Intra-articular steroids could speed up OA progression

The long held practice of injecting patients with steroids every few months to relieve the pain of knee osteoarthritis should be ‘actively discouraged’ say Australian experts after findings from a US study show that long term steroid use may in fact speed up disease progression.

The findings published in JAMA this week, reveal that patients with knee osteoarthritis (OA) who had received injections of a corticosteroid every three months over two years were left with significantly greater cartilage volume loss and no significant difference in knee pain compared to control group patients who received a saline injection.

The US researchers said their findings indicate that patients with knee OA are unlikely to benefit from corticosteroid injections but concede that patients may have experienced short-term relief, which could have been missed by the timing of their pain measurement assessments.

Rheumatologist and Chair of the Institute of Bone and Joint Research at the University of Sydney, Professor David Hunter told the limbic the findings ‘fly in the face’ of current guideline recommendations about the use of intra-articular steroids for knee OA, which generally support its short-term use.

He said the study will be a ‘wake up call’ for many doctors.

“There are lot of implications here for clinicians – this is a practice so commonly used in a pattern consistent with what happened in this trial.”

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While Professor Hunter said it was unclear at this stage to know just how clinically significant the magnitude of cartilage loss experienced in the treatment group would be compared to the placebo group, he said it is a measure that predicts joint replacement and worse clinical outcomes.

“A lot of clinicians use this practice religiously every three months in their osteoarthritis patients for years on end.  And sure, you might get a short-term benefit from steroids – and that has been shown in other trials – but, over the long term, there is no clinical benefit and you may actually be making your patients worse.”

As for whether there is any sub group of patient who would benefit from the practice, Professor Hunter said it was unlikely however he was clear to make the distinction between short-term use versus long-term.

“If you derive a short term benefit over three months, great but this religious practice of repeated injections over a long period of time, that’s not a strategy you want to go for.  Based on this study I would suggest that we would probably need to be discouraging that behaviour.”

According to Professor Hunter work done in cell and animal studies seem to suggest that steroids may be toxic to the cells that help create cartilage tissue and can cause cartilage cell death.

“There is reasonable pre clinical evidence to suggest that steroids are probably deleterious to the joint and this study is potentially confirming that. I think we really need to be cautious about this practice.”

Also speaking to the limbic, rheumatologist and head of the Musculoskeletal Research Group at the Menzies Institute for Medical Research, Professor Graeme Jones said he would continue to offer the injections to patients already on joint replacement waiting lists but said he would reconsider his advice about the therapy to other patients.

“Before this study we’d tell patients, steroids help symptoms but probably don’t do much for progression. Now were going to have to tell our patients that you may get short term benefit in terms of symptom relief but that comes at the cost of speeding up the structural progression.

“In the absence of a really large study looking at knee replacement you would infer that this might be bad in terms of knee replacement.”

Meanwhile Professor Hunter said strategies like weight management and exercise, use of bracing and other assisted devices like orthotics and canes as well as topical and oral anti inflammatories should be considered instead of injected steroids.

“There’s a long list of better, alternative strategies that we should be thinking about over a longer period in terms of managing a disease that, on average lasts a patient about 30 years. Repeated use of intra articular steroids is not a long-term strategy.”

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