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Huang Y, Lascarides P, Ngai W, Steele K, Hummer CD. Three Weekly Intra-Articular Injections of Hylan G-F 20 vs Arthrocentesis in Patients with Chronic Idiopathic Knee Osteoarthritis: A Multicenter, Evaluator- and Patient-Blinded, Randomized Controlled Trial. CURRENT THERAPEUTIC RESEARCH 2023; 99:100707. [PMID: 37408828 PMCID: PMC10319210 DOI: 10.1016/j.curtheres.2023.100707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 05/22/2023] [Indexed: 07/07/2023]
Abstract
Background Knee osteoarthritis is a leading cause of disability worldwide. Symptoms can vary over time, leading to episodes of worsened symptoms known as flares. Intra-articular injection of hyaluronic acid has demonstrated long-term symptomatic relief in the broader knee osteoarthritis population, although its use in the flare population has not been extensively examined. Objective To assess the efficacy and safety of 3 once-weekly intra-articular injections of hylan G-F 20 (as single and repeat courses) in patients with chronic knee osteoarthritis, including a subpopulation that experienced flare. Methods Prospective randomized controlled, evaluator- and patient-blinded, multicenter trial with 2 phases: hylan G-F 20 vs arthrocentesis only (control) and 2 courses vs single-course hylan G-F 20. Primary outcomes were visual analog scale (0-100 mm) pain scores. Secondary outcomes included safety and synovial fluid analysis. Results Ninety-four patients (104 knees) were enrolled in Phase I, with 31 knees representing flare patients. Seventy-six patients (82 knees) were enrolled in Phase II. Long-term follow-up was 26 to 34 weeks. In flare patients, hylan G-F 20 showed significantly more improvement than the controls for all primary outcomes except pain at night (P = 0.063). Both 1 and 2 courses of hylan G-F 20 showed significant improvements from baseline for primary outcomes with no differences in efficacy between groups in the intention-to-treat population at the end of Phase II. Two courses of hylan G-F 20 showed better improvement in pain with motion (P = 0.0471) at long-term follow-up. No general side effects were reported, and local reactions (pain/swelling of the injected joint) resolved within 1 to 2 weeks. Hylan G-F 20 was also associated with reduced effusion volume and protein concentration. Conclusions Hylan G-F 20 significantly improves pain scores vs arthrocentesis in flare patients with no safety concerns. A repeat course of hylan G-F 20 was found to be well tolerated and efficacious.
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Affiliation(s)
- Yili Huang
- Zucker School of Medicine at Hofstra/Northwell, Northwell Phelps Hospital, Sleepy Hollow, New York
| | - Peter Lascarides
- Northwell Health, Northern Westchester Hospital, Mount Kisco, New York
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Lunny C, Thirugnanasampanthar SS, Kanji S, Ferri N, Pieper D, Whitelaw S, Tasnim S, Nelson H, Reid EK, Zhang JH(J, Kalkat B, Chi Y, Abdoulrezzak R, Zheng DW, Pangka LR, Wang D(XR, Safavi P, Sooch A, Kang KT, Tricco AC. How can clinicians choose between conflicting and discordant systematic reviews? A replication study of the Jadad algorithm. BMC Med Res Methodol 2022; 22:276. [PMID: 36289496 PMCID: PMC9597955 DOI: 10.1186/s12874-022-01750-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 10/04/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction The exponential growth of published systematic reviews (SRs) presents challenges for decision makers seeking to answer clinical, public health or policy questions. In 1997, an algorithm was created by Jadad et al. to choose the best SR across multiple. Our study aims to replicate author assessments using the Jadad algorithm to determine: (i) if we chose the same SR as the authors; and (ii) if we reach the same results. Methods We searched MEDLINE, Epistemonikos, and Cochrane Database of SRs. We included any study using the Jadad algorithm. We used consensus building strategies to operationalise the algorithm and to ensure a consistent approach to interpretation. Results We identified 21 studies that used the Jadad algorithm to choose one or more SRs. In 62% (13/21) of cases, we were unable to replicate the Jadad assessment and ultimately chose a different SR than the authors. Overall, 18 out of the 21 (86%) independent Jadad assessments agreed in direction of the findings despite 13 having chosen a different SR. Conclusions Our results suggest that the Jadad algorithm is not reproducible between users as there are no prescriptive instructions about how to operationalise the algorithm. In the absence of a validated algorithm, we recommend that healthcare providers, policy makers, patients and researchers address conflicts between review findings by choosing the SR(s) with meta-analysis of RCTs that most closely resemble their clinical, public health, or policy question, are the most recent, comprehensive (i.e. number of included RCTs), and at the lowest risk of bias. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-022-01750-2. This is the first empirical study to replicate Jadad algorithm assessments to evaluate discordance across systematic reviews. In 62% (13/21) of cases, we were unable to replicate the Jadad algorithm assessment and ultimately chose a different systematic review than the authors. When assessing systematic reviews using the Jadad algorithm, some steps of the Jadad algorithm were vague in description, making it difficult to operationalise, interpret, and use. The Jadad algorithm has several limitations as it does not account for the last literature search of the systematic review and publication recency of included trials. To assess discordance in the absence of an algorithm, we recommend decision makers consider relevance (objectives that most closely resemble their clinical question), recency (dates of search), comprehensiveness (most trials), and risk of bias (lowest risk of bias SR) when choosing one systematic review across multiple.
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Affiliation(s)
- C Lunny
- grid.17091.3e0000 0001 2288 9830Unity Health Toronto and the Cochrane Hypertension Review Group, St Michael’s Hospital, University of British Columbia, V6T 1Z3 Vancouver, BC Canada
| | - Sai Surabi Thirugnanasampanthar
- grid.17063.330000 0001 2157 2938Epidemiology Division, Institute for Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
| | - S Kanji
- grid.412687.e0000 0000 9606 5108The Ottawa Hospital, Ottawa Hospital Research Institute, Ottawa, Canada
| | - N Ferri
- grid.6292.f0000 0004 1757 1758Division of Occupational Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy ,grid.6292.f0000 0004 1757 1758Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy
| | - D Pieper
- grid.473452.3Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Institute for Health Services and Health System Research, Rüdersdorf, Germany ,grid.473452.3Center for Health Services Research, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
| | - S Whitelaw
- grid.14709.3b0000 0004 1936 8649Faculty of Medicine and Health Sciences, McGill University, Montreal, QC Canada
| | - S Tasnim
- grid.17091.3e0000 0001 2288 9830Cochrane Hypertension Review Group, University of British Columbia, 2176 Health Science Mall, Vancouver, BC V6T 1Z3 Canada
| | - H Nelson
- grid.410356.50000 0004 1936 8331Faculty of Health Sciences, Queen’s University, Kingston, ON Canada
| | - EK Reid
- Nova Scotia Health, Halifax, NS Canada
| | - Jia He (Janet) Zhang
- grid.17091.3e0000 0001 2288 9830Faculty of Science, University of British Columbia, Vancouver, BC Canada
| | - Banveer Kalkat
- grid.17091.3e0000 0001 2288 9830Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC Canada
| | - Yuan Chi
- Beijing Yealth Technology Co., Ltd, Beijing, China ,Cochrane Campbell Global Ageing Partnership, London, United Kingdom
| | - Reema Abdoulrezzak
- grid.17091.3e0000 0001 2288 9830Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC Canada
| | - Di Wen Zheng
- grid.17091.3e0000 0001 2288 9830Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC Canada
| | - Lindy R.S. Pangka
- grid.17091.3e0000 0001 2288 9830Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC Canada
| | - Dian (Xin Ran) Wang
- grid.17091.3e0000 0001 2288 9830Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC Canada
| | - Parisa Safavi
- grid.17091.3e0000 0001 2288 9830Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC Canada
| | - Anmol Sooch
- grid.17091.3e0000 0001 2288 9830Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC Canada
| | - Kevin T. Kang
- grid.17091.3e0000 0001 2288 9830Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC Canada
| | - Andrea C, Tricco
- grid.415502.7Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria St, M5B 1T8 Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Epidemiology Division, Institute for Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St Room 500, M5T 3M7 Toronto, ON Canada ,grid.410356.50000 0004 1936 8331Queen’s Collaboration for Health Care Quality Joanna Briggs Institute Centre of Excellence, School of Nursing, Queen’s University, 99 University Ave, K7L 3N6 Kingston, ON Canada
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Webner D, Huang Y, Hummer CD. Intraarticular Hyaluronic Acid Preparations for Knee Osteoarthritis: Are Some Better Than Others? Cartilage 2021; 13:1619S-1636S. [PMID: 34044600 PMCID: PMC8808930 DOI: 10.1177/19476035211017320] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE This literature review summarizes evidence on the safety and efficacy of intraarticular hyaluronic acid (IAHA) preparations approved in the United States for the treatment of osteoarthritis of the knee. DESIGN A systematic literature search was performed in PubMed, Ovid MEDLINE, and SCOPUS databases. Only studies in which clinical outcomes of individual IAHA preparations alone could be assessed when compared to placebo, no treatment, other standard knee osteoarthritis treatments, and IAHA head-to-head studies were selected. RESULTS One hundred nine articles meeting our inclusion criteria were identified, including 59 randomized and 50 observational studies. Hylan G-F 20 has been the most extensively studied preparation, with consistent results confirming efficacy in placebo-controlled studies. Efficacy is also consistently reported for Supartz, Monovisc, and Euflexxa, but not for Hyalgan, Orthovisc, and Durolane. In the head-to-head trials, high-molecular-weight (MW) Hylan G-F 20 was consistently superior to low MW sodium hyaluronate preparations (Hyalgan, Supartz) up to 20 weeks, whereas one study reported that Durolane was noninferior to Supartz. Head-to-head trials comparing high versus medium MW preparations all used Hylan G-F 20 as the high MW preparation. Of the IAHA preparations with strong evidence of efficacy in placebo-controlled studies, Euflexxa was found to be noninferior to Hylan G-F 20. There are no direct comparisons to Monovisc. One additional IAHA preparation (ie, Synovial), which has not been assessed in placebo-controlled studies, was also noninferior to Hylan G-F 20. CONCLUSION IAHA efficacy varies widely across preparations. High-quality studies are required to assess and compare the safety and efficacy of IAHA preparations.
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Affiliation(s)
- David Webner
- Crozer-Keystone Health System,
Springfield, PA, USA,David Webner, Crozer-Keystone Health
System, 196 W. Sproul Road, Suite 110, Springfield, PA 19064, USA.
| | - Yili Huang
- Northwell Health, Zucker School of
Medicine at Hofstra/Northwell, Hempstead, NY, USA
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Ong K, Lau E, Runa M, Daley W, Altman R. Factors Associated with Knee Arthroplasty in a Knee Osteoarthritis Patient Cohort Treated with Intra-articular Injections of Hylan G-F 20. J Knee Surg 2021; 34:886-897. [PMID: 31874465 DOI: 10.1055/s-0039-3402043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hylan G-F 20 viscosupplementation can be used to treat knee osteoarthritis pain. This study evaluated time to knee arthroplasty (KA), KA risk factors, and health care resource utilization in patients aged ≥18 years with claims in the Optum Clinformatics Data Mart database (2006-2016) for knee osteoarthritis treated with at least one course of hylan G-F 20. Kaplan-Meier analysis estimated KA risk from osteoarthritis diagnosis and first hylan G-F 20 treatment. KA risk factors were determined using multivariate Cox regression. Among 62,033 patients treated with hylan G-F 20 and/or hylan G-F 20 single intra-articular injection, 60 to 64% did not undergo KA 8 years following first injection. KA risk factors from time of osteoarthritis diagnosis and first hylan G-F 20 treatment were similar: increased age, fewer comorbidities, fewer hylan G-F 20 treatments, female sex, and no ultrasound/fluoroscopy for injection guidance. Patients who underwent KA versus those who did not had more office visits and claims for opioids, nonsteroidal anti-inflammatory drugs, and physical therapy. Patients less likely to undergo KA were younger (<40 years), had more comorbidities, received more courses of hylan G-F 20, were males, or received ultrasound/fluoroscopic injection guidance. Patients who did not receive KA versus those who did used fewer health care resources.
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Affiliation(s)
- Kevin Ong
- Exponent, Inc., Philadelphia, Pennsylvania
| | - Edmund Lau
- Exponent, Inc., Biomedical Engineering, Menlo Park, California
| | - Maria Runa
- Exponent, Inc., Philadelphia, Pennsylvania
| | | | - Roy Altman
- Division of Rheumatology and Immunology, Department of Medicine, Los Angeles, California
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Shekhbihi A, Riem S, Pfeiffer M, Haag C. Ungewöhnliche Ursache einer Kniegelenksynovitis. ARTHROSKOPIE 2021. [DOI: 10.1007/s00142-021-00471-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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De Lucia O, Jerosch J, Yoon S, Sayre T, Ngai W, Filippou G. One-year efficacy and safety of single or one to three weekly injections of hylan G-F 20 for knee osteoarthritis: a systematic literature review and meta-analysis. Clin Rheumatol 2020; 40:2133-2142. [PMID: 33108530 PMCID: PMC8121739 DOI: 10.1007/s10067-020-05477-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/21/2020] [Accepted: 10/22/2020] [Indexed: 12/30/2022]
Abstract
The aim of this study was to evaluate the long-term efficacy and safety of single or 1–3 weekly injections of hylan G-F 20 at 1 year following the first injection for knee osteoarthritis (OA). Searches were conducted in PubMed/MEDLINE, Embase, and CENTRAL and included relevant conference proceedings (January 1, 1995–August 17, 2020). Randomized controlled trials (RCTs), non-randomized trials, and observational studies investigating 1-year efficacy and safety of 1–3 weekly injections or single hylan G-F 20 injection for knee OA were included. Primary outcomes were WOMAC pain, physical function, and stiffness. Meta-analyses of RCTs and non-randomized studies were conducted separately. Our search identified 24 eligible studies. Hylan G-F 20, in the meta-analyses of RCTs, showed statistically significant improvement in WOMAC pain (SMCC − 0.98, 95% CI − 1.50, − 0.46), physical function (SMCC − 1.05, 95% CI − 1.28, − 0.83), and stiffness (SMCC − 1.07, 95% CI −1.28, −0.86). Improvement was also seen for VAS pain, SF-36 MCS (mental component summary), and SF-36 PCS (physical component summary). Analyses of non-randomized studies showed similar efficacy estimates. There were no significant differences in efficacy based on injection schedule, nor between RCT and non-randomized studies. Rates of adverse events (AEs) were low for most types of AEs. Hylan G-F 20 (either as single or 1–3 weekly injections) showed improvement in 1-year efficacy outcomes in comparison to baseline and was generally well tolerated. While further research will inform the medical field regarding viscosupplementation treatment options for knee OA, these findings show that hylan G-F 20 at both frequencies/dosages are efficacious and generally well tolerated for long-term use.
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Affiliation(s)
- Orazio De Lucia
- Clinical Rheumatology Unit, Department of Rheumatology and Medical Sciences, ASST Centro Traumatologico Ortopedico G. Pini-CTO, Milan, Italy
| | - Joerg Jerosch
- Orthopedic Department, Johanna Étienne Hospital, Am Hasenberg 46, 41462, Neuss, Germany
| | | | | | - Wilson Ngai
- Global Medical Affairs, Sanofi, Bridgewater, NJ, USA
| | - Georgios Filippou
- ASST Fatebenefratelli, University Hospital "Luigi Sacco", Rheumatology Unit, Via Giovanni Battista Grassi, 74, 20157, Milan, Italy.
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Abu-Hakmeh AE, Fleck AKM, Wan LQ. Temporal effects of cytokine treatment on lubricant synthesis and matrix metalloproteinase activity of fibroblast-like synoviocytes. J Tissue Eng Regen Med 2018; 13:87-98. [DOI: 10.1002/term.2771] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 08/30/2018] [Accepted: 10/18/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Ahmad E. Abu-Hakmeh
- Laboratory for Tissue Engineering and Morphogenesis, Department of Biomedical Engineering; Rensselaer Polytechnic Institute; Troy New York
| | - Allison K. M. Fleck
- Laboratory for Tissue Engineering and Morphogenesis, Department of Biomedical Engineering; Rensselaer Polytechnic Institute; Troy New York
| | - Leo Q. Wan
- Laboratory for Tissue Engineering and Morphogenesis, Department of Biomedical Engineering; Rensselaer Polytechnic Institute; Troy New York
- Center for Biotechnology and Interdisciplinary Studies; Rensselaer Polytechnic Institute; Troy New York
- Center for Modeling, Simulation and Imaging in Medicine; Rensselaer Polytechnic Institute; Troy New York
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Altman R, Hackel J, Niazi F, Shaw P, Nicholls M. Efficacy and safety of repeated courses of hyaluronic acid injections for knee osteoarthritis: A systematic review. Semin Arthritis Rheum 2018; 48:168-175. [DOI: 10.1016/j.semarthrit.2018.01.009] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 01/11/2018] [Accepted: 01/16/2018] [Indexed: 12/12/2022]
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Heger R, Paulsen G, Fickert U, Kresmann M. Open-label Study of Initial and Repeat Treatment Cycles of Hylan G-F 20 in Patients with Symptomatic Knee Osteoarthritis. Open Rheumatol J 2016; 10:88-100. [PMID: 27867433 PMCID: PMC5101633 DOI: 10.2174/1874312901610010088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 09/30/2016] [Accepted: 10/13/2016] [Indexed: 12/18/2022] Open
Abstract
Objective: To evaluate the efficacy and safety of initial and repeat treatment with hylan G-F 20 in patients with symptomatic osteoarthritis (OA) of the knee. Methods: A prospective, multicenter, open-label study in adult patients with symptomatic knee OA (Kellgren-Lawrence grades I-III) undergoing repeat (SC group) or initial (IC group) treatment courses (3 x 2 mL of hylan G-F 20 at weekly intervals) was conducted with a maximum follow-up of 26 weeks. Reduction of pain using the Verbal Pain Questionnaire (VPQ) and Patient Global Assessment (PTGA) scores, concomitant pain medications use, and adverse events (AEs) were evaluated. Results: A total of 842 patients were included (SC group, n=314; IC group, n=528), of whom 616 formed the intent-to-treat (ITT) population (SC group, n=235; IC group, n=381). Of the 462 patients with follow-up at week 26, 311 (67.3%) were defined as responders. In the ITT population, VPQ scores decreased significantly at 26 weeks (p<0.001) compared with baseline. VPQ and PTGA scores decreased significantly (p<0.001) from baseline at all time points, without any significant changes in concomitant medication use. Twenty-four treatment-related AEs (TEAEs) were reported in 2.9% of patients, with most being mild or moderate in intensity and resolving without sequelae. Conclusion: Initial and repeat courses of hylan G-F 20 were effective with a favorable safety profile for knee OA. The large patient population and the study’s pragmatic design suggest that these results could be replicated in routine clinical practice.
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Affiliation(s)
- Robert Heger
- Praxis für Orthopädie, Eltinger Straße 56 71229 Leonberg, Germany
| | - Günther Paulsen
- Chirurgische Gemeinschaftspraxis, Katharinenstr 34, 75031 Eppingen, Germany
| | - Ulrich Fickert
- Chirurgische Praxis, Am Kutzschenstein 2, 01591 Riesa, Germany
| | - Michael Kresmann
- Gemeinschaftspraxis für Orthopädie, Bahnhofsallee 20, 40721 Hilden, Germany
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Therapeutic Effects of Ribunucleinate (Ribonucleotides) in Immuno-Inflammatory and Arthritic Diseases. ACTA ACUST UNITED AC 2015; 70:35-89. [PMID: 26462364 DOI: 10.1007/978-3-0348-0927-6_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Ribonucleic acids from different organs and from yeast have been used for the treatment of chronic and degenerative diseases in the context of naturopathic medicine in the last 60 years. This chapter provides general information about ribonucleinates as therapeutic agents. Past and present pharmacological and clinical investigations are discussed in the field of the central nervous system, sensory organs, cancer and degenerative diseases of joints and vertebra.
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García-Padilla S, Duarte-Vázquez MA, Gonzalez-Romero KE, Caamaño MDC, Rosado JL. Effectiveness of intra-articular injections of sodium bicarbonate and calcium gluconate in the treatment of osteoarthritis of the knee: a randomized double-blind clinical trial. BMC Musculoskelet Disord 2015; 16:114. [PMID: 25963758 PMCID: PMC4493958 DOI: 10.1186/s12891-015-0568-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 04/29/2015] [Indexed: 01/22/2023] Open
Abstract
Background A novel therapeutic management of osteoarthritis (OA) of the knee was assessed. The study aimed to evaluate the effect of monthly sodium bicarbonate with a single (SBCG1) or double dose (SBCG2) of calcium gluconate injections on OA of the knee; as well as the efficacy and safety of both SBCG interventions in the long term. Methods A double-blind parallel-group clinical trial with 74 knee OA patients was performed during 12 months, both SBCG interventions were followed-up for another 6mo after intervention. The outcome variables were the Western Ontario-McMaster University Osteoarthritis Index (WOMAC), the Lequesne’s functional index and joint-space width changes from serial radiographs. Results After 12 months, group SBCG1 decreased −14.8 (95% CI:-14.2, −17.0) and group SBCG2 decreased −14.6 (−16.9, −12.4) in the global WOMAC score, the mean changes represent 80% and 82% lessened pain, respectively. In the Lequesne Functional Index scale, SBCG1 decreased −11.9 (−10.4, −14.2) and SBCG2 decreased -11.9 (−13.8, −10.0), representing 66 and 69% of improvement. Both mean scores were maintained after intervention discontinued. SBCG2 improved the knees’ joint space width more than SBCG1 at 3 and 18 months. Both SBCG interventions were well tolerated after 12 months of treatment Conclusion A solution of sodium bicarbonate and calcium gluconate is effective on reducing the symptoms associated with OA. Its beneficial effect is maintained for one year of continuous monthly administration and at least for 6 months after the administration is discontinued. When the dose of calcium gluconate is increased, it prevents further narrowing of joint-space. Trial registration Clinicaltrials.gov NCT00977444 September 11, 2009.
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Affiliation(s)
- Sandra García-Padilla
- Cindetec A.C, Parque Industrial Querétaro, Jurica 122, C.P. 76220, Santiago de Querétaro, Qro, Mexico.
| | | | | | - María del Carmen Caamaño
- Cindetec A.C, Parque Industrial Querétaro, Jurica 122, C.P. 76220, Santiago de Querétaro, Qro, Mexico. .,Universidad Autónoma de Querétaro, Santiago de Querétaro, Mexico.
| | - Jorge L Rosado
- Cindetec A.C, Parque Industrial Querétaro, Jurica 122, C.P. 76220, Santiago de Querétaro, Qro, Mexico. .,Universidad Autónoma de Querétaro, Santiago de Querétaro, Mexico.
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Pal S, Thuppal S, Reddy KJ, Avasthi S, Aggarwal A, Bansal H, Mohanasundaram S, Bailleul F. Long-Term (1-Year) Safety and Efficacy of a Single 6-mL Injection of Hylan G-F 20 in Indian Patients with Symptomatic Knee Osteoarthritis. Open Rheumatol J 2014; 8:54-68. [PMID: 25328555 PMCID: PMC4196249 DOI: 10.2174/1874312901408010054] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 07/19/2014] [Accepted: 08/23/2014] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION The prevalence of symptomatic knee osteoarthritis (OA) among Asians ≥65 years is estimated to double by 2040. This study was designed to evaluate the safety and efficacy of a single, 6-mL intra-articular injection of hylan G-F 20 in Indian patients with knee OA at 26 weeks through to 52 weeks. METHODS This study was an open-label, multicentre, phase 4 clinical trial. Enrolled patients (N=394) were ≥30 years old with Kellgren-Lawrence grade 1-3 OA; all patients received hylan G-F 20. WOMAC, SF-12, PTGA, and COGA scores, and OA medication use were evaluated at weeks 1, 4, 12, 26, 39, and 52 (initial treatment phase). At 26, 39, or 52 weeks, eligible patients could participate in a repeat treatment phase. McNemar-Bowkers, paired t-tests and ANOVA analyses were performed (alpha=0.05). RESULTS At 26 weeks, statistically significant changes from baseline were observed in all efficacy parameters, including the primary efficacy endpoint of WOMAC A1 (p<0.0001). Improvements continued for 52 weeks. No significant changes occurred in concomitant medication use. Eleven patients (2.8%) were re-injected at week 26 or 52. After repeat injection, statistically significant decreases were observed in WOMAC A1, WOMAC C and PTGA scores (p≤0.028). Twenty-three (5.8%) patients reported 26 local target knee AEs. CONCLUSION Among Indian patients within this study, a 6-mL hylan G-F 20 injection was well tolerated and effective in treating symptomatic knee OA with significant long-term (1 year) improvement of outcomes. When needed, repeat treatment was safe and efficacious for 4 weeks. TRIAL REGISTRATION Clinical Trial Registry of India (CTRI/2010/091/000052) www.ctri.nic.in/Clinicaltrials/login.php.
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Affiliation(s)
| | | | - K J Reddy
- Apollo Hospitals, Andhra Pradesh, India
| | - Sachin Avasthi
- Department of Orthopaedics, GSVM Medical College and Associated Hospital, Uttar Pradesh, India
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Neu CP. Functional imaging in OA: role of imaging in the evaluation of tissue biomechanics. Osteoarthritis Cartilage 2014; 22:1349-59. [PMID: 25278049 PMCID: PMC4185127 DOI: 10.1016/j.joca.2014.05.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 05/06/2014] [Accepted: 05/17/2014] [Indexed: 02/02/2023]
Abstract
Functional imaging refers broadly to the visualization of organ or tissue physiology using medical image modalities. In load-bearing tissues of the body, including articular cartilage lining the bony ends of joints, changes in strain, stress, and material properties occur in osteoarthritis (OA), providing an opportunity to probe tissue function through the progression of the disease. Here, biomechanical measures in cartilage and related joint tissues are discussed as key imaging biomarkers in the evaluation of OA. Emphasis will be placed on the (1) potential of radiography, ultrasound, and magnetic resonance imaging to assess early tissue pathomechanics in OA, (2) relative utility of kinematic, structural, morphological, and biomechanical measures as functional imaging biomarkers, and (3) improved diagnostic specificity through the combination of multiple imaging biomarkers with unique contrasts, including elastography and quantitative assessments of tissue biochemistry. In comparison to other modalities, magnetic resonance imaging provides an extensive range of functional measures at the tissue level, with conventional and emerging techniques available to potentially to assess the spectrum of preclinical to advance OA.
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Affiliation(s)
- C P Neu
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA.
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Abstract
CONTEXT Viscosupplementation (VS) and physical therapy are both used to treat pain associated with knee osteoarthritis (OA). EVIDENCE ACQUISITION PubMed and EMBASE searches were performed to July 2013. Search terms included hyaluronic acid OR hylan, physical therapy OR exercise, AND osteoarthritis. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 4. RESULTS The efficacy and safety of VS in painful knee OA is well documented, as are the appropriate candidates for this intervention. Studies suggest that adding VS to physical therapy and therapeutic exercise may lead to improved pain reduction and increased functionality compared with physical therapy alone. CONCLUSION Appropriately selected patients undergoing physical therapy for knee OA may benefit from VS.
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Affiliation(s)
- Holly J Silvers
- Santa Monica Orthopaedic and Sports Medicine Research Foundation, Santa Monica, California ; Department of Biomechanics and Movement Science, University of Delaware, Newark, Delaware
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Abstract
PURPOSE To provide an overview of the diagnosis and pathophysiology of osteoarthritis (OA), and to describe appropriate treatments for knee OA, with a focus on the efficacy and safety of viscosupplementation. Because nurse practitioners (NPs) can inject viscosupplements, a section on injection technique is included. DATA SOURCES Manuscripts were identified using PubMed and EMBASE with a review of the reference lists from retrieved articles. CONCLUSIONS Viscosupplements are safe and effective at improving function and alleviating knee pain from OA for up to 26 weeks. IMPLICATIONS FOR PRACTICE As the number of patients with OA is increasing, NPs need to be prepared to prescribe various treatment options to alleviate osteoarthritic knee pain, including viscosupplementation.
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Abstract
INTRODUCTION Osteoarthritis (OA) constitutes a growing public health burden and the most common cause of disability in the United States. Non-pharmacologic modalities and conservative pharmacologic therapies are recommended for the initial treatment of OA, including acetaminophen, and topical and oral non-steroidal anti-inflammatory drugs. However, safety concerns continue to mount regarding the use of these treatments and none have been shown to impact disease progression. Viscosupplementation with injections of hyaluronans (HAs) are indicated when non-pharmacologic and simple analgesics have failed to relieve symptoms (e.g., pain, stiffness) associated with knee OA. This review evaluates literature focusing on the efficacy and/or safety of HA injections in treating OA of the knee and in other joints, including the hip, shoulder, and ankle. METHODS Relevant literature on intra-articular (IA) HA injections as a treatment for OA pain in the knee and other joints was identified through PubMed database searches from inception until January 2013. Search terms included "hyaluronic acid" or "hylan", and "osteoarthritis". DISCUSSION Current evidence indicates that HA injections are beneficial and safe for patients with OA of the knee. IA injections of HAs treat the symptoms of knee OA and may also have disease-modifying properties, potentially delaying progression of OA. Although traditionally reserved for second-line treatment, evidence suggests that HAs may have value as a first-line therapy in the treatment of knee OA as they have been shown to be more effective in earlier stages and grades of disease, more recently diagnosed OA, and in less severe radiographic OA. CONCLUSION For primary care physicians who treat and care for patients with OA of the knee, IA injection with HAs constitutes a safe and effective treatment that can be routinely administered in the office setting.
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Affiliation(s)
- M Carrington Reid
- Weill Cornell Medical College, 1484-1486 1st Avenue, New York, NY, 10075, USA,
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Bert JM, Waddell DD. Viscosupplementation with hylan g-f 20 in patients with osteoarthrosis of the knee. Ther Adv Musculoskelet Dis 2012; 2:127-32. [PMID: 22870442 DOI: 10.1177/1759720x10370930] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Viscosupplementation (VIS) is one of several treatment modalities for osteoarthritis of the knee. It is useful in the treatment of osteoarthritis when other methods of conservative care have failed and it may be a safer method of treatment than oral chemical therapy which can have significant side effects with even short-term usage. The biochemical effects of hyaluronic acid are incompletely understood, however there are several accepted modes of action which result in a positive clinical effect on the function of the knee joint. There is some evidence that hyaluronic acid preparations with a higher molecular weight may be more beneficial to the patient. It is commonly used after arthroscopic meniscectomy and or debridement of the knee in a patient with chondral disease. The clinical effects have been well documented in multiple studies in patients with mild to moderate osteoarthritis in study groups before or after arthroscopic surgery of the knee. Adverse events do occur and are easily treated with only rare case reports of systemic effects. Furthermore, there is some evidence that VIS can prolong the need for total knee arthroplasty in the older patient as well.
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Affiliation(s)
- Jack M Bert
- Orthopedic Specialists of Louisiana, 1500 Line Avenue, Suite 101, Shreveport, LA 71101, USA
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20
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Dragomir CL, Scott JL, Perino G, Adler R, Fealy S, Goldring MB. Acute inflammation with induction of anaphylatoxin C5a and terminal complement complex C5b-9 associated with multiple intra-articular injections of hylan G-F 20: a case report. Osteoarthritis Cartilage 2012; 20:791-5. [PMID: 22484575 DOI: 10.1016/j.joca.2012.03.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 03/19/2012] [Accepted: 03/26/2012] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The purpose of this case report was to investigate local immune mechanisms present during an acute inflammatory flare initiated by viscosupplementation with hylan G-F 20 in a patient with osteoarthritis (OA) and past meniscectomy. EXPERIMENTAL DESIGN A patient with a history of bilateral OA and partial left knee meniscectomy, who had received three injections of hylan G-F 20, was diagnosed with an acute flare reaction in the left knee. Her chart was evaluated for clinical, radiological, and laboratory findings and for clinical follow-up. Histopathological synovial examination and real-time polymerase chain reaction (RT-PCR) for genes with major roles in local inflammation and enzyme-linked immunosorbent assays (ELISAs) for markers of complement activation and cytokines were performed. To study the impact of the inflammatory and immune features we compared the case patient with groups of three representative OA and three rheumatoid arthritis (RA) patients. RESULTS The patient exhibited evidence of highly increased acute phase reactant C-reactive protein (CRP) in the blood. The pathological examination of the synovial membrane identified abundant fibrinous exudate with numerous particles of hyaluronan surrounded by a dense infiltrate of neutrophils and eosinophils. The synovium had moderate hypertrophy and sclerosis as well as an inflammatory infiltrate predominantly composed of T lymphocytes and macrophages with scattered perivascular eosinophils and neutrophils. Immunoperoxidase staining identified numerous deposits of C5b-9 in the fibrinous exudates and the synovial membrane of the patient. Similar findings were observed in the RA patients, whereas deposits were rare in OA synovial samples. In addition, both anaphylatoxin C5a and the terminal complement complex C5b-9 were present at high levels, comparable to those in RA patients. The levels of mRNA for interleukin-1 beta (IL-1β), IL-6, and the neutrophil marker myeloperoxidase (MPO) were markedly increased compared to those in the RA and OA patients. CONCLUSIONS This present study is indicative of a pseudo-septic acute inflammatory reaction in response to local accumulation of hylan G-F 20 with the activation of complement and local invasion of pro-inflammatory cells.
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Affiliation(s)
- C L Dragomir
- Tissue Engineering, Repair and Regeneration Program, Hospital for Special Surgery, New York, NY 10021, USA.
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21
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Juhl C, Lund H, Roos EM, Zhang W, Christensen R. A hierarchy of patient-reported outcomes for meta-analysis of knee osteoarthritis trials: empirical evidence from a survey of high impact journals. ARTHRITIS 2012; 2012:136245. [PMID: 22792458 PMCID: PMC3389647 DOI: 10.1155/2012/136245] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 04/05/2012] [Indexed: 12/12/2022]
Abstract
Objectives. To develop a prioritised list based on responsiveness for extracting patient-reported outcomes (PROs) measuring pain and disability for performing meta-analyses in knee osteoarthritis (OA). Methods. A systematic search was conducted in 20 highest impact factor general and rheumatology journals chosen a priori. Eligible studies were randomised controlled trials, using two or more PROs measuring pain and/or disability. Results. A literature search identified 402 publications and 38 trials were included, resulting in 54 randomised comparisons. Thirty-five trials had sufficient data on pain and 15 trials on disability. The WOMAC "pain" and "function" subscales were the most responsive composite scores. The following list was developed. Pain: (1) WOMAC "pain" subscale, (2) pain during activity (VAS), (3) pain during walking (VAS), (4) general knee pain (VAS), (5) pain at rest (VAS), (6) other composite pain scales, and (7) other single item measures. Disability: (1) WOMAC "function" subscale, (2) SF-36 "physical function" subscale, (3) SF-36 (Physical composite score), and (4) Other composite disability scores. Conclusions. As choosing the PRO most favourable for the intervention from individual trials can lead to biased estimates, using a prioritised list as developed in this study is recommended to reduce risk of biased selection of PROs in meta-analyses.
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Affiliation(s)
- Carsten Juhl
- Research Unit for Musculoskeletal Function and Physiotherapy, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, 5230 Odense M, Denmark
- Department of Physiotherapy, Copenhagen University Hospital, Gentofte, 2900 Hellerup, Denmark
| | - Hans Lund
- Research Unit for Musculoskeletal Function and Physiotherapy, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, 5230 Odense M, Denmark
| | - Ewa M. Roos
- Research Unit for Musculoskeletal Function and Physiotherapy, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, 5230 Odense M, Denmark
| | - Weiya Zhang
- Academic Rheumatology, University of Nottingham, Nottingham NG5 1PB, UK
| | - Robin Christensen
- Research Unit for Musculoskeletal Function and Physiotherapy, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, 5230 Odense M, Denmark
- Musculoskeletal Statistics Unit, The Parker Institute, Copenhagen University Hospital, Frederiksberg, 2000 Frederiksberg, Denmark
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Abstract
Viscosupplementation, hyaluronic acid treatment, is an ancillary method for treating patients with symptomatic stage I or II osteoarthritis. Previous studies reported that local reactions occurred more frequently in patients receiving >1 course of treatment compared with patients receiving their first course of treatment. One (2%) of 42 first series patients and 4 (21%) of 19 of repeated series patients had adverse reactions severe enough to seek unscheduled care.This study was performed to determine whether patients receiving >1 series of viscosupplementation had an increased adverse reaction rate. A retrospective chart review was performed on all patients who received >1 series of viscosupplementation during the study. A local adverse reaction was defined as acute swelling and pain in the knee, with no injury or trauma within 72 hours after hyaluronic acid injection.Twenty-eight knees received >1 series of viscosupplementation. The adverse reaction rate to second series injections was 1.28% (3.57% of knees). The adverse reaction rate to ≥3 series was 0.9% (6.67% of knees). This adverse reaction rate was significantly less than the 21% reported in previous studies for multiple series injections (z=-1.90; P<.05) and is not significantly different than the 2% rate of adverse reactions reported for first series injections. No significant difference existed in the adverse reaction rates between 2 series and ≥3 series of viscosupplementation.The current study suggests that the rate of adverse reaction was low at 1.28% of second series viscosupplementation.
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Affiliation(s)
- Tracy A Webber
- Tufts University School of Medicine, Boston, Massachusetts, USA
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Wang Y, Hall S, Hanna F, Wluka AE, Grant G, Marks P, Feletar M, Cicuttini FM. Effects of Hylan G-F 20 supplementation on cartilage preservation detected by magnetic resonance imaging in osteoarthritis of the knee: a two-year single-blind clinical trial. BMC Musculoskelet Disord 2011; 12:195. [PMID: 21861935 PMCID: PMC3201041 DOI: 10.1186/1471-2474-12-195] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Accepted: 08/24/2011] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Although viscosupplementation is an effective symptomatic treatment for knee osteoarthritis (OA), the effect of longer term administration on articular cartilage has not been fully explored. We examined the effect of viscosupplementation with Hylan G-F 20 on knee cartilage over 2 years in patients with knee OA. METHODS In this prospective, single-blind, parallel control group pilot study, 78 patients with symptomatic knee OA (Kellgren-Lawrence grade II and III) were assigned to either intervention group (n = 39 receiving 4 courses of 3 × 2.0 ml of intra-articular Hylan G-F 20 injections at 6 month intervals) or control group (n = 39 receiving usual care for knee OA without injections). Magnetic resonance imaging of the study knee was performed at baseline, 12 and 24 months. Cartilage volume and defects were assessed using validated methods. RESULTS Fifty-five subjects (71%) completed 24 month follow up. Over 24 months, the intervention group had a reduced annual percentage rate of medial and lateral tibial cartilage volume loss (mean ± SD, -0.3 ± 2.7% and -1.4 ± 4.3%) compared with the control group (2.3 ± 2.6% and 1.4 ± 2.6%, P = 0.001 and 0.005 for difference, respectively). The intervention group also showed reduced cartilage defect score increment in the medial tibiofemoral compartment (0.1 ± 1.3) compared with the control group (0.8 ± 1.5, P = 0.05). CONCLUSIONS Six monthly intra-articular injections of Hylan G-F 20 administered to patients with symptomatic knee OA have a beneficial effect on knee cartilage preservation measured by both cartilage volume and cartilage defects. Hylan G-F 20 warrants further evaluation in larger clinical trials as a possible disease-modifying agent in the treatment of knee OA. TRIAL REGISTRATION The study was registered with ClinicalTrials.gov (NCT00393393).
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Affiliation(s)
- Yuanyuan Wang
- Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Australia
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Migliore A, Giovannangeli F, Granata M, Laganà B. Hylan g-f 20: review of its safety and efficacy in the management of joint pain in osteoarthritis. CLINICAL MEDICINE INSIGHTS-ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2010. [PMID: 21151854 DOI: 10.1177/117954411000300001] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Osteoarthritis (OA) is a chronic degenerative joint disease that is a clinically and economically important disease. The increased prevalence of OA with aging, coupled to the demographics of aging populations, make OA a high priority health care problem. Viscosupplementation (VS) is a well-established treatment option in knee OA that is included in the professional guidelines for treatment of this joint disease, and could potentially provide a useful alternative in treating such patients with painful OA. Theoretically VS is an approach that should apply to all synovial joints. OBJECTIVES The aim of this review is to assess the efficacy and safety of viscosupplementation with Hylan GF-20 (Synvisc(®)) in the management of joint pain in osteoarthritis. METHODS THE FOLLOWING DATABASES WERE SEARCHED: Medline, Database of Abstract on Reviews and Effectiveness, Cochrane Database of Systematic Reviews. Furthermore, the lists of references of retrieved publications were manually checked for additional references. The search terms Review, Viscosupplementation, Osteoarthritis, Hyaluronic acid, Hyaluronan, Sodium Hyaluronate, Hylan GF-20, Synvisc, intra-articular injection were used to identify all studies relating to the use of Synvisc(®) viscosupplementation therapy in OA. RESULTS Hylan GF-20 is a safe and effective treatment for decreasing pain and improving function in patients suffering from knee and hip OA but new evidences are emerging for its use in other joints.
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Affiliation(s)
- A Migliore
- UOS of Rheumatology, S.Pietro FBF Hospital, Rome, Italy
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Albano MB, Vidigal L, de Oliveira MZ, Namba MM, da Silva JLV, de Assis Pereira Filho F, Barbosa MA, da Silva EMB. MACROSCOPIC ANALYSES OF THE EFFECTS OF HYALURONATES AND CORTICOSTEROIDS ON INDUCED OSTEOARTHRITIS IN RABBITS' KNEES. Rev Bras Ortop 2010; 45:273-8. [PMID: 27022552 PMCID: PMC4799149 DOI: 10.1016/s2255-4971(15)30368-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To evaluate the effects of intra-articular injections of corticosteroids, native hyaluronic acid and branched-chain hyaluronic acid in experimentally-induced osteoarthrosis. METHODS 44 rabbits underwent anterior cruciate ligament resection and were then divided into four groups of eleven. Group 1: one intra-articular injection of saline solution per week, for three weeks; Group 2: three injections (one per week) of native hyaluronic acid; Group 3: three injections (one per week) of branched-chain hyaluronic acid; Group 4: two injections of betamethasone with an interval of three weeks. The cartilage of the tibial plateaus was evaluated macroscopically twelve weeks after surgery. Changes to the joint surface were graded as follows: Grade 0: smooth joint surface without relief changes; Grade 1: rough surface without any depressions; Grade 2: similar to grade 1, but with depressions on the joint surface; and Grade 3: subchondral bone exposure. The statistical analysis consisted of the use of Student's t test, chi-square test and analysis of variance (ANOVA). The significance level used was 5%. RESULTS A statistical difference was found between the control group and the three study groups 2, 3, 4 in relation to the development and severity of arthrosis. However, there was no difference between the groups regarding the drugs studied. CONCLUSION A similar degree of attenuation of the osteoarthrosis process in the rabbits' knees was found with the use of intra-articular injections of low-molecular-weight and high-molecular-weight glycosaminoglycans, and the corticosteroid betamethasone, compared with placebo.
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Affiliation(s)
- Mauro Batista Albano
- Mestre em Clínica Cirúrgica pela UFPR; Professor do Curso de Especialização em Traumatologia Esportiva e Artroscopia da UFPR; Membro do Serviço de Ortopedia e Traumatologia da UFPR
| | - Leandro Vidigal
- Médico Ortopedista; Aluno de Pós-graduaão Universidade Federal do Paraná (SOT-UFPR)
| | | | - Mario Massatomo Namba
- Mestre em Clínica Cirúrgica pela UFPR; Professor e Coordenador do Curso de Especializa9ão em Traumatologia Esportiva da UFPR; Membro do Serviço de Ortopedia e Traumatologia da UFPR; Membro Titular da SBOT
| | - João Luiz Vieira da Silva
- Mestre e Doutor em Clínica Cirúrgica pela UFPR; Professor do Curso de Especializa9ão em Traumatologia Esportiva e Artroscopia da UFPR; Membro do Serviço de Ortopedia e Traumatologia da UFPR; Membro Titular da SBOT
| | - Francisco de Assis Pereira Filho
- Professor do Curso de Especializa9ão em Traumatologia Esportiva e Artroscopia da UFPR; Membro do Serviço de Ortopedia e Traumatologia da UFPR; Membro Titular da SBOT
| | - Marcio Alves Barbosa
- Professor do Curso de Especializa9ão em Traumatologia Esportiva e Artroscopia da UFPR; Membro do Serviço de Ortopedia e Traumatologia da UFPR; Membro Titular da SBOT
| | - Elias Marcelo Batista da Silva
- Professor do Curso de Especializa9ão em Traumatologia Esportiva e Artroscopia da UFPR; Membro do Serviço de Ortopedia e Traumatologia da UFPR; Membro Titular da SBOT
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Vavken P, Dorotka R. A systematic review of conflicting meta-analyses in orthopaedic surgery. Clin Orthop Relat Res 2009; 467:2723-35. [PMID: 19252958 PMCID: PMC2745448 DOI: 10.1007/s11999-009-0765-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2008] [Accepted: 02/13/2009] [Indexed: 01/31/2023]
Abstract
Meta-analyses are important evaluations in orthopaedic surgery, not only to create clinical guidelines, but also because their findings are included in public health and health policy decision making. However, with increasing numbers of meta-analyses, discordant and frankly conflicting conclusions have been reported. We searched for conflicting meta-analyses, ie, those arriving at different conclusions despite following the same research question, identified potential reasons for these differences, and assessed the statistical significance and clinical importance of differences. We identified conflicting meta-analyses on graft choice in ACL reconstruction and the use of hyaluronic acid. We found significant differences in individual results only for meta-analyses on hyaluronic acid, but the 95% confidence intervals of the magnitude of differences included values as much as 40% for ACL meta-analyses. However, our findings suggest most conflicts derive from differences in the interpretation of pooled results rather than in the actual results. Thus conclusions and interpretations from meta-analyses should be scrutinized as critically as those from any other type of study and subjected to reassessment if deemed necessary.
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Affiliation(s)
- Patrick Vavken
- Department of Orthopedic Surgery, Children’s Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Enders 1016, Boston, MA 02115 USA ,Department of Orthopedic Surgery, Medical University of Vienna, Vienna, Austria
| | - Ronald Dorotka
- Department of Orthopedic Surgery, Medical University of Vienna, Vienna, Austria
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Conduah AH, Baker CL, Baker CL. Managing joint pain in osteoarthritis: safety and efficacy of hylan G-F 20. J Pain Res 2009; 2:87-98. [PMID: 21197297 PMCID: PMC3004631 DOI: 10.2147/jpr.s4732] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The use of intra-articular viscosupplementation in the nonoperative management of patients with osteoarthritis has become quite popular. Recent clinical data have demonstrated that the anti-inflammatory and chondroprotective actions of hyaluronic acid viscosupplementation reduce pain while improving patient function. We review the basic science and development of viscosupplementation and discuss the mounting evidence in support of the efficacy and safety profile of hylan G-F 20. Recent evidence suggesting a disease-modifying effect of hylan G-F 20 is also assessed. Furthermore, although the primary focus of this article is on treatment of osteoarthritis of the knee, we also discuss the use of viscosupplementation in other joints, such as the hip, ankle, and shoulder.
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Conrozier T, Jerosch J, Beks P, Kemper F, Euller-Ziegler L, Bailleul F, Chevalier X. Prospective, multi-centre, randomised evaluation of the safety and efficacy of five dosing regimens of viscosupplementation with hylan G-F 20 in patients with symptomatic tibio-femoral osteoarthritis: a pilot study. Arch Orthop Trauma Surg 2009; 129:417-23. [PMID: 18365224 DOI: 10.1007/s00402-008-0601-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2007] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Viscosupplementation by repeated intra-articular injections of hyaluronic acid (HA) is used widely in the treatment of symptomatic knee osteoarthritis (OA). The number of injections required can limit the availability of treatment and affect patient compliance. The aim of this study was to assess different dosing regimens of hylan G-F 20, a high molecular-weight cross-linked derivative of HA, in the treatment of pain due to knee OA. MATERIALS AND METHODS Pilot, prospective, multi-centre, open-label, randomised trial in 100 patients with unilateral, symptomatic, tibio-femoral OA (Kellgren-Lawrence grade II or III), aged > or =40 years. Patients were randomised to receive varying dosing regimens of hylan G-F 20 (1 x 6 mL, 1 x 4 mL, 2 x 4 mL 2 weeks apart, 3 x 4 mL 1 week apart, or 3 x 2 mL 1 week apart). Adverse events (AE's) were monitored throughout the study. The primary efficacy endpoint was the change from baseline in the patient-rated knee OA pain assessment (100 mm visual analogue scale (VAS)) at 24 weeks. The secondary efficacy criteria included the WOMAC index, patient and physician global assessments using a 100 mm VAS, and knee OA pain assessment at all other visits. Concomitant use of permitted rescue medications (paracetamol) was also assessed. RESULTS The treatment was well tolerated overall. Patients in the 3 x 4 mL group reported the highest percentage of device-related local AE's (30%) while patients in the 1 x 6 mL and 3 x 2 mL groups reported only 10%. There were no serious device-related AEs. There was a statistically significant improvement from baseline at week 24 in all efficacy endpoints for all treatment regimens. The 1 x 6 and 3 x 4 and 3 x 2 mL treatment groups showed the greatest mean improvements (-34.9, -32.6 and -36.7 mm respectively) in the patient-rated knee OA pain assessment VAS. CONCLUSION This study suggests that a single 6 mL injection of hylan G-F 20 may be as efficacious, and as well tolerated, as 3 x 2 mL one week apart. A double-blind, controlled trial is needed to confirm these data.
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Affiliation(s)
- T Conrozier
- Department of Rheumatology, Centre Hospitalier Lyon Sud, Pierre Bénite, France.
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Abstract
OBJECTIVE Intra-articular hyaluronan (HA) or hylan is approved for the treatment of osteoarthritis (OA) knee pain. The authors review here published evidence of efficacy and safety of intra-articular HA for the treatment of knee pain. Since the systemic safety of nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclo-oxygenase (COX-2) inhibitors for OA knee treatment are a current concern, the authors also offer recommendations for repositioning HA in the OA treatment paradigm. METHODS Relevant HA literature was identified by searching MEDLINE and EMBASE from their inception to April 2008 using the search words hyaluronan, hyaluronic acid, sodium hyaluronate, and hylan G-F 20, with knee and OA. Data from randomized, placebo-controlled trials were reviewed and summarized in this article. While not a systematic review, this article reviews the best available evidence for the use of HA to treat knee OA. RESULTS For the most part, patients in the reviewed studies were adults over the age of 40 with mild to severe symptomatic OA of the knee. Reviewed studies demonstrated significant improvements in pain and physical function with HA or sodium hyaluronate and hylan G-F 20. HA or hylan products were most effective between 5 and 13 weeks after injection with improvements also observed at 14-26 weeks or sometimes longer, and were well tolerated with a low incidence of adverse events. HA also provides beneficial treatment effects when administered in conjunction with other therapies. CONCLUSIONS Intra-articular HA or hylan has proven to be an effective, safe, and tolerable treatment for symptomatic knee OA. In an effort to limit cardiovascular, gastrointestinal, and renal safety concerns with COX-2 selective and nonselective NSAIDs and maximize HA efficacy, the authors proposed using HA earlier in the treatment paradigm for knee OA and also as part of a comprehensive treatment strategy.
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Affiliation(s)
- Daniel Brzusek
- Northwest Rehabilitation Associates, Bellevue, WA 98004, USA.
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Conrozier T, Chevalier X. Long-term experience with hylan GF-20 in the treatment of knee osteoarthritis. Expert Opin Pharmacother 2008; 9:1797-804. [DOI: 10.1517/14656566.9.10.1797] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Waddell DD. Viscosupplementation with hyaluronans for osteoarthritis of the knee: clinical efficacy and economic implications. Drugs Aging 2007; 24:629-42. [PMID: 17702533 DOI: 10.2165/00002512-200724080-00002] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Treatment with intra-articular viscosupplementation with hyaluronan (hyaluronic acid) and its derivatives is an important component of the management of osteoarthritis (OA) of the knee. Several intra-articular hyaluronan formulations are now available that vary in their physical properties, duration of effect and treatment schedules. Although aspects regarding their mechanism of action are not completely understood, numerous clinical trials, systematic reviews and meta-analyses have confirmed the efficacy of intra-articular hyaluronan therapies for relieving OA-related pain and improving joint function. Data indicate that intra-articular hyaluronan preparations provide OA pain relief that is comparable to or greater than that observed with conventional treatment, NSAID medications, intra-articular corticosteroids, arthroscopic lavage, physical therapy and exercise. Other studies indicate that multiple courses of hyaluronan are effective. Intra-articular hyaluronan formulations are well tolerated and are associated with a low incidence of adverse effects, usually localised to the injected joint. Local adverse events associated with intra-articular hyaluronan products are typically mild to moderate in severity, benign and transient, although their aetiology is unknown. The cost effectiveness of intra-articular hyaluronan has been demonstrated, but only in a limited number of studies. Cost savings with intra-articular hyaluronan can also be realised with reduction of NSAID medication use and the possibility of delaying total knee replacement, which can reduce the need for costly revision procedures. Because different intra-articular hyaluronan formulations require different numbers of injections and office visits, are associated with variable treatment costs, and provide varying degrees of efficacy, not all intra-articular hyaluronan formulations may be equally cost effective over time.
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Affiliation(s)
- David D Waddell
- Orthopedic Specialists of Louisiana, Shreveport, Louisiana 71101, USA.
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Gomis A, Miralles A, Schmidt RF, Belmonte C. Nociceptive nerve activity in an experimental model of knee joint osteoarthritis of the guinea pig: Effect of intra-articular hyaluronan application. Pain 2007; 130:126-36. [PMID: 17197090 DOI: 10.1016/j.pain.2006.11.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2006] [Revised: 11/08/2006] [Accepted: 11/21/2006] [Indexed: 11/26/2022]
Abstract
Nociceptive impulse activity was recorded extracellularly from single A delta and C primary afferents of the guinea pig's medial articular nerve after induction of an experimental osteoarthritis in the knee joint by partial medial menisectomy and transection of the anterior cruciate ligament (PMM+TACL). Also, the analgesic effects of intra-articular hyaluronan solutions were evaluated. Healthy, PMM+TACL operated, sham-operated (opening of the joint capsule without PMM and TACL surgery) and acutely inflamed (intra-articular kaolin-carrageenan, K-C) animals were used. The stimulus protocol consisted of torque meter-controlled, standardized innocuous and noxious inward and outward rotations of the joint. This stimulus protocol of 50 s duration was repeated every 5 min for 70 min. One day, one week and three weeks after PMM+TACL, the movement-evoked discharges of A delta articular afferents were increased significantly over values found in sham-operated animals. The discharges of C fibers were significantly augmented only one week after PMM+TACL surgery. Filling of the joint cavity with a high viscosity hyaluronan solution (hylan G-F 20, Synvisc) immediately and three days after surgery reduced significantly the enhanced nerve activity observed in joint afferent fibers one day and one week after surgery. Augmentation of movement-evoked discharges in K-C acutely inflamed knee joints was similar to that observed one week after PMM+TACL. Our results indicate that in the PMM+TACL model of osteoarthritis in guinea pigs, enhancement of nociceptive responses to joint movement was primarily associated to post-surgical inflammation. Intra-articular injection of an elastoviscous hyaluronan solution reduced the augmented nerve activity.
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MESH Headings
- Adjuvants, Immunologic/pharmacology
- Animals
- Anterior Cruciate Ligament/drug effects
- Anterior Cruciate Ligament/innervation
- Anterior Cruciate Ligament/surgery
- Carrageenan
- Disease Models, Animal
- Evoked Potentials, Motor/drug effects
- Evoked Potentials, Motor/physiology
- Female
- Guinea Pigs
- Hyaluronic Acid/pharmacology
- Injections, Intra-Articular
- Joint Instability/drug therapy
- Joint Instability/physiopathology
- Kaolin
- Knee Joint/drug effects
- Knee Joint/innervation
- Knee Joint/surgery
- Male
- Menisci, Tibial/drug effects
- Menisci, Tibial/innervation
- Menisci, Tibial/surgery
- Movement/physiology
- Neural Conduction
- Nociceptors/drug effects
- Nociceptors/physiology
- Osteoarthritis, Knee/drug therapy
- Osteoarthritis, Knee/physiopathology
- Pain/drug therapy
- Pain/physiopathology
- Solutions
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Affiliation(s)
- Ana Gomis
- Instituto de Neurociencias de Alicante, Universidad Miguel Hernández-CSIC, 03550 Sant Joan d'Alacant, Spain.
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Abstract
Intra-articular viscosupplementation with hyaluronic acid has become an increasingly accepted therapeutic alternative in the symptomatic management of osteoarthritis. Basic science research has documented numerous potential actions of exogenous hyaluronic acid upon the diseased joint. A substantial aggregate of clinical data suggests that viscosupplementation is clinically safe and suggests some therapeutic efficacy with regard to pain relief. However, a robust placebo effect and industry bias have obscured these outcomes considerably. Although recent attention has focused on the disease-modifying potential of this treatment option, definitive evidence is lacking. This paper will review the development, experience, indications, and clinical outcomes of viscosupplementation therapy in patients with osteoarthritis.
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Affiliation(s)
- Stephen F Brockmeier
- Department of Orthopaedic Surgery, Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC 20007, USA
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Arthrocentesis—Incentives for Using This Minimally Invasive Approach for Temporomandibular Disorders. Oral Maxillofac Surg Clin North Am 2006; 18:311-28, vi. [DOI: 10.1016/j.coms.2006.03.005] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Tehranzadeh J, Mossop EP, Golshan-Momeni M. Therapeutic arthrography and bursography. Orthop Clin North Am 2006; 37:393-408, vii. [PMID: 16846769 DOI: 10.1016/j.ocl.2006.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Arthrography and bursography as therapeutic venues have found their place in the musculoskeletal procedure armamentarium. Therapeutic arthrography not only rules in and rules out the origin of pain but can provide 6 to 9 months of pain relief in diseased joints. Therapeutic arthrography allows injections of anesthetic, corticosteroid, or alternatively hyaluronic acid to be delivered accurately to the source of pain. Corticosteroids have a long history of use in osteoarthritis. Alternative therapy with hyaluronic acid is anew procedure. This article reviews the technique of arthrography in different joints and bursae and discusses the pros and cons of the use of corticosteroids versus viscosupplementation in therapeutic arthrography.
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Affiliation(s)
- Jamshid Tehranzadeh
- Department of Radiological Sciences, R 140, University of California Medical Center, 101 The City Drive, Orange, CA 92868-3298, USA.
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Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G. Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database Syst Rev 2006; 2006:CD005321. [PMID: 16625635 PMCID: PMC8884110 DOI: 10.1002/14651858.cd005321.pub2] [Citation(s) in RCA: 271] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Osteoarthritis (OA) is the most prevalent chronic joint disorder worldwide and is associated with significant pain and disability. OBJECTIVES To assess the effects of viscosupplementation in the treatment of OA of the knee. The products were hyaluronan and hylan derivatives (Adant, Arthrum H, Artz (Artzal, Supartz), BioHy (Arthrease, Euflexxa, Nuflexxa), Durolane, Fermathron, Go-On, Hyalgan, Hylan G-F 20 (Synvisc Hylan G-F 20), Hyruan, NRD-101 (Suvenyl), Orthovisc, Ostenil, Replasyn, SLM-10, Suplasyn, Synject and Zeel compositum). SEARCH STRATEGY MEDLINE (up to January (week 1) 2006 for update), EMBASE, PREMEDLINE, Current Contents up to July 2003, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched. Specialised journals and reference lists of identified randomised controlled trials (RCTs) and pertinent review articles up to December 2005 were handsearched. SELECTION CRITERIA RCTs of viscosupplementation for the treatment of people with a diagnosis of OA of the knee were eligible. Single and double-blinded studies, placebo-based and comparative studies were eligible. At least one of the four OMERACT III core set outcome measures had to be reported (Bellamy 1997). DATA COLLECTION AND ANALYSIS Each trial was assessed independently by two reviewers for its methodological quality using a validated tool. All data were extracted by one reviewer and verified by a second reviewer . Continuous outcome measures were analysed as weighted mean differences (WMD) with 95% confidence intervals (CI). However, where different scales were used to measure the same outcome, standardized mean differences (SMD) were used. Dichotomous outcomes were analyzed by relative risk (RR). MAIN RESULTS Seventy-six trials with a median quality score of 3 (range 1 to 5) were identified. Follow-up periods varied between day of last injection and eighteen months. Forty trials included comparisons of hyaluronan/hylan and placebo (saline or arthrocentesis), ten trials included comparisons of intra-articular (IA) corticosteroids, six trials included comparisons of nonsteroidal anti-inflammatory drugs (NSAIDs), three trials included comparisons of physical therapy, two trials included comparisons of exercise, two trials included comparisons of arthroscopy, two trials included comparisons of conventional treatment, and fifteen trials included comparisons of other hyaluronans/hylan. The pooled analyses of the effects of viscosupplements against 'placebo' controls generally supported the efficacy of this class of intervention. In these same analyses, differential efficacy effects were observed for different products on different variables and at different timepoints. Of note is the 5 to 13 week post injection period which showed a percent improvement from baseline of 28 to 54% for pain and 9 to 32% for function. In general, comparable efficacy was noted against NSAIDs and longer-term benefits were noted in comparisons against IA corticosteroids. In general, few adverse events were reported in the hyaluronan/hylan trials included in these analyses. AUTHORS' CONCLUSIONS Based on the aforementioned analyses, viscosupplementation is an effective treatment for OA of the knee with beneficial effects: on pain, function and patient global assessment; and at different post injection periods but especially at the 5 to 13 week post injection period. It is of note that the magnitude of the clinical effect, as expressed by the WMD and standardised mean difference (SMD) from the RevMan 4.2 output, is different for different products, comparisons, timepoints, variables and trial designs. However, there are few randomised head-to-head comparisons of different viscosupplements and readers should be cautious, therefore, in drawing conclusions regarding the relative value of different products. The clinical effect for some products, against placebo, on some variables at some timepoints is in the moderate to large effect-size range. Readers should refer to relevant tables to review specific detail given the heterogeneity in effects across the product class and some discrepancies observed between the RevMan 4.2 analyses and the original publications. Overall, the analyses performed are positive for the HA class and particularly positive for some products with respect to certain variables and timepoints, such as pain on weight bearing at 5 to 13 weeks postinjection. In general, sample-size restrictions preclude any definitive comment on the safety of the HA class of products; however, within the constraints of the trial designs employed no major safety issues were detected. In some analyses viscosupplements were comparable in efficacy to systemic forms of active intervention, with more local reactions but fewer systemic adverse events. In other analyses HA products had more prolonged effects than IA corticosteroids. Overall, the aforementioned analyses support the use of the HA class of products in the treatment of knee OA.
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Affiliation(s)
- N Bellamy
- University of Queensland, Centre Of National Research On Disability And Rehabilitation Medicine, Level 3, Mayne Medical School, Herston Road, Brisbane, Queensland, Australia, 4006.
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Raynauld JP, Goldsmith CH, Torrance GW. Letter to the Editor: Reply to the letter by Max I. Hamburger. Osteoarthritis Cartilage 2005; 13:1037-8; author reply 1039-40. [PMID: 16169753 DOI: 10.1016/j.joca.2005.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2005] [Indexed: 02/02/2023]
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2005. [DOI: 10.1002/pds.1031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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