Intra-Articular Steroids for a Patient With Osteoarthritis Knee Pain: Risks and Benefits

Authors:
Eric A. Dietrich, PharmD, BCPS, and Kyle Davis, PharmD, BCPS

Citation:
Dietrich EA, Davis K. Intra-articular steroids for a patient with osteoarthritis knee pain: risks and benefits. Consultant. 2017;57(7):427-428.

Osteoarthritis (OA) is a common condition, affecting approximately 10% of US men and 13% of US women older than 60 years.¹ The incidence of OA is likely to increase as a result of the aging of Americans and the growing rate of obesity. Other risk factors for OA include female sex, repetitive use of joints, knee injury, bone density, and muscle weakness; treatment of OA involves modification of these risk factors.

Seen most commonly in the knees and hips, OA is often effectively managed with nondrug measures such as physical therapy, strengthening, and stretching. However, chronic use of analgesic medications is often needed to relieve patients’ pain and improve physical function. When medications alone are unable to achieve these goals, therapeutic intra-articular injections for knee OA can be used. While this modality has been widely used, does sufficient evidence support its use as a safe and effective therapy for patients with symptomatic knee OA?

Patient Case

JJ is a 75-year-old man with a past medical history of hypertension, atrial fibrillation, and OA of the left knee. His height is 178 cm, his weight is 113.5 kg, and his blood pressure at this visit is 134/72 mm Hg. He takes lisinopril, 20 mg daily; acetaminophen, 650 mg every 6 hours; and warfarin, 5 mg daily. His international normalized ratio has been well controlled, ranging from 2.1 to 2.6 over the past 6 checks.

JJ’s knee pain had been adequately controlled with acetaminophen, but recently the pain has progressed—he previously had rated it at 4/10 but now rates it at 6/10. Given his concomitant warfarin therapy (among other reasons), JJ cannot take oral nonsteroidal anti-inflammatory drugs (NSAIDs). While topical NSAIDs may be considered, JJ does not have adequate prescription insurance coverage to make these products affordable.

JJ has heard about injections into the knee to help relieve OA pain. Because he would need to discontinue warfarin temporarily for the procedure, he asks whether the potential risks of such a procedure are outweighed by the benefits he could gain.

The Evidence

The practice of therapeutic injections of corticosteroids has been a longstanding procedure to relieve pain and improve functioning in patients with knee OA. The 2012 American College of Rheumatology treatment recommendations for OA of the hand, hip, and knee state that intra-articular corticosteroids may be used in the initial treatment of OA.² Additionally, the use of intra-articular hyaluronate injections is recommended for patients who do not have an adequate response to initial therapies. However, this practice has never been rigorously studied to fully elucidate the short- or long-term benefits of these injections. Earlier this year, the results were published of a recently concluded randomized, double-blind, placebo-controlled trial evaluating the short- and long-term effects of intra-articular corticosteroid injections in patients with symptomatic knee OA.³

The study enrolled 140 patients with evidence of inflammatory knee OA via ultrasonography at baseline. Patients were randomly assigned to receive an injection once every 3 months of either triamcinolone, 40 mg (n = 70), or normal saline (n = 70). In all, 119 patients completed the study; at 2 years, no significant difference was observed between the 2 groups with respect to pain reduction as measured on a 20-point Likert scale (with a 3.84-point reduction in pain score considered clinically relevant). Triamcinolone injections led to a 1.2-point pain reduction, whereas saline led to 1.9-point reduction (between-group difference, −0.6; 95% CI, −1.6 to 0.3). However, pain was assessed 4 weeks after the injections, at which time the effects may have worn off; but this would still have left patients without analgesia for 2 months prior to their next injection.

Annual magnetic resonance imaging scans showed that patients receiving triamcinolone had a reduction in cartilage volume compared with patients receiving saline (between-group difference, −0.11 mm; 95% CI, −0.20 to −0.03 mm). Treatment-related adverse events were more common in the triamcinolone group (n = 5) compared with the saline group (n = 3); there were no differences in serious adverse events between the 2 groups. The most common adverse event was injection-site pain; 1 patient who received saline injections experienced cellulitis that the researchers judged to be related to the injection.

Clinical Application

The results of this study call into question the true benefits of intra-articular injections for symptomatic knee OA. Importantly, the participants were patients who traditionally have been considered the best candidates for corticosteroid therapy—that is, patients with evidence of inflammation. Although pain assessment occurred 4 weeks after the injections and may have occurred after the analgesic effects had worn off, any benefits that were realized would have been short-lived, and patients were left without analgesia for an additional 2 months until their next scheduled injection, thereby limiting the long-term benefits of this treatment. Combined with the apparent increased rate of cartilage breakdown in the group receiving triamcinolone, there does not appear to be any significant advantage to using triamcinolone injections for symptomatic knee OA.

Additionally, because intra-articular administration of medications has inherent risks for all patients, including the risk of infection, providers should take heed before providing any such therapy. Providers should emphasize the use of nonpharmacologic therapies such as physical therapy, as well as the use of medications with favorable safety and efficacy profiles, reserving intra-articular corticosteroids as a last-line option.

While one could argue that acetaminophen lacks consistent demonstrated efficacy for OA pain, the patient in our case reported adequate symptom control with this medication; when used at appropriate doses, the safety profile of acetaminophen provides a significant advantage over other medications.

Outcome of the Case

After discussing the potential benefits and risks of the intra-articular corticosteroid injections with JJ, he has decided to forgo the procedure. You and JJ have decided that a trial of physical therapy is likely the best option. Additionally, you arranged an appointment for JJ with a dietitian to reduce his weight, which might help alleviate the OA pain in his knees. 

Eric A. Dietrich, PharmD, BCPS, is a graduate of the University of Florida College of Pharmacy and completed a 2-year fellowship in family medicine where he was in charge of an anticoagulation clinic. He works for the College of Pharmacy and the College of Medicine at the University of Florida in Gainesville.

Kyle Davis, PharmD, BCPS, is a graduate of the University of Florida College of Pharmacy in Gainesville and completed a 2-year residency in internal medicine at Indiana University in Indianapolis. He is an internal medicine specialist at Ochsner Medical Center in Jefferson, Louisiana.

REFERENCES:

1. Zhang Y, Jordan JM. Epidemiology of osteoarthritis. Clin Geriatr Med. 2010;​26(3):355-369.
2. Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012;64(4):465-474.
3. McAlindon TE, LaValley MP, Harvey WF, et al. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. JAMA. 2017;317(19):1967-1975.