactions. This is a condition where the knee joint swells and becomes inflamed. The appearance is that of a septic joint. The theory is that this particular preparation causes a chemical synovitis. It happens in 2 % to 8 % of patients given Synvisc. In our early days of Synvisc use we saw this occur in two of our patients. As a result, we switched to exclusive use of Hyalgan and Supartz.
Again, All viscosupplements injections must be administered using ultrasound guidance to ensure proper placement!
One relative contraindication to the use of the natural preparations is a sensitivity or allergy to eggs, feathers, and other chicken products.
Other contraindications are those that are appropriate for any patient being considered for an intra articular injection.
Viscosupplements may not be as useful for patients with severe knee OA (K-L stage 4), malalignment of the knees, and significant obesity.
Viscosupplement therapy should also be accompanied by other therapies for osteoarthritis of the knee including anti-inflammatory medication (if needed), physical therapy, and bracing.
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