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#135 Corticosteroid shots and knees: A match made in osteoarthritis heaven?


CLINICAL QUESTION
What is the effectiveness of intra-articular corticosteroid injections in knee osteoarthritis?


BOTTOM LINE
Corticosteroid intra-articular knee injections reduce osteoarthritis pain ~40% more than placebo and one in every 3-5 patients injected will have global symptom improvement in the first four weeks. Long-term pain relief is less certain but serious adverse events, like joint infection, are very rare (one in >14,000).  



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EVIDENCE
We found six systematic reviews,1-6 each with 5-13 Randomized Controlled Trials (RCTs) and 207-648 patients total. Comparing corticosteroid (triamcinolone 20-40 mg most common, methylprednisolone 40-120 mg next most common) to placebo injections.   
  • Pain: On a 100 point Visual Analogue Scale (VAS) steroids statistically significantly reduced pain (from ~54 baseline)4 more than placebo:  
    • 21-22 points lower at one week,1,2 16.5 points lower at two weeks,3 7.4 points at 3-4 weeks.1 
      • Average ~15 points better between 1-4 weeks.4 
    • At later time points, difference is non-statistically significant.1  
    • Maximal effect may occur at 1.5 weeks.4 
  • Pain: Hitting a particular pain reduction target or global improvement: 
    • 74-78% for steroid vs. 45-54% placebo.1-3  
      • Number Needed to Treat (NNT)=3-5, at 1-4 weeks.1-3 
    • Results at >4 weeks inconsistent: Two found no effect,1,2 one reports NNT=5 at 16-24 weeks.3    
  • Function and stiffness not reliably changed.5   
  • Issues: Included RCTs were frequently small (≤50) and often short (example one week). Pooled results also often included few studies and lacked power.1-6     
Context: 
  • Overall, corticosteroid injections may be most efficacious therapies for knee osteoarthritis in the first 1-4 weeks.4,5  
  • Unclear if one type of steroid better than another.7 
  • Maximum frequency ~4/year.  
    • RCT injected steroids 4x/year for two years without any harms.8 
    • Cohort of 4 injections/year found no harm.9 
  • Which clinical features influence success is unclear10,11 but increased radiographic severity may reduce effectiveness while increased clinical severity (pain and stiffness) may improve effectiveness.10 
  • Risk of joint infection one in 14,000-77,000 following intra-articular injection.12  
  • Guidelines generally recommend corticosteroid intra-articular injections,13,14 although uncertainty (due to insufficient long-term evidence) remains.15 


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Author(s):

  • G. Michael Allan MD CCFP
  • Jeff Jamieson MD

1. Godwin M, Dawes M. Can Fam Physician. 2004; 50:241-8.

2. Bellamy N, Campbell J, Welch V, et al. Cochrane Database Syst Rev. 2006; (2):CD005328.

3. Arroll B, Goodyear-Smith F. BMJ. 2004 Apr 10; 328(7444):869.

4. Bjordal JM, Klovning A, Ljunggren AE, et al. Eur J Pain. 2007; 11:125-38.

5. Bannuru RR, Schmid CH, Kent DM, et al. Ann Intern Med. 2015; 162:46-54.

6. Hepper CT, Halvorson JJ, Duncan ST, et al. J Am Acad Orthop Surg. 2009; 17:638-46.

7. Garg N, Perry L, Deodhar A. Clin Rheumatol. 2014; 33:1695-706.

8. Raynauld JP, Buckland-Wright C, Ward R, et al. Arthritis Rheum. 2003; 48:370-7.

9. Balch HW, Gibson JM, El-Ghobarey AF, et al. Rheumatol Rehabil. 1977; 16:137-40.

10. Maricar N, Callaghan MJ, Felson DT, et al. Rheumatology (Oxford). 2013; 52:1022-32.

11. Hirsch G, Kitas G, Klocke R. Semin Arthritis Rheum. 2013; 42:451-73.

12. Jones T, Kelsberg G, Safranek S. Am Fam Physician. 2014; 90:115-6.

13. Hochberg MC, Altman RD, April KT, et al. Arthritis Care Res (Hoboken). 2012; 64:465-74.

14. Richmond J, Hunter D, Irrgang J, et al. J Am Acad Orthop Surg. 2009; 17:591-600.

15. Jevsevar DS, Brown GA, Jones DL, et al. J Bone Joint Surg Am. 2013; 95:1885-6.

Authors do not have any conflicts to disclose.