#89 Viscosupplementation (Hyaluronic Acid or Hylan): Cushioning the Blow (To Your Wallet)?
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- Reduction in pain (at 3 months), effect size -0.37 (-0.28 to -0.46)
- Just reached minimally important clinical benefit (-0.37 = 9 mm on 100 mm pain scale)
- But many issues,
- Higher quality studies (>100 patients, proper randomization, or blinded outcome assessor) found no clinically meaningful improvement in pain or function
- Publication bias: Negative trials less likely to be published. Five of 6 unpublished studies provided data and showed no effect.
- Adverse events increased
- Serious adverse events: Relative risk 1.41 (1.02-1.97)
- Dropouts due to adverse events: Relative risk 1.33 (1.01-1.74).
- Versus intra-articular placebo: Effect size -0.34 (-0.26 to -0.42)
- No difference versus intra-articular corticosteroid: Effect size -0.02 (+0.12 to -0.17)
- Large placebo effect (expectation bias) from intra-articular administration of medications,
- Intra-articular placebo versus oral placebo: Effect size -0.29 (-0.04 to -0.54).
- Similar results3,4
- No difference in patients reporting global improvement5
- Placebo injections similar to viscosupplementation6
- Clinically meaningful difference not discussed or rarely attained3-8
- Higher quality studies showed smaller benefit3,7
- Patients >65 years with more advanced radiographic osteoarthritis may be less likely to benefit.8
- While the conclusions of some systematic reviews are positive,5-8 these ignore clinically meaningful outcomes and/or include poor-quality, biased studies.
- Systematic review examining the timing of viscosupplementation effect9
- Peak effect at 8 weeks: effect size -0.34 (-0.02 to -0.67) for high-quality studies
- Still less than 0.37 minimally important clinical difference.1
- Systematic review comparing hylan to hyaluronic acid found no difference (except hylan may have more adverse events).10
- Viscosupplementation (1-3 injections) costs $285-500.