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No progression of osteoarthritis with corticosteroid injections

Presented by
Dr Justin J. Bucci, Boston University School of Medicine, USA
ACR 2020
A study presented during the meeting found that corticosteroid injections do not accelerate progression to total knee replacement compared with hyaluronic acid injections.

A recent cohort study suggested a 3-fold higher risk for knee osteoarthritis (OA) progression with the use of corticosteroid (CS) injections, a popular treatment recommended by guidelines. Recipients of CS injections might have more advanced knee OA, which in itself is a risk factor for OA progression, making a comparison of those undergoing CS injections to those who do not questionable, despite statistical adjustments.

Therefore, the current study aimed to explore whether CS injections are associated with increased rates of knee OA progression compared with hyaluronic acid (HA) injections that have not been associated with cartilage loss [1]. “The treatment options for knee OA are limited. Steroid injections are considered a safe and effective intervention for relieving pain from knee OA. Clinicians and patients need to know if steroid injections are making knee OA worse,” Dr Justin J. Bucci (Boston University School of Medicine, USA) explained. Therefore, Dr Bucci and his coworkers used data from 2 large cohort studies of people with knee OA (MOST and OAI) who received either CS or HA injections. They reviewed the rates of radiographic progression and total knee replacement surgery. Patients in the first cohort had medical visits every 12 months, and those in the second cohort had visits every 30 months. Their exams included knee X-rays and questions about their CS or HA injections over the previous 6 months. Knee OA progression was assessed with Kellgren and Lawrence grades (KL) 0-4 and joint space narrowing (JSN) 0-3 in both studies. In OAI, medial joint space (JWS250) was also measured.

Patients with very advanced OA progression (baseline KL 4 score) and those who had received either CS or HA injections in the past were excluded from the study. X-rays from each patient’s medical visits before their first injection were compared to those taken after their last injection. Annualised deterioration rates were calculated for KL, JSN, and JWS250. Multivariable linear regression was used to adjust for known risk factors of OA, including age, sex, BMI, and baseline KL grade.

The researchers analysed 792 knees, including 647 treated with CS injections and 145 with HA injections. They found that the rate of total knee replacement surgery was greater among patients with a single exam in which they reported HA injection compared with those with a single exam in which they reported CS injection (P=0.04). There was no difference between patients reporting injections at multiple exams. Multivariable analysis showed similar rates of X-ray progression for both kinds of injection treatment at either single or multiple medical exams.

The authors concluded that CS injections for knee OA were not associated with a higher rate of radiographic progression or progression to a total knee replacement compared with HA injections. Future research will focus on MRI of knees undergoing treatment with CS injection for OA to better understand its effect.

  1. Bucci JJ, et al. Progression of knee OA with use of intra-articular corticosteroids vs hyaluronic acid. P1652, ACR Convergence 2020, 5-9 Nov.

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