The Radiological Society of North America just concluded their annual meeting and significant studies were presented concerning the current treatment of osteoarthritis.
Osteoarthritis affects at least 500 million people worldwide and the current standard of care includes NSAID and corticosteroid injections for relief of pain and control of this disease.
According to a new study presented at this meeting, taking anti-inflammatories like ibuprofen or naproxen for osteoarthritis may worsen the inflammation in the knee.
Non-steroidal anti-inflammatory drugs are commonly prescribed for osteoarthritis pain and inflammation. However, little is known of the long-term effects on the overall progression these drugs have on the disease.
Johanna Luitjens, MD is a postdoctoral scholar in the Department of Radiology and Biomedical Imaging at the University of California, San Francisco. She presented at the meeting. “NSAIDS are frequently used to treat pain, but it is still an open discussion of how NSAIDS use influences outcomes for osteoarthritis patients. In particular, the impact of NSAIDS on synovitis, or the inflammation of the membrane lining of the joint, has never been analyzed using MRI-based structural biomarkers”.
Dr. Luitjens and colleagues set out to analyze the association between NSAID use and synovitis in patients with osteoarthritis of the knee and to assess how treatment with NSAIDS affects joint structure over time.
Dr. Luitjens stated “Synovitis mediates development and progression of osteoarthritis and may be a therapeutic target. Therefore, the goal of our study was to analyze whether NSAID treatment influences the development or progression of synovitis and to investigate whether cartilage imaging biomarkers, which reflect changes in osteoarthritis, are impacted by NSAID treatment”.
The study group were comprised of 277 patients who had moderate to severe osteoarthritis and were treated with NSAIDS for over one year compared with a similar group of 793 who were not treated with NSAIDS. All participants underwent 3T MRI knee studies initially and again four years later. Images were scored for biomarkers of inflammation.
Cartilage thickness, composition and other MRI measurements served as noninvasive biomarkers evaluating arthritis progression.
The results showed no long-term benefit of NSAID use. Joint inflammation and cartilage quality were worse at baseline in the participants taking NSAIDS compared to the control group and worsened at the four year follow up.
“In this large group of participants, we were able to show that there were no protective mechanisms from NSAIDS in reducing inflammation or slowing down progression of osteoarthritis of the knee joint”. Dr. Luitjens also added, “The use of NSAIDS for their anti-inflammatory function has been frequently propagated in patients with osteoarthritis in recent years and should be revisited, since a positive impact on joint inflammation could not be demonstrated”.
In the second day of the Radiological Society of North America Meeting, two more studies were presented concerning the current treatment of osteoarthritis in the world.
Knee osteoarthritis is a chronic degenerative and progressive condition with an estimated incidence of 800,000 patients each year. More than 10% of patients with knee osteoarthritis seek noninvasive treatment for pain relief through corticosteroid or hyaluronic acid injections yearly.
In the first study, researchers at the University of California, San Francisco included 210 participants, seventy of whom received intraarticular injections, and 140 in the control group who did not receive injections during a two-year period. Of the 70 who received injections, 44 were injected with corticosteroids and 26 were injected with hyaluronic acid. The treatment groups were matched by age, sex, body mass index, pain and physical activity scores and severity of disease.
MRI was performed on all patients at the time of the injection and two years before and two years after. MRI scans focused and graded on the meniscus, bone marrow lesions, cartilage, joint effusion and ligaments. The researchers identified osteoarthritis progression by comparing the imaging scores from the initial and two year follow up scans.
Statistical analysis showed that corticosteroid knee injections were significantly associated with the overall progression of osteoarthritis in the knee specifically in the lateral and medial meniscus areas.
Hyaluronic acid knee injections were not significantly associated with the progression of osteoarthritis of the knee. Compared to the control group, the group who received hyaluronic acid injections showed a decreased progression of osteoarthritis specifically in bone marrow lesions.
“While both corticosteroid and hyaluronic acid injections are reported to help with symptomatic pain relief for knee osteoarthritis, our results conclusively show the corticosteroids are associated with significant progression of knee osteoarthritis up to two years post injection and must be administered with caution”, said Dr. Upadhyay Bharadwaj, the author of the study. She further stated, “Hyaluronic acid, on the other hand, may slow down progression of knee osteoarthritis and alleviate long term effects while offering symptomatic relief”.
In the second study presented, researchers at the Chicago Medical School of Rosalind Franklin University conducted a case control study comparing the radiographic progression of osteoarthritis in patients who received injections of corticosteroids and hyaluronic acid.
The study was conducted by Azad Darbandi who wanted to study the effects of the injections on the progression of the disease.
The team selected a cohort of 150 similar patients from the Osteoarthritis Initiative Database of greater than 14,000 patients. Of the 150 patients, 50 received corticosteroids, 50 received hyaluronic acid and 50 received neither corticosteroid nor hyaluronic acid. The groups were matched by age, sex, body mass index and x-ray findings.
“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 or no treatment at all. The results suggest hyaluronic acid injections should be further explored for the management of knee osteoarthritis symptoms and corticosteroids injection should be utilized with more caution” said Darbandi.
All of these newly presented studies shed significant doubt on the current treatment of osteoarthritis of the knee currently in use in the US and worldwide. One prestigious society still advocates the use of corticosteroids for osteoarthritis and has downplayed the use of hyaluronic acid products. Studies have shown hyaluronic acid volume in an arthritic knee decreases by 50% or more. Certainly, augmenting the volume would return the protective chemistry inside the joint and as proven by these studies, there is no delayed harm to the cartilage. Perhaps, those societies who have continued supporting the use of corticosteroids and not recommended the use of hyaluronic acid should revisit their stance considering these new studies.
Integrative Practice Solutions has been involved in the treatment of osteoarthritis of the knee for over a decade. IPS has been advocating the use of hyaluronic acid products and through the treatment of thousands of patients in association with our partners, the Advanced Arthritis Relief Protocol™ (AARP) has been developed and patented. Although IPS continues to change and modify this program due to advances in medicine and the results of newer studies, currently this treatment protocol has helped many patients gain relief from their painful arthritic knees and begin to regain a higher quality of life.
Integrative Practice Solutions will continue to stay on the forefront of this treatment while providing solutions that do not include drugs such as NSAIDS or corticosteroids.
Dr. Robert McGrath