Steroids and viscosupplements (VS) are two commonly injected substances used to provide mobility of and relief to osteoarthritic joints. Steroids presumably provide relief by controlling inflammation of peripheral joints, while VS seek to reestablish the elasticity and viscosity of the joint's normal synovial fluid. VS are also reported to have anti-inflammatory effects through the reduction of leukocyte function and inflammatory mediators.1,2 The efficacy of both injections for temporarily alleviating joint pain has been demonstrated in various clinical trials.3, 4, and 5
The FDA approved the use of VS in 1997 for the treatment of knee osteoarthritis (OA) and VS have since gained widespread use.6 Although off-label use of VS occur in everyday clinical practice, such as its use for hip and shoulder,7,8 this chapter will focus on the use of these agents for their current FDA indication, the treatment of knee OA.9
See Table 51-1 for a list of current FDA-approved VS.
TABLE 51-1.Manufacturer and Brand Information for Viscosupplements ||Download (.pdf) TABLE 51-1.Manufacturer and Brand Information for Viscosupplements
|Generic name ||Brand name ||Manufacturer ||Number of injections ||Molecular weight (kDa) ||Distinguishing characteristics |
|Hylan G-F 20 (16 mg or 48 mg, respectively) ||SYNVISC or Synvisc-One® ||Genzyme corporation (genzyme.com) ||3 (or 1 with Synvisc-One®) ||6000 || |
Most viscous, highest rate of pseudoseptic reaction10,11
|1% Sodium hyaluronate (20 mg) ||Euflexxa ||Ferring Pharmaceuticals (ferringusa.com) ||3 ||2400-3600 ||Bacterial products |
|Sodium hyaluronate (20 mg) ||Hyalgan ||Sanofi Aventis (sanofi-aventis.us) ||Recommended 5 (can do 3) ||500-730 || |
|1% Sodium hyaluronate (30 mg) || |
[No avian derivatives]
Trademark: Anika Therapeutics, Inc
Distributer: DePuy Mitek, Inc – JNJ company
|3 ||1000-2900 ||Bacterial products |
|1% Sodium hyaluronate (25 mg) ||Supartz ||Smith and Nephew, Inc ||Recommended 5 (can do 3) ||620-1170 ||Avian products |
According to the American College of Rheumatology (ACR), the indications for treating a swollen inflamed knee are:
Failed conservative measures (oral medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, activity modifications, and other lifestyle changes).
Patients who have or are at higher risk for developing NSAID-induced renal dysfunction or gastroduodenal ulcers are excellent candidates for intra-articular steroid injections because they avoid the potential systemic effects that occur with oral NSAIDs.
If there is persistent pain and impaired quality of life following a knee steroid injection, or only short-term benefit from the steroid injection, then VS is the next treatment option to consider. Although steroid injections are reported to have quicker acting pain relief than VS, VS-derived pain relief may last considerably longer, from 4 to 26 weeks.13, 54 Therefore, in some cases the patient will experience ...