Joint Injections in Rheumatoid Arthritis
Over the last several months there has been a few articles that highlighted the benefits of intraarticular (IA) corticosteroid injections (cortisone shots to the joint). My bias in clinical practice has been for sometime to opt for IA injections in lieu of oral or intramuscular corticosteroid injections. I feel the clinical response is more robust and there appear to be less systemic side effects. So what are those benefits?
First and foremost is structural protection of the joint. Some studies have found that not only does the inflammation improve but there is less damage to the joint tissues. Second, the thickness of the synovium (the lining of the joint which is the source of inflammation and joint damage in Rheumatoid Arthritis) decreases resulting in less swelling and less erosion into the bone and cartilage. Third, there seems to be less "spill over" of inflammation from the injected joint to other joints. The result is that even the joints that were not injected improve to some extent. Fourth, there is less side effects. Since the medication is concentrated at the site of inflammation, there is less distribution to other tissues and thus less exposure to the potential harms of the medications. This includes the dreaded suppression of the adrenal glands. Fifth, there appears to be little consequence, if any, to the injected joint.
Finally, there is the surprising potential effect on lymphoma. We know that patients with Rheumatoid arthritis have a two-fold increase in risk of this cancer. Baecklund et al reported their findings from a large cohort study in Sweden. They followed more than seventy thousand patients with RA between 1964 and 1995. 378 patients developed lymphoma. When evaluating for risk factors, they found that the risk of lymphoma was primarily associated with the level of inflammation and not the medications prescribed (as it was previously believed). One surprise was that those patients who received corticosteroids at some point during their treatment had less inflammation and thus a lower risk of developing lymphoma. Actually, that may not seem particularly unexpected. But what was unexpected was that the lowest risk of lymphoma was found among patients who received a greater number of IA corticosteroid injections, more so than systemic corticosteroid therapy.
It seems that joint injections have an impact not only on the joint injected but on the disease process as whole. Following this line of thinking, researchers in Denmark prescribed methotrexate and injected up to four joints every two weeks. They had remarkable results that rivaled those of new biologics. The results are even more remarkable considering that they were using very low doses of methotrexate.
Given much of the recent evidence compounded with my favorable experience with IA corticosteroid therapy, my threshold for injection the joint has significantly decreased.
Furtado RN, Oliveira LM, Natour J.
Polyarticular corticosteroid injection versus systemic administration in treatment of rheumatoid arthritis patients: a randomized controlled study.
J Rheumatol. 2005 Sep;32(9):1691-8.
Leitch R, Walker SE, Hillard AE.
The rheumatoid knee before and after arthrocentesis and prednisolone injection: evaluation by Gd-enhanced MRI.
Clin Rheumatol. 1996 Jul;15(4):358-66.
Emkey RD, Lindsay R, Lyssy J, Weisberg JS, Dempster DW, Shen V.
The systemic effect of intraarticular administration of corticosteroid on markers of bone formation and bone resorption in patients with rheumatoid arthritis.
Arthritis Rheum. 1996 Feb;39(2):277-8
Balch HW, Gibson JM, El-Ghobarey AF, Bain LS, Lynch MP.
Repeated corticosteroid injections into knee joints.
Rheumatol Rehabil. 1977 Aug;16(3):137-40.
Hetland ML, et al
Combination treatment with methotrexate, cyclosporine, and intraarticular betamethasone compared with methotrexate and intraarticular betamethasone in early active rheumatoid arthritis: An investigator-initiated, multicenter, randomized, double-blind, parallel-group, placebo-controlled study.
Arthritis Rheum. 2006 Apr 27;54(5):1401-140
Baecklund E, et al
Association of chronic inflammation, not its treatment, with increased lymphoma risk in rheumatoid arthritis.
Arthritis Rheum. 2006 Mar;54(3):692-701.
First and foremost is structural protection of the joint. Some studies have found that not only does the inflammation improve but there is less damage to the joint tissues. Second, the thickness of the synovium (the lining of the joint which is the source of inflammation and joint damage in Rheumatoid Arthritis) decreases resulting in less swelling and less erosion into the bone and cartilage. Third, there seems to be less "spill over" of inflammation from the injected joint to other joints. The result is that even the joints that were not injected improve to some extent. Fourth, there is less side effects. Since the medication is concentrated at the site of inflammation, there is less distribution to other tissues and thus less exposure to the potential harms of the medications. This includes the dreaded suppression of the adrenal glands. Fifth, there appears to be little consequence, if any, to the injected joint.
Finally, there is the surprising potential effect on lymphoma. We know that patients with Rheumatoid arthritis have a two-fold increase in risk of this cancer. Baecklund et al reported their findings from a large cohort study in Sweden. They followed more than seventy thousand patients with RA between 1964 and 1995. 378 patients developed lymphoma. When evaluating for risk factors, they found that the risk of lymphoma was primarily associated with the level of inflammation and not the medications prescribed (as it was previously believed). One surprise was that those patients who received corticosteroids at some point during their treatment had less inflammation and thus a lower risk of developing lymphoma. Actually, that may not seem particularly unexpected. But what was unexpected was that the lowest risk of lymphoma was found among patients who received a greater number of IA corticosteroid injections, more so than systemic corticosteroid therapy.
It seems that joint injections have an impact not only on the joint injected but on the disease process as whole. Following this line of thinking, researchers in Denmark prescribed methotrexate and injected up to four joints every two weeks. They had remarkable results that rivaled those of new biologics. The results are even more remarkable considering that they were using very low doses of methotrexate.
Given much of the recent evidence compounded with my favorable experience with IA corticosteroid therapy, my threshold for injection the joint has significantly decreased.
Furtado RN, Oliveira LM, Natour J.
Polyarticular corticosteroid injection versus systemic administration in treatment of rheumatoid arthritis patients: a randomized controlled study.
J Rheumatol. 2005 Sep;32(9):1691-8.
Leitch R, Walker SE, Hillard AE.
The rheumatoid knee before and after arthrocentesis and prednisolone injection: evaluation by Gd-enhanced MRI.
Clin Rheumatol. 1996 Jul;15(4):358-66.
Emkey RD, Lindsay R, Lyssy J, Weisberg JS, Dempster DW, Shen V.
The systemic effect of intraarticular administration of corticosteroid on markers of bone formation and bone resorption in patients with rheumatoid arthritis.
Arthritis Rheum. 1996 Feb;39(2):277-8
Balch HW, Gibson JM, El-Ghobarey AF, Bain LS, Lynch MP.
Repeated corticosteroid injections into knee joints.
Rheumatol Rehabil. 1977 Aug;16(3):137-40.
Hetland ML, et al
Combination treatment with methotrexate, cyclosporine, and intraarticular betamethasone compared with methotrexate and intraarticular betamethasone in early active rheumatoid arthritis: An investigator-initiated, multicenter, randomized, double-blind, parallel-group, placebo-controlled study.
Arthritis Rheum. 2006 Apr 27;54(5):1401-140
Baecklund E, et al
Association of chronic inflammation, not its treatment, with increased lymphoma risk in rheumatoid arthritis.
Arthritis Rheum. 2006 Mar;54(3):692-701.
posted by Ricardo Pocurull at 6:11 PM
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