Steroid injections for knee pain linked to worse osteoarthritis progression
A pair of new studies presented at the Radiological Society of North America (RCNA) annual meeting have revealed evidence that corticosteroid injections can hasten progression of knee osteoarthritis. The research, yet to be peer-reviewed and published in a journal, indicates hyaluronic acid injections may be a better pain relief option if available to patients.
A common treatment to relieve severe osteoarthritis pain is injections of corticosteroids. For most patients, these steroid injections can be quite effective at relieving acute pain but over recent years a number of researchers have begun to question the long-term effects of these treatments.
Although some early studies have suggested corticosteroid injections may hasten osteoarthritis progression, the evidence is far from conclusive. Arthritis associations generally recommend these kinds of treatments should be undertaken with caution, and not as a first-line treatment for osteoarthritic pain.
The first new study presented recently, from researchers at the University of California, San Francisco (UCSF), looked at data from participants in a long-term study called the Osteoarthritis Initiative. The researchers compared MRI data from patients receiving either corticosteroid injection or a hyaluronic acid injection to data from a control group receiving neither treatment. MRI images were captured at the time of treatment and again two years later.
Upasana Upadhyay Bharadwaj, from the UCSF Department of Radiology, said the two-year follow up data clearly showed those receiving the steroid injections had greater progression of osteoarthritis in the knee compared to the other two groups. According to Upadhyay Bharadwaj the hyaluronic acid participants interestingly showed slower progression of disease than the control group, suggesting this treatment may offer more long-term benefits while also delivering effective acute pain relief.
“This is the first direct comparison of corticosteroid and hyaluronic acid injections using the semi-quantitative, whole organ assessment of the knee with MRI,” said Upadhyay Bharadwaj. “While both corticosteroid and hyaluronic acid injections are reported to help with symptomatic pain relief for knee osteoarthritis, our results conclusively show that corticosteroids are associated with significant progression of knee osteoarthritis up to two years post-injection and must be administered with caution."
The other new study presented recently at the RCNA annual meeting used a similar research methodology, tracking patients from the Osteoarthritis Initiative project over two years, but focused on changes detectable through X-ray imaging. Again, the study found greater disease progression in the patients receiving corticosteroid injections and potential long-term treatment benefits in patients receiving hyaluronic acid injections.
“Even though imaging findings for all patients were similar at baseline, the imaging hallmarks of osteoarthritis were worse two years later in patients who received corticosteroid injections compared to patients who received hyaluronic acid injections or no treatment at all,” said Azad Darbandi, from the Chicago Medical School of Rosalind Franklin University of Medicine and Science. “The results suggest that hyaluronic acid injections should be further explored for the management of knee osteoarthritis symptoms, and that steroid injections should be utilized with more caution.”
These new findings follow a similar recent study finding long-term use of non-steroidal anti-inflammatory drugs (NSAIDS), such as naproxen or ibuprofen, can also be linked to greater progression of osteoarthritis. While all this research does seem to point to the possibility that traditional anti-inflammatory treatments for osteoarthritis may not be beneficial in the long-term, experts are cautious not to jump to any conclusions regarding causality at this stage.
Speaking to CNN, Darbandi did point out changes in joint structure that can be detected through imaging don't necessarily mean the patient's condition is getting symptomatically worse. So whether these studies are picking up clinically meaningful changes in disease progression is still an open question.
“You might see that the knee looks bad on a radiograph, but the patient might not be having worse symptoms,” said Darbandi.
Jonathan Samuels, from NYU Langone Health, told NBC News it is too soon to definitively say corticosteroid injections are harmful. The research is still preliminary, and there is value in effectively treating a patient's acute pain.
“We don’t have the biology to prove that the injection itself is causing accelerated damage," said Samuels. "It’s hard to connect the dots from injection to damage from this preliminary data. But it’s an important question, because it’s such a common practice to be injected with steroids.”