Knee Viscosupplementation: Cost-Effectiveness Analysis between Stabilized Hyaluronic Acid in a Single Injection versus Five Injections of Standard Hyaluronic Acid

Different doses of hyaluronic acid injections in patients with knee osteoarthritis: A multicenter, randomized, prospective, single-blind, clinical study

BACKGROUND

Many formulations and dosing regimens are available for hyaluronic acid (HA).

OBJECTIVE

To compare different doses of linear, high-molecular weight (HMW) HA injections among patients with knee osteoarthritis (OA).

METHODS

Hundred patients were included in this randomized, single-blinded trial and randomly divided into three HA injection groups. The first group received five weekly 20 mg HA injections, the second group received three weekly 32 mg HA injections, and the third group received a single 48 mg HA injection. Patients were evaluated at baseline, 1, 3, and 6 months after the last injection for pain, stiffness, and function using the visual analog scale (VAS) and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire. Quality of life, patient's global assessment, and Timed Up and Go (TUG) test scores were also evaluated.

RESULTS

There was significant improvement in the WOMAC, VAS-pain, quality of life, patient's global assessment, and TUG test mean scores at all follow-up time points (p< 0.001). However, the groups showed no significant differences in WOMAC, VAS-activity pain, and patient global scores at any follow-up point.

CONCLUSION

Intra-articular injections of different doses of linear HMW HA can improve pain, stiffness, function, and quality of life in patients suffering from knee OA over a six-month period.

Combination of Hyaluronan and Lyophilized Progenitor Cell Derivatives: Stabilization of Functional Hydrogel Products for Therapeutic Management of Tendinous Tissue Disorders

Cultured progenitor cells and derivatives have been used in various homologous applications of cutaneous and musculoskeletal regenerative medicine. Active pharmaceutical ingredients (API) in the form of progenitor cell derivatives such as lysates and lyophilizates were shown to retain function in controlled cellular models of wound repair. On the other hand, hyaluronan-based hydrogels are widely used as functional vehicles in therapeutic products for tendon tissue disorders. The aim of this study was the experimental characterization of formulations containing progenitor tenocyte-derived APIs and hyaluronan, for the assessment of ingredient compatibility and stability in view of eventual therapeutic applications in tendinopathies. Lyophilized APIs were determined to contain relatively low quantities of proteins and growth factors, while being physicochemically stable and possessing significant intrinsic antioxidant properties. Physical and rheological quantifications of the combination formulas were performed after hydrogen peroxide challenge, outlining significantly improved evolutive viscoelasticity values in accelerated degradation settings. Thus, potent effects of physicochemical protection or stability enhancement of hyaluronan by the incorporated APIs were observed. Finally, combination formulas were found to be easily injectable into ex vivo tendon tissues, confirming their compatibility with further translational clinical approaches. Overall, this study provides the technical bases for the development of progenitor tenocyte derivative-based injectable therapeutic products or devices, to potentially be applied in tendinous tissue disorders.

Intra-articular Hyaluronic Acid for Osteoarthritis of the Knee in the United States: A Systematic Review of Economic Evaluations

Background:

The economic impact of intra-articular hyaluronic acid (IAHA) for the treatment of knee pain associated with osteoarthritis (OA) has been evaluated in the United States, but not systematically summarized.

Objective:

We reviewed the literature to determine the economic impact of IAHA for pain associated with knee OA in the United States.

Methods:

A literature review was performed in PubMed (including MEDLINE and MEDLINE In-Process), Embase, the Cochrane Database of Systematic Reviews, and National Health Service Economic Evaluation Database and was limited to English language human studies published from January 2000 to October 2020.

Results:

The literature search identified 215 unique abstracts; of these, 47 were selected for full-text review and 21 studies met the inclusion criteria. Intra-articular hyaluronic acid injections delayed progression to total knee arthroplasty (TKA), and repeated courses of treatment successfully delayed TKA by more than 5 years. Intra-articular hyaluronic acid was found to reduce the use of pain medications overall and reduce the number of patients receiving opioid prescriptions by 6% (P < .001). Several studies showed that IAHA is more cost-effective in treating pain associated with knee OA compared with conventional care with nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, and corticosteroids, and several authors concluded that IAHA should be the dominant treatment strategy.

Conclusions:

Current studies suggest that IAHA may reduce the use of pain medications, such as NSAIDs and opioids, and impact time to TKA procedures, thus potentially decreasing overall treatment costs of knee OA over time. Furthermore, IAHA was determined to be cost-effective against NSAIDs, corticosteroids, analgesics, and conservative treatment. As the safety and efficacy of IAHA for knee OA have been well established, the findings from our literature review may be used to inform future economic evaluations.

Efficacy of single high-molecular-weight versus triple low-molecular-weight hyaluronic acid intra-articular injection among knee osteoarthritis patients

Background

To compare intra-articular (IA) knee injections of a cross-linked high-molecular-weight hyaluronic acid (HMW-HA) with a linear low-molecular weight HA (LMW-HA) in terms of pain and functional improvement among knee osteoarthritis (OA) patients.

Methods

In this single-blinded RCT, the patients were randomly divided into two groups for HA injections. The first group received an HMW-HA (Arthromac) injection, while the other received three weekly LMW-HA (Hyalgan) injections. Pain and function were assessed using the outcome measures including WOMAC, Lequesne and VAS indices, once prior to injection, as well as 2 and 6 months after injections.

Results

A total of 90 patients were included. There was no significant difference in baseline characteristics including age and sex between the two groups. Our analysis showed that total WOMAC, Lequesne and VAS mean scores remarkably improved at both follow-up time-points compared to the baseline measurements (p < 0.001). There was no significant superiority between the two therapeutic protocols according to our outcome measures at any time-point of follow-up. The only except was about the improvement in WOMAC stiffness subscale that was significantly higher in LMW-HA group compared to HMW-HA (p = 0.021). Moreover, no significant difference was observed in minor complications and injection-induced pain scores between the two groups.

Conclusion

This study proved that a single HMW-HA injection is as effective as multiple injections of LMW-HA counterparts in periods of 2 and 6 months follow-up.

This study protocol was registered in Iranian database of RCTs (IRCT; www.irct.ir) with the trial registration number IRCT20130523013442N24 and registration date 2018-07-13.

Investigation of the efficacy of daidzein in experimental knee osteoarthritis-induced with monosodium iodoacetate in rats

BACKGROUND

Osteoarthritis (OA) is a degenerative chronic illness that most frequently occurs in the knee joint. Daidzein (DZ) an isoflavone has anti-inflammatory and antioxidant activity. The aim of this study was to evaluate the effectiveness of DZ as a treatment for experimental knee OA (KOA) in rats.

METHOD

An experimental KOA model was induced by monosodium iodoacetate (MIA) in rats. Thereafter, 49 Wistar albino male rats (250-300 g, 12-16 weeks old) were randomly divided into 7 groups: C (healthy control); DC (KOA + saline); hyaluronic acid (HA); HA+ intraarticular (ia) DZ; oral (po) DZ; ia DZ; HA + po DZ groups. DZ and/or HA were administered intraarticularly to the rats as 50 μL on days 1, 7, 14, and 21. Alternatively, the DZ was administered orally as 0.5 mL twice daily for 21 days. After the treatment, rats were sacrificed by decapitation under general anesthesia. Serum samples were analyzed to determine the total oxidant status (TOS) and total antioxidant status (TAS) and the levels of TNF-α, IL-1β, MMP-13, and DZ. Knee joint samples underwent histopathological examination, and TNF-α, IL-1β, NOS2, and MMP-13 were analyzed with immunohistochemical methods.

RESULTS

HA, DZ, and DZ + HA effectively reduced the levels of TNF-α, IL-1β, and MMP-13 in the serum of the DC group (p < 0.001). In groups that received HA, DZ, or DZ + HA, the serum TAS increased compared with the DC group (p < 0.05). When the DZ + HA combination was used, a more pronounced reduction in the levels of TNFα, NOS2, IL-1β, and MMP-13 was observed in knee joints. In addition, the cracks on the cartilage surface and fibrillation were completely improved in the groups that received HA, DZ, or DZ + HA compared with the DC group.

CONCLUSION

DZ had anti-inflammatory and antioxidant effects in a rat OA model. Therefore, DZ, as monotherapy or especially in combination with HA, may be a promising and beneficial therapy for OA. Key Points •DZ has been shown to reduce TNF-α, IL-1β, and MMP-13 both in serum and in tissue samples taken from the knee-joints. •The cracks on the cartilage surface and fibrillation in KOA were completely improved by using DZ and DZ + HA combination. •DZ may be useful to eliminate/reduce/ameliorate inflammation and oxidative damage in the pathogenesis of KOA. •DZ, alone or in combination with HA, may be a promising natural compound with beneficial effects in the treatment of KOA.

Anti‑inflammatory and anti‑catabolic effect of non‑animal stabilized hyaluronic acid and mesenchymal stem cell‑conditioned medium in an osteoarthritis coculture model

Previous clinical studies have reported the clinical effectiveness of non‑animal stabilized hyaluronic acid (NASHA) and adipose‑derived mesenchymal stromal/stem cells (MSC) in the treatment of knee osteoarthritis (OA). Unlike MSC secreted mediators, in vitro anti‑inflammatory effects of NASHA have not been evaluated. We aimed to evaluate and compare the anti‑inflammatory effect of NASHA and MSC conditioned medium (stem cell‑conditioned medium; SC‑CM), in an explant‑based coculture model of OA. Cartilage and synovial membrane from seven patients undergoing total knee arthroplasty were used to create a coculture system. Recombinant IL‑1β was added to the cocultures to induce inflammation. Four experimental groups were generated: i) Basal; ii) IL‑1β; iii) NASHA (NASHA + IL‑1β); and iv) SC‑CM (SC‑CM + IL‑1β). Glycosaminoglycans (GAG) released in the culture medium and of nitric oxide (NO) production were quantified. Gene expression in cartilage and synovium of IL‑1β, matrix metallopeptidase 13 (MMP13), ADAM metallopeptidase with thrombospondin type 1 motif 5 (ADAMTS5) and tissue inhibitor of metalloproteinases 1 (TIMP1) was measured by reverse transcription‑quantitative PCR. Media GAG concentration was decreased in cocultures with NASHA and SC‑CM (48 h, P<0.05; 72 h, P<0.01) compared with IL‑1β. Production of NO was significantly lower only in SC‑CM after 72 h (P<0.01). In cartilage, SC‑CM inhibited the expression of IL‑1β, MMP13 and ADAMTS5, while NASHA had this effect only in MMP13 and ADAMTS5. In synovium, SC‑CM decreased the expression level of MMP13 and ADAMTS5, while NASHA only decreased ADAMTS5 expression. Both NASHA and SC‑CM increased TIMP1 expression in cartilage and synovium. Treatments with NASHA and SC‑CM were shown to be a therapeutic option that may help counteract the catabolism produced by the inflammatory state in knee OA. The anti‑inflammatory mediators produced by MSC promote a lower expression of inflammatory targets in our study model.

Injections intra articulaires (IA) d'acide hyaluronique (AH) dans le traitement symptomatique de la gonarthrose : une méta-analyse des injections uniques (mono-injections)

Introduction

La viscosupplémentation du liquide synovial par injections intra articulaires (IA) d'acide hyaluronique (AH), est un traitement symptomatique bien connu dans la gonarthrose. La question se pose de savoir si les traitements par injection unique (mono-injection) peuvent présenter autant d'efficacité que les multi-injections (3 à 5).

Méthodes

Une méta-analyse des résultats publiés pour les essais de mono-injections IA de AH a été réalisée. Le critère d'efficacité retenu a été le sous-score douleur de l'indice Western Ontario and MacMaster universities (WOMAC A). Toutes les conceptions d'études ont été admises, depuis les essais randomisés contrôlés jusqu'aux études observationnelles ouvertes à simple bras. Une recherche extensive a été effectuée à partir de PubMed, Google, Google Scholar, et des listes de références trouvées dans les méta-analyses récentes, pour obtenir tous les articles publiés avant fin avril 2018. Les profils des populations furent analysés en termes d'âge, de sexe, d'indice de masse corporelle (IMC) et de stade radiologique selon Kellgren-Lawrence (KL). Les résultats d'injection IA unique de placebo, ont été pris en compte pour créer une base permettant des comparaisons post-hoc. Chaque bras AH IA étudié a été comparé à un bras placebo IA (seul ou mixé), de manière à présenter un profil KL similaire, contrôlé à l'aide du test Chi². Les tailles de l'effet (ES) avec intervalles de confiance (IC 95%) et p-valeurs furent calculées et synthétisées pour chacune des visites de contrôle à 1, 2, 3 et 6 mois. En parallèle, une approche globale a été utilisée afin de représenter les variations par rapport à la baseline, pour chacun des sous-groupes étudiés.

Résultats

En partant de 1 547 citations, 28 études ont été incluses dans la méta-analyse, décrivant 4 129 patients traités par mono-injection: 3 360 ont reçu de l'AH IA et 769 patients ont reçu du placebo IA. Le patient moyen (SD) traité par AH IA était âgé de 61,2 (9,6) ans dont 63% de femmes, avec un IMC de 28,0 (4,1) kg/m², et un stade radiologique à 47% KL III pour 3% KL IV. Un bon appariement du profil KL a été obtenu pour 26 des 31 bras AH IA. Sur l'ensemble de la population AH IA, ES = 0,30 (0,25; 0,35) à 3 mois et ES = 0,39 (0,33; 0,44) à 6 mois. Dans une analyse restreinte, après élimination des cas aberrants, des KL mal appariés et des bras actifs < 30 patients, les résultats sont restés inchangés, ES = 0,29 (0,23; 0,34) et ES = 0,40 (0,34; 0,45) à 3 et 6 mois respectivement, tandis que l'hétérogénéité était améliorée.

Discussion

Il existe certainement des limites à la méthode de comparaison post-hoc versus placebo, appliquée à des essais individuels. Mais pour chaque synthèse par sous-groupe ou groupe, les résultats ont été confirmés en utilisant plusieurs approches statistiques et différentes méthodes de pondération. Cette méta-analyse suggère que les résultats des mono-injections sont similaires à ceux des multi-injections d'acide hyaluronique intra articulaire en termes de soulagement de la douleur, dans le traitement de la gonarthrose.

Elucidation of the time-dependent degradation process in insoluble hyaluronic acid formulations with a controlled degradation rate

Degradation rate of hyaluronic acid to prolong its stability in vivo would be beneficial. We investigated a potential solution for prolonging the stability of hyaluronic acid within the body. We focused on decreasing the swelling ratio to slow the degradation rate of hyaluronic acid by insolubilizing sodium hyaluronate without using potentially harmful substances such as crosslinkers or modifiers. Hyaluronic acid formulations were created with three different swelling ratios and time-dependent morphological changes in hyaluronic acid formulations and were scored based on each swelling ratio. In vivo degradation was modeled in simulated body fluid and the extent of decay of test membranes were monitored over time. Results showed that, by adjusting the swelling ratio, the degradation rate of hyaluronic acid formulation could be controlled. Our research could lead to improvements in many products, not only preventive materials for postoperative adhesions, but also pharmaceutical products such as osteoarthritis treatments and cosmetic medicines.

Comparative Effectiveness of Alternative Dosing Regimens of Hyaluronic Acid Injections for Knee Osteoarthritis: A Systematic Review

CONTEXT

Viscosupplementation is widely used for management of knee osteoarthritis. Many formulations of hyaluronic acid (HA) are available, ranging from a single injection to a series of up to 5 injections per treatment.

OBJECTIVE

To compare efficacy between single and multiple HA injection formulations.

DATA SOURCES

MEDLINE, EMBASE, Cochrane, Web of Science, Scopus databases were all searched.

STUDY SELECTION

Full-text prospective randomized and nonrandomized controlled human trials, cohort studies, and cost-effectiveness evaluations in the English language comparing different injection regimens of viscosupplementation were included.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 1.

DATA EXTRACTION

Data were collected using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Four databases were searched by a librarian and the principal investigator, identifying 6196 articles for screening.

RESULTS

Eleven studies met the inclusion criteria. Of the studies comparing single- with multiple-injection formulations of HA for treatment of knee osteoarthritis, there was no consistent difference in patient-reported outcomes. Furthermore, 5-injection formulations do not appear to be superior to 3-injection formulations.

CONCLUSION

There are limited head-to-head trials comparing viscosupplementation formulations that differ based on number of injections, and in particular, there is a paucity of trials evaluating single-injection formulations. Based on the currently available data, there appears to be similar efficacy with the possibility for greater cost-effectiveness and less patient inconvenience with single-injection formulations.

Intra-Articular Hyaluronic Acid in the Symptomatic Treatment of Knee Osteoarthritis: A Meta-Analysis of Single-Injection Products

Background

Viscosupplementation of the synovial fluid with intra-articular hyaluronic acid (IA HA) is a well-known symptomatic treatment of knee osteoarthritis. The question arises whether a monoinjection (ie, single injection) could be as efficient as multi-injection (ie, 3-5 injections) regimens.

Methods

A meta-analysis of published studies relating to IA HA monoinjection trials was performed. The efficacy criterion was the Western Ontario and MacMaster Universities pain subscore. Any study design was accepted, from randomized control trials to single-arm observational open-label studies. An extensive search was performed using PubMed, Google, Google Scholar, and references found in recent meta-analyses, for all articles published before end of April 2018. Population profiles were analyzed in terms of age, sex, body mass index (BMI), and Kellgren-Lawrence (KL) radiology grades. Results of intra-articular single injection of placebo were collected to create a database allowing post hoc comparisons. Each IA HA study arm was compared to an IA placebo arm (either pooled or not), to present a similar KL profile controlled with the χ² test. The effect size (ES) (95% CI) and P values were calculated and synthesized for each follow-up visit at 1, 2, 3, and 6 months. In parallel, a global approach was used to represent the variations from baseline for each group or subgroup studied.

Results

From 1547 citations, 28 studies were included in the meta-analysis, representing 4129 patients treated with monoinjection: 3360 received IA HA and 769 patients received IA placebo. The mean (SD) IA HA patient was 61.2 (9.6) years, 63% women, BMI 28.0 (4.1), 47% KL III, and 3% KL IV. A good placebo KL profile matching was obtained for 26 of the 31 IA HA arms. For the whole IA HA population, ES = 0.30 (95% CI, 0.25-0.35) at 3 months and ES = 0.39 (95% CI, 0.33-0.44) at 6 months. In a restricted analysis, after removal of outliers, poorly KL matched and active arms <30 patients, results remained unchanged, ES = 0.29 (95% CI, 0.23-0.34) and ES = 0.40 (95% CI, 0.34-0.45) at 3 and 6 months respectively, whilst heterogeneity was improved.

Conclusions

There are certainly limits to the post hoc placebo comparison method, for individual studies. But for each synthesis per subgroup or group, the results were properly confirmed using multiple statistical approaches and weighing methods. This meta-analysis suggests that monoinjections produce results similar to multi-injections of IA HA in terms of pain relief in the treatment of knee osteoarthritis. (Curr Ther Res Clin Exp. 2019; 80:XXX-XXX).

Repair of Damaged Articular Cartilage: Current Approaches and Future Directions

Articular hyaline cartilage is extensively hydrated, but it is neither innervated nor vascularized, and its low cell density allows only extremely limited self-renewal. Most clinical and research efforts currently focus on the restoration of cartilage damaged in connection with osteoarthritis or trauma. Here, we discuss current clinical approaches for repairing cartilage, as well as research approaches which are currently developing, and those under translation into clinical practice. We also describe potential future directions in this area, including tissue engineering based on scaffolding and/or stem cells as well as a combination of gene and cell therapy. Particular focus is placed on cell-based approaches and the potential of recently characterized chondro-progenitors; progress with induced pluripotent stem cells is also discussed. In this context, we also consider the ability of different types of stem cell to restore hyaline cartilage and the importance of mimicking the environment in vivo during cell expansion and differentiation into mature chondrocytes.

Systematic clinical evidence review of NASHA (Durolane hyaluronic acid) for the treatment of knee osteoarthritis

Background

Pain and limitations in joint mobility associated with knee osteoarthritis (OA) are clinically challenging to manage, and advanced progression of disease can often lead to total knee arthroplasty. Intra-articular injection of hyaluronic acid (HA), also referred to as viscosupplementation, is a non-surgical treatment approach for OA, the effectiveness of which may depend on the HA composition, and the length of time over which it resides in the joint. One of the available options for such therapies includes NASHA (Durolane HA), a non-animal, biofermentation-derived product, which is manufactured using a process that stabilizes the HA molecules to slow down their rate of degradation and produce a unique formulation with a terminal half-life of ~1 month. The objectives of the current review were to assess, in patients with OA of the knee, the efficacy and safety of intra-articular treatment with NASHA relative to control (saline) injections, other HA products, and other injectables (corticosteroids, platelet-rich plasma, mesenchymal stem cells).

Methods

This systematic evidence review examines patient outcomes following NASHA treatment as described in published data from studies conducted in subjects with knee OA. A Preferred Reporting Items for Systematic Reviews and Meta-analyses-compliant literature search strategy yielded 11 eligible clinical studies with a variety of comparator arms. Outcomes assessed at various time points following intra-articular treatment included measures of pain, function, quality of life, and incidence of treatment-related adverse events (AEs).

Results

The available evidence reported for the clinical studies assessed demonstrates sustained and effective relief of knee OA symptoms following a single injection of NASHA. In addition, an excellent biocompatibility profile is observed for NASHA as an intra-articular therapy for OA, as reflected by the low rate of AEs associated with treatment.

Conclusion

Treatment with NASHA is an effective and safe single-injection procedure, which can be beneficial in the clinical management of knee OA.