Efficacy of triamcinolone hexacetonide vs. methylprednisolone acetate intraarticular injections in knee osteoarthritis

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SCIENCE
Efficacy of triamcinolone hexacetonide vs. methylprednisolone acetate intraarticular injections in knee osteoarthritis
Key Take-Away: 
  • Pain relief and functional improvement can be achieved after a single injection of both steroid preparations {Triamcinolone hexacetonide (TH) and Methylprednisolone acetate (MA)} and be sustained for as long as 24 weeks.
  • Intraarticular (IA) TH and MA injections are equally effective in treating knee osteoarthritis (OA).

OA is the most common chronic joint disease in the world. Symptomatic knee OA occurs in about 6% of adults aged 30 years or older and its prevalence increases with aging. Significant morbidity results from this condition, leading to pain and disability in over 3.6% of the global population and posing knee OA management as a significant healthcare challenge.

ABSTRACT: 
Background: 

OA is the most common chronic joint disease in the world. Symptomatic knee OA occurs in about 6% of adults aged 30 years or older and its prevalence increases with aging. Significant morbidity results from this condition, leading to pain and disability in over 3.6% of the global population and posing knee OA management as a significant healthcare challenge. The main goals of the symptomatic treatment of knee OA are to promote pain relief and functional improvement.

In this regard, analgesics and nonsteroidal anti-inflammatory drugs (NSAID) may fail to achieve a clinical response, and IA corticosteroid injections can be considered. In fact, there is a large body of evidence on the effectiveness of IA corticosteroid injections, particularly in short term.

Rationale behind research

IA corticosteroid injections are broadly used in knee OA. However, there is still controversy in choosing the most effective preparation.

  • Objective

To compare the efficacy of TH and MA injections in knee OA.

Methods: 

 

Study outcomes

  • Primary Outcome: Pain assessment in the targeted knee by VAS ranging from 0 (no pain) to 100 mm (unbearable pain) at week 4
  • Secondary Outcome:
  • Patient’s pain assessment by VAS at weeks 12 and 24
  • Patient’s global assessment (PtGA) and physician’s global assessment (PGA) of disease by VAS
  • PtGA of disease by Likert scale (LS) with following categories: very well, well, fair, bad and very bad
  • Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire with overall score ranging from 0-96 points.
  • Lequesne index (LI) with overall score ranging from 0-24 points.
  • Outcome measures in rheumatology clinical trials and osteoarthritis research society international (OMERACT-OARSI) response criteria defined by improvements from the baseline in patient’s assessment of pain (VAS) or in WOMAC physical function sub score ≥ 50% with absolute changes ≥ 10 mm in at least 2 of the following 3 measures: the patient’s assessment of pain (VAS), the WOMAC physical function sub score and PtGA of the disease.

Time points

  • Efficacy: Baseline and 4th week, 12th week and 24th week after IA injection
  • Adverse events: 4th week, 12th week and 24th week after IA injection
Results: 

 

Outcomes

  • Baseline: Baseline demographic and clinical characteristics were similar between treatment groups.
  • Primary outcome:
  • There was no significant difference between TH and MA groups in pain assessment by VAS at week 4 (p = 0.352)
  • Improvement in pain from baseline was observed in both groups at week 4 (p<0.001) and sustained in the following 20 weeks with no statistical difference between week 4, week 12, and week 24 evaluations (p=0.272 for both groups)
  • Secondary outcome:
    • There was no significant difference between TH and MA groups in PtGA and PGA of disease by VAS at any study visit (p=0.94 and p=0.54)
    • An improvement from baseline in PtGA and PGA was observed for both groups. However, a statistically significant difference in PtGA of disease was observed for both treatments from week 4 to week 24 (p=0.020 for TH group, and p=0.013 for MA group)
    • No differences between TH and MA groups were observed in PtGA of disease by LS (p=0.86)
    • No significant difference between treatments in total WOMAC score (p=0.23)
    • Improvements in LI were similar between TH and MA groups during the study (p=0.69). Both treatments led to a significant difference between baseline and week 4 distributions (p<0.0001).
    • OMERACT-OARSI criteria of response: There was no significant difference between TH and MA group responses according to OMERACT-OARSI criteria in the study (p=0.54). The response rate at week 4 was 74% in the TH group and 72% in MA group, rates that were sustained until the end of study.
    • Adverse events: There was just one adverse event in MA group, which was post injection arthritis in the day following the procedure, characterized by pain, swelling, redness and joint effusion. No adverse effect was reported in TH group.
Conclusion: 

Intraarticular TH and MA injections are equally effective in treating symptomatic knee OA.Our results differ than RA studies, where the superiority of TH compared with MA was demonstrated.

Intraarticular TH and MA injections are equally effective in treating symptomatic knee OA.Our results differ than RA studies, where the superiority of TH compared with MA was demonstrated. This study showed equal efficacy of both TH and MA in reducing knee pain and promoting function improvement in knee OA. Further research is needed to focus on predictors of response to corticosteroid knee injections.

 

J Rheumatol. 2015 Sep;42(9):1677-84.
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