AIM: Intra-articular corticosteroid injections (IACIs) can reduce osteoarthritis-related pain, with differing levels of response across patient groups. This systematic review investigates what is known about the positive and negative predictors of outcomes in patients with osteoarthritis who undergo IACIs.
METHODS: We systematically searched the Medline, Embase, and Cochrane databases to May 2023 for studies that evaluated patients undergoing IACIs for osteoarthritis and reported on predictors of outcomes in these patients.
RESULTS: Eight studies were included. Two were placebo-controlled trials, six were observational studies. Due to the heterogeneity of outcomes and variables between the studies, it was not possible to pool the results for formal meta-analysis. Higher baseline pain, older age, higher BMI, lower range of movement, higher Kellgren-Lawrence radiographic score, joint effusion, and aspiration were shown to be predictors of a positive response to IACIs in some of the included studies. However, other studies showed no difference in response with these variables, or a negative correlation with response. Sex, smoking, mental health status, hypertension/ischaemic heart disease, diabetes mellitus, duration of symptoms, and socioeconomic status did not demonstrate any correlation with the prediction of positive or negative outcomes after IACIs.
CONCLUSION: Several patient features have been identified as positive predictors of outcomes following IACIs. However, this systematic review has identified inconsistent and variable findings across the existing literature. Further research with standardization of IACI administration and outcome measures is required to facilitate further analysis of the reliability and significance of predictive factors for response to IACIs.
PURPOSE: The purpose of this study was to quantify and compare the clinical relevance of the different intra-articular corticosteroids (CS) effects in vivo for osteoarthritis (OA) treatment.
METHODS: The search was conducted on PubMed, Cochrane, and Web of Science in October 2023. The PRISMA guidelines were used. Inclusion criteria: animal or human randomized controlled trials (RCTs), English language and no time limitation, on the comparison of different intra-articular CS for OA treatment. The articles' quality was assessed using the Cochrane RoB2 and GRADE guidelines for human RCTs, and SYRCLE's tool for animal RCTs.
RESULTS: Eighteen RCTs were selected (16 human and 2 animal studies), including 1577 patients (1837 joints) and 31 animals (51 joints). The CS used were triamcinolone (14 human and 2 animal studies), methylprednisolone (7 human and 1 animal study), betamethasone (3 human studies) and dexamethasone (1 human study). All studies addressed knee OA except for three human and one animal study. A meta-analysis was performed on the comparison of methylprednisolone and triamcinolone in humans with knee OA analysing VAS pain at very short- (≤2 weeks), short- (>2 and ≤4 weeks), mid- (>4 and ≤8 weeks), long- (>8 and ≤ 12 weeks), and very long-term (>12 and ≤24 weeks). Triamcinolone showed better post-injection values compared to methylprednisolone at very short-term (p = 0.028). No difference in terms of VAS improvement was observed at any follow-up.
CONCLUSIONS: The available preclinical and clinical literature provides limited evidence on the comparison of different CS, hindering the possibility of determining the best CS approach in terms of molecule and dose for the intra-articular injection of OA joints.
LEVEL OF EVIDENCE: Level I.
OBJECTIVE: To evaluate the efficacy of intra--articular (IA) glucocorticoid for knee or hip osteoarthritis (OA) in specific subgroups of patients according to the baseline severity of pain and inflammatory signs using individual patient data (IPD) from existing trials. Furthermore, this study aims to assess if a baseline pain cut-off was associated with clinically important effectiveness of IA glucocorticoid. This is an update of an IA glucocorticoid IPD meta-analysis by the OA Trial Bank.
METHOD: Randomized trials evaluating one or more IA glucocorticoid preparations in hip and knee OA, published to May 2018 were selected. IPD of patient and disease characteristics and outcome measures were acquired. The primary outcome was pain severity at short-term follow-up (up to 4 weeks). Potential interaction effect of severe pain (≥70 points, 0-100 scale) and signs of inflammation at baseline were studied using a two-stage approach with general liner model followed by random effects model. Analysis of trend was conducted, assessing if a baseline pain cut-off was associated with the threshold for clinically important treatment effect of IA glucocorticoid compared to placebo.
RESULTS: Four out of 16 eligible randomized clinical trials (n = 641) were combined with the existing OA Trial Bank studies (n = 620), yielding 1261 participants from eleven studies. Participants with severe baseline pain compared to those with less severe pain had greater pain reduction at mid-term (around 12 weeks) (mean reduction: -6.90 (95%CI -10.91; -2.90)), but not at short- and long-term. No interaction effects were found between inflammatory signs and IA glucocorticoid injections compared to placebo at all follow-up time-points. Analysis of trend demonstrated treatment response to IA glucocorticoid from baseline pain levels >50 (0-100 scale) and above.
CONCLUSION: This updated IPD meta-analysis demonstrated that participants with severe pain compared to those with less severe pain at baseline experienced significantly more pain relief with IA glucocorticoid compared with placebo at mid-term.
OBJECTIVE: To clarify the evidence on the magnitude and duration of treatment effect of intra-articular corticosteroid (IAC) injections for knee osteoarthritis (OA) compared to placebo, to evaluate a treatment effect by steroid type, and to describe the reported adverse effects.
DESIGN: Cochrane Controlled Trials Register, Medline, Embase, CINAHL, Scopus, and Web of Science databases were searched. The risk of systematic bias was assessed according to the Cochrane Collaboration's domain-based evaluation framework.
RESULTS: The final sample included eight RCTs with follow-ups from 1 to 26 weeks. The risk of systematic bias was considered low in five and high in three studies. The pooled SMD was -0.58 (95% CI -0.88 to -0.27) and NNT 5.1 (95% CI 10.0 to 3.7). The heterogeneity was considerable. The pooled effect size approached the level of statistical insignificance at four months. The pooled risk ratio of adverse effects was insignificant 0.95 (95% CI 0.34 to 2.55).
CONCLUSION: The IAC had a mild to moderate effect on pain severity up to three months after the injection - much longer than it had previously been reported. The effect may vary substantially in different patient groups and appropriate patient selection is important. The risk of adverse effects was low.
INTRODUCTION: Knee osteoarthritis (KOA) is a significant health problem with lifetime risk of development estimated to be 45%. Effective nonsurgical treatments are needed for the management of symptoms.
METHODS: We designed a network meta-analysis to determine clinically relevant effectiveness of nonsteroidal anti-inflammatory drugs, acetaminophen, intra-articular (IA) corticosteroids, IA platelet-rich plasma, and IA hyaluronic acid compared with each other as well as with oral and IA placebos. We used PubMed, EMBASE, and Cochrane Central Register of Controlled Trials to perform a systematic search of KOA treatments with no date limits and last search on October 7, 2015. Article inclusion criteria considered the following: target population, randomized controlled study design, English language, human subjects, treatments and outcomes of interest, ≥30 patients per group, and consistent follow-up. Using the best available evidence, two abstractors independently extracted pain and function data at or near the most common follow-up time.
RESULTS: For pain, all active treatments showed significance over oral placebo, with IA corticosteroids having the largest magnitude of effect and significant difference only over IA placebo. For function, no IA treatments showed significance compared with either placebo, and naproxen was the only treatment showing clinical significance compared with oral placebo. Cumulative probabilities showed naproxen to be the most effective individual treatment, and when combined with IA corticosteroids, it is the most probable to improve pain and function.
DISCUSSION: Naproxen ranked most effective among conservative treatments of KOA and should be considered when treating pain and function because of its relative safety and low cost. The best available evidence was analyzed, but there were instances of inconsistency in the design and duration among articles, potentially affecting uniform data inclusion.
OBJECTIVE: The aims of this study were to systematically review clinimetrics of commonly assessed ultrasound pathologies in knee, hip and hand osteoarthritis (OA), and to conduct a meta-analysis for each clinimetric.
METHODS: MEDLINE, EMBASE, and Cochrane Library databases were searched from their inceptions to September 2016. According to the OMERACT Instrument Selection Algorithm, data extraction focused on ultrasound technical features and performance metrics. Methodological quality was assessed with modified 19-item Downs and Black score and 11-item Quality Appraisal of Diagnostic Reliability (QAREL) score. Separate meta-analyses were performed for clinimetrics: 1)inter-rater/intra-rater reliability; 2)construct validity; 3)criteria validity; and 4)internal/external responsiveness. SPSS, Excel and Comprehensive Meta-analysis were used.
RESULT: Our search identified 1126 records; of these, 100 were eligible, including a total of 8542 patients and 32373 joints. The average Downs and Black score was 13.01, and average QAREL was 5.93. The stratified meta-analysis was performed only for knee OA, which demonstrated moderate to substantial reliability [minimum kappa>0.44(0.15,0.74), minimum ICC>0.82(0.73-0.89)], weak construct validity against pain(r=0.12 to 0.27), function(r=0.15 to 0.23), and blood biomarkers(r=0.01 to 0.21), but weak to strong correlation with plain radiography(r=0.13 to 0.60), strong association with MRI [minimum r=0.60(0.52,0.67)] and strong discrimination against symptomatic patients(OR=3.08 to 7.46). There was strong criterion validity against cartilage histology [r=0.66(-0.05,0.93), and small to moderate internal(SMD=0.20 to 0.58) and external(r=0.35 to 0.43) responsiveness to interventions.
CONCLUSION: Ultrasound demonstrated strong criterion validity with cartilage histology, poor to strong correlation with patient findings and MRI, moderate reliability, and low responsiveness to interventions.
OBJETIVOS: El ácido hialurónico y los corticosteroides son terapias intraarticulares (IA) comúnmente utilizadas para el tratamiento de la osteoartritis de rodilla leve a moderada (OA). Muchos ensayos que evalúan la eficacia de las terapias administradas con IA usan comúnmente las inyecciones salinas IA como brazo comparador de placebo. Utilizando una revisión sistemática y metanálisis, nuestro objetivo fue evaluar el beneficio clínico asociado con el uso de solución salina IA en ensayos de terapias IA en el tratamiento de pacientes con OA dolorosa de rodilla. MÉTODOS: Se realizaron búsquedas en las bases de datos de MEDLINE y Embase para artículos publicados hasta el 14 de agosto de 2014. Dos revisores evaluaron la elegibilidad de reportes potenciales y el riesgo de sesgo de los ensayos incluidos. Se analizó la reducción del dolor corto (≤ 3 meses) ya largo plazo (6-12 meses) del grupo salino de los ensayos incluidos utilizando diferencias de medias estandarizadas (SMDs, estimadas asumiendo un efecto nulo en un grupo de comparación) que fueron combinadas y ponderadas usando Un modelo de efectos aleatorios. Los eventos adversos relacionados con el tratamiento (AE) se tabularon y se presentaron utilizando estadísticas descriptivas. Resultados: De 40 ensayos controlados aleatorios (ECA) elegibles para inclusión sólo 38 proporcionaron datos suficientes para ser incluidos en el metanálisis. Basándose en datos con moderada incoherencia, se encontró que la solución salina de IA mejoraba significativamente el dolor de rodilla a corto plazo en 32 estudios con 1705 pacientes (DMS = -0,68; IC del 95%: -0,78 a -0,57; P <0,001; I (2) = 50 %). El dolor de rodilla a largo plazo disminuyó significativamente después de la inyección de IA con solución salina en 19 estudios con 1445 pacientes (DME = -0,61; IC del 95%: -0,76 a -0,45; P <0,001) con un grado sustancial de inconsistencia (I 2) = 74%). En total, 29 de los ensayos incluidos informaron sobre eventos adversos, ninguno de los cuales encontró serias AE relacionados con el tratamiento después de la inyección de IA con solución salina. CONCLUSIONES: El alivio del dolor observado con solución salina IA debe inducir a los proveedores de atención médica a considerar la eficacia adicional de los tratamientos actuales de IA que usan comparadores salinos en estudios clínicos y los desafíos de identificar la inyección salina IA como un "placebo".
OBJECTIVE: To evaluate the efficacy of intra-articular (IA) glucocorticoids for knee or hip osteoarthritis (OA) in specific subgroups of patients with severe pain and inflammatory signs using individual patient data (IPD) from existing trials.
DESIGN: Randomized trials evaluating one or more IA glucocorticoid preparation in patients with knee or hip OA, published from 1995 up to June 2012 were selected from the literature. IPD obtained from original trials included patient and disease characteristics and outcomes measured. The primary outcome was pain severity at short-term follow-up (up to 4 weeks). The subgroup factors assessed included severe pain (≥70 points, 0-100 scale) and signs of inflammation (dichotomized in present or not) at baseline. Multilevel regression analyses were applied to estimate the magnitude of the effects in the subgroups with the individuals nested within each study.
RESULTS: Seven out of 43 published randomized clinical trials (n = 620) were included. Patients with severe baseline pain had a significantly larger reduction in short-term pain, but not in mid- and long-term pain, compared to those with less severe pain at baseline (Mean Difference 13.91; 95% Confidence Interval 1.50-26.31) when receiving IA glucocorticoid injection compared to placebo. No statistical significant interaction effects were found between inflammatory signs and IA glucocorticoid injections compared to placebo and to tidal irrigation at all follow-up points.
CONCLUSIONS: This IPD meta-analysis demonstrates that patients with severe knee pain at baseline derive more benefit from IA glucocorticoid injection at short-term follow-up than those with less severe pain at baseline.
ANTECEDENTES: los controles con placebo son esenciales en la evaluación de la eficacia de los tratamientos médicos. Aunque no está claro si las diferentes intervenciones placebo para la osteoartritis varían en eficacia, las diferencias sistemáticas afectarían sustancialmente interpretación de los resultados de los ensayos controlados con placebo.
Objetivo: Evaluar los efectos de los tipos alternativos de placebo en los resultados de dolor en la artrosis de rodilla.
FUENTES DE INFORMACIÓN: MEDLINE, EMBASE, Web of Science, Google Scholar, y Base de Datos Cochrane desde el comienzo hasta 1 de junio de 2015 y no publicados datos.
SELECCIÓN DE ESTUDIOS: 149 ensayos aleatorios de adultos con osteoartritis de rodilla que informaron los resultados de dolor y se compararon fármacos ampliamente usados contra oral, intraarticular, tópica y oral más placebos tópicos.
EXTRACCIÓN DE DATOS: Se forma independiente doble extrajeron los datos del estudio; la calidad del estudio se evaluó utilizando el riesgo de Cochrane herramienta de sesgo.
SÍNTESIS: El efecto placebo que se evaluaron mediante el uso de una red metanálisis con 4 nodos con placebo separadas (modelo diferencial) mostraron que el placebo intraarticular (tamaño del efecto, 0,29 [95% intervalo de credibilidad, 0,09 a la 0,49]) y placebo tópico ( el tamaño del efecto, 0,20 [intervalo de credibilidad, 0,02 a la 0,38]) tenían significativamente mayores tamaños del efecto que el placebo oral. Este modelo diferencial mostró marcadas diferencias en las eficacias relativas y la jerarquía de los tratamientos activos en comparación con un modelo de red que considera todos los placebos equivalente. En el modelo para la contabilidad efectos diferenciales, intra-articular y terapias tópicas fueron superiores a los tratamientos orales en la reducción del dolor. Cuando se ignoraron estos efectos diferenciales, fármacos anti-inflamatorios no esteroides orales eran superiores.
LIMITACIONES: Pocos estudios compararon diferentes placebos directamente. El estudio no pudo concluir si decisivamente gravedad de la enfermedad y las co-intervenciones difieren sistemáticamente entre los ensayos que evalúan diferentes placebos.
Conclusión: Todos los placebos no son iguales, y algunos pueden desencadenar respuestas clínicamente relevantes. efectos placebo diferenciales pueden alterar sustancialmente las estimaciones de la eficacia relativa de los tratamientos activos, una consideración importante para el diseño de ensayos clínicos y la interpretación de sus resultados.
PRIMARIA FUENTE DE FINANCIACIÓN: Agencia para la Investigación y Calidad.
Intra-articular corticosteroid injections (IACIs) can reduce osteoarthritis-related pain, with differing levels of response across patient groups. This systematic review investigates what is known about the positive and negative predictors of outcomes in patients with osteoarthritis who undergo IACIs.
METHODS:
We systematically searched the Medline, Embase, and Cochrane databases to May 2023 for studies that evaluated patients undergoing IACIs for osteoarthritis and reported on predictors of outcomes in these patients.
RESULTS:
Eight studies were included. Two were placebo-controlled trials, six were observational studies. Due to the heterogeneity of outcomes and variables between the studies, it was not possible to pool the results for formal meta-analysis. Higher baseline pain, older age, higher BMI, lower range of movement, higher Kellgren-Lawrence radiographic score, joint effusion, and aspiration were shown to be predictors of a positive response to IACIs in some of the included studies. However, other studies showed no difference in response with these variables, or a negative correlation with response. Sex, smoking, mental health status, hypertension/ischaemic heart disease, diabetes mellitus, duration of symptoms, and socioeconomic status did not demonstrate any correlation with the prediction of positive or negative outcomes after IACIs.
CONCLUSION:
Several patient features have been identified as positive predictors of outcomes following IACIs. However, this systematic review has identified inconsistent and variable findings across the existing literature. Further research with standardization of IACI administration and outcome measures is required to facilitate further analysis of the reliability and significance of predictive factors for response to IACIs.
Pregunta de la revisión sistemática»Revisión sistemática de intervenciones
