No Evidence that Intra-articular Corticosteroids Are Effective in Treating Hand Osteoarthritis

A review in Drugs & Aging has found no evidence that intra-articular (IA) corticosteroids or hyaluronic acid (HA) are more effective than placebo in treating carpometacarpal (CMC) and interphalangeal (IP) osteoarthritis (OA).

Hand osteoarthritis (OA) is relatively common among men and women over the age of 70, and there are no treatments that modify the disease course. Thus, symptom alleviation through the use of assistive devices, splints, and NSAIDS is the typical aim for therapy. “Local treatment could be an attractive treatment modality, especially in elderly patients with more comorbidities,” the study authors note.

One such treatment is the injection of corticosteroids into the affected joint, which may decrease inflammation and consequently relieve the symptoms of OA. Those perceived benefits, however, come with side effects such as infectious arthritis and cartilage damage. Another well-known intra-articular treatment is the injection of hyaluronic acid in the osteoarthritic joint (commonly called viscosupplementation).

Viscosupplementation is based on the physiologic importance of hyaluronan in the synovial fluid, and it is hypothesized that this can restore the reduced viscoelasticity of the synovial fluid in osteoarthritic joints and thus decrease pain, improve mobility and restore the natural protective functions of hyaluronan in the joint. “Experts do not yet agree on the usefulness of this form of intra-articular therapy, since EULAR guidelines specify that intra-articular hyaluronan may be useful in treating thumb-base OA, whereas ACR guidelines conditionally recommend not using intra-articular hyaluronates,” the researchers note.

A literature review using the Cochrane tool identified 13 trials of 864 patients, comparing either corticosteroids or hyaluronic acid (HA) versus placebo (n = 4 and n = 3), and corticosteroids versus HA (n = 6). Single studies investigated infliximab, dextrose, and different HAs. The overall risk of bias was unclear or high in most trials, according to the reviewers. Meta-analysis of two trials comparing corticosteroids with placebo in CMC OA showed no improvement in pain [mean difference −3.56, 95% confidence interval (CI) −13.87 to 6.75, scale 0—100). HA also appeared not efficacious compared with placebo in CMC OA. One trial comparing corticosteroids with placebo in IP OA demonstrated significantly improved pain during movement, but no convincing evidence for efficacy of corticosteroids or HA over the other or alternative therapies was found.

“For patients with CMC OA, intra-articular injections with corticosteroids or hyaluronic acid do not seem to be more effective than placebo, although in the short term these treatments are probably not associated with important adverse events other than local side effects,” the reviewers concluded. “Despite the apparent beneficial safety profile of intra-articular treatments, at least in short-term use, which would suggest an interesting treatment option for clinicians treating elderly patients, the lack of efficacy discourages the use of these treatments for hand OA. More well-performed studies investigating these therapies in this patient group are unlikely to substantially change this conclusion.”