VISCOSUPPLEMENTATION, CORTISONE AND NON STEROIDAL ANTI-INFLAMMATORY DRUGS:

“What Works and How to Keep it Safe”

 

William D. Stanish, M.D.,F.R.C.S.(C),F.A.C.S.

Professor of Surgery

Dalhousie University

Director, Orthopaedic and Sport Medicine

Clinic of Nova Scotia

Halifax, Nova Scotia

 

Viscosupplementation in the Treatment of Osteoarthritis

 

#1     Hyaluronan in both articular tissues and synovial fluid plays a critical role in contributing to joint homeostasis and maintaining normal function. It has been recognized for many years that in osteoarthritis the molecular weight and concentration of hyaluronan is diminished.

 

#2.    Recognition that there is altered synthesis of hyaluronan by synovial sites in osteoarthritis, led to the concept of viscosupplementation.

 

#3     Viscosupplementation was first used to treat post traumatic osteoarthritis in race horses in the early 1970's. It has been used to treat human osteoarthritis in some countries since 1987.

 

#4     Most studies of viscosupplementation with hyaluronan have shown them to be better than placebo and as effective as non steroidal anti-inflammatories in the treatment of osteoarthritis.

 

#5     There are two classes of hyaluronan based products currently available for clinical use. Low molecular weight hyaluronan (0.5 - 1.2 MW) and hylan molecular weight. In general, the higher the molecular weight of hyaluronan product, the longer it resides in the joint.

 

#6     Recent controlled randomized clinical trials confirm that five weekly intraarticular injections of hyaluronan in patients with osteoarthritis are generally well tolerated, provide sustained relief of pain and improved patient function, and were as at least as effective with fewer adverse reactions as continuous treatment with Naproxen for 26 weeks.

 

#7     There is accumulating evidence from animal models of osteoarthritis that hyaluronan based therapy may be chondro protective.

 

References:

  1. Marshall, KW. Viscosupplementation for Osteoarthritis:”Current Status, Unresolved Issues and Future Directions”. Viscosupplementation: A new concept in the treatment of arthritis. J. of Rheumatology, 1993. Suppl. 39, 3-9.  Marshall, KW.  The Current Status of Hyalan Therapy for the Treatment of Osteoarthritis. Today's Therapeutic Trends, 1997. 15:99-108.
  2. Lussier, A. et al. Viscosupplementation with Hyalan for the Treatment of Osteoarthritis. Findings from clinical practice in Canada. J. of Rheumatology, 1996. 23:1579-1585.
  3. Altman, RD et al. lntra-articular Sodium Hyaluronate in the Treatment of Patients with Osteoarthritis of the Knee. A randomised clinical trial.  J. of Rheumatology, 1998. 25:11: 2203-2212.
  4. Smith, MM, Ghosh, P. The Synthesis of Hyaluronic Acid by Human Synovial Fibroblosts is inluenced by the Nature of Hyaluronate in the Extra Cellular Environment.  Rheumatological J. lnternational, 1987. 7: 113-122.
  5. Ghosh P. The Role of Hyaluronic Acid in Health and Disease: lnteractions with cells, cartilage and components of the synovial fluid.  Clinics In Experimental Rheumatology, 1994. 12: 75-82.

 

Intra- and Peri-articular Use of Corticosteroids in the Knee and Shoulder

 

#1     There are few clinical indications for the use of intra-articular steroids in  chronic osteoarthritis.

 

#2     Theoretically corticosteroids might inhibit cartilage formation and repair: this has been found in animal studies when injected in very high doses.

 

#3     Osteoarthritis has been recognized to have an inflammatory component since the turn of the 19th century; more recent studies continue to corroborate this fact.  As such, intra-articular steroids could in theory slow or halt the disease process.  In the dog model of osteoarthritis, intra-articular steroids reduced the severity of cartilage lesions as well as the size and number of osteophytes.

 

#4     A few blinded controlled trials have demonstrated a statistically significant decrease in subjective pain perception with steroids at one week after injection of Triamcinolone.  However, at 4 or more weeks follow-up, differences between control and treatment cases had resolved.

 

#5     lntra-articular steroids have a role in managing the acute exacerbation of osteoarthritis.  They may offer significant short term relief and any concerns regarding detrimental effects in the articular cartilage are academic, particularly in the patient that is nearing total knee arthroplasty. .

 

References:

  1. The intraarticular and Periarticular Use of Corticosteroids in the Knee and Shoulder. Clinical J. of Sports Medicine, 1994. 4:155-159.
  2. Dieppe PA, Sathapatayavongs B, Jones HE, et al. Intra-articular steroids in osteoarthritis. Rheumatol Rehabil, 1980. 19(4):221-217.
  3. Doyle DV. Tissue calcification and inflammation in osteoarthritis. J. Pathol, 1982. 136(3):199-216.
  4. Friedman DM, Moore ME. The effect of intra-articular steroids in osteoarthritis: a double-blind study. J. Rheumatol, 1980. 7(6):850-856.
  5. Jones AK, Al-Janabi MA, Solanki K, et al. In vivo leukocyte migration in arthritis. Arthritis Rheum, 1991. 34(3):270-275.
  6. Pelletier JP, Martel-Pelletier J. In vivo protective effects of prophylactic treatment with tiaprofenic acid or intra-articular corticosteroid on osteoarthritic lesions in the experimental dog model. J. Rheumatol, 1991. 18(suppl 27):127-130.

 

Nonsteroidal Anti-Inflammatory

 

#1     The tissue response to injury initiates a cascade consisting of inflammation and hyperalgesia.  After a nauseous stimulus, peripheral nerves release prostaglandins, substance P and related peptides.

 

#2     The resultant prostaglandin mediated inflammatory process is characterized by vasodilation, increased vascular permeability, followed by hyperalgesia.

 

#3     Traditionally the analgesic properties of NSAIDs have been attributed to their effects on the peripheral synthesis of prostaglandins.  This would cause a decrease in the inflammatory response to injury, reducing pain perception.

 

#4     Recent in vivo animal studies suggest that the central response to painful stimuli may be modulated by NSAID inhibition of prostaglandin synthesis.

 

#5     Therefore it has been suggested that NSAIDs can reduce both acute pain and the subsequent hyperalgesia response via central mechanisms.

 

We may conclude that NSAIDs “will continue to be used commonly in Sports Medicine and their use can neither be condemned or strongly recommended.  The prudent Sports Medicine practitioner must weight the benefits and risks of the use of NSAIDs and decide for each injury whether these drugs should be given”.

 

Reference:

  1. Souter AJ, Fredman B, White PF. Controversies in the Perioperative Use of Nonsteroidal Anti-inflammatory Drugs. Anesth. Analg. 1994. 79:1178-1190.

 

  1. Weiler JM. Clinics in Sports Medicine. July 1992. 11(3):625-641.

 

 

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