Pain treatment options for osteoarthritis.

Osteoarthritis is one of the most common diseases of the joints and spine and is characterized by degenerative changes starting in the cartilage. Joint changes cause pain, stiffness, swelling, and a loss of normal joint function. Several international recommendations address the choice of treatment methods for osteoarthritis. However, because there is still no effective causal treatment leading to a remission of the disease, this is a complex issue. Even the possibilities of effective but safe treatment of pain, which is the most common problem accompanying osteoarthritis, are very limited. All current international recommendations for the treatment of osteoarthritis agree on the crucial role of non-pharmacological treatment and the choice of a comprehensive approach to the treatment of osteoarthritis. Pharmacological treatment includes non-opioid analgesics, opioids, symptomatic slow-acting osteoarthritis drugs, or intra-articular corticosteroids. A new trend is to maximize the potential of existing analgesics by combining them. Using drugs from different classes with complementary mechanisms of action provides a better opportunity for effective analgesia at reduced doses of individual agents. The use of fixed combinations is also advantageous.

Injectable therapies for knee osteoarthritis.

Knee osteoarthritis is a degenerative arthritis that mainly affects older adults. Over time, osteoarthritis can result in significant and sustained discomfort, pain, and disability. Current treatment focuses on the alleviation of pain and functional impairment. While arthroplasty is the definitive management option, it subjects patients to surgical complications, and the possibility of surgical revisions. In addition, many patients are not surgical candidates. Instead, pharmacological therapy is recommended first-line for most patients. On top of pharmacological therapy, there are a range of non-operative procedural options available. However, leading professional guidelines vary in their recommendations for these agents. Therefore, we present a review of recent randomized controlled trials and meta-analyses on injectable corticosteroids, hyaluronic acid (HA), platelet-rich plasma (PRP), mesenchymal stem cell injections, and ozone therapy. The preliminary data reveal the strongest evidence in favour of corticosteroid injections, although there are promising findings regarding the long-term efficacy of HA and PRP.

Response to intra-articular cortisone injections in knee osteoarthritis patients with and without effusion on ultrasound: A pilot study.

Objective: Inflammation, manifesting as effusion and synovitis, is thought to contribute to pain in knee osteoarthritis (OA). We conducted a pilot study to investigate recruitment feasibility and assess whether effusion on ultrasound of the knee was associated with greater reduction in knee pain after corticosteroid injection. Methods: A pilot study was conducted from 2020 to 2021 including patients ≥40 years with knee OA undergoing clinically indicated corticosteroid injections. At baseline, participants completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) Pain subscale and had an ultrasound of the injected knee(s) to assess for effusion, defined as anechoic material in the suprapatellar recess. KOOS Pain was re-assessed two weeks following injection. We used mixed linear models to evaluate the change in KOOS Pain scores for knees with and without effusion to determine estimates of the magnitude of association. Results: We recruited 10 participants who contributed 16 knees from 4 clinical sessions. The mean age was 68 years (standard deviation [SD] 13) and 90% were female. Six knees had effusion. At baseline, knees without effusion had greater pain (mean KOOS Pain 44, SD 19) compared to those with effusion (mean KOOS Pain 51, SD 15). Knees without effusion had a 6 point (95% CI -16, 28) greater improvement in KOOS Pain 2-weeks post injection compared to those with effusion. Conclusion: This pilot study demonstrated clinic-based recruitment was feasible. We did not observe clinically important or statistically significant differences in pain relief post corticosteroid injection between knee OA patients with or without effusion.

The efficacy and safety of intra-articular injection of triamcinolone acetonide versus triamcinolone hexacetonide for treatment of juvenile idiopathic arthritis.

OBJECTIVES: Juvenile idiopathic arthritis (JIA) is the most common childhood rheumatic disease. Intra-articular corticosteroids joint injection (IAJI), with triamcinolone hexacetonide (TH) or triamcinolone acetonide (TA), is an effective additional treatment for oligo and polyarticular JIA. Previous studies have shown the benefits of TH over TA; however, TA is still used in many pediatric rheumatology centers. Our unit has experience with both regimens, and therefore we aimed to compare the efficacy and safety of TA versus TH for JIA patients. METHODS: Chart review of JIA patients who were randomly (based on drug availability) treated with TA or TH IAJI during 2010-2019. Primary outcomes for efficacy were defined as full recovery from arthritis one month after IAJI and a relapse rate of arthritis 3 months after IAJI. Primary outcome for safety was defined as the occurrence of adverse events (AEs) during the follow up period after IAJI. RESULTS: Overall, 292 joints of 102 JIA patients were treated (138 TA/154 TH joints). Complete recovery after one month was documented in 107 (69.6%) of TA treated joints and 96 (69.5%) of TH treated joints (P = 0.232). However, rate of relapse after 3 months was significantly higher for TA treated joints (27 (20.1%) vs. 13 (8.8%), respectively, P < 0.01). No AEs were documented except minor scars at four joint injection sites. CONCLUSION: The recovery from arthritis was similar (~ 70%) with both regimens, however relapse rate was more than double in TA as compared to TH injected joints. These findings are important due to a contemporary shortage of TH in the US market.

Changes in prescription pain medication and intra-articular corticosteroid utilization after intra-articular bio-fermentation derived hyaluronic acid use in patients undergoing multimodal pain management.

BACKGROUND: Multiple interventions may be used to treat symptomatic knee osteoarthritis (OA), but concerns have been raised about the safety and efficacy of some therapies. Clinical trials have shown that hyaluronic acid (HA) can provide pain relief up to 6 months and possibly to 12 months, while real-world data has shown that pain medication and intra-articular corticosteroid (CS) injection utilization are reduced within 6 months after HA. OBJECTIVE: To examine changes in prescription pain medication and CS utilization during 1 year after multimodal therapy that included high molecular weight, bio-fermentation derived HA (Bio-HA) use for knee OA. METHODS: Commercial and Medicare Supplemental claims data (IBM MarketScan Research Databases) (1 January 2012, through 31 December 2018) was used to identify unilateral Bio-HA patients using multimodal therapy (any combination of CS injection, opioids, and non-opioid pain medication). Monthly therapy utilization was compared in the 12 months after Bio-HA therapy initiation to the 4-month intra-multimodal period. RESULTS: A total of 13,999 patients underwent Bio-HA therapy with concurrent multimodal therapy. The number of filled opioid prescriptions decreased from 2,913.0/month to 2,861.5/month after Bio-HA, with a reduction in mean monthly prescriptions from 0.60 to 0.43 per user (p < 0.001). A number of opioid days supplied also decreased from 48,914/month to 39,730/month, with a decrease from 10.1/month to 6.0/month per user (p < 0.001). Bio-HA patients had prescription pain medication-free days for 71% of the time post-multimodal period compared to 53% during the intra-multimodal period (p < 0.001). The proportion of patients with CS injections after Bio-HA decreased from 53.8% to 29.6% (p < 0.001). Total monthly CS injections decreased from 2,292 to 663. CONCLUSIONS: Our data suggest that high molecular weight Bio-HA, as part of multimodal therapy, may be effective in providing longer-term pain relief with the reduction in pain therapy (CS injections and opioids) and increase in prescription pain medication-free days.

Juvenile idiopathic arthritis in Harlequin ichthyosis, a rare combination or the clinical spectrum of the disease? Report of a child treated with etanercept and review of the literature.

BACKGROUND: Harlequin ichthyosis (HI) is the most severe phenotype of autosomal recessive congenital ichthyosis. Juvenile Idiopathic Arthritis (JIA) represents a heterogenous group of disorders all sharing the clinical manifestation of chronic arthritis. Association of HI and chronic arthritis has been reported in few cases. CASE PRESENTATION: We report the case of a child with HI who developed a severe form of chronic polyarthritis during the first years of life, treated with repeated multiple joint injections, methotrexate and etanercept with good response and without any adverse events. CONCLUSION: The reported case and the literature review highlighted the presence of a peculiar severe seronegative polyarthritis with early onset in a series of patients with HI, suggesting that polyarthritis may be a specific manifestation of HI, rather than a rare combination of two separate conditions.

Risk of adrenal insufficiency following intra-articular or periarticular corticosteroid injections among children with chronic arthritis.

Objectives Intra-articular and/or periarticular corticosteroid injection (IACI) is a common procedure in pediatric rheumatology. Despite many adult studies demonstrating a significant risk of adrenal insufficiency (AI) following the procedure, very little evidence is available in the pediatric literature regarding this risk. The main goal of this study is to evaluate the prevalence of AI in children with chronic arthritis following IACI. Methods This is a retrospective study including children aged 0-18 years who had an IACI from June 2017 to July 2019. An 8:00 morning cortisol (8MC) sample was drawn around two weeks after the injection, and an ACTH 1mcg stimulation test was performed if morning cortisol level was low. AI was defined as an 8MC under 50 nmol/L or an abnormal ACTH stimulation test. Risks factors for AI and its duration were assessed. Results Sixty patients were included in this study. AI prevalence was 30% with 18 of 60 affected patients. The corticosteroid dose injected was statistically associated with the development of AI. Median duration of AI was 181 days for the nine patients who were followed up until resolution of AI. Four patients developed symptoms of AI, namely fatigue (2 of 4), nausea (2 of 4) and abdominal pain (3 of 4). None were hospitalized or died. Conclusions In this cohort of children with chronic arthritis who had an IACI, we found a high prevalence of AI. Monitoring and counseling of such complication is warranted until further evidence is available.

Decrease in opioid and intra-articular corticosteroid burden after intra-articular hyaluronic acid for knee osteoarthritis treatment.

Aim: We studied changes in opioid prescriptions and corticosteroid injection use for knee osteoarthritis patients before and after intra-articular hyaluronic acid (HA) use and opioid prescriptions before and after knee arthroplasty (KA). Materials & methods: A total of 1,017,578 knee osteoarthritis members were ascertained from a commercial claims database (Health Intelligence Company LLC, IL, USA) using ICD9/ICD10 diagnosis codes. Results: Eighty two percent of HA patients did not fill opioid prescriptions postinjection, with 54% of opioid users discontinuing fills. Two-thirds of KA patients filled opioid prescriptions within 6 months postsurgery, with 78% of opioid users continuing fills and 62% of nonusers initiating use. Conclusion: Alternative therapies, such as HA, that reduce opioid use may alleviate opioid addiction risks for KA patients who use opioids in the pre- and postoperative periods.

A comparison of 4-year total medical care costs, adverse outcomes, and opioid/prescription analgesic use for 3 knee osteoarthritis pain treatments: Intra-articular hyaluronic acid, intra-articular corticosteroids, and knee arthroplasty.

OBJECTIVES: To compare the medical costs associated with treatments for knee osteoarthritis (OA): intra-articular corticosteroids (ICS) and intra-articular hyaluronic acid (IHA) primarily, and ICS/IHA vs knee arthroplasty (TKA) secondarily. METHODS: This was a retrospective analysis of an insurance claims database. Eligible members had diagnosed OA and no claims for ICS, IHA, or TKA during the 6-18-month look-back period. Cohorts of interest over the 4-year observation period were: patients who received ICS only, those who received IHA only, and those who received TKA only. Outcomes assessed included: (1) total allowed medical costs, (2) claims for pre-specified, treatment-related adverse outcomes and costs, and (3) opioid and/or prescription analgesic use and costs. Data extraction began on the date of the first ICS, IHA, or TKA in 2013 until December 31, 2017. RESULTS: Of the 260,828 patients who qualified, 126,831 were taking monotherapy (IHA=3703, ICS=117,588, TKA = 5540). Adjusted 4-year per patient per month (PPPM) costs were lowest in the IHA cohort ($733); PPPM costs were $1230 in the ICS cohort and $1548 in the TKA cohort. A smaller percentage of patients in the IHA (7.1%) vs ICS (8.4%) or TKA cohort (11.8%) experienced any of the pre-specified adverse outcomes. Adverse outcome-related costs in the IHA cohort were lower ($19.91) than costs in the ICS ($32.18) and TKA cohorts ($31.12). Per-patient opioid and analgesic prescriptions were consistently and significantly lower in the IHA (range, 0.70-0.96) vs ICS cohort (range, 2.0-2.26) for Years 1 through 4. Usage rates were significantly lower in the IHA cohort vs TKA cohort in Year 1 (0.96 vs 4.77) and not different in Years 2 through 4 (TKA range, 0.76-1.08). In Year 1, opioid and prescription analgesic costs were significantly lower in the IHA vs ICS and TKA cohorts ($3.45 vs $11.14 and $12.82). After Year 1, opioid and prescription analgesic costs were significantly higher in the ICS (range, $13.83-15.96) vs IHA (range, $3.02-3.87) and TKA cohorts (range, $3.43-4.97). CONCLUSIONS: Patients in the IHA cohort had lower total medical care costs, fewer adverse outcomes, and lower use/costs of opioids and prescription analgesics vs patients in the ICS and TKA cohorts. Reducing total medical care costs and minimizing opioid/analgesic use should be a treatment goal when selecting therapies for patients with knee OA.

Joint lavage followed by intra-articular injection of hyaluronic acid and/or corticosteroids in patients with severe hemophilic arthropathy of the knee: Is this intervention really effective?

INTRODUCTION: The aim of this review is to explore the scientific rationale and evidence for a potential benefit of joint lavage followed by intra-articular injection of hyaluronic acid and/or corticosteroids in patients with severe hemophilic arthropathy of the knee (SHAK). Areas covered: This article is a narrative review of the evidence for potential benefits of joint lavage followed by intra-articular injection of hyaluronic acid and corticosteroids in SHAK compared with osteoarthritis of the knee in non-hemophilia patients. Expert commentary: Although some reports on hemophilic arthropathy with a low-grade of evidence seem to indicate a benefit of joint lavage followed by intra-articular injection of hyaluronic acid and/or corticosteroids in patients with SHAK, the short-lived improvements afforded by hyaluronic acid, and the doubtful benefits of corticosteroids and joint lavage in hemophilia, do not warrant their use in hemophilic patients. The scientific rationale of these procedures is poor and they are not recommended.

Recent therapeutic advances in juvenile idiopathic arthritis.

Over the past two decades, the management of juvenile idiopathic arthritis (JIA) has been revolutionized by the increased tendency toward early aggressive interventions and the availability of the novel biologic medications. In 2017, three novel randomized controlled trials have evaluated the effectiveness and tolerability of golimumab and tocilizumab in polyarticular JIA, and shown that methotrexate may increase and prolong the effect of intra-articular corticosteroid injection in children with oligoarthritis. A more rational approach to the management of JIA is being fostered by the recent publication of therapeutic recommendations, consensus treatment plans, and advice for the optimal care. A few months ago, an international consensus effort has led to the development of the recommendations for the treat-to-target in JIA. The application of this strategy in routine care may improve disease outcome. Because the potential of attaining inactive disease in children with JIA has markedly increased, there is an urgent need for randomized controlled trials, analyses of clinical data sets, and expert advice to guide discontinuation of medications once complete disease quiescence has been achieved.