medwireNews: Recurrent intra-articular corticosteroid injections (IACIs) are often inferior to other injectables, including placebo, for the long-term improvement of pain, function, and quality of life (QoL) in people with osteoarthritis (OA), meta-analysis data suggest.
“Whilst the RCTs [randomized controlled trials] demonstrated improvements from baseline in pain, function, QoL, stiffness and radiographical attributes for recurrent IACIs beyond three months and up to 24 months, in many cases, the comparators (including placebo) demonstrated an equal or superior effect, or the effect attenuated at the maximal duration of follow-up,” write Richard Donovan (University of Bristol, UK) and co-authors in Osteoarthritis and Cartilage.
They identified 10 RCTs that compared individuals who received recurrent (two to eight) IACIs with those who received other injectables or placebo for between 6 and 24 months. Eight of the studies were among people with knee OA (n=763) and two were among people with trapeziometacarpal OA (n=121).
For the people with knee OA, four studies compared IACIs with hyaluronic acid, one used platelet-rich plasma (PRP) as an active comparator, one used the anti-inflammatory agent orgotein, and two studies used saline as a placebo comparator.
For those with trapeziometacarpal OA, the comparators were hyaluronic acid and PRP in one study each.
The researchers report that, at 3 months, there was no significant difference in VAS knee pain scores between people who did and did not receive IACIs (standardized mean difference [SMD]=0.33 points). However, at 6 and 9 months, there were significantly greater improvements among patients who received comparator injections relative to those who were given IACIs, at SMDs of 1.05 and 2.06 points, respectively.
By 12 months, the difference between the two groups was attenuated (SMD=0.83 points) and was smaller still at 24 months (SMD=–0.01 points).
For knee function, assessed using the WOMAC function scale (in three studies) or the Lequesne functional index (in two studies), both groups reported improvements between 3 and 12 months, but the response was significantly greater – peaking at 9 months – with the comparator injections than with the IACIs, at SMDs of 0.82 to 3.52. At 24 months, there was no significant difference between treatment groups.
A similar pattern was seen for QoL in patients with knee OA, assessed using the 36-Item Short Form Survey score, with significantly greater improvements in the comparator versus IACI arms at both 3 and 6 months.
The two studies among patients with trapeziometacarpal OA showed similar outcomes.
A subgroup analysis of the studies that compared IACIs with saline found that the active treatment provided no significant benefits in terms of pain or function at 12 or 24 months.
Donovan et al note that “none of the included studies assessed important longer-term outcomes such as the systemic side-effects of recurrent IACIs, whether recurrent IACIs accelerate OA, the time-to-future surgical interventions (e.g., arthroscopy or arthroplasty), or the risk of future prosthetic joint infection.”
They therefore conclude: “Future research should seek to identify whether recurrent IACIs pose significant long-term harms.”
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Osteoarthritis Cartilage 2022; doi:10.1016/j.joca.2022.07.011