Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions
Intra-Articular Triamcinolone for Knee Osteoarthritis
JAMA; 2017 May 16; McAlindon, LaValley, et al
Two years of intra-articular triamcinolone resulted in significantly greater cartilage volume loss and no significant difference in knee pain when compared with intra-articular saline among patients with symptomatic knee osteoarthritis, a recent study found. The 2-year randomized, placebo-controlled, double-blind clinical trial included 140 patients (mean age 58 years, 75 women) randomized to either intra-articular triamcinolone 40 mg (n=70) or saline (n=70) every 12 weeks. Patients were enrolled at Tufts Medical Center beginning February 11, 2013 and all completed the study by January 1, 2015. Researchers found:
- Intra-articular triamcinolone resulted in significantly greater cartilage volume loss vs saline for a mean change in index compartment cartilage thickness of -0.21 mm vs -0.10 mm and no significant difference in pain (-1.2 vs -1.9).
- The saline group had 3 treatment-related adverse events; the triamcinolone group had 5 and a small increase in hemoglobin A1c levels.
McAlindon TE, LaValley MP, Harvey WF, et al. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with Knee osteoarthritis. A randomized clinical trial. JAMA. 2017;317(19):1967-1975. doi:10.1001/jama.2017.5283.
This study supports the long-held concern that repeated exposure to corticosteroids will hasten cartilage degradation (at least in disease-oriented measurements of cartilage volume) in the setting of osteoarthritis of the knee. The effect on a patient’s long term function and pain remains unclear. This study suggests that corticosteroids provide no pain benefit, yet the injection type (1 mL of triamcinolone vs. 1 mL of saline), as well as the injection interval (every 3 months, scheduled), do not correlate with the clinical practice of most. This study measured pain at 3-month intervals. The best evidence supporting corticosteroid benefit is in the first 6 weeks and corticosteroid benefit past 13 weeks has great variability across studies.1 Clinicians should help patients weigh the risk of cartilage degradation with the pain benefit in choosing this intervention for knee osteoarthritis. As with any intervention, we should continually assess the effectiveness and discontinue use when the benefit subsides. —Susan K. Fidler, MD