A double-blind randomized comparative study of triamcinolone hexacetonide and dexamethasone intra-articular injection for the treatment of knee joint arthritis in rheumatoid arthritis

Coordinating Macrophage Targeting and Antioxidation by Injectable Nanocomposite Hydrogel for Enhanced Rheumatoid Arthritis Treatment

Rheumatoid arthritis (RA), an immune-mediated inflammatory disease, is characterized by a large number of infiltrated immune cells and abnormally elevated reactive oxygen species (ROS) in the joint. Various proinflammatory factors secreted by macrophages and the elevated ROS by inflammatory cells are deeply intertwined and together contribute to joint damage. Targeted and sustained anti-inflammation and antioxidation strategies are needed for RA treatment. To alleviate the oxidative stress and target the source of inflammatory cytokines, we developed a thermosensitive injectable hydrogel, Dex-DSLip/Cro@Gel, to coordinate the targeted anti-inflammatory and antioxidation effects. Within the injectable gel, dexamethasone (Dex)-loaded liposomes (Dex-DSLip), modified with dextran sulfate (DS), target macrophages via interaction with scavenger receptor A (SR-A). Simultaneously, crocin I (Cro) is loaded in the gel with a high loading capacity. The porous structure of Dex-DSLip/Cro@Gel successfully prolongs the retention time of both drugs and sustains the release of Dex and Cro. After intra-articular injection of Dex-DSLip/Cro@Gel in RA rats, the expression of inflammatory factors in the ankle joints was significantly reduced. Joint erythema and bone erosion were markedly alleviated. Through the synergistic effects of Dex and Cro, Dex-DSLip/Cro@Gel demonstrates targeted anti-inflammatory and antioxidation effects as well as mitigated bone erosion and long-term therapeutic effects for RA. This thermosensitive injectable nanocomposite hydrogel synergizes anti-inflammatory and antioxidation effects and targets the microenvironment in the joint, offering a new approach for RA treatment.

Periprosthetic Joint Infection Risk After Primary Total Knee Arthroplasty: Are All Preoperative Corticosteroid Injections the Same?

BACKGROUND

Previous evidence has demonstrated an increased risk of periprosthetic joint infection (PJI) following primary total knee arthroplasty (TKA) in patients receiving corticosteroid injection (CSI) within 3 months of surgery. The study aimed to determine if PJI risk after TKA varied among different corticosteroid agents.

METHODS

A total of 85,073 patients undergoing primary TKA from 2009 to 2019 were identified from a large national database. Of these, 1,092 (1.3%) received an ipsilateral, intra-articular CSI within 90 days of TKA. These patients were compared to those not receiving CSI using multivariate logistic regressions following 1:4 propensity score matching, with PJI development as the primary outcome.

RESULTS

Patients given an injection of any corticosteroid within 90 days of TKA had significantly higher PJI rates compared to controls (1.6 versus 0.41%; P < .001). This finding was driven by patients receiving methylprednisolone acetate (n = 543) or betamethasone (n = 153), with prevalence rates of 1.7 and 2.6%, respectively (P = .003 and P = .01, respectively). No significant increase in the rate of PJI was observed for patients receiving triamcinolone (1.2%; P = .08; n = 342) or dexamethasone (0.0%; P = 1; n = 54) within 90 days preceding TKA. PJI risk for all agents, administered more than 90 days preoperatively normalized to control levels (0.51 versus 0.34%).

CONCLUSIONS

These results suggest that PJI risk varies with CSI type. In this large database study, only patients given methylprednisolone acetate or betamethasone injections within 90 days of surgery had significantly higher PJI rates compared to controls.

Circulating and Synovial Monocytes in Arthritis and Ex-Vivo Model to Evaluate Therapeutic Modulation of Synovial Monocytes

Monocytes are innate immune cells that play a dual role in protection of host against pathogens and initiation and perpetuation of inflammatory disorders including joint diseases. During inflammation, monocytes migrate from peripheral blood to tissues via chemokine receptors where they produce inflammatory factors. Monocytes are classified into three subsets, namely: classical, intermediate and non-classical, each subset has particular function. Synovium of patients with inflammatory joint diseases, such as rheumatoid arthritis and psoriatic arthritis as well as osteoarthritis, is enriched by monocytes that differ from circulatory ones by distinct subsets distribution. Several therapeutic agents used systemically or locally through intra-articular injections in arthritis management modulate monocyte subsets. This scoping review summarized the existing literature delineating the effect of common therapeutic agents used in arthritis management on circulating and synovial monocytes/macrophages. As certain agents have an inhibitory effect on monocytes, we propose to test their potential to inhibit synovial monocytes via an ex-vivo platform based on cultured synovial fluid mononuclear cells derived from patients with rheumatic diseases. Information obtained from the ex-vivo platform can be applied to explore the therapeutic potential of medications in clinical practice.

Efficacy of tumor necrosis factor inhibitor combined with intra-articular injection of triamcinolone acetonide in the treatment of refractory rheumatoid arthritis synovitis: a retrospective study

OBJECTIVE

To investigate whether there is a difference in the efficacy of intra-articular injection of tumor necrosis factor (TNF) inhibitor and triamcinolone acetonide (HA) in rheumatoid arthritis (RA) patients with recurrent synovitis after the first intra-articular injection of HA.

METHODS

RA patients who relapsed 12 weeks after the first HA treatment were enrolled in this study. After joint cavity extraction, recombinant human TNF receptor-antibody fusion protein (TNFR:FC) (25 mg or 12.5 mg) or HA (1 ml or 0.5 ml) was injected then. The changes in the visual analog scale (VAS), joint swelling index, and joint tenderness index before and 12 weeks after reinjection were compared and analyzed. The changes in synovial thickness, synovial blood flow, and fluid dark zone depth before and after reinjection were observed by ultrasound.

RESULTS

Forty-two RA patients were enrolled, including 11 males and 31 females, with an average age of 46.79 ± 12.61 years and an average disease duration of 7.76 ± 5.44 years. After 12 weeks of intra-articular injection of HA or TNFR:FC, the VAS scores were significantly lower than those before treatment (P < 0.01). After 12 weeks of injection, the scores of the joint swelling index and tenderness index in both groups were significantly decreased compared with those before treatment. There was no significant difference in synovial thickness under ultrasound in the HA group before and after injection, while the synovial thickness in the TNFR:FC group was significantly improved after 12 weeks (P < 0.01). After 12 weeks of injection, the grade of synovial blood flow signal in both groups decreased significantly compared with that before treatment, especially in the TNFR:FC group. After 12 weeks of injection, the depth of the liquid dark area under ultrasound decreased significantly in the HA group and TNFR:FC group compared with that before treatment (P < 0.01).

CONCLUSION

Intra-articular injection of a TNF inhibitor is an effective method for the treatment of recurrent synovitis after conventional hormone therapy. Compared with HA treatment, it can reduce synovial thickness. Key Points • Intra-articular injection of a TNF inhibitor is an effective method for the treatment of recurrent synovitis after conventional hormone therapy. • Compared with HA treatment, intra-articular injection of biological agents combined with glucocorticoids can not only relieve joint pain but also significantly inhibit joint swelling. • Compared with HA treatment, intra-articular injection of biological agents combined with glucocorticoids cannot only improve synovial inflammation but also inhibit synovial proliferation. • For the treatment of refractory RA synovitis, biological agents combined with glucocorticoid injection are an effective and safe option.

Calcium complexes of oxicams: new dimensions in rheumatoid arthritis treatment

Various metals have been complexed with drugs to improve their cellular impact. Inflammatory diseases like rheumatoid arthritis (RA) are characterized by unbalanced production of proinflammatory cytokines (PICs) and prostaglandins with decreased levels of vitamin D and calcium. The inflammation can be suppressed through targeting the formation of PICs or related enzymes by various treatment strategies that involve the use of corticosteroids, disease-modifying antirheumatic drugs and NSAIDs. We present a detailed review on the impact of calcium complexes of oxicams as an advanced treatment strategy for RA. The calcium complexes demonstrate promising capabilities to cure the disease, improve the strength of bones and suppress PICs in RA.

Dexmedetomidine alleviates hyperalgesia in arthritis rats through inhibition of the p38MAPK signaling pathway

BACKGROUND

Dexmedetomidine (DEX) has showed significant analgesic effects in neuropathic pain, but the underlying mechanism has remained elusive. Our present study aimed to explore the effect of DEX on hyperalgesia with the involvement of p38MAPK signaling pathway a rat model of monoarthritis (MA).

METHODS

MA rat model was induced by injection of Complete Freund's Adjuvant (CFA). Pathological changes of ma rats were observed by HE staining and Safranin-O/Fast Green staining. Ankle circumference, paw withdrawal latency (PWL) and paw withdrawal threshold (PWT) was measured to judge the degree of hyperalgesia in MA rats. Immunohistochemistry and ELISA were applied to observe the degree of inflammation in rats. Western blot analysis was conducted to detect expression of p38MAPK signaling pathway-related factors. The mechanism of p38MAPK signaling pathway in MA rats was observed via treatment of Anisomycin or SB203580 combined with DEX.

RESULTS

After 8 h of CFA induction, joint swelling and hyperalgesia occurred in rats. There were obvious pathological changes in the joint cavity, the joint cavity space became narrow and synovial bursa became rough. A large number of inflammatory cell infiltration was observed under microscope. After injection of DEX and SB203580, PWT and PWL was prolonged, the expression of serum inflammatory factors was decreased, and the expression of p38MAPK signaling pathway-related factors was decreased; while all the detected indexes were recovered in MA rats after treated with DEX and Anisomycin.

CONCLUSIONS

Our study provided evidence that DEX could alleviate hyperalgesia in arthritis rats through inhibition of the p38MAPK signaling pathway.

Comparative effectiveness of pharmacological interventions on mortality and the average length of hospital stay of patients with COVID-19: a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Up to now, numerous randomized controlled trials (RCTs) have examined various drugs as possible treatments for Coronavirus Disease 2019 (COVID-19), but the results were diverse and occasionally even inconsistent with each other. To this point,we performed a systematic review and meta-analysis to assess the comparative effectiveness of pharmacological agents in published RCTs.

AREAS COVERED

A literature search was performed using PubMed, SCOPUS, EMBASE, and Web of Science databases. RCTs evaluating mortality and the average length of hospital stay to standard of care (SOC)/placebo/control were included. RCTs mainly were classified into five categories of drugs, including anti-inflammatory, antiviral, antiparasitic, antibody and antibiotics. Meta-analysis was done on 5 drugs classes and sub-group meta-analysis was done on single drugs and moderate or severe stage of disease.

EXPERT OPINION

Mortality and the average length of hospital stay of COVID-19 patients were significantly reduced with anti-inflammatory drugs (odds ratio [OR]: 0.77, 95% confidence interval [CI]: 0.69 to 0.85, P<0.00001, and mean difference [MD]: -1.41, CI:-1.75 to -1.07, P<0.00001, respectively) compared to SOC/control/placebo. Furthermore, antiparasitic was associated with reduced length of hospital stay (MD: -0.65, CI: -1.26 to -0.03, P<0.05) in comparison to SOC/placebo/control. However, no effectiveness was found in other pharmacological interventions.

The comparison of dexamethasone and triamcinolone periarticular administration in total knee arthroplasty: retrospective cohort study

Background

Intraoperative periarticular injection of corticosteroid effectively reduces perioperative pain in total knee arthroplasty (TKA). However, which corticosteroid is most effective for intraoperative periarticular injection remains controversial. We compared the effects of corticosteroids between dexamethasone and triamcinolone acetonide periarticular administration for reducing pain and postoperative nausea and increasing fasting blood glucose concentrations during the perioperative period following TKA.

Methods

One hundred and two patients who underwent TKA from August 2018 to September 2020 were divided into two groups: one received 10 mg dexamethasone for intraoperative periarticular injection and another receiving 40 mg triamcinolone acetonide. Postoperative pain scores at rest and during walking and nausea scores were recorded using a 0-to-10 Numerical Rating Scale. C-reactive protein (CRP) and fasting blood glucose levels were measured pre- and postoperatively.

Results

Pain scores in the triamcinolone group were significantly lower than in the dexamethasone group at rest 7 days postoperatively (1.5 vs. 2.0; p = 0.046) and while walking at both 72 h (3.9 vs. 4.8; p = 0.008) and 7 days postoperatively (3.2 vs. 4.0; p = 0.03). The CRP levels in the triamcinolone group were significantly lower than in the dexamethasone group at 7 days postoperatively (1.6 mg/dl vs. 3.0 mg/dl: p < 0.001). The fasting blood glucose levels at 1 day postoperatively were increased in both groups but not significantly different between the groups. No significant differences in the nausea score were noted between the groups.

Conclusions

Triamcinolone acetonide periarticular administration provided greater pain relief by reducing inflammation to a greater degree than dexamethasone.

Exploring the Anti-Rheumatoid Arthritis Mechanisms of Curcumin

Objective: To research curcumin on rheumatoid arthritis (RA) symptoms. Materials and Methods: Dividing Sixty SD male rats among six groups: normal control group, model group, dexamethasone (DXM) group and curcumin low, medium and high dosage groups (25, 50, 100 mg/kg body weight) every days. We adopted the CIA (collagen induced arthritis) rat model. All rats were subjected to 28 days of intragastric administration wherein we observed the rats’ state, weight, degree of paw swelling, arthritis index and pathological changes of ankle joints. Their serologic contents of IL-1β, IL-6 and TNF-α were examined by Elisa method and IKK-α, IKK-β and NF-κB in joint synovial tissues were tested via IHC assay. Results: Curcumin inhibited paw swelling within the CIA rat model, decreasing the serologic content of IL-1β, IL-6 and TNF-α. It also decreased the protein expressions of IKK-α, IKK-β and and NF-κB in synovial tissues. Its effects were dose-dependent and weaker than those of DXM. Conclusion: Curcumin is effective against RA by means of transcribing the IKK-α/-β/NF-κB pathway

Photodynamic therapy for synovial hyperplasia in patients with refractory rheumatoid arthritis: a study protocol for a randomized, double-blind, blank-controlled prospective trial

BACKGROUND

Persistent synovial hyperplasia with inflammation in rheumatoid arthritis is one of the main pathogeneses of refractory rheumatoid arthritis (RRA). Photodynamic therapy (PDT) causes less trauma than steroid injections or arthroscopic synovectomy while providing stronger targeting and more durable curative effects. The aim of this trial was to evaluate the short-, medium-, and long-term clinical efficacy of PDT when applied as a treatment for RRA synovial hyperplasia and synovitis.

METHODS AND ANALYSIS

This protocol is for a single-center, randomized, double-blind, blank-controlled prospective trial. A sample of 126 RRA patients will be randomly divided into 3 groups: the control group, the "PDT once" group, and the "PDT twice" group, with 42 participants per group. The trial will be conducted by the Rheumatology and Immunology Department of the Integrated Hospital of Traditional Chinese Medicine, Southern Medical University. The Ultrasound Compound Score of Synovitis (UCSS) has been selected as the primary outcome measure. The secondary outcome measures include knee joint clinical assessments, ratio of relapse, duration of remission, Disease Activity Score in 28 joints (DAS28), inflammation indexes, serum concentrations of specific antibodies, and changes in articular structures as detected by X-ray scans in the 48th week. The improvement ratios of the UCSS at the 8th, 24th, and 48th weeks (compared with baseline) reflect short-, medium-, and long-term time frames, respectively.

ETHICS AND DISSEMINATION

The protocol was approved by the Medical Ethics Committee of the Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, China (Approval No. granted by the ethics committee: NFZXYEC-2017-005) and then entered in the Chinese Clinical Trials Registry under registration number ChiCTR1800014918 (approval date: February 21, 2018). All procedures are in accordance with Chinese laws and regulations and with the Declaration of Helsinki by the World Medical Association (WMA). Any modifications of this protocol during execution will need additional approval from the Ethics Committee of our hospital.

TRIAL REGISTRATION NUMBER

ChiCTR1800014918 .

Cell-specific expression of ENACα gene by FOXA1 in the glucocorticoid receptor pathway

Introduction:

The glucocorticoid receptor (GR) is one of the most widely studied ligand-dependent nuclear receptors. The combination of transcriptional regulatory factors required for the expression of individual genes targeted by GR varies across cell types; however, the mechanisms underlying this cell type–specific regulation of gene expression are not yet clear.

Methods:

Here, we investigated genes regulated by GR in two different cell lines, A549 and ARPE-19, and examined how gene expression varied according to the effect of pioneer factors using RNA-seq and RT-qPCR.

Results:

Our RNA-seq results identified 19 and 63 genes regulated by GR that are ARPE-19-specific and A549-specific, respectively, suggesting that GR induces the expression of different sets of genes in a cell type–specific manner. RT-qPCR confirmed that the epithelial sodium channel (ENACα) gene is an ARPE-19 cell-specific GR target gene, whereas the FK506 binding protein 5 (FKBP5) gene was A549 cell-specific. There was a significant decrease in ENACα expression in FOXA1-deficient ARPE-19 cells, suggesting that FOXA1 might function as a pioneer factor enabling the selective expression of ENACα in ARPE-19 cells but not in A549 cells.

Conclusion:

These findings indicate that ENACα expression in ARPE-19 cells is regulated by FOXA1 and provide insights into the molecular mechanisms of cell type–specific expression of GR-regulated genes.

Common Practices in Intra-Articular Corticosteroid Injection for the Treatment of Knee Osteoarthritis: A Survey of the American Association of Hip and Knee Surgeons Membership

BACKGROUND

Knee osteoarthritis nonoperative management options remain limited. Our aim is to define the current American Association of Hip and Knee Surgeons (AAHKS) members' practices and perceptions in terms of the frequency, formulation, use of concomitant aspiration, maximum lifetime number of injections, efficacy, interval between injection and surgery and complication rates.

METHODS

A 22-question survey based on Likert scale response anchors was approved and distributed by the AAHKS Research Committee to its membership by email during the Spring 2019 meeting. Data were managed with REDCap software.

RESULTS

Membership response totaled 537 of 2365 (22.7%) members. Highlights include every respondent using intra-articular corticosteroid injections (ICIs) in their practice, and most use a three-month minimum interval, although the preferred interval is longer. Near consensus was found waiting three months before surgery. There was a great variability in the number of injections allowed, and injections before surgery were very common. Nearly all responders use a local anesthetic mixture with the cortisone injection, but there was great variation in corticosteroid type: methylprednisolone (42%), triamcinolone (41%), betamethasone (13.3%), and dexamethasone (3.7%).

CONCLUSION

The results of our survey indicate the majority of the AAHKS members who completed the survey use ICIs routinely for treatment of knee osteoarthritis. There was near consensus in ICIs, which is effective with decreasing efficacy over serial injections, and an absolute minimum interval between injections was believed by most to be three months with no clearly defined lifetime limit and strong consensus for a three-month preoperative interval. The formulation of steroid, local anesthetic, and skin preparation technique varied greatly.

Polymer colloids as drug delivery systems for the treatment of arthritis

The most common types of arthritis are osteoarthritis (OA) and rheumatoid arthritis (RA) which are themain causes of disability and pain among older people. Current treatment of arthritis mainly consists of oral and intra-articular medications. Despite the efficacy of the intraarticular injections over the oral treatment, it is still limited by the rapid clearance of the injected drug. Therefore, a rational design of drug delivery systems (DDSs) able to delivery drugs in controlled manner and for required period of time to the arthritis joint is a key in developing safe and effective formulations for OA and RA. In this paper various colloidal systems like nanoparticles, liposomes, cationic carriers, hydrogels, and emulsion-based carriers were presented and discussed in light of their use and efficacy as delivery systems to transport therapeutics for arthritis treatment. Factors influencing the delivery efficacy such as size, charge, structure, drug uptake, retention and its release profile alongside with cytocompatibility and safety were addressed. Moreover, the advantages and disadvantages of the different colloidal systems were emphasised.

Proteomic analysis reveals dexamethasone rescues matrix breakdown but not anabolic dysregulation in a cartilage injury model

Objectives

In this exploratory study, we used discovery proteomics to follow the release of proteins from bovine knee articular cartilage in response to mechanical injury and cytokine treatment. We also studied the effect of the glucocorticoid Dexamethasone (Dex) on these responses.

Design

Bovine cartilage explants were treated with either cytokines alone (10 ng/ml TNFα, 20 ng/ml IL-6, 100 ng/ml sIL-6R), a single compressive mechanical injury, cytokines and injury, or no treatment, and cultured in serum-free DMEM supplemented with 1% ITS for 22 days. All samples were incubated with or without addition of 100 nM Dex. Mass spectrometry and western blot analyses were performed on medium samples for the identification and quantification of released proteins.

Results

We identified 500 unique proteins present in all three biological replicates. Many proteins involved in the catabolic response of cartilage degradation had increased release after inflammatory stress. Dex rescued many of these catabolic effects. The release of some proteins involved in anabolic and chondroprotective processes was inconsistent, indicating differential effects on processes that may protect cartilage from injury. Dex restored only a small fraction of these to the control state, while others had their effects exacerbated by Dex exposure.

Conclusions

We identified proteins that were released upon cytokine treatment which could be potential biomarkers of the inflammatory contribution to cartilage degradation. We also demonstrated the imperfect rescue of Dex on the effects of cartilage degradation, with many catabolic factors being reduced, while other anabolic or chondroprotective processes were not.

Efficacy and safety of glucocorticoids in rheumatoid arthritis: Systematic literature review

OBJECTIVES

1) To systematically and critically review the evidence on the characteristics, efficacy and safety of glucocorticoids (CS) in rheumatoid arthritis (RA); 2) to generate practical recommendations.

METHODS

A systematic literature review was performed through a sensitive bibliographic search strategy in Medline, Embase and the Cochrane Library. We selected randomized clinical trials that analyzed the efficacy and/or safety of CS in patients with RA. Two reviewers performed the first selection by title and abstract. Then 10 reviewers selected the studies after a detailed review of the articles and data collection. The quality of the studies was evaluated with the Jadad scale. In a nominal group meeting, based on the results of the systematic literature review, related recommendations were reached by consensus.

RESULTS

A total of 47 articles were finally included. CS in combination with disease-modifying antirheumatic drugs help control disease activity and inhibit radiographic progression, especially in the short-to-medium term and in early RA. CS can also improve function and relieve pain. Different types and routes of administration are effective, but there is no standardized scheme (initial dose, tapering and duration of treatment) that is superior to others. Adverse events when using CS are very frequent and are dose-dependent and variable severity, although most are mild. Seven recommendations were generated on the use and risk management of CS.

CONCLUSIONS

These recommendations aim to resolve some common clinical questions and aid in decision-making for CS use in RA.

Cancer chemotherapeutics in rheumatoid arthritis: A convoluted connection

Chemotherapy is one of the most popular therapeutic strategies to treat cancer. However, cancer chemotherapeutics have often been associated with impairment of the immune system, which might consequently lead to an augmented risk of autoimmune disorders, such as rheumatoid arthritis. Though the accurate mechanistic facets of rheumatoid arthritis induction have not been interpreted yet, a conglomeration of genetic and environmental factors might promote its etiology. What makes the scenario more challenging is that patients with rheumatoid arthritis are at a significantly elevated risk of developing various types of cancer. It is intriguing to note that diverse cancer chemotherapy drugs are also commonly used to treat symptoms of rheumatoid arthritis. However, a colossal multitude of such cancer therapeutics has demonstrated highly varied results in rheumatoid arthritis patients, including both beneficial and adverse effects. Herein, we attempt to present a holistic account of the variegated modalities of this complex tripartite cross-talk between cancer, rheumatoid arthritis and chemotherapy drugs in order to decode the sinuous correlation between these two appalling pathological conditions.

Comparison of the effectiveness on intra-articular and subcutaneous TNF inhibitor in rheumatoid arthritis patients

The objective of this study is to evaluate the efficacy of single intra-articular (IA) injection of tumor necrosis factor α (TNFα) inhibitor in knee joints comparing with subcutaneous injection in rheumatoid arthritis (RA) patients. Forty-eight RA patients with 73 knee arthritis were divided into three groups, group A: received a single injection of TNF inhibitor into knee joints; group B: received regular subcutaneous injection; and group C: received both of the regimen as groups A and B. Ultrasound, erythrocyte sedimentation rate, C-reactive protein (CRP), patients' global visual analogue scale (VAS), and 28-joint Disease Activity Score (DAS28) were collected pre- and post-therapy 4 weeks. The results of the study are as follows: (1) CRP, VAS, and DAS28 of all groups improved significantly post-therapy (p < 0.05); (2) After therapy, synovial hypertrophy (SH) decreased significantly from 4.40 ± 1.86 mm to 2.74 ± 1.88 mm (p < 0.05) and power Doppler (PD) signal decreased significantly from 2.63 ± 0.75 to 1.50 ± 0.93 (p < 0.01) in group A. Synovial effusion (SE), SH, and PD showed no significant improvement in group B. SE decreased significantly from 9.84 ± 4.70 mm to 5.89 ± 4.47 mm (p < 0.05), SH decreased significantly from 4.52 ± 1.97 mm to 2.49 ± 1.73 mm (p < 0.01), and PD decreased significantly from 2.46 ± 0.66 to 1.38 ± 1.04 (p < 0.01) in group C; and (3) The improvement rate of SH and PD in both groups A and C was obviously higher than that of group B (p < 0.05). Single IA injection of TNFα inhibitor was an effective treatment in improvement of SH and PD of knee joints than subcutaneous injection in RA patients.

Radial Extracorporeal Shock Wave Therapy for Relief of Arthralgia in Rheumatoid Arthritis

More than one-third of the population with rheumatoid arthritis requires adjuvant analgesic treatment after antirheumatic therapy. In addition to analgesics, another option is radial extracorporeal shock wave therapy (rESWT), a novel physical therapy that has been successfully used in the treatment of many types of chronic soft tissue pain. We report a series of 15 patients who suffered from arthralgia after being on disease-modifying antirheumatic drugs for more than 3 months. Participants received rESWT for 3 months as an adjuvant therapy. Compared to the pretherapy baseline, follow-up at 3 months post-therapy revealed a significant reduction in resting state visual analog scale scores from 2.90 ± 0.74 to 0.80 ± 0.79 (P = 0.004), active state visual analog scale scores from 5.70 ± 1.33 to 2.20 ± 0.63 (P < 0.001), morning stiffness duration from 2.25 ± 0.79 to 1.05 ± 0.69 hours (P = 0.004), disease activity score with 28-joint counts based on erythrocyte sedimentation rate from 6.34 ± 0.72 to 4.19 ± 0.59 (P = 0.001), and Health Assessment Questionnaire scores from 10.20 ± 2.35 to 5.00 ± 2.62 (P = 0.005). The pre-post changes in erythrocyte sedimentation rate and C-reactive protein were not statistically significant. By the end of treatment, 11 participants stopped analgesics completely; the other 4 participants were on a smaller dosage. No severe adverse effects related to rESWT were observed. To our knowledge, this is the first report using this therapy to treat arthralgia in rheumatoid arthritis.