Intraarticular corticosteroid for treatment of osteoarthritis of the knee
Editorial Group: Cochrane Musculoskeletal Group
Published Online: 19 APR 2006
Assessed as up-to-date: 31 DEC 2005
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Bellamy N, Campbell J, Welch V, Gee TL, Bourne R, Wells GA. Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD005328. DOI: 10.1002/14651858.CD005328.pub2.
- Publication Status: Edited (no change to conclusions)
- Published Online: 19 APR 2006
Osteoarthritis (OA) is a common joint disorder. In the knee, injections of corticosteroids into the joint (intraarticular (IA)) may relieve inflammation, and reduce pain and disability.
To evaluate the efficacy and safety of IA corticosteroids in treatment of OA of the knee.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2003), MEDLINE (to January (week 1) 2006 for update), EMBASE, PREMEDLINE (all to July 2003), and Current Contents (Sept 2000). Specialised journals, trial reference lists and review articles were handsearched.
Randomised controlled trials of IA corticosteroids for patients with OA of the knee: single/double blind, placebo-based/comparative studies, reporting at least one core OMERACT III outcome measure.
Data collection and analysis
Methodological quality of trials was assessed, and data were extracted in duplicate. Fixed effect and random effects models, giving weighted mean differences (WMD), were used for continuous variables. Dichotomous outcomes were analysed by relative risk (RR).
Twenty-eight trials (1973 participants) comparing IA corticosteroid against placebo, against IA hyaluronan/hylan (HA products), against joint lavage, and against other IA corticosteroids, were included.
IA corticosteroid was more effective than IA placebo for pain reduction (WMD -21.91; 95% confidence interval (CI) -29.93 to -13.89) and patient global assessment (the RR was 1.44 (95% CI 1.13 to 1.82)) at one week post injection with an NNT of 3 to 4 for both, based on n=185 for pain on 100 mm visual analogue scale (VAS) and n=158 for patient global assessment. Data on function were sparse at one week post injection and neither statistically significant nor clinically important differences were detected.
There was evidence of pain reduction between two weeks (the RR was 1.81 (95% CI 1.09 to 3.00)) to three weeks (the RR was 3.11 (95% CI 1.61 to 6.01), but a lack of evidence for efficacy in functional improvement.
At four to 24 weeks post injection, there was lack of evidence of effect on pain and function (small studies showed benefits which did not reach statistical or clinical importance, i.e. less than 20% risk difference). For patient global, there were three studies which consistently showed lack of effect longer than one week post injection. However, all were fairly small sample sizes (less than 50 patients per group). This was supported by another study which did not find statistically significant differences, at any time point, on a continuous measure of patient global assessment (100 mm VAS).
In comparisons of corticosteroids and HA products, no statistically significant differences were in general detected at one to four weeks post injection. Between five and 13 weeks post injection, HA products were more effective than corticosteroids for one or more of the following variables: WOMAC OA Index, Lequesne Index, pain, range of motion (flexion), and number of responders. One study showed a difference in function between 14 to 26 weeks, but no differences in efficacy were detected at 45 to 52 weeks. In general, the onset of effect was similar with IA corticosteroids, but was less durable than with HA products.
Comparisons of IA corticosteroids showed triamcinolone hexacetonide was superior to betamethasone for number of patients reporting pain reduction up to four weeks post injection (the RR was 2.00 (95% CI 1.10 to 3.63). Comparisons between IA corticosteroid and joint lavage showed no differences in any of the efficacy or safety outcome measures.
The short-term benefit of IA corticosteroids in treatment of knee OA is well established, and few side effects have been reported. Longer term benefits have not been confirmed based on the RevMan analysis. The response to HA products appears more durable. In this review, some discrepancies were observed between the RevMan 4.2 analysis and the original publication. These are likely the result of using secondary rather than primary data and the statistical methods available in RevMan 4.2. Future trials should have standardised outcome measures and assessment times, run longer, investigate different patient subgroups, and clinical predictors of response (those associated with inflammation and structural damage).
Plain language summary
Intraarticular corticosteroid for osteoarthritis
Osteoarthritis (OA) is the most common form of chronic arthritis worldwide. Intraarticular (IA) corticosteroid products provide opportunity to treat OA in individual knee joints. To evaluate the efficacy, effectiveness and safety of IA corticosteroid products in knee OA, we have conducted a systematic review using Cochrane methodology. The analyses support the contention that the IA corticosteroid class of products is superior to placebo. The response is generally rapid, but may not be sustained in the longer term. Hyaluronic acid (HA) products, while slower in onset of action, may have a more sustained duration of benefit. The types of patients who may potentially benefit from IA corticosteroid versus HA therapy may differ. In general, sample size restrictions preclude any definitive comment on the safety of the IA corticosteroid class of products; however, within the constraints of the trial designs employed, no major safety issues were detected. Overall, the aforementioned analyses support the use of the IA corticosteroid class of products in the treatment of OA knee.
搜尋包括Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2003), MEDLINE (to January (week 1) 2006 for update) MBASE, PREMEDLINE (all to July 2003), and Current Contents (Sept 2000)。同時手動搜尋專業雜誌及所選回顧文章之參考文獻。
28個研究包含1973例病患於分析中，包括關節內注射類固醇與安慰劑、hyaluronan/hylan (HA products)、關節腔沖洗、其它關節內注射類固醇之比較。關節內注射類固醇比安慰劑減少疼痛(WMD −21.91; 95% CI −29.93 to −13.89)及一週後病患整體評估RR 1.44 (95% CI 1.13 to 1.82)，NNT 3到4﹝100 mm VAS疼痛n = 185； 病患整體評估n = 158﹞。注射後一週之功能改善資料少，且無統計及臨床上差異。在兩週到三週之疼痛減少相對風險分別為1.81 (95% CI 1.09 to 3.00)及3.11 (95% CI 1.61 to 6.01)，但功能改善無證據。注射4到24個月後，在疼痛及功能無證據顯示有效果﹝小型研究顯示有益處，但未達統計或臨床顯著改善20% 以上﹞。病患整體評估方面，有3篇顯示注射一週後缺乏效果，但皆為小樣本每組小於50人之研究。另一篇以100 mm VAS為連續變項研究也顯示無顯著改善。關節內注射類固醇與hyaluronan/hylan (HA)比較注射後1到4週無統計顯著差異。注射後5到13週後，HA在以下變項中至少一項比關節內注射類固醇有效：WOMAC OA Index, Lequesne Index，疼痛，活動範圍(彎曲)，及有反應病人數目。有1篇顯示注射14到26週後功能有改善，但45到52週後無顯著改善。整體而言，開始有效時間相似，但HA注射效果比較持久。類固醇注射4週後疼痛改善triamcinolone hexacetonide比betamethasone有效R .00 (95% CI 1.10 to 3.63)。關節內注射類固醇與關節腔沖洗，在效果與安全性方面無顯著差異。
此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。
膝退化性關節炎是常見慢性關節疾病。關節內注射類固醇治療提供治療膝退化性關節炎的機會。整體而言，支持關節內注射類固醇治療膝退化性關節炎比安慰劑好。關節內注射類固醇效果反應快，但不一定持久。Hyaluronic acid (HA)反應較慢，但較持久，兩者有反應的族群可能不同。因樣本數少，限制安全性結論，但在研究中無重大副作用出現。整體而言，支持關節內注射類固醇治療治療膝退化性關節炎。