The Efficacy of Intra-articular Triamcinolone Acetonide 5mg vs. 10 mg vs. 40 mg in Patients With Knee Osteoarthritis
Summary
Osteoarthritis of the knee is a common problem that is increasing in prevalence as the population ages. In a knee with osteoarthritis, there is variable damage to the articular cartilage and underlying bone that can cause varying degrees of pain. When pain is bothersome, osteoarthritis is treated to improve functional abilities. One of the most recognized and used treatments is intra-articular cortisone injection. Cortisone is a powerful anti-inflammatory drug that is used to reduce pain. Unfortunately, cortisone can have significant side effects, even when injected locally. The frequency and intensity of these side effects depend largely on the total dose injected. The main side effects include increased blood sugar levels, increased blood pressure and a temporary decrease in the secretion of the stress hormone, cortisol. In the long term, a decrease in articular cartilage thickness in the injected join and overall bone density reduction is also reported. Despite many years of routine use, the smallest effective dose of cortisone injected into the knee joint is unknown. The main objective of the study is to determine the impact on pain and function of different doses of cortisone injected into the knee. The cortisone chosen for this study is triamcinolone acetonide (TA).
Timeline
- Start
- 2024-01-15
- Primary completion
- 2025-12
- Completion
- 2026-02
Publications
- Background Sharma L. Osteoarthritis of the Knee. N Engl J Med. 2021 Jan 7;384(1):51-59. doi: 10.1056/NEJMcp1903768. No abstract available.
- Background Khan M, Bhandari M. Cochrane in CORR(R): Intra-articular Corticosteroid For Knee Osteoarthritis. Clin Orthop Relat Res. 2018 Jul;476(7):1391-1392. doi: 10.1097/CORR.0000000000000358. No abstract available.
- Background Hunter CW, Deer TR, Jones MR, Chang Chien GC, D'Souza RS, Davis T, Eldon ER, Esposito MF, Goree JH, Hewan-Lowe L, Maloney JA, Mazzola AJ, Michels JS, Layno-Moses A, Patel S, Tari J, Weisbein JS, Goulding KA, Chhabra A, Hassebrock J, Wie C, Beall D, Sayed D, Strand N. Consensus Guidelines on Interventional Therapies for Knee Pain (STEP Guidelines) from the American Society of Pain and Neuroscience. J Pain Res. 2022 Sep 8;15:2683-2745. doi: 10.2147/JPR.S370469. eCollection 2022.
- Background HOLLANDER JL. Intra-articular hydrocortisone in arthritis and allied conditions; a summary of two years' clinical experience. J Bone Joint Surg Am. 1953 Oct;35-A(4):983-90. No abstract available.
- Background HOLLANDER JL, BROWN EM Jr, JESSAR RA, BROWN CY. Hydrocortisone and cortisone injected into arthritic joints; comparative effects of and use of hydrocortisone as a local antiarthritic agent. J Am Med Assoc. 1951 Dec 22;147(17):1629-35. doi: 10.1001/jama.1951.03670340019005. No abstract available.
- Background Johnston PC, Lansang MC, Chatterjee S, Kennedy L. Intra-articular glucocorticoid injections and their effect on hypothalamic-pituitary-adrenal (HPA)-axis function. Endocrine. 2015 Mar;48(2):410-6. doi: 10.1007/s12020-014-0409-5. Epub 2014 Sep 3.
- Background Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, Callahan L, Copenhaver C, Dodge C, Felson D, Gellar K, Harvey WF, Hawker G, Herzig E, Kwoh CK, Nelson AE, Samuels J, Scanzello C, White D, Wise B, Altman RD, DiRenzo D, Fontanarosa J, Giradi G, Ishimori M, Misra D, Shah AA, Shmagel AK, Thoma LM, Turgunbaev M, Turner AS, Reston J. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res (Hoboken). 2020 Feb;72(2):149-162. doi: 10.1002/acr.24131. Epub 2020 Jan 6.
- Background Shah A, Mak D, Davies AM, James SL, Botchu R. Musculoskeletal Corticosteroid Administration: Current Concepts. Can Assoc Radiol J. 2019 Feb;70(1):29-36. doi: 10.1016/j.carj.2018.11.002.
- Background Cushman DM, Bruno B, Christiansen J, Schultz A, McCormick ZL. Efficacy of Injected Corticosteroid Type, Dose, and Volume for Pain in Large Joints: A Narrative Review. PM R. 2018 Jul;10(7):748-757. doi: 10.1016/j.pmrj.2018.01.002. Epub 2018 Jan 31.
- Background Cushman DM, Ofek E, Syed RH, Clements N, Gardner JE, Sams JM, Mulvey JL, McCormick ZL. Comparison of Varying Corticosteroid Type, Dose, and Volume for the Treatment of Pain in Small- and Intermediate-Size Joint Injections: A Narrative Review. PM R. 2019 Jul;11(7):758-770. doi: 10.1016/j.pmrj.2018.09.040. Epub 2019 Jun 5.
- Background Utamawatin K, Phruetthiphat OA, Apinyankul R, Chaiamnuay S. The efficacy of intra-articular triamcinolone acetonide 10 mg vs. 40 mg in patients with knee osteoarthritis: a non-inferiority, randomized, controlled, double-blind, multicenter study. BMC Musculoskelet Disord. 2023 Feb 3;24(1):92. doi: 10.1186/s12891-023-06191-6.
- Background Kim KH, Park JW, Kim SJ. High- vs Low-Dose Corticosteroid Injection in the Treatment of Adhesive Capsulitis with Severe Pain: A Randomized Controlled Double-Blind Study. Pain Med. 2018 Apr 1;19(4):735-741. doi: 10.1093/pm/pnx227.
- Background Stout A, Friedly J, Standaert CJ. Systemic Absorption and Side Effects of Locally Injected Glucocorticoids. PM R. 2019 Apr;11(4):409-419. doi: 10.1002/pmrj.12042. Epub 2019 Mar 29.
- Background Habib GS. Systemic effects of intra-articular corticosteroids. Clin Rheumatol. 2009 Jul;28(7):749-56. doi: 10.1007/s10067-009-1135-x. Epub 2009 Feb 28.
- Background Habib GS, Bashir M, Jabbour A. Increased blood glucose levels following intra-articular injection of methylprednisolone acetate in patients with controlled diabetes and symptomatic osteoarthritis of the knee. Ann Rheum Dis. 2008 Dec;67(12):1790-1. doi: 10.1136/ard.2008.089722. No abstract available.
- Background Choudhry MN, Malik RA, Charalambous CP. Blood Glucose Levels Following Intra-Articular Steroid Injections in Patients with Diabetes: A Systematic Review. JBJS Rev. 2016 Mar 22;4(3):e5. doi: 10.2106/JBJS.RVW.O.00029.
- Background Habib GS, Miari W. The effect of intra-articular triamcinolone preparations on blood glucose levels in diabetic patients: a controlled study. J Clin Rheumatol. 2011 Sep;17(6):302-5. doi: 10.1097/RHU.0b013e31822acd7c.
- Background Taliaferro K, Crawford A, Jabara J, Lynch J, Jung E, Zvirbulis R, Banka T. Intraocular Pressure Increases After Intraarticular Knee Injection With Triamcinolone but Not Hyaluronic Acid. Clin Orthop Relat Res. 2018 Jul;476(7):1420-1425. doi: 10.1007/s11999.0000000000000261.
- Background Wernecke C, Braun HJ, Dragoo JL. The Effect of Intra-articular Corticosteroids on Articular Cartilage: A Systematic Review. Orthop J Sports Med. 2015 Apr 27;3(5):2325967115581163. doi: 10.1177/2325967115581163. eCollection 2015 May.
- Background McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M, Ward RJ. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA. 2017 May 16;317(19):1967-1975. doi: 10.1001/jama.2017.5283.
- Background Wheeler SG. Steroid Knee Injections for Arthritis Are No Better than Placebo in a Randomized Controlled Trial. J Gen Intern Med. 2020 Oct;35(10):3137-3139. doi: 10.1007/s11606-020-05647-y. No abstract available.
- Background Schneider BJ, Mattie R, Smith C. Cumulative Lifetime Steroid Exposure via Epidural Administration. Pain Med. 2019 Nov 1;20(11):2323-2324. doi: 10.1093/pm/pnz203. No abstract available.
- Background Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K, Christy W, Cooke TD, Greenwald R, Hochberg M, et al. Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association. Arthritis Rheum. 1986 Aug;29(8):1039-49. doi: 10.1002/art.1780290816.
- Background Kohn MD, Sassoon AA, Fernando ND. Classifications in Brief: Kellgren-Lawrence Classification of Osteoarthritis. Clin Orthop Relat Res. 2016 Aug;474(8):1886-93. doi: 10.1007/s11999-016-4732-4. Epub 2016 Feb 12. No abstract available.
- Background Dworkin RH, Turk DC, Farrar JT, Haythornthwaite JA, Jensen MP, Katz NP, Kerns RD, Stucki G, Allen RR, Bellamy N, Carr DB, Chandler J, Cowan P, Dionne R, Galer BS, Hertz S, Jadad AR, Kramer LD, Manning DC, Martin S, McCormick CG, McDermott MP, McGrath P, Quessy S, Rappaport BA, Robbins W, Robinson JP, Rothman M, Royal MA, Simon L, Stauffer JW, Stein W, Tollett J, Wernicke J, Witter J; IMMPACT. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain. 2005 Jan;113(1-2):9-19. doi: 10.1016/j.pain.2004.09.012. No abstract available.
- Background Sullivan GM, Artino AR Jr. Analyzing and interpreting data from likert-type scales. J Grad Med Educ. 2013 Dec;5(4):541-2. doi: 10.4300/JGME-5-4-18. No abstract available.
- Background Tarhan S, Unlu Z. Magnetic resonance imaging and ultrasonographic evaluation of the patients with knee osteoarthritis: a comparative study. Clin Rheumatol. 2003 Sep;22(3):181-8. doi: 10.1007/s10067-002-0694-x.
- Background Messier SP, Resnik AE, Beavers DP, Mihalko SL, Miller GD, Nicklas BJ, deVita P, Hunter DJ, Lyles MF, Eckstein F, Guermazi A, Loeser RF. Intentional Weight Loss in Overweight and Obese Patients With Knee Osteoarthritis: Is More Better? Arthritis Care Res (Hoboken). 2018 Nov;70(11):1569-1575. doi: 10.1002/acr.23608.
- Background Salaffi F, Stancati A, Silvestri CA, Ciapetti A, Grassi W. Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale. Eur J Pain. 2004 Aug;8(4):283-91. doi: 10.1016/j.ejpain.2003.09.004.
- Background Bellamy N, Hochberg M, Tubach F, Martin-Mola E, Awada H, Bombardier C, Hajjaj-Hassouni N, Logeart I, Matucci-Cerinic M, van de Laar M, van der Heijde D, Dougados M. Development of multinational definitions of minimal clinically important improvement and patient acceptable symptomatic state in osteoarthritis. Arthritis Care Res (Hoboken). 2015 Jul;67(7):972-80. doi: 10.1002/acr.22538.
- Background Seror P, Pluvinage P, d'Andre FL, Benamou P, Attuil G. Frequency of sepsis after local corticosteroid injection (an inquiry on 1160000 injections in rheumatological private practice in France). Rheumatology (Oxford). 1999 Dec;38(12):1272-4. doi: 10.1093/rheumatology/38.12.1272.
- Background Manchikanti L, Cash KA, Pampati V, Damron KS, McManus CD. Evaluation of lumbar transforaminal epidural injections with needle placement and contrast flow patterns: a prospective, descriptive report. Pain Physician. 2004 Apr;7(2):217-23.
- Background Friedman DM, Moore ME. The efficacy of intraarticular steroids in osteoarthritis: a double-blind study. J Rheumatol. 1980 Nov-Dec;7(6):850-6.
- Background Pattrick M, Doherty M. Facial flushing after intra-articular injection of steroid. Br Med J (Clin Res Ed). 1987 Nov 28;295(6610):1380. doi: 10.1136/bmj.295.6610.1380. No abstract available.
- Background Gitkind AI, Shah B, Thomas M. Epidural corticosteroid injections as a possible cause of menorrhagia: a case report. Pain Med. 2010 May;11(5):713-5. doi: 10.1111/j.1526-4637.2009.00775.x. Epub 2010 Jan 8.
- Background Suh-Burgmann E, Hung YY, Mura J. Abnormal vaginal bleeding after epidural steroid injection: a paired observation cohort study. Am J Obstet Gynecol. 2013 Sep;209(3):206.e1-6. doi: 10.1016/j.ajog.2013.06.045. Epub 2013 Jun 28.
Drugs
| Evaluation | Drug | Modality | Dose | Route |
|---|---|---|---|---|
| Subject | Triamcinolone Acetonide | Other / unclassified | 5 mg | Other |
| Subject | Triamcinolone Acetonide | Other / unclassified | 10 mg | Other |
| Subject | Triamcinolone Acetonide | Other / unclassified | 40 mg | Other |