Louise Chang, MD
Finding relief from knee pain can be a trying experience for the nearly 27 million Americans who live with osteoarthritis. Non-steroidal anti-inflammatory drugs (NSAIDs) help many, but these medications can have serious side effects, including ulcers and serious gastrointestinal bleeding. What’s more, supplements such as glucosamine and chondroitin, which were once hailed as miracles, have not always lived up to their claims in clinical studies.
Although joint replacement surgery is an option for many with advanced osteoarthritis (OA), new types of injections may help postpone the need for knee replacement surgery -- and help relieve pain in people who are not candidates for the surgery.
From steroids and hyaluronic acid to Botox (yes, the same Botox used by millions to paralyze their wrinkles) and stem cells, injectables do have a growing and important role in the multi-pronged approach to treating OA.
“Using injections to treat OA is becoming more mainstream,” says Jennifer L. Solomon, MD, an assistant attending physiatrist at the Hospital for Special Surgery and a clinical instructor at Weill Cornell Medical College, both in New York City. “These are good options that can improve quality of life, especially for people who can’t undergo joint replacement.”
Knees hurt? “Steroid injections can decrease inflammation, which can cause joint cartilage breakdown and can be very effective at relieving OA pain,” says Edward Puzas, PhD, a professor of orthopedics at the University of Rochester at Rochester, NY.
But corticosteroid injections are certainly not a panacea for OA, says Elaine Husni, MD, MPH,the vice chair of rheumatology and the director of Arthritis and Musculoskeletal Center at the Cleveland Clinic in Ohio.
“Steroids are more of a one-time, last-resort treatment, and some people do get a lot of pain relief that lasts for months and months,” she says. Steroid injections can also be used with other treatments such as NSAIDs. “Sometimes we use NSAIDs to get rid of stiffness and steroids for the pain,” Husni says.
Solomon agrees. “If there is a lot of inflammation and acute irritation, steroid injections are the way to go,” she tells WebMD. “If the pain is really more chronic, I still go with hyaluronic acid.”
Joint-lubricating injections of hyaluronan or hyaluronic acid also play a role in treating OA. Known as viscosupplementation, these injections basically replenish a substance found in normal joint fluid called hyaluronic acid. Several brands are available, including Euflexxa, Hyalgan, Orthovisc, Supartz, Synvisc, and Synvisc-One.
When injected directly into the knee, these OA treatments allow the cartilage surfaces of the bones to glide over each other more smoothly. They also act as a shock absorber to cushion your knee joint. Although these injections are only approved for the knee, some doctors use them for other arthritic joints, Solomon says.
Hyaluronic injections can help postpone the need for knee replacement surgery in people who have not had success with other OA treatments; but the injections don’t work for everyone. Even if they do work, there can be a large degree of variability in the response, Solomon says.
“Hyaluronic injections are for people with moderate or advanced OA,” Husni says. “If your OA is too advanced or too mild, they don’t work much at all.”
Depending on the injectable your doctor thinks is right for you, treatment involves one or more injections and may relieve symptoms up to six months before repeat treatment is needed.
The same Botox injections that have helped millions of Americans eliminate their frown lines, forehead creases, and crows feet may also help relieve OA pain in the knees and shoulders, and the results may last up to three months, says Jasvinder Singh, MBBS, MPH, a staff physician at the Minneapolis VA Medical Center in Minnesota, and assistant professor of medicine at the University of Minnesota in Minneapolis.
Although “promising,” this research is still in its infancy, Singh tells WebMD. “Both corticosteroid and hyaluronic acid injections are accepted, approved, and commonly used treatments for OA, but botulism toxin in the joints is not approved by the federal Food and Drug Administration, so it’s in a slightly different category and needs more evidence that it works and that it’s safe,” he says. Botox (onabotulinumtoxin A) is approved to treat certain wrinkles, arm spasticity, certain neck and eye problems, excessive underarm sweating, and chronic headache.
Exactly how Botox works in joints is not fully understood, but it may inhibit the release of certain proteins from nerves in the joint, which may decrease the pain sensation.
There are other promising experimental injections for treating osteoarthritis on the horizon. Solomon is one of a growing cadre of doctors using the body’s own stem cells and growth factors to stimulate the cartilage’s natural healing process.
“We take blood, isolate the growth factors in the blood, and inject them back into the knee,” she says. “There is not good hard evidence out there yet, but my clinical experience is that it works,” she says.
Stem cells are another possibility. These are unspecialized cells that can turn into other types of cells, and there is some research that suggests stem cells can be used to repair the damaged cartilage in OA.
“There have been some very encouraging animal studies in which we use stem cells to regenerate the cartilage surface in joints,” Puzas says.
These treatments may help change the way OA is treated.
As of now, “you can repair the cartilage or regenerate it,” he says. “Once OA has gone far enough, there is not enough cartilage left to repair, but it may be possible to regenerate it using stem cell technology.”
Treating OA is not just about surgery, or injectables, or weight loss, or bracing or any of the other osteoarthritis treatments out there. Successfully treating OA requires a personalized multi-disciplinary approach. This may include bracing, activity modification, weight loss (if necessary), medications, injections, and/or surgery.
“We are getting away from the one-type-of-treatment approach,” Husni says. “It’s about what you want to do, how active you need to be, and how motivated you are.” Doctors can then design a treatment plan especially for you.
SOURCES:Jennifer L. Solomon, MD , assistant attending physiatrist, the Hospital for Special Surgery, New York City; clinical instructor, Weill Cornell Medical College, New York City.Elaine Husni, MD, MPH,vice chair of rheumatology and director of Arthritis and Musculoskeletal Center, Cleveland Clinic, Ohio.Edward Puzas, PhD, professor of orthopedics, University of Rochester, Rochester, N.Y.Jasvinder Singh,MBBS, MPH, staff physician, Minneapolis VA Medical Center, Minnesota; assistant professor of medicine, University of Minnesota, Minneapolis.News release, Food and Drug Administration.
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