The impact of treatment with hylan G-F 20 on progression to total hip arthroplasty in patients with symptomatic hip OA: a retrospective study

Systematic Literature Review and Expert Opinion for the Use of Viscosupplementation with Hyaluronic Acid in Different Localizations of Osteoarthritis

Osteoarthritis (OA) is a significant cause of disability. Considering the increasing diffusion of the viscosupplementation (VS) with hyaluronic acid (HA), the International Symposium Intra Articular Treatment (ISIAT) appointed a Technical Expert Panel (TEP) to identify the criteria for successful VS with a specific HA in OA; this through a systematic literature review (SLR), performed following the PRISMA guidelines interrogating Medline, Embase, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Grey Matters and American College of Rheumatology (ACR/EULAR) databases and the opinion of international experts. The research included only studies on adults and humans without limitations of language or time of publication. Researchers extracted both quantitative and qualitative data from each study. Mixed Methods Appraisal Tool (MMAT) was used to perform quality analysis for the level of evidence. The SLR retrieved 385 papers, 25 of which were suitable for the analysis. The TEP focused on the different formulations of the product Sinovial^® [HA 0.8%, HA 1.6%, HA 2%, 800–1200 kDa, HA 3.2% (1400–2100 kDa/65–110 kDa)]. The choice was due to the vast amount of evidence available. The TEP weighed the evidence in two rounds of a Delphi survey; the results, and any disagreement, were discussed in a final session. Three domains were considered: 1) the patients’ characteristics associated with the best results; 2) the contraindications and the conditions linked to increased risk of failure; 3) the clinical conditions in which VS is considered appropriate. The TEP concluded that VS with HA is safe and effective in the treatment of knee and hip OA of grades I to III and that it is possible to undertake VS in other situations (eg grade IV Kellgren-Lawrence – KL); a comprehensive examination of the patient should be performed before the procedure.

Viscosupplementation for hip osteoarthritis: Does systematic review of patient-reported outcome measures support use?

INTRODUCTION

Osteoarthritis of the hip is one of the leading causes of disability worldwide. There is lack of agreement among providers and governing agencies regarding the efficacy of hyaluronic acid (HA) for the management of hip osteoarthritis (OA). Therefore, the purpose of this systematic review was to determine how HA administration impacts 1) patient reported outcome measures (PROMs) and 2) rates of conversion to THA.

METHODS

The PubMed, EBSCO host, and Google Scholar electronic databases were queried for all studies published between January 1st, 2000 and January 1st, 2020 that reported on outcomes following HA administration for treatment of hip OA. The following keywords were implemented with AND and OR Boolean operators: "hip"; "osteoarthritis"; "arthritis"; "viscosupplementation"; "hyaluronic acid." Our final analysis included 39 studies and reported on a total of 5,864 patients receiving injections of HA.

RESULTS

All studies reporting on visual analog scale (VAS), patient global assessment, and total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores demonstrated improvements following HA administration. For the Lequesne Index (LI), WOMAC pain, WOMAC function, and Harris Hip Score (HHS) values, a majority of studies reported that HA would prove beneficial, with one analysis suggesting a lack of improvement. There was inconsistent evidence across studies regarding the effectiveness of HA compared to other intra-articular injections. The formulation of the administered viscosupplementation did not appear to influence outcomes. Furthermore, rates of conversion to THA were relatively low when evaluating 1- to 4-year follow-up intervals.

DISCUSSION

Non-comparative studies consistently demonstrated that HA can achieve satisfactory pain reduction and functional improvement. However, there was not enough evidence in the current literature regarding whether HA is superior to placebo or other types of intra-articular injections. Future studies should continue to compare HA to other treatment modalities in randomized controlled trials with larger sample sizes.

Effectiveness and Tolerability of Repeated Courses of Viscosupplementation in Symptomatic Hip Osteoarthritis: A Retrospective Observational Cohort Study of High Molecular Weight vs. Medium Molecular Weight Hyaluronic Acid vs. No Viscosupplementation

Background: Nonsurgical management of symptomatic hip osteoarthritis needs real-world evidence. We evaluated the effectiveness and tolerability of US-guided intra-articular treatment of two hyaluronic acids (HAs) commercially available in Italy and investigated predictors of response.

Methods: Outpatient records including three cohorts: 122 subjects treated with medium (1,500–3,200 kDa; Hyalubrix^®) molecular weight (MW) or high (hylan G-F20; Synvisc^®) MW HAs and 20 controls taking NSAIDs/analgesics on demand were retrospectively analyzed. Pain VAS score, WOMAC, NSAID/analgesic consumption, and causes of suspension were available at 1, 6, 12, and 24 months after first administration. As selection bias usually affects observational retrospective studies, a quasi-randomization process was attained by performing propensity score approach.

Results: Propensity score adjustment successfully allowed comparisons among balanced groups of treatments. VAS and WOMAC considerably decreased over time in treated groups independently of the radiological grade (p<0.001). On the other hand, the control group showed only a slight and rather uneven variation in VAS. Mean score changes were comparable in both HA cohorts from the earliest stages (ΔVAS(HA1,500–3,200kDa)_T1vsT0 = −20%; ΔVAS(hylan G-F20)_T1vsT0 = −23%/ΔWOMAC(HA1,500–3,200kDa)_T1vsT0 = −17%; ΔWOMAC(hylan G-F20)_T1vsT0 = −19%), reaching a further substantial reduction after 12 months (ΔVAS(HA1,500–3,200kDa)_T12vsT0 = −52%; ΔVAS(hylan G-F20)_T12vsT0 = −53%/ΔWOMAC(HA1,500–3,200kDa)_T12vsT0 = −45%; and ΔWOMAC(hylan G-F20)_T12vsT0 = −47%). Almost 11% (=13/122) of ineffectiveness and few moderate local side effects 3% (=4/122) were detected.

Conclusions: Viscosupplementation in a real-life setting seems to provide a sound alternative in pain management in comparison to oral NSAIDs/analgesics, guaranteeing a reduced intake of pain killer medications. Analgesic effectiveness, functional recovery, and reduced joint stiffness extend and improve over 12 and 24 months, suggesting that repeated administrations achieve an additive effect.

Evaluating the use of intra-articular injections as a treatment for painful hip osteoarthritis: a randomized, double-blind, multicenter, parallel-group study comparing a single 6-mL injection of hylan G-F 20 with saline

OBJECTIVE

Hip osteoarthritis (OA) is difficult to treat. Steroid injections reduce pain with short duration. With widespread adoption of office-based, image-guided injections, hyaluronic acid is a potentially relevant therapy. In the largest clinical trial to-date, we compared safety/efficacy of a single, 6-mL image-guided injection of hylan G-F 20 to saline in painful hip OA.

METHOD

357 patients were enrolled in a multicenter, double-blind, randomized saline placebo- controlled trial. Subjects were ≥35 years of age, with painful (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]-A1:5.0-8.0; numeric rating scale [NRS]: 0-10) mild-to-moderate hip OA (Kellgren-Lawrence grade II/III) and minimal contralateral hip pain (WOMAC-A1 < 4). Outcome measures included "pain on walking" (WOMAC-A1 and -A), Patient Global Self-Assessment (PTGA), WOMAC-A1 responder rate (+≥2 points on NRS), and adverse events (AEs) over 26 weeks.

RESULTS

357 patients (hylan G-F 20 single:182; saline:175) were enrolled. Both groups demonstrated significant pain improvement from baseline over 26 weeks (P < 0.0001); saline-induced pain reduction was a remarkable 35%. WOMAC-A and PTGA scores also significantly improved (P < 0.0001). No statistically significant difference was observed between groups in WOMAC-A1 scores (hylan G-F 20 single:-2.19 ± 0.16; saline:-2.26 ± 0.17) or WOMAC-A1 responders (41-52%). Treatment-related AE rates at target hip were similar (hylan G-F 20 single:23 patients [12.8%]; saline:12 [7.0%]). Posthoc analysis found, despite protocol requirements, many patients had psychological (31%) or potential neuropathic pain (27.5%) conditions.

CONCLUSION

A single 6-mL hylan G-F 20 injection or saline for painful hip OA resulted in similar, statistically significant/clinically relevant pain and function improvements up to 6 months following injection; no differences between hylan G-F 20 and saline placebo were observed.

The effectiveness of intra-articular injections of Hyalubrix® combined with exercise therapy in the treatment of hip osteoarthritis

Purpose

Osteoarthritis (OA) is the most common joint disorder in the elderly, causing significant pain which negatively affects mobility and quality of life. The aim of the study was to assess the effectiveness of ultrasound image-guided intra-articular injections of Hyalubrix^® combined with exercise therapy in the treatment of hip osteoarthritis.

Methods

This was a single site, prospective, open-label, Investigator-initiated study. Forty patients were enrolled and received three ultrasound image-guided injections of Hyalubrix^®, 45 days apart, combined with three sessions a week of physical therapy (proprioceptive rehabilitation of the lower limbs; gait training; balance training) up to a total of 30 sessions (10 weeks), starting from one week after the first injection.

Results

The primary objective was to achieve a lasting reduction in OA symptoms related to pain during activity. During the course of the study the pain perceived by the patient during activity dropped from a mean value of 6.94 cm to a mean value of 1.46 cm and showed a statistically significant decrease from visit 1 compared to baseline (p < 0.05) which was confirmed at all the subsequent time points. Significant improvements were also observed in the evaluation of the secondary objectives: hip disability; OA-related pain at rest; daily functioning and NSAIDs intake.

Conclusions

Results from this study including 40 patients for a total of 65 treated hips demonstrate a significant improvement in OA-related pain, hip disability, and patient's daily functioning as well as a reduction in NSAIDs intake. Patients suffering from hip OA seem to benefit from the treatment with Hyalubrix^® injections plus exercise therapy.

Intra-articular therapy in hip osteoarthritis

Several therapeutic options have been used in the past for treatment of patients with hip osteoarthritis (HO). In recent years we have witnessed to the introduction of the intra-articular injection (IA) of hyaluronic acid (HA) in clinical practice. This technique was initially used to treat knee arthritis, for which was actually introduced, but hip anatomy itself (deeper joint structure) and technical features (different methods) pose more challenges. However, results look promising in terms of symptoms improvement and delaying prosthetic surgery. Indeed, it does appear mandatory to increase pool of available data with further studies in order to refine techniques, make them more effective, and target patients who could potentially benefit more than others from treatment.

Caution should be used in long-term treatment with oral compounds of hyaluronic acid in patients with a history of cancer

Intra-articular administration of hyaluronic acid is a valuable therapeutic tool for the management of patients with osteoarthritis. However, in recent years numerous formulations containing hyaluronic acid administrable by oral route have entered the market. Even if there are some data in the literature that have shown their effectiveness, systemic administration may expose a greater risk in certain situations. In fact, although hyaluronic acid is not considered a drug it is certain that it can interact with specific receptors and promote cell proliferation. This interaction may be potentially hazardous in cancer patients for which these oral formulations should be contraindicated.

Differences Regarding Branded HA in Italy, Part 2: Data from Clinical Studies on Knee, Hip, Shoulder, Ankle, Temporomandibular Joint, Vertebral Facets, and Carpometacarpal Joint

OBJECTIVES

The aim of the current study is to collect scientific data on all branded hyaluronic acid (HA) products in Italy that are in use for intra-articular (IA) injection in osteoarthritis (OA) compared with that reported in the leaflet.

METHODS

An extensive literature research was performed for all articles reporting data on the IA use of HA in OA. Selected studies were taken into consideration only if they are related to products based on HAs that are currently marketed in Italy with the specific joint indication for IA use in patients affected by OA.

RESULTS

Sixty-two HA products are marketed in Italy: 30 products are indicated for the knee but only 8 were proved with some efficacy; 9 products were effective for the hip but only 6 had hip indication; 7 products proved to be effective for the shoulder but only 3 had the indication; 5 products proved effective for the ankle but only one had the indication; 6 products were effective for the temporomandibular joint but only 2 had the indication; only 2 proved effective for vertebral facet joints but only 1 had the indication; and 5 products proved effective for the carpometacarpal joint but only 2 had the indication.

CONCLUSIONS

There are only a few products with some evidences, while the majority of products remain without proof. Clinicians and regulators should request postmarketing studies from pharmaceuticals to corroborate with that reported in the leaflet and to gather more data, allowing the clinicians to choose the adequate product for the patient.

[Injection treatment with hyaluronic acid]

This article presents the spectrum of indications for the use of hyaluronic acid (HA) based on the recommendations of the European League Against Rheumatism (EULAR), the American College of Rheumatology (ACR), the Osteoarthritis Research Society International (OARSI), the International Institute for Health and Clinical Excellence (NICE) and the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) taking the reality of patient care in Europe into account.

Effectiveness and utility of hyaluronic acid in osteoarthritis

Osteoarthritis (OA) is a chronic degenerative joint disease characterized by pain and progressive functional limitation. Viscosupplementation with intra-articular hyaluronic acid is a treatment option in knee OA that is included in the professional guidelines for treatment of this joint disease, but potentially should apply to all synovial joints in order to reduce pain and improve joint lubrication. Exogenous HA can enhance chondrocyte HA synthesis, prevent the degradation of cartilage and promote its regeneration. Moreover it can reduce the production of proinflammatory mediators and matrix metalloproteinases involved in OA pathogenesis. This mini review highlights the evidence of hyaluronic acid in reducing osteoarthritis symptoms and structural damage, as well as its ability to delay prosthetic surgery. Viscosupplementation should be considered as a long-term therapy.

Consensus statement on viscosupplementation with hyaluronic acid for the management of osteoarthritis

Viscosupplementation (VS) with hyaluronic acid is currently used by physicians to treat osteoarthritis. However, many aspects of this treatment remain questionable and subject of controversy. A group of 8 experts in this field, from European countries, met to debate on 24 statements previously listed by the group members. Based on an extensive research of the literature and expert opinion, a consensus position has been proposed for each statement. Agreement was achieved on some recommendations. In particular, the expert achieved unanimous agreement in favor of the following statements: VS is an effective treatment for mild to moderate knee OA; VS is not an alternative to surgery in advanced hip OA; VS is a well-tolerated treatment of knee and other joints OA; VS should not be used only in patients who have failed to respond adequately to analgesics and NSAIDs; VS is a "positive" indication but not a "lack of anything better" indication; the dosing regimen must be supported by evidence-based medicine; cross-linking is a proven means for prolonging IA residence time of HA; the best approach to inject accurately knee joint is the lateral mid-patellar one; when VS is performed under fluoroscopy, the amount of radiopaque contrast agent must be as low as possible to avoid viscosupplement dilution. These clear recommendations have been established to help practitioners in the use of viscosupplementation.

Bilateral Hip Joint Hylan G-F 20 Granulomatous Synovitis due to Viscosupplementation Injections

We present the diagnosis of bilateral granulomatous inflammation of the hip joints associated with Hylan G-F 20 viscosupplementation injections. Clinicians recommending therapeutic Hylan injections for the management of hip arthritis should maintain clinical awareness regarding this potential complication.

Viscosupplementation for osteoarthritis: a primer for primary care physicians

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.