Corticosteroids for Osteoarthritis
A little history
Corticosteroid injections (CSI) have been used in the treatment of joint pain since 1948, pioneered by Philip Hench [1] initially for joints affected by rheumatoid arthritis. Soon after, their use for osteoarthritis (OA) was adopted and in the 75 years since, corticosteroid injections have been a mainstay of treatment for osteoarthritic joints. To stand the test of time they must be a high value option for treatment of osteoarthritis right!?
So what is this drug?
The corticosteroid preparations used today are a synthetic derivative of the naturally occurring hormone cortisol, produced in the adrenal gland. They exert an anti-inflammatory effect alongside an immunosuppressive effect, the latter being the rationale why their use during the COVID-19 pandemic was largely limited. The use of an anti-inflammatory drug seemed sensible for the medical community when OA was felt to be a classic inflammatory disease. Over recent years, our understanding has evolved to viewing OA as a whole joint disorder [2] yet despite this shift of understanding related to the pathogenesis, the use of corticosteroid injections has continued to proliferate.
The evidence base
The use of corticosteroid injections in the treatment of joint OA has been extensively researched in the knee and the hip with other joints having less evidence to support their use. A recent systematic review and meta-analysis reported that:
“corticosteroid injections offer clinically perceivable pain relief and functional improvement higher than the placebo effect only at short-term follow-up in patients affected by knee OA, with benefits losing clinical relevance after 6 weeks [3]”(Bensa). For hip OA the evidence points towards CSI’s to be an efficacious therapy for pain reduction up to 12 weeks [4] (Zhong). The third most common body region for the use of CSI is the joints in the hand affected by OA. A recent review by Estee et al [5] found that there was no significant effect of intra-articular corticosteroids on pain or function at 4-6 weeks or over 3-12 months in carpometacarpal OA.
Research related to corticosteroid therapy for OA is limited by a lack of methodological rigour, often without a placebo control group or longer term follow up. So if the research is pointing towards only a short term benefit with recommendations for further research, where does that leave us at the clinical coal face?
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