Hyaluronic acid injections relieve knee pain

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Applied Evidence

Hyaluronic acid injections relieve knee pain

J Fam Pract. 2005 September;54(9):758-767

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References

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There are 2 other potential limitations of this meta-analysis. Five studies allowed pain to be treated with analgesics such as acetaminophen or NSAIDs,^12,13,16-18 and use of acetaminophen or NSAIDs may have altered the response to hyaluronic acid treatment. An intention-to-treat analysis was performed in only 2 studies (by Altman and Huskisson),^16,18 wherein a post-hoc and “last observation carried forward” analysis showed a trend favoring hyaluronic acid. The treatment effects may have been smaller had the other trials used an intention to treat analysis.

This meta-analysis confirms that viscosupplementation with hyaluronic acid is modestly effective in short term relief of pain in knee osteoarthritis. Our meta-analysis included only double-blinded, randomized trials published in English language in humans using VAS as the pain outcome measure, and our conclusions are very similar to those of Lo.²

Indications for use. Hyaluronic acid is helpful in relieving pain for carefully selected patients with knee osteoarthritis who have not responded to adequate use of systemic therapeutic agents, including acetaminophen, NSAIDs and COX-2 inhibitors and topical agents, along with lifestyle modification such as weight reduction and exercise.

Patients should have a trial for at least three months of conservative therapy or be unable to tolerate NSAIDs before a decision to give 3- to 5-injection course with hyaluronic acid is made.

Hyaluronic acid may be an option when there is a need to delay knee surgery in middle-aged persons¹ or for patients who have failed other treatments.

Time to pain relief. To improve adherence to treatment, tell patients receiving intra-articular hyaluronic acid that the benefits in pain reduction may not be noticeable until 5 to 10 weeks after the last injection.

Cost. Although the cost of hyaluronic acid treatment is covered by Medicare and most insurance plans for symptomatic osteoarthritis of knee, documentation in patient medical records should indicate the signs and symptoms supporting the diagnosis and functional impairment. Objective data to support a diagnosis of osteoarthritis such as x-ray, arthroscopy report, computed tomography scan, or magnetic resonance imaging should be available in the event of a review.

The cost of 1 hyaluronic acid (30 mg/mL) injection is approximately $230. Considering a course of 3 to 5 weekly knee injections, and adding other pharmacy, hospital, or clinic charges, the cost per treatment may exceed $1000 per knee.^26,27 The cost-benefit of pain control with viscosupplementation must be carefully compared with other therapeutic agents and regimens currently available for knee osteoarthritis management.

FIGURE 3
Studies evaluated at outcome measurement time (week 1)

Egger’s publication bias plot for the studies evaluated at outcome measurement time (week 1) not significant (+2.3, P=0.096, 95% CI: –0.5, +5.2).

Acknowledgments

Jeff Welge, PhD, University of Cincinnati Medical Center, Center for Bio-statistical Services, for comments on final data analysis and presentation, Marie Marley, PhD for editing the manuscript, and Charity Noble for help in preparation of this manuscript.

CORRESPONDING AUTHOR
Arvind Modawal, MD, MPH, MRCGP, University of Cincinnati Department of Family Medicine/Geriatrics, PO Box 670582, Cincinnati, OH 45267-0582. E-mail: modawaa@fammed.uc.edu